Incidental Findings from 16,400 Brain MRI Examinations of Research Volunteers.

BACKGROUND AND PURPOSE: Incidental findings are discovered in neuroimaging research, ranging from trivial to life-threatening. We describe the prevalence and characteristics of incidental findings from 16,400 research brain MRIs, comparing spontaneous detection by nonradiology scanning staff versus formal neuroradiologist interpretation. MATERIALS AND METHODS: We prospectively collected 16,400 brain MRIs (7782 males, 8618 females; younger than 1 to 94 years of age; median age, 38 years) under an institutional review board directive intended to identify clinically relevant incidental findings. The study population included 13,150 presumed healthy volunteers and 3250 individuals with known neurologic diagnoses. Scanning staff were asked to flag concerning imaging findings seen during the scan session, and neuroradiologists produced structured reports after reviewing every scan. RESULTS: Neuroradiologists reported 13,593/16,400 (83%) scans as having normal findings, 2193/16,400 (13.3%) with abnormal findings without follow-up recommended, and 614/16,400 (3.7%) with "abnormal findings with follow-up recommended." The most common abnormalities prompting follow-up were vascular (263/614, 43%), neoplastic (130/614, 21%), and congenital (92/614, 15%). Volunteers older than 65 years of age were significantly more likely to have scans with abnormal findings (P < .001); however, among all volunteers with incidental findings, those younger than 65 years of age were more likely to be recommended for follow-up. Nonradiologists flagged <1% of MRIs containing at least 1 abnormality reported by the neuroradiologists to be concerning enough to warrant further evaluation. CONCLUSIONS: Four percent of individuals who undergo research brain MRIs have an incidental, potentially clinically significant finding. Routine neuroradiologist review of all scans yields a much higher rate of significant lesion detection than selective referral from nonradiologists who perform the examinations. Workflow and scan review processes need to be carefully considered when designing research protocols.

Deep Brain Nuclei T1 Shortening after Gadobenate Dimeglumine in Children: Influence of Radiation and Chemotherapy.

BACKGROUND AND PURPOSE: Intrinsic T1-hyperintense signal has recently been reported in the deep gray nuclei on brain MR imaging after multiple doses of gadolinium-based contrast agents. Most reports have included adult patients and excluded those undergoing radiation or chemotherapy. We investigated whether T1 shortening is also observed in children and tried to determine whether radiochemotherapy is a risk factor for this phenomenon. MATERIALS AND METHODS: In this single-center retrospective study, we reviewed clinical charts and images of all patients 18 years of age or younger with ≥4 gadobenate dimeglumine-enhanced MRIs for 6 years. Seventy-six children (mean age, 9.3 years; 60 unconfounded by treatment, 16 with radiochemotherapy) met the selection criteria (>4 MR imaging examinations; mean, 8). T1 signal intensity ratios for the dentate to pons and globus pallidus to thalamus were calculated and correlated with number of injections, time interval, and therapy. RESULTS: Among the 60 children without radiochemotherapy, only 2 had elevated T1 signal intensity ratios (n = 20 and 16 injections). Twelve of the 16 children with radiochemotherapy showed elevated signal intensity ratios. Statistical analysis demonstrated a significant signal intensity ratio change for the number of injections (P < .001) and amount of gadolinium (P = .008), but not for the interscan time interval (P = .35). There was a significant difference in the average signal intensity ratio change between those with and without radiochemotherapy (P < .001). Chart review revealed no new neurologic deficits in any patients, related to their underlying conditions and prior surgeries. CONCLUSIONS: Compared with published adult series, children show a similar pattern of T1 hyperintense signal changes of the dentate and globus pallidus after multiple gadobenate dimeglumine injections. The T1 signal changes in children may have a later onset but are accelerated by radiochemotherapy.

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.

Magnetic source imaging of late evoked field responses to vowels: toward an assessment of hemispheric dominance for language.

OBJECT: The goal of this study was to determine whether the late neuromagnetic field elicited by simple speech sounds, which is detected by magnetoencephalography, may be used to estimate hemispheric dominance for language and to guide or constrain the intraoperative search for essential language sites. If sufficiently robust, a noninvasive method for assessing hemispheric dominance for language could reduce the necessity for amobarbital testing and the extent of intraoperative cortical stimulation-based mapping, both of which carry the risk of morbidity. METHODS: Fifteen patients undergoing surgery for tumors during which intraoperative language mapping would be performed and two additional patients in whom intracarotid amobarbital testing confirmed right-hemisphere language dominance participated. Following a primary auditory response sources of late neuromagnetic fields elicited by vowel stimuli were modeled and coregistered using magnetic resonance images to form magnetic source (MS) images. A laterality index (LI) was calculated by summing the number of equivalent current dipolar sources in the late fields detected from each hemisphere. In 14 right-handed patients, 10 displayed left asymmetric LIs (0.37 +/- 0.16. mean +/- standard error of the mean in 14 patients). For both right-hemisphere dominant patients in whom an LI was obtainable, the LI was rightward. Stimulation-mapped essential language sites were found in 7 of 15 patients. For six of these seven patients, the MS image-derived LI was leftward. CONCLUSIONS: Asymmetry in single equivalent dipole modeling of the late neuromagnetic field evoked by simple speech sounds correlates with hemispheric language dominance, although not to the degree necessary for individual clinical predictions. With further development, MS imaging of simple language tasks may be used preoperatively to predict language dominance and even to identify or constrain the intraoperative search for likely sites of essential language cortex.

Functional activity within brain tumors: a magnetic source imaging study.

OBJECTIVE: To determine whether low-grade gliomas contain functional cortical activity more often than high-grade gliomas within radiologically defined abnormal tissue. METHODS: Patients with intra-axial cerebral lesions located in the vicinity of eloquent brain cortex preoperatively underwent magnetic source imaging. A dual 37-channel biomagnetometer was used to perform the imaging. Evoked magnetic fields were analyzed using the single-equivalent dipole representation to ascertain the neuronal source. Stimuli included painless tactile somatosensory stimulation of fingers, toes, and lips and auditory presentation of pure sinusoidal tones. RESULTS: A retrospective analysis of 106 nonconsecutively treated patients, who had undergone preoperative magnetic source imaging between February 1996 and December 1999, revealed that 24.5% of the patients had been at risk for neurological deficits, because functionally active tissue was located within or at the border of the tumor. Functional activity was found within the radiologically defined lesion in 18% of Grade 2 tumors, in 17% of Grade 3 tumors, and in 8% of Grade 4 tumors. CONCLUSION: The results confirm that, regardless of tumor grade, intra-axial brain tumors may involve or directly border on functional cortex. The degree of involvement of functionally viable cortex appeared greater for low-grade tumors than for high-grade lesions. On the other hand, high-grade lesions were more likely to be associated with functional cortex at their margins or within peritumoral edema. To safely maximize tumor resection, preoperative functional imaging and intraoperative electrophysiological mapping of the cerebral cortex and the white matter tracts are deemed necessary.

Radiologic-pathologic findings in raccoon roundworm (Baylisascaris procyonis) encephalitis.

A 13-month-old boy developed eosinophilic meningoencephalitis, retinitis, and a protracted encephalopathy with severe residual deficits. The initial MR examination revealed diffuse periventricular white matter disease, and follow-up images showed atrophy. Brain biopsy, serology, and epidemiologic studies lead to the diagnosis of Baylisascaris procyonis infection, a parasitic disease contracted through exposure to soil contaminated by the eggs of a common raccoon intestinal roundworm. The pathologic, epidemiologic, and imaging features of this disease are herein reviewed.

Presurgical mapping with magnetic source imaging: comparisons with intraoperative findings.

We compare noninvasive preoperative mapping with magnetic source imaging to intraoperative cortical stimulation mapping. These techniques were directly compared in 17 patients who underwent preoperative and postoperative somatosensory mapping of a total of 22 comparable anatomic sites (digits, face). Our findings are presented in the context of previous studies that used magnetic source imaging and functional magnetic resonance imaging as noninvasive surrogates of intraoperative mapping for the identification of sensorimotor and language-specific brain functional centers in patients with brain tumors. We found that magnetic source imaging results were reasonably concordant with intraoperative mapping findings in over 90% of cases, and that concordance could be defined as "good" in 77% of cases. Magnetic source imaging therefore provides a viable, if coarse, identification of somatosensory areas and, consequently, can guide and reduce the time taken for intraoperative mapping procedures.

A hemispherically asymmetrical MEG response to vowels.

Neuromagnetic fields elicited by vowels and tones were recorded and sources were modeled as single equivalent current dipoles (ECDs) in 1 ms steps 80-400 ms post stimulus. To vowels, the left hemisphere (LH) auditory cortex had nearly twice as many satisfactory ECD fits as the right hemisphere (RH). Tones did not evoke such asymmetry. In particular, in the late field (150-400 ms) the LH had more than twice as many ECDs as the RH, and the spatial distribution of LH sources was more clustered than in the RH. An asymmetrical, focal cortical mechanism for vowel processing was identified that intensified in later auditory processing stages. These data suggest that MEG might be used for non-invasive, language laterality determination with simple vowel-like stimuli.

Diffusion MR imaging. Theory and applications.

Diffusion MR imaging provides a novel way to characterize tissues based on sensitivity to the microscope molecular motion of water. Clinical implementation requires strong, fast hardware and careful post-processing of diffusion parameters. It is important to recognize that diffusion images and derivatives such as the trace of the diffusion tensor are quite specific in reflecting the physical properties of diffusion, but are non-specific for pathology. Restricted diffusion is the earliest clinically detectable sign of ischemia, but similar diffusion changes can be seen with infection and some tumors. Diffusion MR techniques are providing new ways to study problems in oncology, epilepsy, white matter disorders, and infectious diseases, both for research and clinical applications.

Peri-threshold encoding of stimulus frequency and intensity in the M100 latency.

Recent work has suggested that, in addition to spatial tonotopy, pitch and timbre information may be encoded in the temporal activity of the auditory cortex. Specifically, the post-stimulus latency of the maximal cortical evoked neuromagnetic field (M100 or N1m) is a function of stimulus frequency. We investigated the additional effect of varying the stimulus intensity on the M100 response. A 37-channel biomagnetometer recorded neuromagnetic fields over the temporal lobe of healthy volunteers in response to monaurally presented tones. The frequency dependence of the M100 latency remained remarkably invariant even at low stimulus intensity. Thus, for peri-threshold stimuli, frequency information appears encoded in the temporal form of the evoked response.

Magnetic source imaging as a tool for presurgical functional brain mapping.

This article describes magnetic source imaging, a newly-developing technology which can be used to noninvasively map eloquent cortex prior to surgical procedures. It is based on large-array detection of extracranial magnetic fields arising from neuronal currents evoked by peripheral stimulation. A range of evoked and spontaneous neuromagnetic activities are discussed along with clinical examples of the utility of the technique and comparison to other brain mapping techniques, such as positron emission tomography, functional magnetic resonance imaging, EEG, and ECoG.

Processing of vowels in supratemporal auditory cortex.

The auditory evoked neuromagnetic fields elicited by synthesized vowels of two different fundamental frequencies F0 were recorded in six subjects over the left and right temporal cortices using a 37-channel biomagnetometer. Single equivalent current dipole modeling of the fields elicited by all vowel types localized activity to a well-circumscribed area in supratemporal auditory cortex in both hemispheres. There were hemisphere asymmetries in the amplitude and latency of the M100 response. We also observed changes in M100 latency related to vowel type, but not to F0. There was no clear effect of vowel type or F0 on dipole localization for the M100, but a possible vowel type by latency interaction. These M100 data provide further evidence that vowels are processed independently of their pitch.

Sensory mapping in a congenitally deaf subject: MEG and fRMI studies of cross-modal non-plasticity.

It has been proposed that the auditory cortex of deaf subjects may provide an example of cross-modal compensatory plasticity. We investigated whether sensory stimulation could elicit responses from auditory areas of a congenitally deaf subject. Neuromagnetic fields were recorded using a 37-channel biomagnetometer under conditions of: 1) visual stimulation; 2) somatosensory stimulation; and 3) a simple motor task. Visual items were reversing checkerboards and single light spots, presented in various portions of the visual field; somatosensory stimuli were pneumatic taps delivered to individual digit-segments and the lip; the motor task was self-paced finger tapping. In addition, functional magnetic resonance imaging was used to observe the activation elicited by full-field checkerboard and sign language stimuli. No responses to passively presented visual or somatosensory stimuli were observed in the auditory cortex. In contrast, somatosensory, motor, and visual cortices revealed evoked magnetic responses comparable to those from control subjects, indicating canonical anatomic and physiological organization in these areas. These data suggest that primary projection areas do not reveal obvious plastic effects. We suggest that in the human auditory cortex compensatory plasticity emerges primarily as a property of non-primary areas and is best observed under attentionally demanding conditions.

Task-induced asymmetry of the auditory evoked M100 neuromagnetic field elicited by speech sounds.

The auditory evoked neuromagnetic fields elicited by synthesized speech sounds (consonant-vowel syllables) were recorded in six subjects over the left and right temporal cortices using a 37-channel SQUID-based magnetometer. The latencies and amplitudes of the peaks of the M100 evoked responses were bilaterally symmetric for passively presented stimuli. In contrast, when subjects were asked to discriminate among the same syllabic stimuli, the amplitude of the M100 increased in the left and decreased in the right temporal cortices. Single equivalent current dipole modeling of the activity elicited by all stimulus-types localized to a well-circumscribed area in supratemporal auditory cortex. The results suggest that attentional modulation affects the two supratemporal cortices in a differential manner. Task-conditioned attention to speech sounds is reflected in lateralized supratemporal cortical responses possibly concordant with hemispheric language dominance.

Noninvasive somatosensory monitoring of the injured inferior alveolar nerve using magnetic source imaging.

PURPOSE: This study evaluates magnetoencephalography (MEG) as an objective monitor for the evaluation of post-traumatic inferior alveolar nerve injuries. MATERIALS AND METHODS: Six patients with unilateral inferior alveolar nerve injuries were assessed using conventional sensory examination techniques. All damaged nerves, and their contralateral controls, were then reexamined using MEG technology. Regions of somatosensory-induced magnetic activity were superimposed on three-dimensional magnetic resonance imaging (MRI) scans to give cortical magnetic source images (MSI). All patients subsequently underwent surgical exploration of the damaged nerves. RESULTS: All six patients had no sensitivity to conventional testing on the damaged side. On evaluation with MEG, all six control nerves had an appropriate cortical signal in response to repetitive lip stimulation. Somatosensory stimulation of two of the six damaged nerves resulted in cortical magnetic field changes. Surgical exploration showed that the four nerves with negative MEG tests had discontinuity defects. In contrast, the two patients with positive MEG signals had intact nerves. CONCLUSION: This technology may differentiate between intact but damaged nerves and transected nerves.

MR in partial epilepsy: value of high-resolution volumetric techniques.

PURPOSE: To assess the utility of high-resolution volumetric MR examinations with thin partition size for patients with simple partial epilepsies that were well located with electrical and clinical criteria. METHODS: Fifteen patients with normal standard MR findings were studied with three-dimensional Fourier transform volumetric MR examinations using thin (1 to 1.5 mm) partition size. Imaging was done in the coronal plane, then reformatted manually on an independent console with each gyrus analyzed in the planes parallel and perpendicular to its axis. RESULTS: Cortical abnormalities were detected in 8 of the 15 patients in the study. Surgical resection of the affected cortex in 2 patients showed polymicrogyria in one and dysplastic cortical organization in the other. CONCLUSION: In this preliminary study, 3-D Fourier transform volumetric MR examinations with thin partition size appeared to be useful in identifying cortical dysplasias in patients with localized simple partial epilepsies.

Correlation of functional magnetic source imaging with intraoperative cortical stimulation in neurosurgical patients.

This study compared noninvasive preoperative functional imaging by using magnetoencephalography (MEG) with intraoperative direct cortical stimulation in ten patients undergoing neurosurgery. The goal was to assess the accuracy and reliability of MEG-based functional imaging in these patients as a possible replacement or adjunct for direct cortical stimulation with electrocorticography. Objective comparison of intraoperative mapping with preoperative MEG procedures was achieved by intraoperative recording of mapped cortical locations for motor responses using an interactive image-guided surgical device, the ISG viewing wand, with which mapping points could be marked on a previously acquired (MRI) set. In all ten patients, at least one stimulation site elicited a response during both MEG and intraoperative mapping. The central sulcus ipsilateral to the lesion was only directly visible on high-resolution MRIs in 3/10 cases and equivocally in 2/10. Coregistered with MRI to form magnetic source images (MSIs), MEG predictions of the postcentral gyrus were possible in all 10 cases. In all 10 cases, these were in agreement with intraoperative estimation of the precentral gyrus. Functional mapping of somatosensory cortex was achieved noninvasively in surgical patients by using MSI. The accuracy, compared with cortical stimulation, was always sufficient to define motor and somatosensory strips.