Diagnosis of CADASIL disease in normotensive and non-diabetics with lacunar infarct.

BACKGROUND: CADASIL (Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy) is characterized by recurrent cerebral ischemic episodes of the lacunar subtype usually without traditional vascular risk factors. We investigated the frequency of CADASIL among selected patients with cerebral ischemia of the lacunar subtype. METHODS: we studied patients under 65 years old who presented cerebral ischemia of the lacunar subtype without hypertension, diabetes mellitus or other causes that explained the cerebral ischemia. On the skin biopsies, we performed immunostaining analysis on 5µm frozen sections with monoclonal antibody anti-Notch 3 (1E4). We also performed a genetic analysis of the Notch 3 gene (exons 3,4,5,6,11 and 19). RESULTS: of 1.519 patients analyzed, only 57 (3.7%) fulfilled the selection criteria, and 30 of them accepted to participated in the study. We studied 30 patients, mean age was 53 years (range 34 to 65), 50% were men and all patients suffered a lacunar stroke. Immunostaining analysis was positive in two patients (6.6%) and the genetic analysis confirmed a mutation characteristic of CADASIL in exon 4 nt 622C/T (Arg 182 Cys) and 694 T/C (Cys206Arg) respectively. CONCLUSIONS: CADASIL disease was present in 6.6% of patients younger than 65 years with a lacunar stroke and without hypertension or diabetes mellitus. Screening for CADASIL should be considered in these patients.

MRI findings in Möbius syndrome: correlation with clinical features.

The authors studied the MRI findings of three patients with Möbius syndrome. Möbius syndrome is a rare congenital disorder characterized by complete or partial facial diplegia accompanied by other cranial nerve palsies. MRI demonstrated brainstem hypoplasia with straightening of the fourth ventricle floor, indicating an absence of the facial colliculus. These MRI features suggest the diagnosis of Möbius syndrome and correlate with the clinical and neurophysiologic findings.

Detection of intracranial metastases: a multicenter, intrapatient comparison of gadobenate dimeglumine-enhanced MRI with routinely used contrast agents at equal dosage.

RATIONALE AND OBJECTIVES: To compare gadobenate dimeglumine (MultiHance) with other commercially available MRI contrast agents for the detection of intracranial metastases. METHODS: A retrospective assessment was performed on MR images from 22 patients enrolled in a prior phase II clinical trial of gadobenate dimeglumine. Each patient underwent two examinations: a first examination with one of three "comparator" agents (gadopentetate dimeglumine, gadodiamide, and gadoterate meglumine) at a dosage of either 0.1 or 0.2 mmol/kg, and then a similar examination with gadobenate dimeglumine at equal dosage. All images were evaluated randomly for lesion number and location in unpaired and then paired fashion by two independent, masked neuroradiologists. A third assessor performed quantitative assessments on the available complete sets of digitally recorded images (10 cases). RESULTS: The findings for the comparator agents were pooled. Sensitivity for lesion detection with gadobenate dimeglumine (93%-100%) was markedly superior to that of comparator-enhanced examinations (65%-73%). The increase of lesion-to-brain contrast of the main lesion was consistently greater with gadobenate dimeglumine than with comparator agents relative to unenhanced contrast (+43% vs. +27%). CONCLUSIONS: Gadobenate dimeglumine proved to be a more efficacious agent than comparator contrast agents for the detection of intracranial metastatic lesions: superior efficacy was noted by both reviewers for total lesion count as well as for sensitivity and positive predictive value for lesion detection. The higher relaxivity of gadobenate dimeglumine might explain the superior sensitivity of gadobenate dimeglumine-enhanced MRI for the detection of central nervous system metastases.

Preoperative embolization of intracranial meningiomas.

The goal of preoperative embolization of intracranial meningiomas is to facilitate their surgical removal by reducing tumor vascularity and decreasing blood loss during surgery. This study is based on personal experience with about 100 embolized meningiomas and on the experience of others. Embolization is performed during the same session as diagnostic angiography. The appropriate embolic materials (absorbable or nonabsorbable) are chosen according to the location of the tumor, the size of the feeding arteries, the blood flow, and the presence of any potentially dangerous vessels (dangerous anastomoses between external carotid artery and internal carotid or vertebral arteries, arteries supplying the cranial nerves). Preoperative embolization appeared to be very useful in large tumors with pure or predominant external carotid artery supply (convexity meningiomas), in skull-base meningiomas, and in middle fossa and paracavernous meningiomas. It was also useful in falx and parasagittal meningiomas receiving blood supply from the opposite side and in posterior fossa meningiomas. CT low densities demonstrated after embolization did not always correlate with necrosis on microscopic examination, and large areas of infarction could be found despite normal CT. Embolic material was found on pathologic examination in 10%-30% of cases; fresh or recent ischemic and/or hemorrhagic necrosis consistent with technically successful embolization was demonstrated in 40%-60% of cases. With careful technique complications are rare.

[Intracranial hemorrhage in patients undergoing anticoagulant treatment with acenocoumarol]. / Hemorragia intracraneal en pacientes sometidos a tratamiento anticoagulante con acenocumarol.

Between 1980 and 1985, 2,012 patients treated with acenocoumarol were followed up. 31 of them had intracranial hemorrhage (ICH), representing an incidence of 1.54%. Its mortality rate was as high as 45%. The most common indication of anticoagulant therapy was cardiac valvular disease. No precipitating factors or concomitant hemorrhages in other sites were detected. Most patients with ICH were, at the time of the accident, within the therapeutic anticoagulant range. The most common localization of ICH was intraparenchymal; most of them developed after one year of anticoagulant therapy. In 32% of instances there was previous hypertension and previous stroke in 26%. ICH had a three times greater incidence in patients over 65 years. The patients who died showed larger hematomas than survivors in computed tomography.

Does higher gadolinium concentration play a role in the morphologic assessment of brain tumors? Results of a multicenter intraindividual crossover comparison of gadobutrol versus gadobenate dimeglumine (the MERIT Study).

BACKGROUND AND PURPOSE: Gadobenate dimeglumine has proved advantageous compared with other gadolinium-based contrast agents for contrast-enhanced brain MR imaging. Gadobutrol is a more highly concentrated agent (1.0 mol/L). This study intraindividually compared 0.1-mmol/kg doses of these agents for qualitative and quantitative evaluation of brain tumors. MATERIALS AND METHODS: Adult patients with suspected or known brain tumors underwent 2 identical MR imaging examinations at 1.5T, 1 with gadobenate dimeglumine and the other with gadobutrol, both at a dose of 0.1-mmol/kg body weight. The agents were injected in randomized order separated by 3-14 days. Imaging sequences and acquisition timing were identical for the 2 examinations. Three blinded readers evaluated images qualitatively for diagnostic information (lesion extent, delineation, morphology, enhancement, global preference) and quantitatively for CNR and LBR. RESULTS: One hundred fourteen of 123 enrolled patients successfully underwent both examinations. Final diagnoses were intra-axial tumors, metastases, extra-axial tumors, "other" tumors, and "nontumor" (49, 46, 8, 7, and 4 subjects, respectively). Readers 1, 2, and 3 demonstrated preference for gadobenate dimeglumine in 46 (40.7%), 54 (47.4%), and 49 (43.0%) patients, respectively, compared with 6, 7, and 7 patients for gadobutrol (P < .0001, all readers). Highly significant (P < .0001, all readers) preference for gadobenate dimeglumine was demonstrated for all other qualitative end points. Inter-reader agreement was good for all evaluations (κ = 0.414-0.629). Significantly superior CNR and LBR were determined for gadobenate dimeglumine (P < .019, all readers). CONCLUSIONS: Significantly greater morphologic information and lesion enhancement are achieved on brain MR imaging with 0.1-mmol/kg gadobenate dimeglumine compared with gadobutrol at an equivalent dose.

Contrast-enhanced MR imaging of brain lesions: a large-scale intraindividual crossover comparison of gadobenate dimeglumine versus gadodiamide.

BACKGROUND AND PURPOSE: The higher relaxivity of gadobenate dimeglumine compared with gadodiamide is potentially advantageous for contrast-enhanced brain MR imaging. This study intraindividually compared 0.1-mmol/kg doses of these agents for qualitative and quantitative lesion enhancement. MATERIALS AND METHODS: Adult patients with suggested or known brain lesions underwent 2 identical MR imaging examinations at 1.5T, one with gadobenate dimeglumine and the other with gadodiamide. The agents were administered in randomized order separated by 3-14 days. Imaging sequences and postinjection acquisition timing were identical for the 2 examinations. Three blinded readers evaluated images qualitatively for diagnostic information (lesion extent, delineation, morphology, enhancement, and global preference) and quantitatively for contrast-to-noise ratio (CNR). RESULTS: One hundred thirteen of 138 enrolled patients successfully underwent both examinations. Final diagnoses were intra-axial tumor, metastasis, extra-axial tumor, or other (47, 27, 18, and 21 subjects, respectively). Readers 1, 2, and 3 demonstrated global preference for gadobenate dimeglumine in 63 (55.8%), 77 (68.1%), and 73 (64.6%) patients, respectively, compared with 3, 2, and 3 patients for gadodiamide (P < .0001, all readers). Highly significant (P < .0001, all readers) preference for gadobenate dimeglumine was demonstrated for all qualitative end points and for CNR (increases of 23.3%-34.7% and 42.4%-48.9% [spin-echo and gradient-refocused echo sequences, respectively] for gadobenate dimeglumine compared with gadodiamide). Inter-reader agreement was good for all evaluations (kappa = 0.47-0.69). Significant preference for gadobenate dimeglumine was demonstrated for all lesion subgroup analyses. CONCLUSION: Significantly greater diagnostic information and lesion enhancement are achieved on brain MR imaging with 0.1-mmol/kg gadobenate dimeglumine compared with gadodiamide at an equivalent dose.

Imaging of parasellar lesions.

UNLABELLED: The sellar and parasellar region is an anatomically complex area that represents a crucial crossroad of important adjacent structures, e.g. orbits, cavernous sinus and its content, polygon of Willis, hypothalamus through the pituitary stalk and dural reflections forming the diaphragm sellae and the walls of the cavernous sinuses. Although the cavernous sinus represents the most relevant parasellar structure, from the practical and clinical point of view all the structures that surround the sella turcica can be included in the parasellar region. CT and, mainly, MRI are the imaging modalities to study and characterise the normal anatomy and the majority of processes in this region. We present a practical short review of the most relevant CT and MRI characteristics, such as location, nature of contrast enhancement and presence of cystic components, together with clinical findings, which permit differentiation of the most frequent and less common lesions found in the parasellar region. LEARNING OBJECTIVES: -A short review of the anatomy and clinical symptoms related to the parasellar region. -Radiological characterisation, mainly by MRI, of the many lesions that alter the structure and function of sellar and parasellar anatomy. -Description of the MRI features that permit differentiation among less common lesions.

Prognostic factors in intraparenchymatous hematoma with ventricular hemorrhage.

Intraventricular hemorrhage following intraparenchymatous hematoma is thought to be a frequent and often fatal event. Computerized tomography has proved to be valuable for its diagnosis. Hospital records of seventy-eight patients with intraparenchymatous hematoma and intraventricular hemorrhage diagnosed by computerized tomography were retrospectively reviewed to evaluate initial clinical features and CT findings in order to assess potential prognostic factors.

Etiology of moya moya disease acquired or congenital.

Nine cases of Moya Moya disease collected since 1968 are presented. The absence of inflammatory signs and the high percentage of congenital malformations is emphasized. However, despite the post-mortem findings in one of the cases, no etiologic factor has been conclusively demonstrated.

Some aspects of the spinal cord circulation in cervical myelopathy.

Under usual technical conditions, it is possible, in a great percentage of cases, to visualize angiographically the afferent radiculospinal artery feeding the anterior cervical spinal axis, coming from the vertebral arteries. The level of its emergence is varied, predominating at C5--C6. This radiculospinal artery can be directly affected by a spondylotic lesion at the foraminal level and is one of the causes of the ischemic syndrome observed in the cerival myelopathies resulting from this process.

CT appearance of low attenuation areas in basal ganglia in childhood: report of 23 cases.

Low attenuation areas were seen at CT in the basal ganglia of 23 patients aged less than 15 years. The relationship between CT images and pathological findings is investigated and the differential diagnosis is made.

Short review of CT in the study of some intraspinal diseases.

We present our experience of the usefulness of high definition computed tomography (HDCT) in 30 cases of isolated intraspinal pathology (12 extramedullary and 18 intramedullary cases). The results are assessed in comparison to myelography.

CT for the follow-up of cranial trauma.

The author's experience in diagnosing lesions of cerebral trauma with the CT scanner are outlined. The study is divided into acute and chronic lesions. Special attention is drawn to the morphology of subdural and intracerebral haematomas, which is dependent upon their duration.

Ventricular enlargement in young chronic schizophrenics.

The ventricular brain ratio (VBR) was measured in a group of 33 young in-patient schizophrenics and 25 controls. Results confirmed significant lateral ventricular enlargement in the schizophrenic patients, but could not demonstrate any association between the VBR and age or length of illness. Some aspects of the studied sample are discussed.

Dynamic study of arachnoid cysts with metrizamide.

Intracranial arachnoid cyst do not usually present diagnostic problems when studied by CT, since they appear as low density images similar to those produced by CSF, do not change on intravenous contrast perfusion, and are located extraparenchymatously. Sometimes, however, their diagnosis can become difficult or doubtful mainly in cases of deep, basal or paramedian cysts [12, 18, 22, 24]. On the other hand, the functional or dynamic aspects of these structures remain unknown when the study is limited to simple CT. Computed cisternography with metrizamide (CCM) and time control will not only show the relationship between these structures and the arachnoid space but also their dynamic aspect, which may determine the surgical treatment.

Clinical symptomatology and computerized tomography in brain metastasis.

In 50 patients with a diagnosis of brain metastasis, a study was made commencing with the appearance of the first neurological symptom. Severe headaches were observed in 48% of the patients, followed by a change in character in 11% and motor disorders in 11%. The search for initial neurological signs will help dictate the precise moment of using the scanner to confirm the diagnosis, thus hopefully allowing for a quicker treatment and improving the survival rates of these patients.

Thalamic hemorrhage. A study of 23 patients with diagnosis by computed tomography.

A series of 23 patients with thalamic hemorrhage with computed tomography confirmation is reported. Nine of these died, all had hematomas larger than 3.3 cm. The value of the syndrome of downward and convergent ocular deviation is stressed, and its possible mechanisms are analyzed. The characteristics and mechanisms of the pupillary abnormalities are reported, as well as the speech abnormalities observed in patients with lesions of the dominant hemisphere. Prognostic conclusions are drawn.