Wall enhancement as a biomarker of intracranial aneurysm instability: a histo-radiological study.

BACKGROUND: The aim of this is to explore the histological basis of vessel wall enhancement (WE) on magnetic resonance imaging (MRI), which is a strong radiological biomarker of aneurysmal prone to rupture compared to other classical risk predictors (e.g., PHASES score, size, morphology). METHODS: A prospective observational study was performed including all consecutive patients presenting with a saccular intracranial aneurysm at Vall d'Hebron University Hospital between October 2017 and May 2019. The patients underwent high-resolution 3 T MRI, and their aneurysms were classified into asymptomatic, symptomatic, and ruptured. A histological and immunohistochemical study was performed in a subgroup of patients (n = 20, of which 15 presented with WE). Multiple regression analyses were performed to identify predictors of rupture and aneurysm symptoms. RESULTS: A total of 132 patients were enrolled in the study. WE was present in 36.5% of aneurysms: 22.9% asymptomatic, 76.9% symptomatic, and 100% ruptured. Immunohistochemical markers associated with WE were CD3 T cell receptor (p = 0.05) and CD45 leukocyte common antigen (p = 0.05). Moreover, WE is an independent predictor of symptomatic and ruptured aneurysms (p < 0.001). CONCLUSIONS: Aneurysms with WE present multiple histopathological changes that may contribute to wall disruption and represent the pathophysiological basis of radiological WE. Moreover, WE is an independent diagnostic predictor of aneurysm symptoms and rupture.

Relationship between visuoperceptual functions and parietal structural abnormalities in temporal lobe epilepsy.

Progressive gray matter volume reductions beyond the epileptogenic area has been described in temporal lobe epilepsy. There is less evidence regarding correlations between gray and white matter volume changepres and multi-domain cognitive performance in this setting. We aimed to investigate correlations between volume changes in parietal structures and visuospatial performance in temporal lobe epilepsy patients. we performed a cross-sectional study comparing global and regional brain volume data from 34 temporal lobe epilepsy patients and 30 healthy controls. 3D T1-weighted sequences were obtained on a 3.0 T magnet, and data were analyzed using age and sex-adjusted linear regression models. Global and regional brain volumes and cortical thickness in patients were correlated with standardized visual memory, visuoperceptual, visuospatial, and visuoconstructive parameters obtained in a per-protocol neuropsychological assessment. temporal lobe epilepsy patients had smaller volume fractions of the deep gray matter structures, putamen and nucleus accumbens, and larger cerebrospinal fluid volume fraction than controls. Correlations were found between: 1) visual memory and precuneus and inferior parietal cortical thickness; 2) visuoperceptual performance and precuneus and supramarginal white matter volumes; 3) visuospatial skills and precuneus, postcentral, and inferior and superior parietal white matter volumes; 4) visuoconstructive performance and inferior parietal white matter volume. Brain volume loss is widespread in temporal lobe epilepsy. Volumetric reductions in parietal lobe structures were associated with visuoperceptual cognitive performance.

Risk Factors, Radiological and Clinical Outcomes in Subclinical and Clinical Pituitary Apoplexy.

BACKGROUND: Pituitary apoplexy (PA) can be symptomatic, namely acute apoplexy (APA), or asymptomatic or subclinical (SPA). OBJECTIVE: To describe the clinical characteristics and evolution of the patients with APA compared to SPA Patients and methods: Retrospective, longitudinal database analysis. RESULTS: We identified 58 patients with PA, and 37 accomplished the inclusion criteria (17 men, median age 47.7 years). A total of 29 (78.4%) had APA (17 underwent surgery, and 12 were conservatively managed), and 8 (21.6%) had SPA. The presence of non-functioning pituitary adenoma (NFPA) odds ratio (OR): 29.36 (95% confidence interval (CI): 1.86-462.36) and the largest size OR 1.10 (95% CI: 1.01-1.2) elevated the risk of having surgery. Hypopituitarism developed in 35.1% without significant differences between APA and SPA. In non-surgical patients, adenoma volume shrunk spontaneously at one year magnetic resonance imaging (MRI), without statistical differences between the conservatively treated and SPA group. CONCLUSIONS: APA is more frequent in larger NFPAs, and this subset of patients has a higher risk of surgery. Hypopituitarism is quite frequent even in patients with SPA, and, therefore, long-term follow-up is mandatory. In the non-surgical group, the pituitary tumour shrinkage is clinically relevant after one year of PA. Consequently, surgery indication in NFPA should be delayed and reassessed if patients remain asymptomatic.

Magnetic resonance imaging findings in focal-onset status epilepticus.

BACKGROUND AND PURPOSE: Magnetic resonance imaging (MRI) is commonly used in the diagnostic work-up for status epilepticus (SE). The purpose of this study was to characterize MRI features in SE patients and determine their association with clinical and electroencephalography (EEG) findings. The mid-term consequences of baseline MRI features were also analysed. METHODS: This is a prospective study including consecutive patients with SE who underwent brain MRI within 240 h after SE onset. The MRI protocol included T1-weighted (T1WI), T2-weighted (T2W), fluid-attenuated inversion recovery (FLAIR) and diffusion-weighted imaging (DWI) sequences. Follow-up MRI was performed after SE resolution in some patients. RESULTS: Sixty patients (56.7% men, mean age 58.3 years) were included. SE-related MRI abnormalities were seen in 31 (51.7%), manifesting as hyperintensities on T2W/FLAIR imaging (58.1%) and DWI (74.2%) sequences. Hippocampal and pulvinar involvement was seen in 58.0% and 25.8% of patients, respectively. MRI abnormalities were associated with a longer SE duration (p = 0.013) and the presence of lateralized periodic discharges (LPDs) on EEG (p < 0.001). Amongst the 33 follow-up MRIs, nine (27.3%) showed mesial temporal sclerosis (MTS), which was associated with severe clinical status (p = 0.031), hippocampal oedema (p = 0.001) and LPDs (p = 0.001) at baseline. A poorer clinical outcome was associated with baseline T2W/FLAIR imaging hyperintensities (p = 0.003). CONCLUSION: MRI showed abnormalities in more than half of SE patients. A longer SE duration and LPDs on EEG were associated with SE-related MRI abnormalities and the development of MTS.

Shrinkage by the third month predicts long-term response of macroprolactinoma after cabergoline.

OBJECTIVE: Transsphenoidal surgery (TSS) is mainly indicated in prolactinomas when dopamine agonist treatment fails. However, there is no established early predictor of cabergoline (CBG) response. The present study was aimed to identify predictors of CBG resistance in order to select patients who may benefit from early TSS. DESIGN: Retrospective longitudinal study. METHODS: We reviewed the medical record of patients diagnosed with prolactinoma after 2010. Inclusion criteria: macroprolactinomas under CBG treatment with serial prolactin levels and MRI before treatment and 3 and 12 months afterwards. The main outcome was tumour size shrinkage ≥ 50% (using the two largest diameters in sagittal view) after 12 months of CBG (TS_50). The capacity of the most important clinical and biochemical variables in predicting the main outcome was examined. RESULTS: A total of 185 prolactinomas where included: 124 (67.0%) were microadenomas and 61 (33.0%) were macroadenomas of which 27 patients meet de inclusion criteria; median age (42.5 years; (IQR: 28.0)). The median follow-up was (67.5 months; (IQR: 30.2)). Ten patients (37.0%) underwent surgery after more than 1 year of CBG. The volume reduction at the first MRI (3-4 months) was the unique valuable predictor: (OR: 1.16 (95% CI: 1.02-1.32)) of TS_50. A tumour volume shrinkage of ≥ 30% in the first 3-4 months of CBG therapy predicts TS_50 with an AUC (0.95 (CI: 0.76-0.99)). CONCLUSION: Tumour shrinkage in the first 3-4 months after starting treatment with CBG is a good tool for predicting the long-term response and can help clinicians to take more appropriated and personalized decisions.

Peri-ictal magnetic resonance imaging in status epilepticus: Temporal relationship and prognostic value in 60 patients.

PURPOSE: Magnetic resonance imaging (MRI) changes associated with status epilepticus (SE) have been described in recent studies. Our aim was to evaluate the diagnosis and prognosis of the peri-ictal MRI changes detected in SE patients. METHOD: All adults diagnosed with SE and examined by MRI within 240 h after SE onset were enrolled (2011-2017). Demographic, clinical and electroencephalography data, and functional status at admission and discharge were collected. MRI findings were recorded and relationships between clinical and MRI data, and between these data and functional outcome were analyzed. RESULTS: Sixty patients included, 50% women, mean age 57.5 years. Median duration of SE was 51.46 h and median time from SE onset to MRI was 86.5 h. Of the total, 41.7% had a restricted diffusion pattern on diffusion-weighted imaging (DWI) and 63.3% had hyperintensities suggestive of edema on T2-weighted (T2WI)/FLAIR sequences. The factors independently associated with T2WI hyperintensities were the presence of acute cerebral lesions (p = 0.023), baseline STESS (p = 0.007), and MRI performed within 84 h (p = 0.007). Variables independently associated with diffusion restriction were a potentially fatal cause (p = 0.020), SE duration >24 h (p = 0.022), and MRI performed within the first 84 h (p = 0.045). In patients undergoing MRI within 84 h, the DWI and T2WI abnormalities were both highly associated with an unfavorable outcome. CONCLUSIONS: Characteristic signal changes on DWI and T2WI sequences were seen in approximately half our SE patients undergoing early (<84 h) brain MRI studies, and were independently related to the patients' functional status at discharge.

Epileptic features and survival in glioblastomas presenting with seizures.

INTRODUCTION: The prognostic value of seizures in patients with glioblastoma is currently under discussion. The objective of this research was to study the risk factors associated with seizures occurring at the diagnosis of glioblastoma and the role of seizures as a predictive factor for survival. MATERIAL AND METHODS: We prospectively analyzed the clinical data over the course of the disease, baseline MR imaging, and histological characteristics (p53 overexpression, the Ki67 proliferation index, and presence of the IDH1 R132H mutation), in glioblastomas treated in a single hospital from November 2012 to July 2014. The study follow-up cutoff point was October 2015. RESULTS: In total, 56 patients were recruited (57% men, mean age 57 years). Median baseline score on the Karnofsky performance scale was 80. Complete tumor debulking followed by radiochemotherapy was achieved in 58.9%. Mean survival was 13.6 months. Epileptic seizures were the presenting symptom in 26.6% of patients, and 44.6% experienced seizures at some point during the course of the disease. On multivariate analysis, the single factor predicting shorter survival was age older than 60 years (hazard ratio 3.565 (95%CI, 1.491-8.522), p=0.004). Seizures were associated with longer survival only in patients younger than 60 years (p=0.035). Younger age, the IDH1 R132H mutation, and p53 overexpression (>40%) were related to seizures at presentation. Baseline MRI findings, including tumor size, and the Ki67 proliferation index were not associated with the risk of epileptic seizures or with survival. Prophylactic antiepileptic drugs did not increase survival time. CONCLUSIONS: Seizures as the presenting symptom of glioblastoma predicted longer survival in adults younger than 60 years. The IDH1 R132H mutation and p53 overexpression (>40%) were associated with seizures at presentation. Seizures showed no relationship with the tumor size or proliferation parameters.

Prognostic implications of epilepsy in glioblastomas.

OBJECTIVES: The role of seizures and antiepileptic treatments associated with glioblastoma is a current topic of discussion. The objective of this study is to characterize and establish implications of epilepsy associated with glioblastoma. PATIENTS AND METHODS: We retrospectively analyzed the medical history, focused on epileptic features of 134 histologically diagnosed glioblastoma over a period of 4 years. RESULTS: The sample group had an average age of 56 years and 66% were male. Complete tumor resection was performed in 66% and 64.2% received further radio-oncologic treatment. The average survival rate was 12.4 months and 11.5% survived to 5 years. Epileptic seizures were the presentation symptom in 27% of cases and 51% suffered seizures during the disease, 26% become drug-resistant. Focal evolving to a bilateral convulsive seizures were the most frequent type. Epileptic seizures at presentation independently predicted longer survival (p<0.001). Furthermore, a history of epilepsy or seizures during disease improved survival. Late onset seizures, recurrences or status epilepticus during the course of the disease indicated tumor progression or the final stages of life. Prophylactic antiepileptic drugs did not prevent seizures. Similarly, there was no difference in survival between patients who did not use antiepileptic drugs and those using valproate or levetiracetam. Patients under 60 years, full oncologic treatment and secondary glioblastomas were factors that improved survival (p<0.001). CONCLUSION: Previous history of epilepsy or the onset of seizures as a presentation symptom in glioblastomas predict longer survival. Half of patients have seizures during the course of the disease. Antiepileptic drugs alone do not increase survival in glioblastoma patients.

3 TESLA MR imaging in adults with focal onset epilepsy.

OBJECTIVE: The finding of cerebral epileptogenic lesions in magnetic resonance (MR) has demonstrated to be a relevant prognostic factor for potential surgical candidates. In a series of consecutive adults with focal onset epilepsy, we investigated the yield of 3T MR imaging for detecting epileptogenic cerebral lesions. MATERIALS AND METHODS: We prospectively recruited 161 adult patients with a diagnosis of focal epilepsy, all of whom underwent standardized MR imaging study performed with a 3T magnet. RESULTS: Lesion-related epilepsy was observed in 48% of patients, and 12% of cryptogenic patients showed subtle or non-specific lesions related to the epileptogenic source. The most common findings were focal cortical dysplasia and vascular lesions, followed by mesial temporal sclerosis, tumors, and scars from previous cerebral injuries. Patients older than 72 years were more likely to have vascular epilepsy. CONCLUSIONS: Diagnostic assessment using a standardized 3T MR imaging protocol for focal-onset epilepsy detects lesions in nearly half the patients. Our results indicate that elders with focal epilepsy should be searched for vascular lesions.

Imaging findings of Pott's disease.

Tuberculosis (TB) continues to be an important public health problem in developed countries especially in deprived socioeconomic groups, older people, immunocompromised patients, drug-therapy resistant cases and the immigrant population. The spine is the most frequent location of musculoskeletal TB. The wide range of clinical presentations results in difficulties and delays in diagnosis. Advanced disease mimics other infections and malignancy. The diagnosis of spinal infections relies on three main factors: clinical symptoms, imaging and bacteriological culture. Advanced imaging such as Magnetic Resonance Imaging (MRI), Multidetector Computed Tomography (MDCT) and Fluor18-Deoxiglucose Positron Emission Tomography combined with CT (F-18 FDG PET-CT) demonstrate lesion extent, serve as guide for biopsy with aspiration for culture, assist surgery planning and contribute to follow-up. Diagnosis of TB cannot be established solely on the basis of clinical tests or imaging findings and biopsy may be required. Differential diagnosis between tuberculous and pyogenic spondylitis is of clinical importance, but may be difficult on the basis of radiological findings alone. Findings not pathognomonic but favoring tuberculous etiology include: slow progression of lesions with late preservation of disk space, involvement of several contiguous segments, large intraosseous and paraspinal abscesses containing calcifications, and body collapse with kyphotic deformity. In this essay the highlights of TB imaging are reviewed through published literature. In addition, we review retrospectively the radiological findings of 48 patients with tuberculous spondylitis treated from 1993 to 2010. There were 23 male and 25 female patients with a mean age of 53 years.