Extrapontine myelinolysis (osmotic demyelination syndrome)

Findings

Figure 1: Sagittal T1 image taken parasagitally at the level of the dentate nucleus. There are T1 hypointensities within the subcortical white matter and in the brachium pontis.
Figure 2: Axial T2 at the level of the cerebral subcortical white matter. There is T2-hyperintensity in the centrum semiovale bilaterally. The signal abnormality is fairly symmetrical.
Figure 3: Axial T2 at the level of the splenium of the corpus callosum. There are T2-hyperintensities within the splenium of the corpus callosum and asymmetrical T2-hyperintensities along the corticospinal tracks within the posterior limbs of internal capsules.
Figure 4: Axial T2 at the level of the middle cerebellar peduncles. There is T2-hyperintensity within the brachium pontis bilaterally. Note that the signal abnormality is symmetrical. Also note that the signal within the pons was normal.
Figure 5: Axial FLAIR at the level of the splenium of the corpus callosum. There are FLAIR-hyperintensities within the splenium of the corpus callosum and asymmetrical FLAIR -hyperintensities along the corticospinal tracks within the posterior limbs of internal capsules.
Figure 6 and Figure 7: Axial diffusion weighted and ADC map images at the level of the middle cerebellar peduncles. There is increased signal in both DWI and in the ADC map, consistent with the subacute stage of myelinolysis (four weeks after onset of symptoms). The DWI and ADC maps at the level of the centrum semiovale and splenium (not shown) demonstrated similar findings.


Diagnosis: Extrapontine myelinolysis (osmotic demyelination syndrome)


Central pontine myelinolysis (CPM), was first described in 1959 in patients with a history of alcoholism and malnutrition. Extrapontine myelinolysis (EPM) is the extrapontine manifestation of osmotic myelinolysis and can occur with or without central pontine myelinolysis. In one autopsy series, myelinolysis was found to be confined to the pons (CPM) in about 50% of cases, combined CPM and EPM occurred in about 30 % of cases, and exclusive EPM occurred in about 20% of cases7.

CPM and EPM are characterized by symmetrical loss of myelin with relative preservation of axons and neuronal cell bodies. Pathologically, there is dissolution of the myelin sheaths of fibers. There is however, no evidence of inflammation. The myelinolysis occurs with relative sparing of the nerve cells and axon cylinders.

Although initial reports were largely confined to chronic alcoholics, osmotic myelinolysis has also been seen in patients with electrolyte disturbances, particularly hyponatremia that has been rapidly corrected (more then 10mmol/l/day), and in liver transplant patients being immune-suppressed with cyclosporine. Alcohol continues to be a particularly frequent etiology (up to 40% of cases)7.

Osmotic myelinolysis can affect a variety of sites resulting in a variety of symptoms. The MRI appearance is characteristic with lesions being symmetrical. However, the timing of the appearance of lesions on MRI may be significantly delayed. If there is a strong clinical suspicion of the diagnosis, repeat imaging at 1 to 2 weeks may reveal lesions that were not initially apparent. Diffusion weighted imaging (DWI) might have the capability of detecting lesions undetectable on conventional MRI earlier, with one case report in the literature showing an altered DWI in a patient within 24 hours of symptoms at a time when conventional MRI findings were inconspicuous.

The prognosis of the osmotic demyelination syndrome is variable. In a reported series, about 6 % of patients died, about 32 % survived but were left dependent, about 32% had some deficits but were independent, and about 30% recovered completely. Initial clinical features are not predictive of outcome and a recent case series found conventional MRI findings were not prognostic but the prognostic role of diffusion-weighted imaging is still unclear 3,4,8.

In conclusion, CPM and EPM are the same disease, sharing the same pathology, associations, and time course but differing in clinical manifestations due to differences in the affected structures. Both diseases have lesions that are strikingly symmetrical.

Memories of a Nocturnal Walk in Boac (First part)

Boac is a small lovely town caught between the old culture of the past and the new trappings of the present times. On the one hand it is an old town: its streets are lined with century old houses, and the people still bearing the ancient culture of a bygone age. On the other hand it is a modern town, too: internet cafes, videoke bars, and other modern trappings can also be seen, a sign of the town's acceptance of modern amenities.

I had stayed in Boac for only a week. Yet, I wanted to know more of the town, its history, its culture, its people. Although a total stranger, I knew I had to walk its every street. I wanted to observe the town for the sake of observation, and not just because I wanted to intrude into other peoples' lives.

And so, one night, I slipped out of my hotel room, and photographed the town and its lovely evening life. The people were very friendly, and I came to know many of them. Of course, I didn't want to be rude, and so I photographed only when I knew nobody was looking.

And so here are some of my pictures of that wonderful, memorable nocturnal walk in Boac, Marinduque.

A Sleeping Family Near a Cubao ATM machine

(click image enlarge)

While having one of my usual nocturnal walks in Cubao, I noticed this poor family sleeping in their makeshift home near a BPI ATM Machine. Despite their obvious poverty, the mother and her children sleep well. The father, I later learned, was away digging for some empty mineral water bottles in the trash cans in Aurora Boulevard. April 28, 2008 11pm.

Radiology Grand Rounds XXIII

Here is a case of Cannavan's Disease for the Radiology Grand Rounds submitted by Dr Sumer Sethi of Teleradiology Providers. Concept and Archive of the Radiology Grand Rounds is available at- Radiology Grand Rounds.

Canavan’s disease
Deficiency of N- acetylaspartate cyclase enzyme – Increase in NAA.

"Canavan disease demonstrates bilateral symmetric T2 white matter hyperintensity, including involvement of the subcortical arcuate fibers. This disease appears diffusely throughout the cerebral white matter, does not enhance at computed tomography (CT) or MR imaging, and demonstrates variable involvement of the basal ganglia and cerebellar white matter. For example, both Canavan disease and Alexander disease demonstrate macrocephaly with bilaterally symmetric increased T2 signal intensity of cerebral white matter and involvement of subcortical arcuate fibers. MR spectroscopy, however, has been shown to be a useful diagnostic tool in making this distinction. There is an accumulation of NAA in patients with Canavan disease because of a deficiency in the myelin synthesis pathway; thus, MR spectroscopy reveals a markedly elevated NAA peak. "

In other white matter diseases there is Axonolysis hence NAA decreases, Defective myelination leads to increased Choline and lactate is seen in the activer disease.

Further reading (Radiology 2006;241:310-324.)

Hope you enjoyed this edition of Radiology Grand Rounds submissions are requested for the next Radiology Grand Rounds posted every month last sunday. If you interested in hosting any of the future issues contact me at sumerdoc-AT-yahoo-DOT-com.

Case by-Dr.Sumer K Sethi, MD
Consultant Radiologist ,VIMHANS and CEO-Teleradiology Providers
Editor-in-chief, The Internet Journal of Radiology
Director, DAMS (Delhi Academy of Medical Sciences)

MR Spectroscopy in Meningioma

MR spectroscopy may provide additional information in cases in which the differential diagnosis
of tumors by neuroimaging is difficult. Cho reflects membrane turnover, correlates with malignancy in astrocytic tumors, and forms high peaks in meningioma. The most common proton spectrum found in meningiomas is a high Cho peak with low or absent NAA and Cr and variable amounts of lactate. Most important, an unusually high ratio of Ala to Cr has been found in meningiomas because of the high Ala and low Cr content, and this is a relatively specific finding for meningioma. Alanine is seen as doublet centered at 1.47 ppm and inverts on the long-TE sequence.

Reference- AJNR Am J Neuroradiol 20:882–885, May 1999

The New Ali Mall Cubao

Cubao tycoon Jorge Araneta finally decides to renovate old Ali Mall, one of the oldest shopping malls in the country. Ali Mall , which was built in 1976 and named in honor of the great boxing champion Muhammad Ali, has been one of the iconic hang-outs in Cubao, long before there was Farmer's or Rustan's, or the SM Malls. Ali Mall was a big part of my childhood, and I spent some very sweet memories there.

During High School, my classmates and I would sneak from our school to hang-out in the skating rink and eat Coney Island Ice Cream. My classmates would then "tambay" in the foodcourt to look out for free taste of foods, while I head to National Bookstore to read my favorite paperbacks.

Back then, with very little money in my pocket, I couldn't possibly buy the books I wanted. Instead I read in the bookstore itself, making it into a library, reading in installments, despite the sign in the shelf that reads "No Private Reading Please".

When I finally saved some money from my allowances, I try to buy all the books that I can afford, and so was able to build a personal library, even at a very young age. There was no Booksale then, and so I was always forced to buy new books at brand new prices. Looking back, I realized how naive my taste for books were at that time.

Now Ali Mall is changing. Although I miss its old dilapidated look, I welcome the new and better changes as part of Araneta Cubao's complete make-over. Araneta Cubao itself is rapidly changing. There will be more buildings to rise as the projected Manhattan Condominiums take more of Araneta Cubao's landscape. In the next few years, most old buildings in Cubao (like Rustan's and the Bus Terminal) will be leveled to the ground to give way to more modernized buildings.

Well, that's just how things go. We can't always live in the past :)

Earth Day

Yesterday was Earth Day. From now on, I would prefer that everyday should be Earth Day.

I am a lover of Earth. From outer space, Earth looks a lovely planet, the oceans are landforms are visible. It's a beautiful, beautiful planet. It's the only one we have. Even if they find that Mars or Saturn can be liveable, I would prefer living in Earth.

But now, things are becoming ugly. We fill our atmosphere with smoke and gas. The air we breath, once invisible, is now visible. It's so dirty you can now be able to see it.

You see, solution for Climate Change does not lie on some genius scientists working in the laboratory, finding the solutions for it. The solution lies within each of us living on Earth. The solution for Climate Change is every person's responsibility. We now know the symptoms. We must work on the cure.

When there is a pain in your body, it tells you something about your body. Pain is an indication that there is something wrong. Yet some people tend to ignore them. It will go away, they think. But eventually they die of heart attack, of cancer, of infection.... why? because they didn't listen to what their body is telling them.

The Earth as we know it is changing. We have burned more fuels in the last 80 years than the earth has burned in the last 100 million years! Yet, millions of tons of fuels are still being burned everyday.

A scientific fact: A live frog in a pan filled with water over a heated stove, will eventually boil itself to death. It will not even struggle to get out of it.

We, humankind, are supposedly the most intelligent of all life forms on the Earth. Yet, it's obvious now that our very intelligence is only at par with the frogs. We are burning ourselves to death. And we are not doing anything about it. At least not enough. Like Dr. Frankenstein, we have created a monster. And we can no longer control it.

A parable:

In the beginning there was only Man and animals. But Man was so lonely, and so the animals around him became worried. The bear said to the man: "Why are you so lonely?" , Man replied: "Because I'm not as strong as you". The bear said: "I'll give you then my strength".

But Man was still lonely, and the eagle said:"Why are you so lonely?. Man replied: "Because I'm not as fast as you are". The eagle said: "Well then, i'll give you my agility and speed!"

But as usual, the Man was still lonely. And the owl asked him: "What's wrong my friend?". Man said "I'm lonely becuase I didn't have your intelligence", and the Owl said: "Don't be so sad then, you can have my intelligence"

And the man walked away still not feeling satisfied with all the gifts he had from the animals. The Earth said to the animals: "Look, I'm afraid now. We have given everything we had for Man, but still he's not satisfied. The future will come that we have given him everything, and Man will still not be satisfied".

And that future is now.

CNS arteriovenous malformation (AVM)

Findings

There is a large, diffuse left cerebral hemisphere arteriovenous malformation, which is located mostly within the posterior left frontal lobe. The remainder of the brain parenchyma appears within normal limits. On the MR angiogram, there is a large left frontal and parietal lobe mass of tangled vessels supplied mostly by left MCA, but also left ACA branches. On the conventional angiogram, there is a tangle of vessels in the left parietal lobe, with arterial supply from the prefrontal and post frontal branches of the Rolandic division. There is venous drainage drainage into the superior sagittal sinus and sphenoparietal sinus.

Diagnosis: CNS arteriovenous malformation


Key points

Classic imaging finding is "bag of worms" from flow voids.
Minimal or no mass effect.
Strong enhancement on CT.
MRI characteristics varies with flow rate and presence / age of hemorrhage.
Peak presentation between 20 and 40 years old.
50% will hemorrhage; 25% will have seizures.
Rare spontaneous regression.
Treatment includes embolization, radiosurgery, and also surgical resection.

Choroid plexus cyst

Findings

The patient has an approximately 6-7 mm choroid plexus cyst.


Diagnosis: Choroid plexus cyst


Discussion

Choroid plexus cysts are a relatively frequent finding on obstetrical sonographic imaging with an incidence of 0.2 to 2.5%. They are thought to occur due to folding of the neuroepithelium with trapping of secretory products and desquamated cells. On histological evaluation of these choroids plexus cysts, there is no epithelial lining, and they are usually filled with clear colored fluid which may have some debris.

The importance of recognizing this finding is related to its association with karyotypic abnormalities, most commonly trisomy 18. Almost 40-70% of patients with trisomy 18 (Edward syndrome = constellation of findings including micrognathia or facial cleft, omphalocele, clenched hands with overlapping index fingers, rocker-bottom feet, small cerebellum with prominent cisterna magna) have choroid plexus cysts which often times are bilateral and larger than 1 cm in diameter. However, in the absence of any other anatomical abnormalities, less than 1% of fetuses with choroid plexus cysts will have trisomy 18. There is also a reported association of choroid plexus cysts with trisomy 21 (up to 17%) although less commonly than with trisomy 18.

Management of the pregnancy upon detection of these cysts is controversial. Almost 90% of choroids plexus cysts resolve by the 28th week of gestation. In over 95% of the patients, there is no clinical significance. However, the decision to perform amniocentesis is based on the results of the serum triple screen results (Edward syndrome = low maternal AFP, low HCG, low estiol), maternal age, and the presence of any other anatomic abnormalities. In the presence of any other anatomic abnormality and choroid plexus cysts, there is a 4% incidence of Edward syndrome. Some obstetricians will order follow-up obstetrical ultrasounds to evaluate for resolution of these cysts. However, even if the choroid plexus cysts resolve, there is no effect on the reduction of likelihood of karyotypic abnormalities.


Radiologic overview

Ultrasound is the widely accepted standard radiological imaging modality for obstetrical fetal anatomy survey. Part of the standard set of sonographic images obtained during the fetal intracranial survey include an "axial" image plane through the lateral ventricles for purposes of ventricular measurement to exclude hydrocephalus. The choroid plexus is often the most echogenic structure within the head. Choroid plexus cysts most often appear as well circumscribed anechoic structures within the brightly echogenic choroid plexus tissue located in the atria of the lateral ventricles. Identification of these cysts should prompt a thorough sonographic evaluation for other potential anomalies including an enlarged cisterna magna or myelomeningocele, omphalocele, or extremity malformations.

Choroid plexus cysts can also be seen on fetal MRI examinations. On MR, these cysts will follow fluid signal intensity which will be low on T1 and bright on T2 image sequences.

Choroid plexus carcinoma

Findings


Figure 1: Axial T2 WI shows a large, heterogeneous, lobulated, frond-like lesion within the left lateral ventricle with a prominent flow void suggestive of a vessel within the lesion. There is diffuse dilatation of the ventricular system.
Figure 2: Axial T2 weighted image demonstrates another heterogeneous lesion in the right Foramen of Luschka.
Figure 3 and Figure 4 : Axial and coronal T1 fat suppressed post gadolinium MR images demonstrate heterogeneous enhancement within the mass lesions with diffuse leptomeningeal enhancement in the interpeduncular and perimesencephalic cisterns. Parenchymal invasion is also seen with enhancing foci in the left occipital region.
Figure 5: Axial T1 fat suppressed post gadolinium MR image through the abdomen demonstrates circumferential leptomeningeal enhancement around the cord.


Diagnosis: Choroid plexus carcinoma


The choroid plexus is the neuroepithelial tissue responsible for the production of CSF within the cerebral ventricular system. Neoplasms of the choroid plexus are uncommon tumors which can form anywhere there is choroid in the ventricular system. These tumors occur in proportion to the amount of normally present choroid tissue. The lateral ventricle is the most common site (50% of cases), followed by the fourth ventricle (40%) and the third ventricle (5%). About 5% of choroid plexus tumors arise in more than one location.

Choroid plexus tumors usually present in the first decade of life. Most choroid plexus tumors (about 80%) occur as the benign, slowly growing papilloma, a WHO grade I tumor with a favorable overall prognosis. The malignant variant manifests as a much more biologically aggressive WHO grade III tumor, and is far more common in children than adults.

Clinical presentation is usually due to increased intracranial pressure and hydrocephalus, due mainly to CSF overproduction, but mechanical obstruction and impaired CSF resorption may also contribute.

Choroid plexus papillomas usually present as lobulated intraventricular masses with intense, homogeneous enhancement in a child. These tumors are soft, well-circumscribed cauliflower-like masses with prominent lobulations peripherally. The mass can be hyperattenuating on CT with calcification seen in 25%. Necrosis resulting in heterogeneity and parenchymal invasion are characteristic features for choroid plexus carcinoma. Extension from one ventricle to another or into the cerebellopontine angle is a characteristic feature. The presence of focal neurological signs also suggests choroid plexus carcinoma due to parenchymal invasion. CSF seeding can be seen with both papilloma and carcinomas and enhanced MRI of the entire neuraxis is recommended prior to surgery to evaluate extent of disease.

Maryland

Did you know that Apple now sells more music online than Walmart sells over the counter?

So, we're returning from our trip from the east coast and I thought I'd share with you a couple of fun tidbits and things I've learned during our trip.

1. Colleen can't say Mythbusters.

2. As Grandmom is telling us "I would hate to have Alzheimer's Disease, it must be horrible." She takes a fork full of food and hits herself in the chin.

3. I passed my HUD inspection class. I'm one of five people who passed the class, and one of nine people the class started with.

4. People on the Metro are unsocial, and quite unresponsive when you try to start the wave throughout the metro car.

5. Uncle Daniel is a talented triangle player.

6. Stomp The Yard is an awesome movie!

7. Jennifer will physically attack you if you play the 'Mosquito Ringtone' anywhere near her.

8. Wes loves housework.

9. I thought I did at first, but I realized that I'm not quite sure why the grilled onions provided at the hot dog stands have a weird wet tomato sauce.

10. I have a double in Hollywood. Most of the East Coast Winters family (Richard, Mary, Sean and Kevin) are convinced that I am Jerry Trainor (Spencer, the older brother from the Disney Channel show ICarly.)

11. Don't you dare, ever, ever, ever FUCK WITH GRANDMOM'S MANHATTAN!!!!!

12. Grandmom sent us out the door telling us a joke about oral sex. I was able to get some of the good stuff on video here…. Just click this link! Grandmom's Great Joke!

Now I'm Fucking Obama

A new fantastic "I'm Fucking" Video

I'm Fucking Obama

Central neurocytoma

Findings

There is an enhancing heterogeneous suprasellar mass adjacent to the third ventricle. Mass effect on the cerebral peduncles and lateral and third ventricles.

Differential Diagnosis:
- Neurocytoma
- Subependymoma
- Craniopharyngioma
- Low-grade glioma


Diagnosis: Central neurocytoma


Key points

Typically supratentorial, intraventricular, bubbly, well circumscribed mass with low grade enhancement. Calcification is present 50-70%. (this patient does not demonstrate some of these features).
Extraventricular extension is a poor prognostic sign (as in this case).
Often attached to septum pellucidum.
Commonly cause obstructive hydrocephalus due to obstruction of foramen of Monro.
CT typically shows mixed solid and cystic architecture with rare hemorrhage.
Decreased metabolism on PET.
<1% of intracranial neoplasms.
Present from age 20 to 40 with signs of increased intracranial pressure.
Subependymoma may be radiographically indistinguishable, but is typically in those older than 40 and is more commonly related to the 4th ventricle (whereas CN involves the 4th ventricle extremely rarely).

Osteoblastoma

Findings

Figure 1: Axial CT image of the cervical spine with bone windows demonstrates a round, well-defined sclerotic lesion in the right C5 facet.
Figure 2 and Figure 3: Coronal and sagittal MIP CT images demonstrate that the expansile portion of the lesion involves the transverse process, facet and lamina with sparing of the vertebral body.

Differential diagnosis of posterior element lesions
- Aneurysmal bone cyst
- Hemangioma
- Osteoid osteoma/osteoblastoma
- Giant cell tumor


Diagnosis: Osteoblastoma (path proven)


Osteoblastomas are benign osteoid forming lesions which commonly occur in the spine (42%). They are differentiated from osteoid osteomas by their larger size. Osteoblastoma presents as an expansile, geographic lesion with a sclerotic margin occurring in the posterior elements. The lesions may be centered in the pedicle, lamina, transverse or spinous process. Osteoblastomas may exhibit a range of densities varying from a lucent, mixed or blastic appearance. This accounts for the range of appearances on T1 and T2 weighted MR images. Because they are osteoid-forming lesions, osteoblastomas demonstrate increased uptake on bone scan.

Although osteoblastomas usually present with a narrow zone of transition with surrounding sclerosis, they may present with aggressive features with a wide zone of transition and cortical breakthrough. Prostaglandins released by the lesion may cause extensive peritumoral edema. This peripheral inflammatory response may result in periosteal reaction in the adjacent ribs, pleural thickening or effusion and ossification of the ligamentum flavum.

Patients with osteoblastomas usually present in their 2nd to 3rd decade of life (90%). Osteoblastoma is a differential diagnostic consideration of “painful scoliosis.” The most common signs and symptoms include dull pain with scoliosis concave to the side of the lesion. Neurologic symptoms may arise from compression of the cord or nerve roots. Treatment of the lesion involves curettage with bone graft. Occasionally, radiofrequency ablation is used. However, the proximity of the lesion to the cord often limits the use of this treatment. Preoperative embolization is sometimes employed as well.

Takayasu’s arteritis

Findings

The MRA demonstrates focal stenoses of the right innominate artery, proximal right subclavian artery, and proximal left common carotid artery with post-stenotic dilatation. There is also marked narrowing of the right internal carotid artery and focal stenosis of the proximal left subclavian artery before the left vertebral, with reconstitution distal to the left vertebral. The CT angiogram again demonstrates segmental large vessel vascular stenoses and left common carotid fusiform aneurysm.

Differential Diagnosis:
- Takayasu's arteritis
- Temporal arteritis
- Atherosclerosis
- Syphilitic aortitis
- Fibromuscular dysplasia
- Idiopathic arteritis


Diagnosis: Takayasu’s arteritis


Key points

Defined as a granulomatous inflammation affecting predominately elastic arteries (aorta, main aorta branches, and pulmonary arteries). This is the only aortitis that causes stenosis or occlusion of the aorta.
Most commonly involves left subclavian, left common carotid, brachiocephalic trunk, renal arteries, celiac trunk, SMA, and pulmonary arteries.
Affects females more often than males (8:1). More often affects oriental persons aged 12-66.
For the first few months to years, the patient experiences a prepulseless phase that has fevers, sweats, myalgias, weight loss, and arthralgias, The pulseless phase then shows signs of limb ischemia and renovascular hypertension. Patients often have an ESR > 20 mm/hour.
Acutely there is granulomatous infiltration of the elastic fibers of the media that progresses to a fibrotic stage over weeks to months. The fibrosis leads to constriction from proliferation, thrombosis, and aneurysm formation.
Treat with steroids, and then angioplasty after active inflammation subsides.
Angiography (and CT angiography) may demonstrate wall thickening, stenoses, occlusions, luminal and mural calcium and thrombus deposition.

Classification
- Type I: is the classic pulseless type involving the subclavian, carotid, and brachiocephic trunk
- Type II: is a combination of types I and III
- Type III: is the atypical coarctation type involving the descending thoracic and abdominal aorta with major branches
- Type IV: is the dilated type with dilatation of the aortic length and its branches

Paraneoplastic limbic encephalitis (PLE)

Additional clinical history: 50-year-old female with a history of small cell lung cancer (SCLC) presents with a history of worsening short term memory over the last 3 months.


Findings

Figure 1: Axial FLAIR MR image demonstrates increased signal in the left medial temporal lobe, uncus and hippocampus.


Diagnosis: Paraneoplastic limbic encephalitis (PLE)



Paraneoplastic limbic encephalitis (PLE) is a remote neurologic effect of cancer outside of the CNS. It is the most common of the clinical paraneoplastic syndromes. The typical presenting symptoms include short-term memory loss, seizure, or psychologic features such as mood or behavioral disturbance.

The most frequent neoplasms associated with PLE are SCLC, testicular tumors, breast cancer, Hodgkin’s lymphoma, and thymoma. SCLC makes up the majority of cases. Up to 60% of patients do not have the diagnosis of cancer at presentation, with neurologic symptoms preceding the discovery of tumor by weeks to months.

The etiology involves immune mediated injury by autoantibodies or cytotoxic T-cells. Pathological studies reveal neuronal loss, perivascular inflammatory infiltrates and microglial nodules in affected limbic structures, without cancer cells.

Serologic markers for PLE are anti-Hu in small cell lung cancer and anti-Ta in patients with testicular cancer. Identification of these markers coupled with the characteristic MRI finding helps establish the diagnosis.

Typical MRI findings include unilateral or bilateral mesial temporal lobe hyperintensity on T2 weighted images or FLAIR. On T1 sequences, the mesial temporal lobes may be hypointense. Herpes simplex encephalitis may have similar findings in early stages of disease. However, the patients usually develop mass effect and signs of edema. Herpes encephalitis is an acute febrile illness whereas PLE is a subacute illness. This fact makes clinical correlation particularly important.

Treatment is primarily at targeting the primary malignancy.

Over The Hills!

That's the best blog title to blog story connection ever.....

Anyway...... This will be short and sweet..... Did you know that the series premier of "The Hills" on MTV on March 24, 2008 was not only the highest rated series premiere of "The Hills" television program, but it was the highest rated series premiere ever on cable television!!!!

Leaving Marinduque

I just spent the entire Holy Week in Marinduque. For sure it was an exhilirating adventure and I have some of the sweetest memories of the province. The whole experience was utterly engaging and can hardly be forgotten. I'm thankful to the Marinduquenos for giving me a temporary home while away from my true home.

I could have gone there with a companion, but I decided to go alone. I am by no means a loner, and I have several friends who would have gladly come with me. But I wish to be alone on this kind of trips. Nothing to worry except myself. I could go in and out of my hotel anytime. I could go to one place or another on impulse. Wade into the fields, hike into the hills, walk down the spreading sands of the fine beach. And it was wonderful. Sometimes, to be really alone with yourself can be one of the happiest moments in one's life.

Leaving the island of Marinduque after the week-long joyful festivities is quite saddening. On the Monday after the Festival, the flags and banderitas were lowered down, the welcome signs were being pulled down, tourists begin to leave, and the island becomes once more a place of simplicity, complacency, and beauty. I'm sure every tourist who visited the island leave with a kind of sadness in their hearts.

Meantime, here's a short video of the Port of Balanacan as we leave the island of Marinduque to head back to Luzon. I know that I will come back to Marinduque sometime in the future. And if you haven't gone there yet, schedule your first visit there on the next Holy Week. The good people of Marinduque will warmly welcome you, as I had been.

Holy Moses

The late Charlton Heston, winner of the Best Actor Academy Award for his work in the movie "Ben Hur", passed away this Sunday. He famously played Moses in the movie "The Ten Commandments". What other role did he have in the movie "The Ten Commandments"?

Colleen, Noah and I arrived here in Maryland on Friday to visit Grandmom and attend a Housing and Urban Development class. I started talking to Grandmom on Saturday night about Leo.

Grandmom told me that she had heard about a young Marine coming back from duty, who was going to be attending her church, and she had told the priest that she was looking forward to meeting the young man. That young man was Leo…..

Also, Leo was walking to the church with his parents and saw Grandmom running across the street, he pointed her out to his parents and told them that this was the girl he was going to marry.

Most of you probably already knew this story, but it was the first time I had heard it, and I thought it was cute….. So you will all have to hear it again….. Sounds like a scene in a movie doesn’t it?

So….. I wouldn’t had known the answer to this trivia question either, so don’t feel bad. Charlton Heston also played the Voice of God in the movie "The Ten Commandments". On a side note, Charlton Heston’s son, Fraser Clarke Heston, played Moses as an infant in the movie.