Abstract Advances in the diagnosis and treatment of multiple myeloma have led to the modification of diagnostic criteria and initiation of therapy, incorporating myeloma-defining events into the CRAB criteria. Imaging has evolved from radiographic study to whole-body techniques, including low-dose computed tomography (LDCT), 18F-fluorodeoxyglucose positron emission tomography (PET/CT), and whole-body magnetic resonance imaging (MRI), being an important part of the evaluation of myeloma precursors, the staging of the disease and the evaluation of treatment response. LDCT has greater sensitivity in the detection of bone lesions compared to the radiographic study, MRI has the greatest sensitivity in the evaluation of bone marrow infiltration and PET/CT is the method of choice in the evaluation of treatment response. The radiologist must know the morphological characteristics of the lesions originating from myeloma in the different techniques and recognize the advantages and disadvantages of the different types of study.

Resumen Los avances en el diagnóstico y el tratamiento del mieloma múltiple han llevado a la modificación de los criterios diagnósticos y de inicio de terapia, incorporándose a los criterios CRAB los eventos definitorios de mieloma. Las imágenes han evolucionado desde el estudio radiográfico hasta las modalidades de cuerpo completo, incluyendo la tomografía computada de baja dosis (TCBD), la tomografía computada por emisión de positrones (PET/CT) con 18F-fluorodesoxiglucosa y la resonancia magnética (RM) de cuerpo completo, siendo parte importante de la evaluación de los precursores del mieloma, de la estadificación de la enfermedad y de la evaluación de la respuesta a tratamiento. La TCBD posee mayor sensibilidad en la detección de lesiones óseas en comparación con el estudio radiográfico, la RM la mayor sensibilidad en la evaluación de la infiltración de la médula ósea y la PET/CT es la modalidad de elección en la valoración de la respuesta al tratamiento. El radiólogo debe conocer las características morfológicas de las lesiones originadas del mieloma en las distintas modalidades y reconocer las ventajas y desventajas de los diferentes tipos de estudio.

RESUMEN Los schwannomas cervicales son tumores encapsulados benignos de la vaina nerviosa que corresponden a menos del 0,1% de los tumores de cabeza y cuello. Suelen presentarse como una tumoración cervical asintomática. Son lesiones cuyo tratamiento de primera línea es la resección quirúrgica. Es fundamental el uso de neuromonitorización durante el procedimiento y realizar una cirugía en conjunto con un especialista en nervios periféricos. En ocasiones resulta dificultoso conservar la funcionalidad del nervio involucrado. Se presenta el caso de una paciente de 27 años que consulta por una tumoración cervical derecha. Se realizaron tomografía computarizada y resonancia magnética nuclear cervical que evidenciaron una imagen sugestiva de schwannoma de neumogástrico. Se realizó la exéresis completa de la lesión con neuromonitorización intraoperatoria. Presentó una disfonía transitoria en posoperatorio.

ABSTRACT Schwannomas are encapsulated benign tumors that arise from the peripheral nerve sheaths and account for 0.1% of head and neck tumors. They usually present as asymptomatic lateral neck masses. Surgical resection is the first-line therapy of these lesions. Intraoperative neuromonitoring is essential, and a neurosurgeon specializing in peripheral nerves needs to participate during surgery. Preservation of nerve functioning is sometimes difficult. We report the case of a 27-year-old female patient sought medical care due to a mass in the right lateral region of the neck. Computed tomography scan and nuclear magnetic resonance imaging suggested the presence of a pneumogastric schawannoma. The tumor was totally resected with intraoperative neuromonitoring. The patient evolved with transient dysphonia.

Abstract Introduction: Refractory Status Epilepticus (RSE) is a serious medical emergency where the seizure does not subside despite conventional pharmacological treatment. The continuous presence of episodes lasting 24 hours or more is described as super-refractory status epilepticus (SRSE). This case report details the complex in teraphy management and explores a multidisciplinary approach. Case presentation: A 32-year-old male with a history of focal epilepsy secondary to head trauma in childhood. Enters emergency with a RSE episode. Barbiturate coma, plasmapheresis and ketogenic diet were administered. The Magnetic Resonance Imaging revealed a lesion in the right fronto-temporo-insular cortex, areas of hypermetabolism on Positron Emission Tomography and continuous epileptiform activity on video-electroencephalogram. Palliative surgery was chosen, achieving successful resolution of the SRSE and Engel Scale IA classification at 14 months of follow up. Discussion: The SRSE is a critical neurological event with a guarded prognosis and complex therapeutic options. Therapeutic options are described from anticonvulsants, immunotherapy and surgery. The surgical approach emerges as an effective option, especially in cases with structural injuries. Early identification and appropriate therapy are vital to prevent complications. Conclusions: SRSE represents a critical challenge with a high burden of morbidity and mortality. However, epilepsy surgery shows promising results in the context of the structural brain cause responsible for epileptiform activity. The importance of early identification and palliative surgical management as a viable option is highlighted, improving the quality of life of patients.

Resumen Introducción: El estado epiléptico refractario (EER) constituye una emergencia médica grave, donde la crisis no cede a pesar del tratamiento farmacológico convencional. Se describe como estado epiléptico superrefractario (EESR) la continua presencia de episodios con una duración de 24 horas o más. Este reporte de caso detalla la complejidad en el manejo y explora un enfoque multidisciplinario. Presentación del caso: Paciente masculino de 32 años con antecedente de epilepsia focal secundaria a traumatismo craneoencefálico en la niñez, quien ingresó en contexto de EESR, el cual recibió coma barbitúrico, plasmaféresis y dieta cetogénica. En los exámenes, la resonancia magnética reveló una lesión en la región frontotemporal insular derecha; en la tomografía por emisión de positrones se observaron zonas de hipermetabolismo y en el videoelectroencefalograma una continua actividad epileptiforme. Se optó por la cirugía paliativa, logrando la resolución exitosa del EESR y una clasificación Engels IA a los 14 meses. Discusión: El EESR es un evento neurológico crítico con pronóstico reservado y opciones terapéuticas desafiantes. Se describen opciones terapéuticas desde anticonvulsivantes, inmunoterapia y cirugía, donde el abordaje quirúrgico emerge como una opción eficaz, especialmente en casos con lesiones estructurales. La identificación temprana y la terapia adecuada son vitales para prevenir complicaciones. Conclusiones: El EESR representa un desafío crítico con alta carga de morbimortalidad, sin embargo, la cirugía de epilepsia muestra promisorios resultados en el contexto de causa cerebral estructural, responsable de la actividad epileptiforme. Se destaca la importancia de la identificación temprana y el manejo quirúrgico paliativo como opción viable, mejorando la calidad de vida de los pacientes.

Abstract Susac’s Syndrome (SS) is an occlusive immune-mediated microangiopathy that preferentially affects cerebral, retinal and cochlear arterioles. Classically, it is associated with the triad of visual defects, encephalopathy and sensorineural hearing loss (SNH). Diagnosis is based on clinical features and findings from fluorescein angiography (FA), brain magnetic resonance imaging (CE-MRI) and audiometry. Treatment is based on high-dose corticosteroid therapy and must be started as soon as possible to prevent permanent sequelae. The clinical case presented is about a 34-year-old woman with multiple visits to the Emergency Department due to persistent headaches, psychomotor slowing and focal neurological deficits lasting 2 months. From the study carried out, multiple hyperintense lesions were found on T2 CE-MRI involving the corpus callosum, areas of retinal ischemia and hyperfluorescence on FA and bilateral moderate SNH at high frequencies on the audiogram. The diagnosis of SS was assumed and immunosuppressive therapy was started, maintaining clinical and audiometric surveillance.

Resumo A Síndrome de Susac (SS) é uma microangiopatia imunomediada oclusiva que atinge preferencialmente as arteríolas cerebrais, retinianas e cocleares. Classicamente, associa-se à tríade de defeitos visuais, encefalopatia e hipoacusia neurossensorial (HNS). O diagnóstico baseia-se na clínica e achados da angiografia fluoresceínica (AF), ressonância magnética cerebral (RMN-CE) e audiometria. O tratamento assenta na utilização de corticoterapia em altas doses e deve ser iniciado o mais precocemente possível para prevenir sequelas permanentes. O caso clínico apresentado é de uma mulher de 34 anos com múltiplas idas ao Serviço de Urgência por cefaleias persistentes, lentificação psicomotora e défices neurológicos focais com dois meses de evolução. Do estudo efetuado, foram constatadas múltiplas lesões hiperintensas na RMN-CE em T2 a envolver o corpo caloso, áreas de isquemia retiniana e hiperfluorescência na AF e HNS moderada bilateral nas frequências elevadas no audiograma. Assumiu-se o diagnóstico de SS e iniciou-se terapêutica imunossupressora, mantendo-se vigilância clínica e audiométrica.

ABSTRACT Cavernous sinus hemangioma is considered as a vascular malformation or as a vascular tumor. It is usually extra-axially located, but it is histologically different from cavernomatous cerebral malformations. Clinical features may include headache, visual alterations or cranial nerve palsy. Diagnostic methods include CT scans, but the best is contrast-enhanced magnetic resonance imaging (MRI). Therapy may be microsurgery or radiotherapy. We present the case of a 30-year-old male, with no relevant past history, who had suffered with headache for three years, and diplopia for the last seven months, due to paresis affecting the sixth cranial nerve. Contrast-enhanced MRI showed an expansive lesion in the right cavernous sinus, with regular borders, T1 hypointense, with significant contrast uptake, T2 and FLAIR hyperintense, with no diffusion restriction. A craniotomy plus total resection of the tumor with hemostatic matrix support for controlling bleeding was performed. This patient developed complete ophthalmoparesis that improved over time. It was concluded that cavernous sinus hemangioma is an unusual condition, with high associated morbidity and mortality rates, but good results may be achieved with an adequate surgical technique.

RESUMEN Los hemangiomas del seno cavernoso son considerados como malformaciones vasculares o tumores vasculares, se desarrollan extraaxiales, pero son histológicamente distintos a la malformación cavernomatosa cerebral. Su clínica puede ser cefalea, alteraciones visuales o paresia de pares craneales. Los métodos diagnósticos son la tomografía, pero principalmente la resonancia contrastada. El tratamiento puede ser mediante microcirugía o radioterapia. Se presenta el caso de un varón de 30 años, sin antecedentes, con 3 años de evolución de cefalea, y 7 meses de diplopía por paresia del VI par craneal. La resonancia contrastada evidencia un proceso expansivo en el seno cavernoso derecho, bordes regulares, hipointensa en T1, hipercaptador de contraste, hiperintensa en T2 y FLAIR, que no restringe en difusión. Se le realizó una craneotomía más resección total de la tumoración con apoyo de matriz hemostática para el control del sangrado. En el posoperatorio presento oftalmoparesia completa que fue mejorando en el tiempo. Se concluye que el hemangioma del seno cavernoso es una patología rara, con alta morbimortalidad asociada, pero con una adecuada técnica quirúrgica se pueden obtener buenos resultados.

Abstract During the last decades, the magnetic resonance imaging (MRI) has become an strategic tool for diagnosis, staging and surveillance in patients with rectal cancer. To differentiate patients with locally advanced rectal tumors from those who do not, determinate neoadjuvant therapy or total mesorectal excision, respectively. After neoadjuvant chemoradiotherapy, those who achieve complete clinical response may be considered for inclusion in an active surveillance scheme known as “watch and wait” (WW). WW strategy consists of three pillars, rectal digital exam, endoscopy and the MRI, and the main purpose is to reach the early detection of tumoral regrowth. Regarding MRI, the high-resolution T2-weighted images in conjunction with DWI, and the ADC map plays a key role in this instance. WW leads to avoid resective surgeries with high morbidity rates. The rectal digital exam and endoscopy are complementaries to MRI, whose main limitation is the detection of lesions with no mucosal involvement. This reason places the MRI as a cornerstone in tumoral regrowth, detecting not only luminal regrowth, but those in which the rectal wall is not involved, and thus, not accessible for the other surveillance methods. To our knowledge, this is the first pictorial essay in which imaging regrowth patterns are described. The purpose of this is to emphasize the MRI protocol study and to describe the different forms of tumoral regrowth in order to reach the early tumoral regrowth detection.

Resumen En las últimas décadas, la resonancia magnética (RM) ha cobrado un rol fundamental en el diagnóstico, la estadificación y el seguimiento de los pacientes con cáncer de recto. En la estadificación inicial, que sean o no tumores localmente avanzados es lo que determina el tratamiento neoadyuvante o quirúrgico, respectivamente. Posterior a la neoadyuvancia, los pacientes que logren una respuesta clínica completa pueden ser considerados para la inclusión dentro de un esquema de vigilancia activa, comúnmente conocido como watch and wait (WW). La estrategia WW se basa en tres pilares, que son el examen digital rectal, la endoscopía y la RM, buscando detectar la presencia temprana de recrecimiento tumoral. En relación a la RM, la secuencia potenciada en T2 de alta resolución, junto con la de difusión (DWI) y el mapa de ADC, son las piezas clave para la detección temprana de recrecimiento. La estrategia de WW lleva a evitar cirugías resectivas con una alta morbilidad y deterioro de la calidad de vida. El examen digital rectal y la endoscopía son métodos de vigilancia complementarios a la RM, con su principal limitación en lesiones sin compromiso mucoso. Esta razón posiciona a la RM como un pilar indispensable para su implementación, detectando no solo áreas de recrecimiento parietal, sino también aquellas extramurales no accesibles por los otros métodos de vigilancia. En nuestro conocimiento, este es el primer ensayo iconográfico que se centra en el análisis estricto del recrecimiento tumoral en pacientes bajo esquema de WW por RM. El objetivo es enfatizar el protocolo de estudio en estos pacientes y mostrar las distintas formas de recrecimiento tumoral con el fin de lograr su detección temprana.

ABSTRACT We present the case of a 56-year-old patient with fever of unknown origin associated with chest and lumbar pain. Multimodality imaging revealed diffuse peri-aortitis in the thoracic aorta without involvement of the aortic valve, contributing substantially to the diagnosis of Ig G4-associated aortitis. Immunosuppressive therapy was started. Follow-up at five months with cardiac magnetic resonance imaging showed a reduction in the inflammatory process in the thoracic aorta.

RESUMEN Presentamos el caso de un paciente de 56 años, con cuadro febril de origen desconocido asociado a dolor torácico y lumbar. La imagen multimodal demostró periaortitis difusa en la aorta torácica sin afectación de la válvula aórtica, lo que contribuyó sustancialmente al diagnóstico de aortitis asociada a Ig4. Se inició tratamiento inmunosupresor. El seguimiento a los 5 meses, la resonancia magnética cardíaca mostró una reducción del proceso inflamatorio en la aorta torácica.

RESUMO A incidência de malformações linfáticas em crianças é estimada em 6% de todas as malformações vasculares benignas. Têm sido desenvolvidos novos tratamento para doenças linfáticas orbitárias. Nosso objetivo é descrever um caso clínico de malformação venolinfática orbitária em um menino de 10 anos de idade, causando proptose e edema palpebral. A lesão foi tratada inicialmente com escleroterapia local. No entanto, a lesão teve recidiva e foi tratada com sucesso com sirolimo oral. Ainda são necessários estudos prospectivos para estabelecer a dose apropriada e a duração do tratamento com sirolimo nesses pacientes. 6 benignas orbitárias 1 idade palpebral local entanto oral pacientes

ABSTRACT It is estimated that lymphatic malformations in children account for 6% of all benign vascular malformations. New medical therapies have been developed for the management of lymphatic orbital disease. The purpose of this article was to describe a clinical case of orbital venolymphatic malformation in a 10-year-old boy, causing proptosis and palpebral edema. The lesion was initially treated with local sclerotherapy. However, the lesion relapsed, and was successfully treated with oral sirolimus. Prospective studies are warranted to determine the appropriate dose and extend the indications of sirolimus in these patients. 6 disease 10yearold yearold 10 year old boy edema sclerotherapy However relapsed patients 1

Resumen: Introducción: la piomiositis (PMS) es una infección bacteriana aguda o subaguda del músculo esquelético. Entidad rara en pediatría, suele acompañarse de la formación de abscesos. Se presenta más frecuentemente en preescolares de sexo masculino, afectando mayoritariamente a extremidades y región pélvica. La manifestación multifocal es frecuente. El principal agente etiológico es Staphylococcus aureus. Caso clínico: 3 años, sexo masculino, sano. Consulta por fiebre continua de hasta 39 ºC de seis días de evolución, dolor de ambos miembros inferiores a predominio izquierdo, cojera y repercusión general. Examen físico: tumoración en muslo izquierdo de límites difusos de 13 x 5 cm, lisa, firme, impresiona adherida a planos musculares, dolorosa. Sin elementos fluxivos en la piel. Ecografía de partes blandas: aumento de tejidos blandos de la extremidad. Resonancia magnética (RM): abscesos que comprometen logia de los aductores del miembro izquierdo, el vasto externo del muslo derecho, musculatura paravertebral lumbar izquierda y cérvico-torácica izquierda. Tratamiento: drenaje, requiere de múltiples limpiezas quirúrgicas y antibioticoterapia prolongada. Cultivo de la lesión: Staphylococcus aureus meticilino resistente (SAMR). Buena evolución clínica e imagenológica. Discusión: la PMS ha presentado una incidencia creciente con la aparición del SAMR. La ecografía es un método adecuado para realizar diagnóstico local. La experiencia en la interpretación de la RM permite pesquisar el compromiso multifocal, identificando focos sin traducción clínica. La antibioticoterapia y el drenaje quirúrgico son los pilares del tratamiento. El pronóstico es bueno en la mayoría de los casos.

Summary: Introduction: pyomyositis (PMS) is an acute or subacute bacterial infection of the skeletal muscle. It is a rare infection in pediatrics, and it is usually accompanied by abscess formation. It occurs more frequently in male preschoolers, mostly affecting the extremities and pelvic region. The multifocal manifestation is frequent. The main etiological agent is Staphylococcus aureus. Clinical case: 3 year-old, male, healthy patient. He consulted for continuous fever of up to 39ºC of 6 days of evolution, pain in both lower limbs predominantly on the left, lameness and general repercussions. Physical examination: a 13 x 5 cm tumor in the left thigh with diffuse limits, smooth, firm, adhered to muscle layers, painful. Without fluxive elements on the skin. Soft tissue ultrasound: enlargement of the soft tissues of the extremity. Magnetic resonance imaging (MRI): abscesses involving the adductor lodge of the left limb, the vastus lateralis of the right thigh, left lumbar paravertebral musculature and left cervical-thoracic musculature. Treatment: drainage, requires multiple surgical cleanings and prolonged antibiotic therapy. Culture of the lesion: methicillin-resistant Staphylococcus Aureus (MRSA). Good clinical and imaging evolution. Discussion: PMS has had an increasing incidence with the appearance of MRSA. Ultrasound is a suitable method for local diagnosis. Experience in the interpretation of MRI has enabled us to research multifocal involvement, identifying unobserved foci during clinical check-up. Antibiotic therapy and surgical drainage are the main treatments. The prognosis is good in most cases.

Resumo: Introdução: Ia Piomiosite (TPM) é uma infecção bacteriana aguda ou subaguda do músculo esquelético. É uma entidade rara em pediatria, costuma vir acompanhada de formação de abscessos. Ocorre com maior frequência em pré-escolares do sexo masculino, afetando principalmente as extremidades e a região pélvica. A manifestação multifocal é comum. O principal agente etiológico é o Staphylococcus aureus. Caso clínico: paciente 3 anos, sexo masculino, hígido. Consulta por febre contínua de até 39ºC há 6 dias, dor em ambos os membros inferiores predominantemente esquerdo, claudicação e repercussão geral. Exame físico: tumor na coxa esquerda com limites difusos de 13 x 5 cm, liso, firme, aparentemente aderido aos planos musculares, doloroso. Sem elementos fluidos na pele. Ultrassonografia de tecidos moles: aumento dos tecidos moles da extremidade. Ressonância magnética (RM): abscessos envolvendo o alojamento adutor do membro esquerdo, vasto lateral da coxa direita, músculos paravertebrais lombares esquerdos e cérvico-torácicos esquerdos. Tratamento: drenagem, requer múltiplas limpezas cirúrgicas e antibioticoterapia prolongada. Cultura da lesão: Staphylococcus aureus resistente à meticilina (MRSA). Boa evolução clínica e imagiológica. Discussão: a TPM tem tido uma incidência crescente com o aparecimento do MRSA. A ultrassonografia é um método adequado para diagnóstico local. A experiência na interpretação de ressonância magnética permite-nos investigar o envolvimento multifocal, identificando focos sem tradução clínica. A antibioticoterapia e a drenagem cirúrgica são os pilares do tratamento. O prognóstico é bom na maioria dos casos.

BACKGROUND: Human immunodeficiency virus (HIV) infection, low cluster of differentiation (CD)4 counts and antiretroviral therapy can cause cholestasis and raised transaminases. In acute pancreatitis, this may render biochemical predictors of a gallstone aetiology inaccurate. METHODS: In a prospective observational study, acute pancreatitis was diagnosed by standard criteria. Cholecystolithiasis and bile duct diameter were diagnosed by ultrasound. Cholestasis was defined as two of the following: bilirubin > 21 umol/l, γ glutamyl transferase > 78 U/l, alkaline phosphatase > 121 U/l. Cholangitis was defined as cholestasis and any two sepsis criteria: (temperature > 38°C, WCC > 12.6 x10(9)/L, pulse > 90 beats/min). Cholangitis, cholestasis, and bile duct diameter greater that 1 cm were indications for endoscopic retrograde cholangiopancreatography (ERCP). These parameters' ability to predict gallstone pancreatitis (GSP) and choledocholithiasis were compared in HIV+ve and HIV-ve patients. RESULTS: Sixty-two (26%) of 216 patients had GSP. Twenty four were HIV+ve patients. More HIV+ve patients had cholestasis (p = 0.059) and ERCP (p = 0.004). In HIV+ve patients alanine aminotransferase (ALT) > 100 U/L, gamma glutamyl transferase (GGT) > 2 upper limit of normal and cholestasis had a negative predictive value of 92%, 96.7% and 95.2% respectively. In HIV-ve patients, negative predictive value (NPV) was 84%, 83.8% and 84.6% respectively. Bile duct stones were demonstrated at ERCP in 6 (25%) and 3 (8%) of HIV+ve and HIV-ve patients respectively (p = 0.077). Five of 14 ERCP patients had no bile duct stones. HIV+ve and HIV-ve groups had two deaths each. CONCLUSION: Absence at presentation of the abnormal parameters analysed were good predictors of a non-gallstone aetiology particularly in HIV+ve patients. Prior, magnetic resonance cholangiopancreatography (MRCP) or endoscopic ultrasound (EUS) would reduce the number of non-therapeutic ERCPs.

Resumo Antecedentes A dor do membro fantasma (DMF) ocorre após amputações e pode persistir de forma crônica e debilitante. A estimulação magnética transcraniana repetitiva (EMTr) é um método de neuromodulação não invasivo capaz de influenciar a função cerebral e modular a excitabilidade cortical. Sua eficácia no tratamento da dor crônica é promissora. Objetivo Avaliar as evidências sobre a eficácia e segurança do uso da EMTr no tratamento da DMF, observando os parâmetros de estimulação utilizados, efeitos colaterais e benefícios da terapia. Métodos Trata-se de uma revisão sistemática de artigos científicos publicados na literatura nacional e internacional utilizando plataformas eletrônicas. Resultados Foram identificados 252 artigos. Duzentas e quarenta e seis publicações foram removidas por estarem duplicadas ou atenderem aos critérios de exclusão. Após a seleção, foram revisados seis estudos, sendo dois ensaios clínicos randomizados e quatro relatos de caso. Todos os estudos avaliados indicaram algum grau de benefício da EMTr no alívio dos sintomas dolorosos, mesmo que temporariamente. A percepção da dor foi menor ao final do tratamento quando comparada ao período anterior às sessões e permaneceu durante o acompanhamento do paciente. Não houve padronização dos parâmetros de estimulação utilizados. Não houve relatos de eventos adversos graves. Os efeitos da terapia a longo prazo não foram avaliados. Conclusão Existem alguns benefícios, mesmo que temporários, no uso da EMTr para alívio dos sintomas dolorosos na DMF. A estimulação de alta frequência em M1 demonstrou um efeito analgésico significativo. Dado o potencial demonstrado, mas limitado pela escassez de estudos de alta qualidade, são necessários mais estudos controlados para estabelecer e padronizar o uso clínico do método. DMF (DMF debilitante (EMTr cortical promissora utilizados Tratase Trata se eletrônicas 25 exclusão seleção caso temporariamente paciente graves temporários M significativo demonstrado qualidade 2

Abstract Background Phantom limb pain (PLP) occurs after amputations and can persist in a chronic and debilitating way. Repetitive transcranial magnetic stimulation (rTMS) is a non-invasive neuromodulation method capable of influencing brain function and modulating cortical excitability. Its effectiveness in treating chronic pain is promising. Objective To evaluate the evidence on the efficacy and safety of using rTMS in the treatment of PLP, observing the stimulation parameters used, side effects, and benefits of the therapy. Methods This is a systematic review of scientific articles published in national and international literature using electronic platforms. Results Two hundred and fifty two articles were identified. Two hundred and forty six publications were removed because they were duplicated or met the exclusion criteria. After selection, six studies were reviewed, those being two randomized clinical trials and four case reports. All evaluated studies indicated some degree of benefit of rTMS to relieve painful symptoms, even temporarily. Pain perception was lower at the end of treatment when compared to the period prior to the sessions and remained during patient follow-up. There was no standardization of the stimulation parameters used. There were no reports of serious adverse events. The effects of long-term therapy have not been evaluated. Conclusion There are some benefits, even if temporary, in the use of rTMS to relieve painful symptoms in PLP. High-frequency stimulation at M1 demonstrated a significant analgesic effect. Given the potential that has been demonstrated, but limited by the paucity of high-quality studies, further controlled studies are needed to establish and standardize the clinical use of the method. PLP (PLP way (rTMS noninvasive non invasive excitability promising used platforms identified criteria selection reviewed temporarily followup. followup follow up. up follow-up events longterm long term temporary Highfrequency High frequency M effect highquality high quality

More attention has been paid to immunotherapy for ovarian cancer and the development of tumor vaccines. We developed a trichostatin A (TSA)-modified tumor vaccine with potent immunomodulating activities that can inhibit the growth of ovarian cancer in rats and stimulate immune cell response in vivo. TSA-treated Nutu-19 cells inactivated by X-ray radiation were used as a tumor vaccine in rat ovarian cancer models. Prophylactic and therapeutic experiments were performed with TSA-modified tumor vaccine in rats. Flow cytometry and ELISpot assays were conducted to assess immune response. Immune cell expression in the spleen and thymus were detected by immunohistochemical staining. GM-CSF, IL-7, IL-17, LIF, LIX, KC, MCP-1, MIP-2, M-CSF, IP-10/CXCL10, MIG/CXCL9, RANTES, IL-4, IFN-γ, and VEGF expressions were detected with Milliplex Map Magnetic Bead Panel immunoassay. TSA vaccination in therapeutic and prophylactic models could effectively stimulate innate immunity and boost the adaptive humoral and cell-mediated immune responses to inhibit the growth and tumorigenesis of ovarian cancer. This vaccine stimulated the thymus into reactivating status and enhanced infiltrating lymphocytes in tumor-bearing rats. The expression of key immunoregulatory factors were upregulated in the vaccine group. The intensities of infiltrating CD4+ and CD8+ T cells and NK cells were significantly increased in the vaccine group compared to the control group (P<0.05). This protection was mainly dependent on the IFN-γ pathway and, to a much lesser extent, by the IL-4 pathway. The tumor cells only irradiated by X-ray as the control group still showed a slight immune effect, indicating that irradiated cells may also cause certain immune antigen exposure, but the efficacy was not as significant as that of the TSA-modified tumor vaccine. Our study revealed the potential application of the TSA-modified tumor vaccine as a novel tumor vaccine against tumor refractoriness and growth. These findings offer a better understanding of the immunomodulatory effects of the vaccine against latent tumorigenesis and progression. This tumor vaccine therapy may increase antigen exposure, synergistically activate the immune system, and ultimately improve remission rates. A vaccine strategy designed to induce effective tumor immune response is being considered for cancer immunotherapy. vaccines TSAmodified modified vivo TSAtreated treated Nutu19 Nutu 19 Nutu-1 Xray X ray staining GMCSF, GMCSF GM CSF, CSF GM-CSF IL7, IL7 IL 7, 7 IL-7 IL17, IL17 17, 17 IL-17 LIF LIX KC MCP1, MCP1 MCP 1, 1 MCP-1 MIP2, MIP2 MIP 2, 2 MIP-2 MCSF, MCSF M M-CSF IP10/CXCL10, IP10CXCL10 IPCXCL IP 10/CXCL10, 10 CXCL10 CXCL IP-10/CXCL10 MIGCXCL9 MIGCXCL MIG CXCL9 MIG/CXCL9 RANTES IL4, IL4 4, 4 IFNγ, IFNγ IFN γ, γ immunoassay cellmediated mediated tumorbearing bearing CD4 CD CD8 P<0.05. P005 P P<0.05 . 0 05 (P<0.05) extent IL- effect exposure progression system rates Nutu1 Nutu- IL1 IL-1 MCP- MIP- IP10 IP10/CXCL10 IP10CXCL1 10CXCL10 10/CXCL10 CXCL1 IP-10/CXCL1 MIG/CXCL P00 P<0.0 (P<0.05 IP1 IP10/CXCL1 IP10CXCL 10CXCL1 10/CXCL1 IP-10/CXCL P0 P<0. (P<0.0 IP10/CXCL 10CXCL 10/CXCL P<0 (P<0. P< (P<0 (P< (P

SUMMARY Hypopituitarism is a rare clinical condition that can present as a partial or complete absence of pituitary hormones. Hypopituitarism is most commonly caused by a sellar or parasellar mass, particularly a tumor, and the gold standard for its differential diagnosis is magnetic resonance imaging (MRI). Intrasellar aneurysm is an unusual cause of hypopituitarism. Indeed, about 0.17% of all cases of hypopituitarism are due to intrasellar aneurysms. We report the case of a 72-year-old man who was admitted to the hospital due to gastrointestinal symptoms and malnourishment. Due to persistent hyponatremia and spontaneous hypoglycemia in laboratory findings, the examination of the hypothalamic-pituitary-adrenal axis was eventually initiated, and the patient was later diagnosed with an unruptured aneurysm of the ophthalmic segment of the right internal carotid artery with sellar extension as a cause of panhypopituitarism. A combined endovascular treatment was performed with stent-assisted coil embolization of the aneurysm, and the patient was prescribed oral hormonal therapy. At the 1-year follow-up visit, no improvement in pituitary function was observed, and a pituitary MRI showed complete aneurysm occlusion and partial empty sella with significantly decreased pituitary volume. Aneurysms of the internal carotid artery are rare and may be associated with hypopituitarism and delayed diagnosis due to their unusual clinical presentation. Endovascular procedures, such as coil embolization of the aneurysm, could be the treatment of choice in these patients. Persistent hypopituitarism may occur even after successful treatment of the aneurysm. hormones mass tumor MRI. . (MRI) Indeed 017 0 17 0.17 aneurysms 72yearold yearold 72 year old malnourishment findings hypothalamicpituitaryadrenal hypothalamic adrenal initiated panhypopituitarism stentassisted stent assisted therapy 1year 1 followup follow up visit observed volume presentation procedures patients (MRI 01 0.1 7 0.

Bacterial ventriculitis is an uncommon, often fatal complication of intracranial bacterial infection. This case report describes a nine-month-old spayed female Goldendoodle that presented with a history of acute onset generalised seizures. The initial clinical examination, neurological examination and minimum database laboratory tests were unremarkable, and the dog was diagnosed with probable idiopathic epilepsy. Three weeks thereafter, the patient developed breakthrough clustering orofacial and generalised seizures. Magnetic resonance imaging (MRI) findings were consistent with bacterial ventriculitis. Broad-spectrum antibiotic and supportive therapy was initiated pending cerebrospinal fluid (CSF) analysis, serology and bacterial culture; however, the patient died eight hours after initiating treatment. To our knowledge, this is the first case report of suspected bacterial ventriculitis in a dog in South Africa and describes its atypical clinical presentation, progression and unique MRI findings.

Resumo Antecedentes A talomotomia por ultrassons focados - guiada por imagem de ressonância magnética (MRgFUS) surgiu recentemente como um tratamento inovador para pacientes com tremor essencial (TE) refratário ao tratamento médico. Objetivo Este estudo observacional retrospectivo tem como objetivo apresentar os resultados dos primeiros cinco pacientes com TE refratário à medicação submetidos ao tratamento com MRgFUS numa unidade médica pioneira em Portugal. Métodos Realizamos uma revisão retrospectiva dos dados clínicos dos cinco primeiros pacientes submetidos a talamotomia MRgFUS unilateral do núcleo ventral intermédio (Vim) para tratamento do TE medicamente refratário em nossa unidade médica. Resultados A idade média dos pacientes era de 65,4 (26–84) anos, e 60% eram do sexo masculino. Todos os pacientes tinham história familiar de TE. A duração média da doença foi de 17,4 anos, e todos eram destros. De acordo com a preferência individual, em 4 pacientes, a talamotomia foi realizada no lado esquerdo, e em um, no lado direito. A talamotomia por MRgFUS levou a melhorias significativas tanto na pontuação da escala de classificação clínica para tremor (CRST), de 62%, e na pontuação composta da CRST para a mão tratada, de 73%. Todos os pacientes apresentaram melhorias na funcionalidade e na qualidade de vida, de 52%. Não foram observados efeitos adversos graves e os que ocorreram durante e após o procedimento foram ligeiros e transitórios. Conclusão Os resultados iniciais da primeira unidade médica MRgFUS de Portugal indicam melhorias na qualidade de vida dos pacientes, com efeitos adversos ligeiros e transitórios. Estes dados reforçam a evidência crescente sobre a eficácia e segurança da talamotomia por MRgFUS como opção viável para pacientes com TE resistente à medicação. (MRgFUS (TE médico Vim (Vim 654 65 65, 26–84 2684 26 84 (26–84 anos 60 masculino 174 17 17, destros individual esquerdo direito CRST, , (CRST) 62 62% tratada 73 73% 52 52% transitórios 6 26–8 268 2 8 (26–8 1 (CRST 7 5 26– (26– (26 (2 (

Abstract Background The magnetic resonance imaging-guided focused ultrasound (MRgFUS) has emerged as an innovative treatment for patients with medically refractory essential tremor (ET). Objective This retrospective observational study aims to present the results of the first five patients with medically refractory ET who underwent MRgFUS treatment at this pioneering medical unit in Portugal. Methods We conducted a retrospective chart review for the first five patients who underwent unilateral MRgFUS thalamotomy of the ventral intermediate (Vim) nucleus to treat medically refractory ET at our medical unit. Results The mean patient age was 65.4 (26–84) years, and 60% were male. All patients had a family history of ET. The mean duration of disease was 17.4 years (range 10–24 years), and their dominant hand was the right. According to personal preference, the thalamotomy was performed on the left side in four patients, and on the right side in one. The MRgFUS thalamotomy led to significant improvements in both the clinical rating scale for tremor (CRST) score, by 62%, and the CRST composite score for the treated hand, by 73%. All patients experienced improvements in functionality and quality of life, by 52%. No severe adverse events were observed, and those that did occur during and following the procedure were mild and transient. Conclusion The initial results from Portugal's first MRgFUS medical unit indicate promising outcomes, with improvement in quality of life, as well as mild and temporary adverse events These findings contribute to the growing body of literature supporting the efficacy and safety of MRgFUS as a viable treatment option for patients with medication-resistant ET. imagingguided imaging guided (MRgFUS . (ET) Portugal Vim (Vim 654 65 4 65. 26–84 2684 26 84 (26–84 60 male 174 17 17. range 1024 10 24 10–2 , years) preference one (CRST 62 62% 73 73% life 52 52% observed transient Portugals s outcomes medicationresistant medication resistant (ET 6 26–8 268 2 8 (26–8 1 102 10– 7 5 26– (26– (26 (2 (