Distinctive electro-clinical, neuroimaging and histopathological features of temporal encephaloceles associated to epilepsy.

OBJECTIVE: Encephaloceles (ENCs) may cause clinical complications, including drug-resistant epilepsy that can be cured with epilepsy surgery. METHODS: We describe clinical, diagnostic, and neuropathological findings of 12 patients with temporal ENC and epilepsy evaluated for surgery and compare them with a control group of 26 temporal lobe epilepsy (TLE) patients. RESULTS: Six patients had unilateral and 6 bilateral temporal ENCs. Compared to TLEs, ENCs showed i) later epilepsy onset, ii) higher prevalence of psychiatric comorbidities, iii) no history of febrile convulsions, and iv) ictal semiology differences. Seven patients had MRI signs of gliosis, and 9 of intracranial hypertension. Interictal EEG analysis in ENCs demonstrated significant differences with controls: prominent activity in the beta/gamma frequency bands in frontal regions, interictal short sequences of low-voltage fast activity, and less frequent and more localized interictal epileptiform discharges. Ictal EEG patterns analyzed in 9 ENCs showed delayed and slower contralateral spread compared to TLEs. All ENCs that underwent surgery (7 lobectomies and 1 lesionectomy) are in Engel class I. Neuropathological examination revealed 4 patterns: herniated brain fragments, focal layer I distortion, white matter septa extending into the cortex, and altered gyral profile. CONCLUSIONS AND SIGNIFICANCE: The described peculiarities might help clinicians to suspect the presence of largely underdiagnosed ENCs.

A Critical Appraisal of the Quality of Vertigo Practice Guidelines Using the AGREE II Tool: A EuroAIM Initiative.

OBJECTIVES: The aim of this review is to assess the methodological quality of guidelines for the management of vertigo and dizziness and to compare their recommendations, with specific focus on neuroimaging. DATABASES REVIEWED: MEDLINE, EMBASE, National Guideline Clearinghouse, and National Institute for Health and Clinical Excellence database. METHODS: In March 2022, a systematic search was performed to find practice guidelines of management of vertigo and dizziness. The evaluation of guidelines quality was performed independently by four authors using the AGREE II tool. We excluded from the results those guidelines that were not primarily focused on vertigo and dizziness, such as national/international guidelines in which vertigo and dizziness were only briefly mentioned. RESULTS: Our strategy of literature search identified 161 studies, and 18 guidelines were selected for the appraisal. Only five guidelines reached the acceptance level in the overall result (at least 60%), with three of them reaching the highest scores (at least 80%). The highest scores were found in Domain 6 "Editorial Independence," Domain 1 "Scope and purpose," and Domain 4 "Clarity of presentation" (median value = 66%, 62%, and 61%, respectively). The remaining domains showed a low level of quality: Domain 2 "Stakeholder Involvement," Domain 3 "Rigor of development," and Domain 5 "Applicability" had median values of 27%, 27%, and 22%, respectively. The quality of these guidelines was very low, because of low involvement of multidisciplinary teams in writing guidelines recommendations. CONCLUSION: Considering all guidelines, only three had a "high" overall score, whereas 13 of 18 (72%) of them were rated as of "low" quality. Future guidelines might take this into account to improve clinical applicability.

Neurophysiology-Guided Laser Interstitial Thermal Therapy: A Synergistic Approach For Motor Function Preservation. Technical Note.

BACKGROUND: Laser interstitial thermal therapy (LITT) is a minimally invasive ablative technique with specific indications for neuro-oncology, especially in the case of lesions in eloquent areas. Even being performed through a small catheter under stereotactic conditions, the risk of damaging vital structures such as white matter tracts or cortical eloquent areas is not negligible. The mechanism of damage can be related to catheter insertion or to excessive laser ablation. An accurate preoperative workup, aimed at locating the eloquent structures, can be combined with a real-time intraoperative neurophysiologic monitoring to reduce surgical morbidity while maximizing the efficacy of LITT. METHODS: We developed a synergistic approach for neurophysiology-guided LITT based on state-of-the-art technologies, namely, magnetoencephalography, diffusion tensor imaging, and intraoperative neurophysiologic monitoring. RESULTS: As a result, we improved the planning phase thanks to a more precise representation of functional structures that allows the simulation of different trajectories and the identification of the most suitable trajectory to treat the lesion while respecting the functional boundaries. Catheter insertion is conducted under continuous neurophysiologic feedback and the ablation phase is modeled on the functional boundaries identified by stimulation, allowing it to be extremely accurate. CONCLUSIONS: An integrated approached guided by neurophysiology is able to reduce the surgical morbidity even in a relatively accurate technique such as LITT. To the best of our knowledge, this represents the first report on this synergistic approach which could really impact the treatment of tumors in eloquent areas. Future studies are needed in the effort to implement this approach in functional or epilepsy neurosurgery as well.

Interhemispheric Pediatric Meningioma, YAP1 Fusion-Positive.

Meningiomas are uncommon in children and usually arise in the context of tumor-predisposing syndromes. Recently, YAP1-fusions have been identified for the first time as potential NF2-independent oncogenic drivers in the development of meningiomas in pediatric patients. We report a case of a YAP1-fusion-positive atypical meningioma in a young child and compare it with the previous ones reported. Extending the clinico-pathological features of YAP1-fused meningiomas, we suggest additional clues for diagnosis and emphasize the urgent need for an integrated multilayered diagnostic approach, combining data from histological and molecular analyses, neuroradiology, and clinical findings.

MRI in Late-Onset Rasmussen Encephalitis: A Long-Term Follow-Up Study.

Late-onset Rasmussen encephalitis (LoRE) is a rare unihemispheric progressive inflammatory disorder causing neurological deficits and epilepsy. The long-term radiological evolution has never been fully described. We retrospectively analyzed the MR images of 13 LoRE patients from a total of 136 studies, and searched for focal areas of volume loss or signal intensity abnormality in grey matter or white matter. Each subject had a median of nine MRI studies (IQR 7-13). Frontal and temporal lobes were the most affected regions (13/13 and 8/13, respectively) and showed the greatest worsening over time in terms of atrophic changes (9/13 and 5/8, respectively). A milder cortical atrophy was found in the insular and parietal lobes. The caudate nucleus was affected in seven patients. Hyperintensities of grey matter and white matter on T2-WI and FLAIR images were observed in all patients, and transiently in eight patients. In two cases out of the latter patients, these transient alterations evolved into atrophy of the same region. Disease duration was significantly associated with signal abnormalities in the grey matter at last follow-up. LoRE MRI alterations are milder, and their progression is markedly slower compared to radiological findings described in the childhood form.

MRI physics and technical issues: Where do Italian radiographers search for information?

INTRODUCTION: Our aim was to investigate the means radiographers and radiographers in training (RTrs) use to seek information on magnetic resonance imaging (MRI) physics and technical issues. METHODS: An estimated 3000 radiographers and RTrs were reached by e-mail. We proposed an online survey with eight English-language multiple choice questions investigating how often radiographers have doubts about MRI physics or technical issues, where and what kind of information they search for, and on which websites. The statistical χ2 test was used. RESULTS: We obtained 300 answers from European professionals (228 radiographers, 72 RTrs) from 9 European countries, with 288 of 300 (96%) responses coming from Italy. Within the Italian respondents, 41% of RTrs have doubts about MRI physics versus 56% of radiographers (p = 0.028). Basic MRI sequences details are more searched by RTrs (36%) than radiographers (22%) (p = 0.088), as well as clinical protocols (64% versus 44%, p = 0.054). Radiographers and RTrs mostly search on the Internet (74% versus 81%, p = 0.404); "older colleagues" are more frequently asked for information by RTrs (27% versus 61%, p = 0.001), they consult the "MRI manufacturer" less frequently (11% versus 34%, p = 0.001); and 66% of radiographers and 72% of RTrs search "in mother-language and English" (p = 0.590). For clinical protocols RTrs prefer the website mriquestions.com (17% versus 44%, p = 0.001). Websites most used were: mriquestions.com (41%), radiopaedia.org (31%), and mrimaster.com (13%). In addition, 30 respondents mentioned using the Italian site fermononrespiri.com. CONCLUSION: Italian radiographers and RTrs frequently search for information about MRI physics and technical issues, with slight differences between groups regarding sources and clinical protocols. Protocol setting, and MRI physics and sequences seem to be the main limitations of RTr knowledge. To remedy this gap, more time on training/university lectures and a rethinking of the practical training activities is required.

Lean body weight versus total body weight to calculate the iodinated contrast media volume in abdominal CT: a randomised controlled trial.

OBJECTIVES: Iodinated contrast media (ICM) could be more appropriately dosed on patient lean body weight (LBW) than on total body weight (TBW). METHODS: After Ethics Committee approval, trial registration NCT03384979, patients aged ≥ 18 years scheduled for multiphasic abdominal CT were randomised for ICM dose to LBW group (0.63 gI/kg of LBW) or TBW group (0.44 gI/kg of TBW). Abdominal 64-row CT was performed using 120 kVp, 100-200 mAs, rotation time 0.5 s, pitch 1, Iopamidol (370 mgI/mL), and flow rate 3 mL/s. Levene, Mann-Whitney U, and χ2 tests were used. The primary endpoint was liver contrast enhancement (LCE). RESULTS: Of 335 enrolled patients, 17 were screening failures; 44 dropped out after randomisation; 274 patients were analysed (133 LBW group, 141 TBW group). The median age of LBW group (66 years) was slightly lower than that of TBW group (70 years). Although the median ICM-injected volume was comparable between groups, its variability was larger in the former (interquartile range 27 mL versus 21 mL, p = 0.01). The same was for unenhanced liver density (IQR 10 versus 7 HU) (p = 0.02). Median LCE was 40 (35-46) HU in the LBW group and 40 (35-44) HU in the TBW group, without significant difference for median (p = 0.41) and variability (p = 0.23). Suboptimal LCE (< 40 HU) was found in 64/133 (48%) patients in the LBW group and 69/141 (49%) in the TBW group, but no examination needed repeating. CONCLUSIONS: The calculation of the ICM volume to be administered for abdominal CT based on the LBW does not imply a more consistent LCE.

Glue embolization of a pial arteriovenous fistula of the spinal artery.

There are no clear guidelines about the treatment Pial Arteriovenous Fistulae (PAVF). For high-risk and severally symptomatic fistulae surgery is the first choice of treatment, including feeding artery ligation, surgical resection, radiosurgery and endovascular embolization techniques. We described a case of a patient with a symptomatic PAVF at the craniocervical junction fed by the anterior spinal artery, successfully treated with endovascular approach consisting of glue embolization of the feeding vessel.

Correlation of Preoperative Von Willebrand Factor with Magnetic Resonance Imaging Perfusion and Permeability Parameters as Predictors of Prognosis in Glioblastoma.

BACKGROUND: Angiogenesis has been shown to be strictly related to tumor malignancy. Glioblastoma (GBM) is highly vascularized and von Willebrand Factor (VWF) plays a potent proangiogenic role. Dynamic contrast-enhanced and dynamic susceptibility contrast magnetic resonance imaging (MRI) represent a widely accepted method to assess GBM microvasculature. Our aim was to investigate the correlation between plasma VWF:Ag, permeability, and perfusion MRI parameters and examine their potential in predicting GBM patient prognosis. METHODS: We retrospectively analyzed preoperative dynamic contrast-enhanced, dynamic susceptibility contrast MRI, and VWF:Ag level of 26 patients with GBM. We assessed the maximum values of relative cerebral blood flow and volume, volume transfer constant Ktrans, plasma volume (Vp) and reflux rate constant between fractional volume of the extravascular space and blood plasma (Kep). Nonparametric Mann-Whitney test and Kaplan-Meier survival analyses were conducted and a P value < 0.05 was considered statistically significant. RESULTS: The median VWF:Ag value was 248 IU/dL and the median follow-up duration was about 13 months. We divided patients according to low-VWF:Ag and high-VWF:Ag and we found significant differences in the median follow-up duration (19 months vs. 10 months; P = 0.04) and in Ktrans (0.31/minute vs. 0.53/minute; P = 0.02), and Kep (1.79/minute vs. 3.89/minute; P = 0.005) values. The cumulative 1-year survival was significantly shorter in patients with high-VWF:Ag and high-Kep compared with patients with low-VWF:Ag and low-Kep (37.5% vs. 68%; P = 0.05). CONCLUSIONS: These findings, in a small group of patients, suggest a role for VWF:Ag, similar to Ktrans, and Kep as a prognostic indicator of postoperative survival of patients with GBM.

Abdominal CT: a radiologist-driven adjustment of the dose of iodinated contrast agent approaches a calculation per lean body weight.

BACKGROUND: The contrast agent (CA) dose for abdominal computed tomography (CT) is typically based on patient total body weight (TBW), ignoring adipose tissue distribution. We report on our experience of dosing according to the lean body weight (LBW). METHODS: After Ethics Committee approval, we retrospectively screened 219 consecutive patients, 18 being excluded for not matching the inclusion criteria. Thus, 201 were analysed (106 males), all undergoing a contrast-enhanced abdominal CT with iopamidol (370 mgI/mL) or iomeprol (400 mgI/mL). LBW was estimated using validated formulas. Liver contrast-enhancement (CEL) was measured. Data were reported as mean ± standard deviation. Pearson correlation coefficient, ANOVA, and the Levene test were used. RESULTS: Mean age was 66 ± 13 years, TBW 72 ± 15 kg, LBW 53 ± 11 kg, and LBW/TBW ratio 74 ± 8%; body mass index was 26 ± 5 kg/m2, with 9 underweight patients (4%), 82 normal weight (41%), 76 overweight (38%), and 34 obese (17%). The administered CA dose was 0.46 ± 0.06 gI/kg of TBW, corresponding to 0.63 ± 0.09 gI/kg of LBW. A negative correlation was found between TBW and CA dose (r = -0.683, p < 0.001). CEL (Hounsfield units) was 51 ± 18 in underweight patients, 44 ± 8 in normal weight, 42 ± 9 in overweight, and 40 ± 6 in obese, with a significant difference for both mean (p = 0.004) and variance (p < 0.001). A low but significant positive correlation was found between CEL and CA dose in gI per TBW (r = 0.371, p < 0.001) or per LBW (r = 0.333, p < 0.001). CONCLUSIONS: The injected CA dose was highly variable, with obese patients receiving a lower dose than underweight patients, as a radiologist-driven 'compensation effect'. Diagnostic abdomen CT examinations may be obtained using 0.63 gI/kg of LBW.

A critical appraisal of the quality of low back pain practice guidelines using the AGREE II tool and comparison with previous evaluations: a EuroAIM initiative.

PURPOSE: To assess the methodologic quality of guidelines for the management of low back pain (LBP) and compare their recommendations. METHODS: No ethics committee approval was needed for this systematic review. In March 2017, a systematic search was performed using MEDLINE, EMBASE, National Guideline Clearinghouse, and National Institute for Health and Clinical Excellence to find practice guidelines of assessment and management of LBP. The evaluation of guidelines quality was performed independently by four authors using the AGREE II tool, and the results were compared with previous appraisals performed in 2004 and 2009. RESULTS: Of 114 retrieved guidelines, eight were appraised. All except one reached the level of "acceptable" in overall result, with two of them reaching the highest scores. Only two guidelines reached a level of "acceptable" in every domain; the others had at least one domain with low scores. The guidelines had the higher scores (range = 63-94%) on "Scope and purpose" and "Clarity of presentation" (47-89%). "Stakeholder Involvement" has the highest variability between the guidelines results (40-96%). "Rigor of Development" reached an intermediate mean result (34-90%), "Applicability" (42-70%), and "Editorial Independence" (38-85%). Only three guidelines had a radiologist among authors and reached higher scores compared to guidelines without a radiologist among the authors. Compared to previous assessments, low-level guidelines were 53% in 2004, 36% in 2009, and 13% in 2017. CONCLUSIONS: Considering all guidelines, only one had a "low" overall score, while half of them were rated as of "high" quality. Future guidelines might take this into account to improve clinical applicability.

How is shoulder ultrasound done in Italy? A survey of clinical practice.

OBJECTIVES: To define when an ultrasound examination of the shoulder can be considered complete and how many examinations currently performed in Italy are actually complete according to that definition. MATERIALS AND METHODS: Reports and images of previously performed ultrasound examinations of the shoulder of patients seen in 2014 for interventional procedures were reviewed for the following items, according to guidelines published by the European Society of Musculoskeletal Radiology: long biceps, subscapularis, supraspinatus, external rotators, acromioclavicular joint, subacromial bursa, subacromial space, coraco-acromial ligament, and the posterior recess. The first six items were considered mandatory in a complete shoulder ultrasound examination. The specialization of the performing physician was noted. The number of complete examinations performed by different physicians was compared with the number of incomplete examinations. RESULTS: We analyzed 324 examinations (212 women, 112 men; mean age = 47 ± 12 years). The most frequently reported item was the supraspinatus tendon (83 %), the least frequently reported was the posterior recess (3 %). The image that was most frequently found was the long head of the biceps tendon (77 %), the least frequently found was the coraco-acromial ligament (3 %). The median number of images/examination was 6 (25th-75th percentiles, range 4-9). The mean number of unrecognizable images was 3 (2-4). A radiologist performed the examination in 269 patients (83 %). The rate of complete examinations was 47 %. The number of complete examinations performed by physicians from different specialties was not significantly different from that of incomplete examinations (P = 0.228). CONCLUSIONS: Complete shoulder ultrasound examinations account for less than 50 % of those performed in clinical practice in some Italian regions. Standardized scanning protocols and structured reporting may help to improve this figure and consistency among providers performing these examinations.