Influence of arterial transit time delays on the differentiation between tumor progression and pseudoprogression in glioblastoma by arterial spin labeling magnetic resonance imaging.

Arterial spin labeling (ASL) and dynamic susceptibility contrast (DSC) magnetic resonance imaging (MRI) have shown potential for differentiating tumor progression from pseudoprogression. For pseudocontinuous ASL with a single postlabeling delay, the presence of delayed arterial transit times (ATTs) could affect the evaluation of ASL-MRI perfusion data. In this study, the influence of ATT artifacts on the perfusion assessment and differentiation between tumor progression and pseudoprogression were studied. This study comprised 66 adult patients (mean age 60 ± 13 years; 40 males) with a histologically confirmed glioblastoma who received postoperative radio (chemo)therapy. ASL-MRI and DSC-MRI scans were acquired at 3 months postradiotherapy as part of the standard clinical routine. These scans were visually scored regarding (i) the severity of ATT artifacts (%) on the ASL-MRI scans only, scored by two neuroradiologists; (ii) perfusion of the enhancing tumor lesion; and (iii) radiological evaluation of tumor progression versus pseudoprogression by one neuroradiologist. The final outcome was based on combined clinical and radiological follow-up until 9 months postradiotherapy. ATT artifacts were identified in all patients based on the mean scores of two raters. A significant difference between the radiological evaluation of ASL-MRI and DSC-MRI was observed only for ASL images with moderate ATT severity (30%-65%). The perfusion assessment showed ASL-MRI tending more towards hyperperfusion than DSC-MRI in the case of moderate ATT artifacts. In addition, there was a significant difference between the prediction of tumor progression with ASL-MRI and the final outcome in the case of severe ATT artifacts (McNemar test, p = 0.041). Despite using ASL imaging parameters close to the recommended settings, ATT artifacts frequently occur in patients with treated brain tumors. Those artifacts could hinder the radiological evaluation of ASL-MRI data and the detection of true disease progression, potentially affecting treatment decisions for patients with glioblastoma.

MRI phenotypes of glioblastomas early after treatment are suggestive of overall patient survival.

Background: Distinguishing true tumor progression (TP) from treatment-induced abnormalities (eg, pseudo-progression (PP) after radiotherapy) on conventional MRI scans remains challenging in patients with a glioblastoma. We aimed to establish brain MRI phenotypes of glioblastomas early after treatment by combined analysis of structural and perfusion tumor characteristics and assessed the relation with recurrence rate and overall survival time. Methods: Structural and perfusion MR images of 67 patients at 3 months post-radiotherapy were visually scored by a neuroradiologist. In total 23 parameters were predefined and used for hierarchical clustering analysis. Progression status was assessed based on the clinical course of each patient 9 months after radiotherapy (or latest available). Multivariable Cox regression models were used to determine the association between the phenotypes, recurrence rate, and overall survival. Results: We established 4 subgroups with significantly different tumor MRI characteristics, representing distinct MRI phenotypes of glioblastomas: TP and PP rates did not differ significantly between subgroups. Regression analysis showed that patients in subgroup 1 (characterized by having mostly small and ellipsoid nodular enhancing lesions with some hyper-perfusion) had a significant association with increased mortality at 9 months (HR: 2.6 (CI: 1.1-6.3); P = .03) with a median survival time of 13 months (compared to 22 months of subgroup 2). Conclusions: Our study suggests that distinct MRI phenotypes of glioblastomas at 3 months post-radiotherapy can be indicative of overall survival, but does not aid in differentiating TP from PP. The early prognostic information our method provides might in the future be informative for prognostication of glioblastoma patients.

[A man with hanging eyelids]. / Een man met hangende oogleden.

A 73-year-old man came to the outpatient clinic because of diplopia and hanging eyelids. Neurological examination revealed fatigueable bilateral ptosis. The patient had a strong positive ice pack-test. Myasthenia gravis preached on top of the differential diagnosis. Subsequent blood tests showed antibodies against ACh-receptors and confirmed the diagnosis.