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Proforma For Registration of Subject For Dissertation: TH RD
Proforma For Registration of Subject For Dissertation: TH RD
Proforma For Registration of Subject For Dissertation: TH RD
BANGALORE
ANNEXURE – II
PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION
1 Name of the Candidate Dr. SINDU P. GOWDAR
and Address D/O PRAKASH GOWDAR
#3087, 9TH MAIN, 3RD CROSS,
(in Block Letters)
M.C.C ‘B’ BLOCK
DAVANGERE, 577004
KARNATAKA.
2 Name of the Institution J.J.M. MEDICAL COLLEGE,
DAVANGERE – 577 004.
3 Course of the Study and Subject POSTGRADUATE
M.D. IN RADIO-DIAGNOSIS
Pediatric white matter diseases are divided into four categories based on high-
intensity abnormalities seen on long TA images and correlative clinical information:
demyelinating disease, dysmyelinating disease, developmental delay (of myelination), and
white matter abnormalities of unknown origin. The last group of pediatric white matter
diseases is those of unknown origin. It is in this group that perhaps MR had its greatest
impact in lesion-detection capabilities.2
MRI will play a key role in the diagnostic evaluation of MS in children. Application of
more advanced MRI techniques such as MR spectroscopy (MRS), magnetization transfer
(MT), and diffusion tensor (DT) imaging yield more tissue-specific insights into neuro-
axonal and white matter integrity than conventional MRI assessment.4
The newly emerging field of axonal fiber tracking from DTI data 43, 44 may have a
major impact on our understanding of the clinical manifestations of degenerative and
inflammatory disease processes. Not only can a primary site of axonal injury be determined
with DTI, but it may be that Wallerian degeneration45 and perhaps even axonal pathways
underpinning cortical remodeling could be visualized.6
A study was done on 14 (11 male, three female) patients with a DSM-IV diagnosis of
schizophrenia (n¼7) or schizoaffective disorder (n¼7) as determined by the Structured
Clinical Interview for the DSM-IV by A. Ardekani et al. Using a rigorous voxelwise
analysis, they have demonstrated reductions in WM integrity in patients with schizophrenia
or schizoaffective disorder compared to healthy control subjects. The regional distribution of
these differences is consistent with other reported structural brain abnormalities in
schizophrenia. By assessing differences in WM integrity across the whole brain, this method
can inform hypothesis-driven studies of WM integrity in schizophrenia as well as other
disorders of the brain.9
In a study done by van der Voorn, MD et al, Forty-one patients (19 male, 22 female;
mean age, 15.4 years) and 41 control subjects (25 male, 16 female; mean age, 11.3 years)
were included. Twelve patients had a hypomyelinating disorder; 14 had a demyelinating
disorder; five had a disorder characterized by myelin vacuolation; and 10 had a disorder
characterized by cystic degeneration. It was concluded that quantitative MR techniques can
be used to discriminate between different types of white matter disorders and to classify
white matter lesions of unknown origin with respect to underlying pathologic conditions.10
In a study by de Leeuw FE et al, a total of 1077 subjects aged between 60–90 years
were randomly sampled from the general population. Of all subjects 8% were completely
free of subcortical white matter lesions, 20% had no periventricular white matter lesions, and
5% had no white matter lesions in either of these locations. It was concluded that the
prevalence and the degree of cerebral white matter lesions increased with age. Women
tended to have a higher degree of white matter lesions than men. This may underlie the
finding of a higher incidence of dementia in women than in men, particularly at later age.12
In a study by Tourbah A et al, fifty six patients among whom 39 had white matter
diseases had MRI of the brain comparing FLAIR sequence to a conventional proton density
sequence. Flair sequence allowed to detect 18 additional hypersignal (HS) that were not
present on T2 sequence. These HS were located in the periventricular areas for 5 of them,
near the cortical sulci in 10, and in the centrum semi-ovale for 3. FLAIR sequence permitted
analyze 41 other lesions that were not obvious on proton density sequences. Thirty five of
them were thus confirmed to be HS : 31 in the paracortical areas, 3 in the paraventricular
regions and one in the internal capsule, whereas the remaining 6 were normal sulci of the
brain. FLAIR sequence increases the sensitivity of MRI in white matter diseases.13
In a study by Kjos BO et al, seventy-six children with developmental retardation of
unknown cause underwent MR imaging of the brain. Twenty-one (28%) had positive MR
findings, including nine with atrophy, six with delayed myelination, four with multiple focal
white matter lesions, three with hypoplastic white matter, and three with migration
abnormalities. The frequency of abnormality was highest in nonautistic children with
associated neurologic physical findings (61%) but was also significant in nonautistic
children without neurologic findings (23%). They concluded that MR will reveal brain
abnormalities in about one third of nonautistic children with developmental retardation of
unknown cause, and more often in those with neurologic deficits, seizures, or a small head
size.14
Because demyelinating disease of the brain occasionally presents with large ring-
enhancing lesions on computed tomography (CT) scans and magnetic resonance images
(MRIs), Masdeu JC et al, sought to determine whether the ring pattern differed from that
found in other common brain lesions with ring enhancement. The observers rated the
contrast enhancement pattern as (1) open ring, with enhancement in the border of the lesion
abutting the white matter; (2) closed ring; or (3) uncertain. For all diagnostically certain
cases (n = 112), inter-rater agreement was excellent (kappa = 0.75). As an average of the two
reviewers, scans for 11 of 132 cases were read as uncertain; 89% of adrenoleukodystrophy
cases, 41% of the multiple sclerosis cases, 3% of tumors, and 9% of infections were
classified as having the open-ring pattern. Overall, 66% of demyelinating lesions had an
open-ring pattern compared with 7% of the non-demyelinating lesions (chi2 = 41.2, p <
0.0001). An open-ring pattern of enhancement is more likely to be associated with
demyelinating lesions than with nondemyelinating lesions.16
6.3 Objective of the study:
1. To evaluate the role of magnetic resonance imaging in white matter diseases
2. To establish an accurate diagnosis and to narrow down the differential diagnosis in
various white matter diseases
3. To assess the severity and extent of the underlying lesion in various conditions of
white matter diseases.
4. To demonstrate the different patterns of abnormal myelination in white matter
diseases.
7. MATERIALS AND METHOD
7.1 Source of data
The main source of data for the study is patients from the following teaching hospital
attached to Bapuji Education Association, J.J.M. Medical College, Davangere.
1. Bapuji Hospital
2. Chigateri General Hospital
3. Women and child health care hospital.
Appropriate MR sequences and multiplanar imaging will be performed for every patient.
Technique:
Imaging will be done with 1.5 Tesla Philips Achieva Machine using Sense Head
coils. The following sequences will be selected as required.
1. Localizer sequence conventional spin echo.
2. Sagittal FLAIR, STIR, T1 FS
3. Axial and sagittal T1 images
4. Axial, sagittal and coronal T2 images
5. Proton density images.
6. Diffusion weighted imaging and ADC map
7. Axial Grey matter only and white matter only sequences
OPTIONAL SEQUENCES:
8. DTI and FT; IV contrast study; TOF angiography shall be included in the study as
and when required.
7.2 Method of collection of Data (including sampling procedures if any)
All patients referred to the department of Radio diagnosis with clinical history
suspicious of white matter diseases in a period of 2 years from October 2012 to October
2014 will be subjected for the study.
Initially a minimum of 30 cases are intended to be taken up, however it may be extended
up to 50 cases depending upon the availability of cases within the study period.
Inclusion criteria:
1. Patients with clinical suspicion of white matter diseases.
2. Incidental finding of white matter diseases/ lesions.
3. Patients of all age groups.
Exclusion criteria:
The study will exclude
1. Patients with clinical suspicion of post-traumatic white matter injury.
2. Patients with Intracranial tumors and metastatic disease.
3. Patients having history of claustrophobia.
4. Patient having history of metallic implants insertion, cardiac pacemakers and metallic
foreign body in situ.
Duration of study: 2 years
Data Analysis: Proportion study
13) Tourbah A, Deschamps R, Stievenart JL, Lopez A, Zizen IMT, Caen LO et al.
Magnetic resonance imaging using FLAIR pulse sequence in white matter disease.
Neuroradiology 1996; 23(4): 217-222
14) Kjos BO, Umansky R, Barkovich AJ. MR of the brain in children with developmental
retardation of unknown cause. AJNR 1990; 11: 1035-1040
15) M. Filippi, C. Baratti, T. Yousry, M. A. Horsfield, S. Mammi, C. Becker, R. Voltz, S.
Spuler, A. Campi, M. F. Reiser, and G. Comi . Quantitative assessment of MRI lesion
load in multiple sclerosis: A comparison of conventional spin-echo with fast fluid
attenuated inversion recovery. Brain (1996) 119(4): 1349-1355
doi:10.1093/brain/119.4.1349
16) Masdeu JC, Moreira J, Trasi S, Visintainer P, Cavaliere R, Grundman M. The open
ring. A new imaging sign in demyelinating disease. J Neuroimaging 1996; 6: 104–7.
9 Signature of Candidate
ASSOCIATE PROFESSOR
DEPARTMENT OF RADIO-DIAGNOSIS,
J.J.M. MEDICAL COLLEGE,
DAVANGERE – 577 004.
11.2 Signature
12.2 Signature