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Segmentation of skull and scalp in 3-D human MRI using mathematical morphology.

We present a new technique for segmentation of skull and scalp in T(1)-weighted magnetic resonance images (MRIs) of the human head. Our method uses mathematical morphological operations to generate realistic models of the skull, scalp, and brain that are suitable for electroencephalography (EEG) and magnetoencephalography (MEG) source modeling. We first segment the brain using our Brain Surface Extractor algorithm; using this, we can ensure that the brain does not intersect our skull segmentation. We next generate a scalp mask using a combination of thresholding and mathematical morphology. We use the scalp mask in our skull segmentation procedure, as it allows us to automatically exclude background voxels with intensities similar to those of the skull. We find the inner and outer skull boundaries using thresholding and morphological operations. Finally, we mask the results with the scalp and brain volumes to ensure closed and nonintersecting skull boundaries. Visual evaluation indicated accurate segmentations of the cranium at a gross anatomical level (other than small holes in the zygomatic bone in eight subjects) in all 44 MRI volumes processed when run using default settings. In a quantitative comparison with coregistered CT images as a gold standard, MRI skull segmentation accuracy, as measured using the Dice coefficient, was found to be similar to that which would be obtained using CT imagery with a registration error of 2-3 mm.

Algorithms↗

Enhancing the outcome of free latissimus dorsi muscle flap reconstruction of scalp defects.

BACKGROUND: Reconstruction of scalp and calvarial defects after tumor ablation frequently requires prosthetic cranioplasty and cutaneous coverage. Furthermore, patients often have advanced disease and receive perioperative radiotherapy. We evaluated the complications of scalp reconstruction with a free latissimus dorsi muscle flap in this setting. METHODS: The complications and the oncologic and aesthetic outcomes of six consecutive scalp reconstructions with a free latissimus dorsi muscle flap and skin graft in five patients with advanced cancer were retrospectively evaluated. Patient, tumor, defect, reconstructive, and other treatment characteristics were reviewed. Reconstructive and perioperative techniques intended to improve flap survival and aesthetic outcome and reduce complications in these patients. RESULTS: All patients (52-76 years old) had recurrent tumors (sarcoma, melanoma, or squamous cell carcinoma) and received postoperative radiotherapy. The mean scalp defect size was 367 cm(2), and partial-thickness or full-thickness calvarial resection was required in all six cases. No vein grafts were needed. The mean follow-up period and disease-free survival time were 18 and 13 months, respectively. Three patients died of their disease, and two survived disease free. There were no flap failures or dehiscences. Complications consisted of donor site seroma in two patients; partial skin graft loss in one patient; and radiation burns to the flap, face, and ears in one patient. Scalp contour and aesthetic outcome were very good in all cases except for the one case with radiation burns. CONCLUSIONS: Good outcomes were achieved using a free latissimus dorsi muscle flap with a skin graft for flap reconstruction in elderly patients with advanced recurrent cancers who received perioperative radiotherapy. Several technical aspects of the reconstruction technique intended to enhance the functional and aesthetic outcome and/or reduce complications were believed to have contributed to the good results.

Aged↗

A 308-nm excimer laser for the treatment of scalp psoriasis.

BACKGROUND AND OBJECTIVES: Scalp psoriasis is a frustrating disorder whose treatments can all too often be cumbersome and ineffective. Our objective was to test a combination device involving the 308-nm excimer laser in tandem with a hair blower for treating scalp psoriasis. STUDY DESIGN/MATERIALS AND METHODS: Adult subjects with scalp psoriasis unresponsive to class I topical steroids used in conjunction with medicated shampoos were treated with 308-nm excimer laser pulses in conjunction with a hair blower that parted the obstructing hair twice a week for up to 15 weeks. Half of the scalp served as a control. Starting doses were based on standard minimal erythema dose (MED)'s with subsequent increments of up to 20%. RESULTS: Thirteen subjects completed the study without adverse events. Two were dropped due to lack of compliance. At the end of the investigation, the difference in the mean modified PASI scores between the control and treated sites was 4.0 (<0.0001). CONCLUSIONS: The air blower device in conjunction with the 308-nm excimer laser can safely and effectively treat otherwise refractory scalp psoriasis.

Adult↗

Scalp and cranial bone metastasis of endometrial carcinoma: a case report and literature review.

OBJECTIVE: The aim of this study is to report a rare case of scalp and cranial bone metastasis of endometrial carcinoma and review the literature. METHOD: We report a 45-year-old multiparous woman with FIGO Stage 1A Grade II endometrial adenocarcinoma who presented 3 years following total abdominal hysterectomy and bilateral salpingo-oophorectomy with scalp and cranial bone metastasis. Similar cases in the literature are reviewed. RESULTS: The patient metastatic workup revealed local, distant, scalp, and cranial bone metastasis. She died within 6 months. The poor prognosis is similar to that of six other cases reviewed. CONCLUSION: Scalp and cranial bone metastasis following endometrial carcinoma is extremely rare. It is a reflection of a widely disseminated disease and poor prognosis. However, single bone metastasis has a better postmetastatic survival with the help of local radiotherapy than scalp and multiple bone metastasis.

Adenocarcinoma↗

Scalp cooling in the prevention of alopecia in patients receiving depilating chemotherapy.

To assess any difference in the incidence of alopecia during treatment and of skull metastases during follow-up among breast cancer patients undergoing scalp cooling during chemotherapy and those treated at ambient temperatures. A series of 35 breast cancer patients receiving adjuvant chemotherapy were consecutively assigned either to a scalp cooling regimen (19 patients) or to an ambient temperature regimen (16 patients). Hypothermia was administered with electrically cooled caps (SCS II: Amit Technology, Jerusalem) for 1 h after treatment. A significant difference (P = 0.014) was detected in the incidence of alopoecia: 48% (9 patients) of those who had undergone cooling suffered alopoecia, while 81% (13 patients) of the group who had not undergone cooling lost scalp hair. Patient comfort levels were high. Follow-up (median time 14 months) has disclosed no scalp metastases. The implementation of routine scalp hypothermia as part of adjuvant chemotherapy treatment, especially in cancers without tendencies to bone metastases, should be seriously considered.

Alopecia↗

Isolations of dermatophyte from clinically normal scalps in M. canis infections using the hairbrush method.

The scalp hair of patients with dermatophytosis due to M. canis but without scalp lesions, and that of their family members without dermatophytosis were examined using the hairbrush method. The dermatophyte was detected in 93.8% of the scalps of those who lived in homes where cats were kept, and in 25% of those without cats. After the source of infection had been treated, the dermatophyte showed a gradually decreasing presence, finally disappearing altogether, so that no case of the disease on the scalp hair could be found. We inferred from the above findings in M. canis infections that, since the dermatophytes are seen in a high proportion of cases without scalp lesions, the dermatophytes, in many cases, exist only as saprophytes on the hair.

Adult↗

Scalp heat flux in postmature and in growth-retarded fetuses.

Postterm and growth-retarded fetuses share a common problem which can be characterized by a discrepancy between the supply of oxygen and nutrients to, and the demand of the fetus. But, this "insufficient" placental exchange function may also extend to and affect its thermal homeostasis; e.g. when the capacity of convective (placenta) pathways is shifted towards conductive (surface) pathways for heat loss. Therefore, fetal scalp heat flux measurements, where heat serves as an intrinsic tracer for metabolic activity and placental exchange function, promised a new kind of information. In 81 pregnant women during labor we measured fetal scalp heat flux by means of an heat flux transducer attached to the fetal head and after the cervix had dilated to 3 cm. In the healthy fetuses we found a positive linear relationship between scalp heat flux and different anthropometric variables such as body length (r = 0.432, n = 65, P less than 0.01), head circumference and gestational age. In comparison, postmature and growth-retarded fetuses showed higher heat flux values than appropriately grown fetuses of the same length head size and gestational age. Moreover, in those fetuses scalp heat flux decreased by approximately 4 watt/m2 during the second stage and differed in this regard from the control group who showed stable values during labor and delivery. We conclude that scalp heat flux measurements may indicate disturbances of placental exchange before acute hypoxia occurs.

Adult↗

Primary giant congential infantile fibrosarcoma of the scalp: case report and review of literature.

CASE REPORT: A primary giant infantile fibrosarcoma of the scalp in a 6-month-old boy is reported. He presented with a rapidly enlarging right paramedian parietal scalp swelling since birth. There were no signs of raised intracranial tension. Magnetic resonance (MR) imaging of the brain revealed a large vascular scalp tumor extending over the posterior frontal and parietal region bilaterally crossing the midline. There was no intracranial extension. Carotid angiography revealed an extremely vascular tumor supplied by the external carotid artery branches. The tumor was completely resected through a curvilinear scalp incision. Histology was consistent with diagnosis of an infantile fibrosarcoma. The patient had an uneventful course and received no postoperative adjuvant therapy. MR imaging of the brain at follow-up after 5 years showed no evidence of recurrence of tumor. At follow-up after 10 years, he is asymptomatic and leading an active life. DISCUSSION: The pathology and management of primary scalp fibrosarcoma is discussed, and the relevant literature is briefly reviewed.

Fibrosarcoma↗

Betamethasone valerate in foam vehicle is effective with both daily and twice a day dosing: a single-blind, open-label study in the treatment of scalp psoriasis.

BACKGROUND: Psoriasis is a chronic relapsing skin disorder that affects about 2% of the U.S. population and involves the scalp approximately 50% of the time. Topical corticosteroids, including betamethasone valerate, have been used effectively in the treatment of corticosteroid-responsive dermatoses of the skin and scalp. Betamethasone valerate (BMV) in foam vehicle (Luxiq) is designed to improve patient compliance with topical therapy. Superior efficacy over a BMV lotion preparation has been demonstrated with twice-daily use. Even greater compliance would be expected if the drug is effective with once-daily application. PURPOSE: To compare the efficacy of the betamethasone valerate foam (Luxiq) in the treatment of scalp psoriasis following once-daily versus twice-daily dosing. METHODS: Seventy-nine patients with moderate to severe scalp psoriasis from seven centers were enrolled and treated with BMV foam either once a day or twice a day for four weeks. The physician-grader was blinded to the treatment regimen, and the subjects were randomly assigned to either once-daily or twice-daily dosing in a 1:1 ratio. RESULTS: The signs of psoriasis (plaque thickness, scaling, and erythema) were assessed before and after treatment. The investigator's and the patients' global assessments were also evaluated. The composite score improved from 7.7 +/- 2.1 to 3.0 +/- 2.2 with twice-a-day use and from 8.1 +/- 2.2 to 3.9 +/- 2.8 with once-daily use (p > 0.05 for the difference between groups). DISCUSSION: BMV foam is effective for scalp psoriasis with both once-a-day and twice-a-day use. This feature of the BMV foam is encouraging for expected improvement in clinical use.

Administration, Topical↗

Polarity reversal of N20 and P23 somatosensory evoked potentials between scalp and depth recordings.

From depth and scalp electrodes, we recorded MN-SSEPs of a 33-year-old man with right parietal dysfunction and refractory right temporal seizures. A depth lead with 8 electrodes was implanted deep in each parietal-temporal region. Stimulation and recording parameters followed American EEG Society guidelines. Scalp recordings had well-defined P9, P13-14, N18, N20, and P23 potentials with normal conduction times bilaterally. Depth recordings showed potentials of greater number, voltage, and coherence. P13-14 and N18 were recorded at all depth sites with latencies similar to those at the scalp. N18 had markedly greater voltage and duration near the thalamus, with multiple fast components on its ascending phase. In the deep parietal region there was a positivity corresponding to the scalp N20 and a negative potential equal in latency to scalp P23. These findings support an origin of P13-14 caudal to the thalamus, multiple thalamic and possibly rostral brain-stem generators for N18, and generation of N20 and P23 in sensory cortex of subjacent white matter.

Adult↗

Scalp topography of somatosensory evoked potentials following electrical stimulation of femoral nerve.

Up to 29 channels of somatosensory evoked potentials (SEPs) were recorded in 10 normal volunteers following unilateral femoral nerve (FN) and tibial nerve (TN) electrical stimulation. Typical short latency FN SEPs consisted of 6 components, P15, N19, P26, N34, P44 and N56. P15 and N19 were widely distributed on the scalp. The first localized scalp component, P26, was strictly postrolandic and distributed on the contralateral parietal scalp close to midline with a prerolandic phase reversal, N26. This scalp distribution is clearly different from the first localized potential of tibial nerve SEPs. N34 and P44 were maximal at the vertex with a distribution that spread to the ipsilateral central and parietal scalp. The amplitude of P26 increased and latency shortened with increasing stimulus intensity and both values plateaued after the stimulus intensity reached motor threshold. No correlation was found between the peak latency of P26 and body height.

Adolescent↗

SEP testing in deeply comatose and brain dead patients: the role of nasopharyngeal, scalp and earlobe derivations in recording the P14 potential.

Median nerve somatosensory evoked potentials (SEPs) were tested in 50 patients (20 brain dead, 18 comatose and in 12 progressing from coma to brain death, i.e., 32 cases with brain death and 30 cases with coma were recorded). Derivations were taken from nasopharynx, earlobes, scalp, and neck using cephalic and non-cephalic references. Cortical and subcortical SEP components were evaluated, focussing on the P14 potential. There is evidence that rostral and caudal parts of the P14 generator (lemniscus medialis) are differently affected in brain death, resulting in an abolition of the rostral part, while occasionally leaving intact for some time the caudal part. Non-cephalic referenced scalp records pick up the whole P14 dipole, whereas nasopharyngeal and earlobe derivations pick up different parts of P14, depending on the reference used. Scalp-to-nasopharynx records derive the most rostral part of P14; this "rostral P14" was bilaterally lost in all brain dead patients, but preserved in all deeply comatose patients with diffuse brain-stem injuries. Scalp-to-earlobe records, in contrast, picked up a P14 dipole segment reaching more caudally, resulting in a P14 potential also in brain dead patients. It is concluded that midfrontal scalp-to-nasopharynx derivations give the most valuable contribution to the electrophysiological assessment of brain death versus deep coma.

Adolescent↗

The relationship between human long-latency somatosensory evoked potentials recorded from the cortical surface and from the scalp.

In scalp recordings, stimulation of the median nerve evokes a number of long-latency (40-300 msec) somatosensory evoked potentials (SEPs) whose neural origins are unknown. We attempted to infer the generators of these potentials by comparing them with SEPs recorded from the cortical surface or from within the brain. SEPs recorded from contralateral sensorimotor cortex can be characterized as "precentral," "postcentral," or "pericentral." The scalp-recorded P45, N60 and P100 potentials appear to correspond to the pericentral P50, N90 and P190 potentials and are probably generated mainly in contralateral area 1 of somatosensory cortex. The scalp-recorded N70-P70 appear to correspond to the precentral and postcentral N80-P80 and are generated mainly in contralateral area 3b of somatosensory cortex. The scalp-recorded N120-P120 appear to correspond to the intracranial N100-P100 and are probably generated bilaterally in the second somatosensory areas. N140 and P190 (the "vertex potentials") are probably generated bilaterally in the frontal lobes, including orbito-frontal, lateral and mesial (supplementary motor area) cortex. The supplementary sensory area probably generates long-latency SEPs, but preliminary recordings have yet to confirm this assumption. Most of the proposed correspondences are speculative because the different conditions under which scalp and intracranial recordings are obtained make comparison difficult. Human recordings using chronically implanted cortical surface electrodes, and monkey studies of SEPs which appear to be analogs of the human potentials, should provide better answers regarding the precise generators of human long-latency SEPs.

Adolescent↗

Scalp hair characteristics in the newborn infant.

Scalp hair growth and patterning are closely associated with the development of the central nervous system. A number of genetic, metabolic, and neurologic disorders are associated with recognizable scalp hair abnormalities. For this reason, a systematic step-by-step assessment of the hair and scalp should be an integral part of every initial newborn physical assessment. This article reviews the clinically relevant embryology related to fetal scalp hair formation. Normal cycles of hair growth and loss are discussed. A systematic review of typical newborn scalp hair characteristics such as color, quantity, texture, direction of growth, hairlines, and hair whorls is provided. Conditions associated with abnormal hair color, quality, quantity, and distribution are presented in a series of clinical photographs, and their salient features are discussed. Abnormal hair often occurs as a constellation of findings; implications for clinical care and further investigation will be briefly described.

Hair↗

Scalp position and efficacy of transcranial magnetic stimulation.

OBJECTIVE: To assess the impact of the scalp site on the biological effects of TMS. METHODS: We performed high-resolution, three-dimensional whole head magnetic resonance imaging (MRI) in a healthy subject, systematically measured the scalp-to-cortex distance across the head and calculated the resulting electric field in the superficial cortex. RESULTS: The variability in scalp-to-cortex distance led to differences in calculated cortical electric field strengths of a factor of two. A major portion of this variability was explained by a lateral to medial gradient with scalp-to-cortex distances being greatest close to the midline and smallest towards the temporal coordinates. CONCLUSIONS: Because of the medio-lateral gradient in scalp-to-cortex distance interventions tailored on the basis of effects of TMS in the motor system will systematically induce stronger than expected electric currents when performed laterally to the motor spot. SIGNIFICANCE: The biological effects of TMS outside the motor spot may be markedly different from those observed in the motor system and this should be taken into account to optimize TMS for the evaluation or treatment of neuropsychiatric disorders.

Adult↗

Angiosarcoma of the scalp treated with curative radiotherapy plus recombinant interleukin-2 immunotherapy.

PURPOSE: To evaluate the effectiveness of curative radiotherapy (RT) plus recombinant interleukin-2 (rIL-2) immunotherapy regarding the treatment results for angiosarcoma of the scalp. Curative resection of angiosarcoma of the scalp is usually difficult because of the diffuse, clinically undetectable local spread. RT is a rational therapeutic approach, because a wide region of the dermis can be treated, while sparing the underlying normal tissues. Recently, the effectiveness of immunotherapy with rIL-2 has also been reported in the treatment of angiosarcoma of the scalp. METHODS AND MATERIALS: The data of 20 patients with angiosarcoma of the scalp treated with curative RT plus rIL-2 immunotherapy between January 1988 and June 2002 were retrospectively analyzed. The total radiation dose was 70.3 +/- 6.9 Gy. The fractions were 2-3 Gy daily, given 5 d/wk. rIL-2 immunotherapy was performed by transcatheter arterial administration in 10 patients, systemic administration in 11 during the course of RT, and intratumoral injection in 10 during and/or after RT; 12 patients received a combination of two. Five patients underwent limited surgery, and concomitant pacilitaxel chemotherapy was also used in 2 patients. RESULTS: The median survival time for overall, local recurrence-free, and distant metastasis-free survival was 36.2, 11.1, and 17.8 months, respectively. Local recurrence developed in 7 patients (35%), 4 of whom also had evidence of distant metastases. An additional 7 patients (35%) developed distant metastases alone. Recurrence within the radiation field was recognized in 2 patients with systemic rIL-2 administration alone (p < 0.05). Arterial or intratumoral administration combined with systemic administration of rIL-2 resulted in better distant metaststasis-free survival rates (p < 0.05). CONCLUSION: Curative RT plus rIL-2 immunotherapy provided an efficient, effective means of treating angiosarcoma of the scalp. Arterial or intratumoral administration combined with systemic administration of rIL-2 may prolong survival. Additional studies with detailed treatment protocols are recommended.

Aged↗

Expression of the heat shock protein-27 in the adult human scalp skin and hair follicle: hair cycle-dependent changes.

BACKGROUND: Heat shock protein (HSP) is a molecular chaperone involved in protein folding, assembly, and transport and in the regulation of cell growth and differentiation. HSP27 protein is expressed in murine hair follicle (HF) and in human skin during fetal development. In this investigation we hypothesized that HSP27 protein is expressed in the human scalp skin and its expression in HF changes with the transitions form anagen --> catagen --> telogen stages. METHODS: To test this hypothesis, the immunoreactivity of HSP27 protein was examined in human scalp skin by immunofluorescent method. A total of 50 normal human scalp skin biopsy specimens were examined (healthy women, age 53-57 years). In each case, 50 HF were analyzed (35, 10, and 5 follicles in anagen, catagen, and telogen, respectively). RESULTS: HSP27 protein expression was prominent in human scalp anagen, and weak in both catagen and telogen HFs. Within HF, HSP27 protein immunoreactivity was prominent in the outer root sheath, inner root sheath, precorteocytes, and corteocytes of the hair shaft. In addition, HSP27 protein expression was prominent in the epidermis, sebaceous glands, sweat glands, and arrector pili muscles. LIMITATIONS: Only some types of heat shock proteins are known to date. Also, our knowledge about the exact molecular mechanisms involved in the interactions among these protein and other molecular chaperones is still incomplete. CONCLUSIONS: Our investigation reports, for the first time, the expression patterns of HSP27 in human scalp skin and HF. The differential expression of HSP27 during HF cycling suggests its possible roles in human HF biology.

Adult↗

Arteriovenous malformation of the scalp: case report and review of the literature.

BACKGROUND: Arteriovenous malformations (AVMs) of the scalp are relatively rare, and their precise natural course remains to be elucidated. We encountered a patient with a scalp AVM that progressively enlarged over the course of 3 years by capturing feeders from intracranial arteries. To our knowledge, ours is the first serial angiographic depiction of the growth of a scalp AVM and the development of a de novo aneurysm in the superior temporal artery (STA) that performed as a feeder. CASE DESCRIPTION: This 21-year-old female consulted us in 1998 complaining of right tinnitus and a pulsating mass in the retroauricular region. The initial angiogram revealed an AVM in the right temporo-parietal subcutaneous space with feeders from the STA, an occipital artery, a posterior auricular artery, and a middle meningeal artery (MMA). Three years later, she complained of enlargement of the lesion, increased tinnitus, and alopecia. Repeat angiographic study revealed the presence of a nidus and the appearance of new feeders from a contralateral MMA and an ipsilateral middle cerebral artery; there was a de novo saccular aneurysm in the right STA. On the day preceding surgery, the left MMA was embolized to control intraoperative bleeding. The AVM was removed totally without any dermal complications. CONCLUSION: This case suggests that scalp AVMs can become enlarged by capturing subcutaneous or intracranial feeders, and that the consequent hemodynamic stress may induce de novo aneurysms in scalp AVMs. Capillary endothelial cells were strongly immunostained for vascular endothelial growth factor.

Adult↗