Hounsfield unit changes over time in contusions of the brain.

In the United States, traumatic brain injuries are an important cause of death and disability, often with significant financial and legal consequences. Although it is generally accepted by neuroradiologists that the density of cerebral contusions decreases over time, previous research has not addressed this phenomenon directly. In the current study, we reviewed charts of patients who had suffered cerebral contusions and had at least two subsequent computed tomography scans in order to determine whether Hounsfield Units, a measure of density, decreased over time. We found that 100% of contusions decreased in Hounsfield Units over time. In addition, we found that the rate of decrease in density appears to be higher in the first 100 days after the injury. These findings are especially applicable in the area of forensics. For example, they could be used to determine the relative age of two separate brain contusions in the same patient.

Radiological evolution of relapsing polychondritis.

Relapsing Polychondritis (RP) is a systemic condition characterized by chronic, episodic inflammation, especially of cartilaginous and proteoglycan-rich structures. The etiology of this rare autoimmune disease is unknown, and so far, there is very little data available for non-Caucasians. RP presents with a constellation of non-specific inflammation, which sometimes appear in characteristic locations. Radiology is important in supporting the diagnosis, and this paper presents a case of a non-Caucasian patient monitored radiologically from early onset to the terminal stages.

Neurosarcoidosis: clinical features, diagnosis, and management.

Sarcoidosis is a multisystemic granulomatous disease, which uncommonly affects nervous system. However, when present, it may affect both central and peripheral nervous systems and potentially mimics other chronic diseases of the nervous system. Pathogenesis of neurosarcoidosis remains largely unknown, and its diagnosis and management pose serious challenges to clinicians. Early diagnosis and aggressive treatment of neurosarcoidosis are necessary to produce satisfactory clinical outcomes. This review discusses clinical manifestations, current diagnostic studies, and currently available modalities for management of neurosarcoidosis.

Occurrence of extensive spherical amyloid deposits in a prolactin-secreting pituitary macroadenoma: a radiologic-pathologic correlation.

Pituitary adenomas are the most common tumors of the sellar region, but the occurrence of spherical amyloid deposits in a pituitary adenoma is rare. We describe the clinical features, radiologic characteristics, and pathologic findings of 45-year-old man who presented with galactorrhea, hypogonadism, and hyperprolactinemia who had a pituitary adenoma with extensive spherical amyloid deposits. Approximately 30 cases have been reported, almost exclusively in patients with prolactinomas. Treatment with dopaminergic agonists will result in the expected reduction in prolactin levels; however, in most cases, macroadenomas with spherical amyloid deposits fail to decrease in size. The source of the amyloid deposits in prolactinomas is not clearly defined but may be due to abnormal processing of prolactin or its prohormone. These adenomas with spherical amyloid have a characteristic appearance on magnetic resonance imaging with low or heterogeneous intensity on T1 and low intensity on T2-weighted images. Following infusion of gadolinium, there is enhancement of the periphery but not most of the tumor mass. These magnetic resonance imaging characteristics are different than those of typical pituitary adenomas. These differences should alert clinicians to the possibility of extensive spherical amyloid deposits in a prolactin-secreting pituitary adenoma, which may have important clinical implications. In this report, we correlate the radiologic finds with the pathology and compared them with other sellar and parasellar lesions.

A case of glioblastoma in infarcted brain.

Patients with occult cancer of systemic or intracranial origin may clinically present with stroke as an initial manifestation due to tumor-associated hemorrhage and/or infarction. Such cases are usually clearly temporally related. We present a case with separate instances of hemorrhagic infarction and subsequent glioblastoma that were temporally separated by several years. This case may be an illustration of recent findings in mechanisms of brain repair and tumor biology.

The Spectrum of Acute Cerebrovascular Disease in Patients with COVID-19.

(1) Background: COVID-19 infection is responsible for the ongoing pandemic and acute cerebrovascular disease (CVD) has been observed in COVID-19 patients. (2) Methods: We conducted a retrospective, observational study of hospitalized adult patients admitted to our hospital with SARS-CoV-2 and acute cerebrovascular disease. All clinical data were reviewed including epidemiology, clinical features, laboratory data, neuroradiological findings, hospital management and course from 32 patients hospitalized for COVID-19 management with acute cerebrovascular disease. (3) Results: Acute CVD with COVID-19 was associated with higher NIH stroke scale on discharge compared to non-COVID-19 CVDs. Seizures complicated the hospital course in 16% of COVID-19 patients with CVD. The majority of the acute CVDs were ischemic (81%) in nature followed by hemorrhagic (22%). Acute CVD with COVID-19 resulted in average hospital stays greater than twice that of the control group (13 days in COVID-19, 5 days in control). Acute CVD with COVID-19 patients had worse clinical outcomes with 31% patient deaths and 6% discharged to hospice. In the control group, 6% of patients died. (4) Conclusions: Acute CVD associated with COVID-19 tends to be more complicated with unique and adverse clinical phenotype, longer hospital admissions, and worse clinical outcomes.

The effects of high dose interferon-ß1a on plasma microparticles: correlation with MRI parameters.

OBJECTIVES: We previously reported a correlation between levels of micro particles carrying CD31 (PMP(CD31+)) and disease activity in MS. However, the effects of long term (12 month) treatment with high dose, high frequency interferon-ß1a (Rebif™) on plasma levels of PMP(CD31+), PMP(CD146+), and PMP(CD54+) and MRI measures of disease activity have not yet been assessed. METHODS: During this prospective 1-year study, we used flow cytometry to measure changes in plasma micro particles (PMP) bearing CD31 (PMP(CD31+)), CD146 (PMP(CD146+)), and CD54/ICAM-1 (PMP(CD54+)) in 16 consecutive patients with relapsing-remitting MS (RRMS) before and after 3, 6, and 12 months of subcutaneous therapy with interferon-beta1a (44 micrograms, 3X weekly). At each visit, clinical exams and expanded disability status scale (EDSS) scores were recorded. RESULTS: Plasma levels of PMP(CD31+), and PMP(CD54+) were significantly reduced by treatment with IFN-ß1a. PMP(CD146+) appeared to decrease only at 3 months and did not persist at 6 and 12 months (p = 0.0511). In addition, the decrease in plasma levels of PMP(CD31+) and PMP(CD54+) levels at 12 months were associated with a significant decrease in the number and volume of contrast enhancing T1-weigthed lesions. CONCLUSION: Our data suggest that serial measurement of plasma micro particles (PMP), particularly in the initial stages of MS (when neuro-inflammatory cascades are more intense), may serve as reliable and reproducible surrogate markers of response to IFN-ß1a therapy for MS. In addition, the progressive decline in plasma levels of PMP(CD31+) and PMP(CD54+) further supports the concept that IFN-ß1a exerts stabilizing effect on the cerebral endothelial cells during pathogenesis of MS.

Electromagnetic hypersensitivity: evidence for a novel neurological syndrome.

OBJECTIVE: We sought direct evidence that acute exposure to environmental-strength electromagnetic fields (EMFs) could induce somatic reactions (EMF hypersensitivity). METHODS: The subject, a female physician self-diagnosed with EMF hypersensitivity, was exposed to an average (over the head) 60-Hz electric field of 300 V/m (comparable with typical environmental-strength EMFs) during controlled provocation and behavioral studies. RESULTS: In a double-blinded EMF provocation procedure specifically designed to minimize unintentional sensory cues, the subject developed temporal pain, headache, muscle twitching, and skipped heartbeats within 100 s after initiation of EMF exposure (p < .05). The symptoms were caused primarily by field transitions (off-on, on-off) rather than the presence of the field, as assessed by comparing the frequency and severity of the effects of pulsed and continuous fields in relation to sham exposure. The subject had no conscious perception of the field as judged by her inability to report its presence more often than in the sham control. DISCUSSION: The subject demonstrated statistically reliable somatic reactions in response to exposure to subliminal EMFs under conditions that reasonably excluded a causative role for psychological processes. CONCLUSION: EMF hypersensitivity can occur as a bona fide environmentally inducible neurological syndrome.

Simulated MR magnetic field induces steady-state changes in brain dynamics: Implications for interpretation of functional MR studies.

We examined whether a magnetic field comparable to one of the fields produced during MRI induced steady-state changes in brain electrical activity while the field was applied (called a presence effect to distinguish it from evoked potentials). The electroencephalogram was measured from standard scalp locations in the presence and absence of 100-200 microT, 60 Hz, and the effect of the field was evaluated by nonlinear (recurrence analysis) and linear techniques; individual subjects served as their own controls. Using recurrence analysis, changes in brain activity lasting 1 sec (the longest interval considered) were found in 21 of 22 subjects (P < 0.05 for each subject). The presence effect was not detected using linear analysis and was reversible, as indicated by a return of brain activity to baseline levels in all subjects within 2 sec of field offset. The possible role of artifacts or systematic errors was ruled out by studies using electrical phantoms and by analyses of electroencephalograms recorded during sham exposure. It is reasonable to expect that actual scanner magnetic fields also produce nonlinear steady-state perturbations of brain dynamical activity. The effect may influence the picture of brain connectivity inferred in some functional MR studies.

Biomarkers of Seizure Activity in Patients With Intracranial Metastases and Gliomas: A Wide Range Study of Correlated Regions of Interest.

Introduction: Studies quantifying cortical metrics in brain tumor patients who present with seizures are limited. The current investigation assesses morphometric/volumetric differences across a wide range of anatomical regions, including temporal and extra-temporal, in patients with gliomas and intracranial metastases (IMs) presenting with seizures that could serve as a biomarker in the identification of seizure expression and serve as a neuronal target for mitigation. Methods: In a retrospective design, the MR sequences of ninety-two tumor patients [55% gliomas; 45% IM] and 34 controls were subjected to sophisticated morphometric and volumetric assessments using BrainSuite and MATLAB modules. We examined 103 regions of interests (ROIs) across eight distinct cortical categories of interests (COI) [gray matter, white matter; total volume, CSF; cortical areas: inner, mid, pial; cortical thickness]. The primary endpoint was quantifying and identifying ROIs with significant differences in z-scores based upon the presence of seizures. Feature selection employing neighborhood component analysis (NCA) determined the ROI within each COI having the highest significance/weight in the differentiation of seizure vs. non-seizure patients harboring brain tumor. Results: Overall, the mean age of the cohort was 58.0 ± 12.8 years, and 45% were women. The prevalence of seizures in tumor patients was 28%. Forty-two ROIs across the eight pre-defined COIs had significant differences in z-scores between tumor patients presenting with and without seizures. The NCA feature selection noted the volume of pars-orbitalis and right middle temporal gyrus to have the highest weight in differentiating tumor patients based on seizures for three distinct COIs [GM, total volume, and CSF volume] and white matter, respectively. Left-sided transverse temporal gyrus, left precuneus, left transverse temporal, and left supramarginal gyrus were associated with having the highest weight in the differentiation of seizure vs. non-seizure in tumor patients for morphometrics relating to cortical areas in the pial, inner and mid regions and cortical thickness, respectively. Conclusion: Our study elucidates potential biomarkers for seizure targeting in patients with gliomas and IMs based upon morphometric and volumetric assessments. Amongst the widespread brain regions examined in our cohort, pars orbitalis, supramarginal and temporal gyrus (middle, transverse), and the pre-cuneus contribute a maximal potential for differentiation of seizure patients from non-seizure.

Childhood and teenage stroke.

OBJECTIVE: The purpose of this manuscript is to review the various etiologies and to discuss the therapeutic issues in childhood stroke. METHODS: A PubMed search of literature pertaining to childhood stroke was conducted from 1983 to 2008 using specific key search words pertinent to cerebrovascular disorders in childhood. RESULTS: The analysis of the multiple causes of childhood stroke including arterial ischemic strokes and cerebral venous thrombosis was presented. Current therapy and outcome data in childhood stroke are also discussed throughout the length of the article. CONCLUSIONS: With increasing vigilance among physicians and improved neuroimaging modalities, the diagnosis of childhood stroke is now made earlier, with increasing frequency and greater accuracy. However, larger and well-controlled studies regarding the optimal management of childhood stroke in terms of the use of both antithrombotic drugs and anticoagulation are still needed in addition to longitudinal follow-up studies of children with stroke.

Clinically presenting acute/subacute ischemic stroke: differential diagnosis of the non-enhanced CT hypodensity by advanced neuroimaging.

OBJECTIVES: Patients presenting to the emergency room with an acute or subacute onset of focal neurological deficits are evaluated initially by non-contrast computed tomogram (CT) of the brain. This is primarily carried out to differentiate an ischemic from hemorrhagic stroke. However, other neurological conditions may have a similar clinical presentation as well as only hypodensities on CT scan, thus mimicking ischemic stroke. This review focuses on the advanced neuroimaging modalities that help differentiate these other conditions from a cerebral infarction. METHODS: The literature was reviewed in order to ascertain what conditions would clinically and by CT mimic an acute/subacute ischemic infarction, and what advanced neuroimaging techniques would be most useful in differentiating these conditions. RESULTS: Several infectious, inflammatory, metabolic and vascular diseases were found with clinical presentations identical to subacute/acute ischemic cerebral infarction, which also could demonstrate only hypodensities on a non-enhanced CT scan. However, advanced neuroimaging techniques could readily differentiate these conditions from ischemic infarction. CONCLUSIONS: As presented in this review, although several diseases initially present a diagnostic dilemma upon presentation because of their clinical and non-enhanced CT similarities to cerebral infarction, advanced diagnostic neuroimaging readily establishes their unique pathologies.

Stroke and dementia.

OBJECTIVE: The current review covers causes and risk factors of vascular dementia, including single infarct, multi-infarct and cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy. Comparisons and distinctions are made between vascular dementia and Alzheimer's dementia, including shared vascular features and risk factors, differential diagnosis based on presenting history, neuropsychological testing results and neuroimaging findings. Neuropsychological findings associated with vascular dementia are discussed, and efforts towards stroke prevention and limiting the recurrence of stroke, as well as emerging treatment possibilities for cognitive decline associated with vascular dementia, are presented. METHODS: A PubMed-based literature review was performed to acquire recent peer-reviewed publications on vascular dementia. RESULTS: Stroke is one of the leading causes of disability, dementia and death. Within the USA, roughly 660,000 persons will experience a stroke each year. Although many individuals go on to demonstrate substantial improvement and recovery following stroke, a substantial percentage show residual effects including dementia. Vascular dementia has variable causes and manifestations, and research is revealing increasingly more common ground between vascular dementia and Alzheimer's dementia. However, vascular dementia often remains clinically distinct from Alzheimer's dementia, and profiles of neuropsychological impairment can be used to differentiate vascular dementia from the more common Alzheimer's dementia with some success. CONCLUSION: Vascular dementia causes dependence and disability. Most stroke survivors show improvement, but many develop dementia. Understanding for vascular dementia has recently improved, leading to improved treatment planning. Further research, especially on treatment for vascular dementia, is greatly needed.

A pitfall in pituitary imaging using standard head magnetic resonance (MR).

We present a case of a young girl complaining of headaches in whom a hypointense area was found in the pituitary gland with a standard magnetic resonance (MR) image of the head. This finding did not agree with clinical symptoms, so a dedicated MR of the sellar region was obtained. We determined that the supposed mass was artifact caused by volume averaging. Volume averaging is the effect of expressing the average density of two structures of a 3D slice on a 2D image. Increased slice thickness leads to increased volume averaging and decreased resolution. Dedicated MR uses thinner 3D slices to reconstruct an image and thus has better spatial resolution than standard MR. We emphasize the need of dedicated MR to evaluate pituitary lesions.

Role of Magnetic Resonance Imaging in Diagnosis of Motor Neuron Disease: Literature Review and Two Case Illustrations.

Motor neuron diseases (MNDs) are a group of devastating neurologic disorders that cause specific damage to the motor neuron cells. The current diagnosis of MND is based on results of the clinical examination and neurophysiologic studies. The length of time of referral to a neuromuscular neurologist and the lack of validated diagnostic criteria can delay diagnosis. Although the role of imaging is currently most useful in excluding other conditions, several attempts to incorporate neuroimaging in the diagnosis of the disease and assessment of progression have shown promising results.We conducted a literature review via searches in PubMed and The Cochrane Database using multiple relevant terms to the topic. Two cases with a challenging diagnosis of MND are described, with a thorough discussion of how the diagnosis was suggested on the basis of magnetic resonance imaging evidence in each case. Advanced magnetic resonance imaging findings can be useful tools that add to the diagnostic criteria of MNDs, especially in cases where reaching a definitive diagnosis is difficult. Such findings might enable clinicians to reach an early diagnosis that can improve the patient's quality of life and prolong survival.

Combination therapy with interferon beta-1a and doxycycline in multiple sclerosis: an open-label trial.

OBJECTIVE: To evaluate the efficacy, safety, and tolerability of combination therapy with intramuscular interferon beta-1a and oral doxycycline, a potent inhibitor of matrix metalloproteinases, in patients with relapsing-remitting multiple sclerosis (RRMS) having breakthrough disease activity. DESIGN: Open-label, 7-month trial. SETTING: Louisiana State University Health Sciences Center, Shreveport. PATIENTS: Fifteen patients with RRMS taking interferon beta-1a with breakthrough disease activity took doxycycline for 4 months. Patients underwent monthly neurologic examination, magnetic resonance imaging of the brain using triple-dose gadolinium, and safety blood work. INTERVENTIONS: Ongoing treatment with intramuscular interferon beta-1a plus oral doxycycline, 100 mg daily, for 4 months. MAIN OUTCOME MEASURES: The primary end point was gadolinium-enhancing lesion number change, and the secondary end points were relapse rates, safety and tolerability of the combination of interferon beta-1a and doxycycline in patients with MS, Expanded Disability Status Scale score, serum matrix metalloproteinase-9 levels, and transendothelial migration of monocytes exposed to serum from patients with RRMS. RESULTS: Combination of doxycycline and interferon beta-1a treatment resulted in reductions in contrast-enhancing lesion numbers and posttreatment Expanded Disability Status Scale values (P < .001 for both). Only 1 patient relapsed. Multivariate analyses indicated correlations between decreased serum matrix metalloproteinase-9 levels and enhancing lesion activity reduction. Transendothelial migration of monocytes incubated with serum from patients with RRMS undergoing combination therapy was suppressed. Adverse effects were mild; no adverse synergistic effects of combination therapy or unexpected adverse events were reported. CONCLUSIONS: Combination of intramuscular interferon beta-1a and oral doxycycline treatment was effective, safe, and well tolerated. Controlled clinical trials in larger cohorts of patients with MS are needed to evaluate the efficacy and tolerability of this combination. Trial Registration clinicaltrials.gov Identifier: NCT00246324

Pseudo-subarachnoid hemorrhage in a patient with acute cerebellar infarction.

OBJECTIVE: Hyperdensity in the basal cisterns on computed tomography (CT) brain scan is a diagnostic feature in subarachnoid hemorrhage. However, false enhancement of the subarachnoid space on CT scan may be seen in diffuse neurological conditions with acute presentation. This is the first reported case of a 'focal lesion' (acute cerebellar infarct) producing a 'pseudo-subarachnoid hemorrhage' secondary to increased intracranial pressure. CLINICAL PRESENTATION: A 42-year-old man presented with acute onset of left hemiataxia and neck pain. CT brain scan showed a left cerebellar infarct. During the admission, he had sudden onset of altered sensorium, and an emergency CT scan showed diffuse cerebral edema and hyperdensity of the basal cisterns. The patient then developed sudden cardiac arrest and all resuscitative measures failed. Autopsy showed no evidence of subarachnoid hemorrhage. CONCLUSION: Pseudo-subarachnoid hemorrhage is a rare clinical entity. It should be considered as a possibility in the evaluation and management of patients presenting acutely with CT brain scan showing hyperdensity of the basal cisterns and vascular imaging revealing absence of any aneurysm or vascular malformation.

Cryptococcal meningitis presenting as pseudosubarachnoid hemorrhage.

A 50-year-old man presented with progressive visual loss, headache, and two days of confusion. A computed tomography of his head suggested subarachnoid hemorrhage with accompanying right parietal ischemic infarction. The magnetic resonance image was consistent with right parietal perisulcal pial and superficial cortical inflammation; a subjacent vasogenic edema with a 1 cm diameter abscess was also present. Funduscopy revealed bilateral multifocal choroidal lesions and retinal perivascular sheathing. He was diagnosed with pseudosubarachnoid hemorrhage secondary to cryptococcal meningitis and choroidal microabscesses with retinal inflammation after a cerebrospinal fluid (CSF) examination revealed cryptococcal yeast forms, as well as high titers of CSF cryptococcal antigen, but no CSF red blood cells.

Amyloidoma presenting as a butterfly glioma on positron emission tomography scan and magnetic resonance-spectroscopy: a case report and review of the literature.

PURPOSE: Isolated amyloidoma rarely involves the nervous system. MATERIALS: We report a patient with progressively worsening triparesis and numbness in his extremities. RESULTS: Magnetic resonance imaging (MRI) of the brain revealed a mass lesion involving both hemispheres, which on positron emission tomography (PET) scan and magnetic resonance-spectroscopy (MR-SPECT) appeared to be a butterfly glioma. However, neuropathological examination revealed a large area with localized vascular amyloidosis. CONCLUSION: This is the first case of a localized central nervous system vascular amyloid to imitate a butterfly glioma on MRI and PET scan studies.

Hemorrhagic Brain Metastases in a Patient with Anaplastic Lymphoma Kinase (ALK)-Rearranged Invasive Mucinous Adenocarcinoma of the Lung.

BACKGROUND Invasive mucinous adenocarcinoma (IMA) is a rare variant of adenocarcinoma of the lung. It frequently shows KRAS mutations, while ALK rearrangement is exceedingly rare. We present a case of ALK-rearranged IMA of the lung presenting with an unusual pattern of brain metastases, radiologically mimicking a cavernous angioma. CASE REPORT A 44-year-old non-smoker female was first diagnosed with lung right lower lobe IMA with ALK rearrangement. Five years after surgery followed by chemotherapy, she developed a sudden onset headache. Brain imaging revealed a hemorrhagic left frontal mass, suspicious for a cavernous angioma. However, the pathology of the resected lesion showed an ALK-rearranged brain metastasis from the IMA of the lung. Interestingly, the metastases showed perivascular tumor infiltrates, accompanied by focal mural invasion, vascular disruption, and hemorrhage. CONCLUSIONS To our knowledge, this is the first reported case of brain metastasis from an ALK-rearranged IMA of the lung. Further investigation of the clinical and pathological characteristics of the ALK-rearranged IMA, including awareness of the possibility for development of brain metastases with tumor-associated vasculopathy and hemorrhage, is warranted.