A Practical Approach to Imaging of the Supplementary Motor Area and Its Subcortical Connections.

PURPOSE OF REVIEW: First, an anatomical and functional review of these cortical areas and subcortical connections with T-fMRI and tractography techniques; second, to demonstrate the value of this approach in neurosurgical planning in a series of patients with tumors close to the SMA. RECENT FINDINGS: Implications in language and cognitive networks with a clear hemispheric lateralization of these SMA/pre-SMA. The recommendation of the use of the advanced neuroimaging studies for surgical planning and preservation of these areas. The SMA/pre-SMA and their subcortical connections are functional areas to be taken into consideration in neurosurgical planning. These areas would be involved in the control/inhibition of movement, in verbal expression and fluency and in tasks of cognitive control capacity. Its preservation is key to the patient's postsurgical cognitive and functional evolution.

Association between subclinical atherosclerosis burden and unrecognized myocardial infarction detected by cardiac magnetic resonance in middle-aged low-risk adults.

AIMS: Evidence on the association between subclinical atherosclerosis (SA) and cardiovascular (CV) events in low-risk populations is scant. To study the association between SA burden and an ischaemic scar (IS), identified by cardiac magnetic resonance (CMR), as a surrogate of CV endpoint, in a low-risk population. METHODS AND RESULTS: A cohort of 712 asymptomatic middle-aged individuals from the Progression of Early SA (PESA-CNIC-Santander) study (median age 51 years, 84% male, median SCORE2 3.37) were evaluated on enrolment and at 3-year follow-up with 2D/3D vascular ultrasound (VUS) and coronary artery calcification scoring (CACS). A cardiac magnetic study (CMR) was subsequently performed and IS defined as the presence of subendocardial or transmural late gadolinium enhancement (LGE). On CMR, 132 (19.1%) participants had positive LGE, and IS was identified in 20 (2.9%) participants. Individuals with IS had significantly higher SCORE2 at baseline and higher CACS and peripheral SA burden (number of plaques by 2DVUS and plaque volume by 3DVUS) at both SA evaluations. High CACS and peripheral SA (number of plaques) burden were independently associated with the presence of IS, after adjusting for SCORE2 [OR for 3rd tertile, 8.31; 95% confidence interval (CI) 2.85-24.2; P < 0.001; and 2.77; 95% CI, 1.02-7.51; P = 0.045, respectively] and provided significant incremental diagnostic value over SCORE2. CONCLUSION: In a low-risk middle-aged population, SA burden (CAC and peripheral plaques) was independently associated with a higher prevalence of IS identified by CMR. These findings reinforce the value of SA evaluation to early implement preventive measures. CLINICAL TRIAL REGISTRATION: Progression of Early Subclinical Atherosclerosis (PESA) Study Identifier: NCT01410318.

The Progression and Early detection of Subclinical Atherosclerosis (PESA) study: rationale and design.

BACKGROUND: The presence of subclinical atherosclerosis is a likely predictor of cardiovascular events; however, factors associated with the early stages and progression of atherosclerosis are poorly defined. OBJECTIVE: The PESA study examines the presence of subclinical atherosclerosis by means of noninvasive imaging and prospectively analyzes the determinants associated with its development and progression in a middle-aged population. METHODS: The PESA study is an observational, longitudinal and prospective cohort study in a target population of 4000 healthy subjects (40-54 years old, 35% women) based in Madrid (Spain). Recruitment began in June 2010 and will be completed by the end of 2013. Baseline examination consists of (1) assessment for cardiovascular risk factors (including lifestyle and psychosocial factors); (2) screening for subclinical atherosclerosis using 2D/3D ultrasound in carotid, abdominal aorta and iliofemoral arteries, and coronary artery calcium score (CACS) by computed tomography; and (3) blood sampling for determination of traditional risk factors, advanced "omics" and biobanking. In addition, a subgroup of 1300 participants with evidence of atherosclerosis on 2D/3D ultrasound or CACS will undergo a combined (18)F-fluorodeoxyglucose-positron emission tomography/magnetic resonance imaging ((18)FDG PET/MRI) study of carotid and iliofemoral arteries. Follow-up at 3 and 6 years will include a repetition of baseline measurements, except for the (18)FDG PET/MRI study, which will be repeated at 6 years. CONCLUSIONS: The PESA study is expected to identify new imaging and biological factors associated with the presence and progression of atherosclerosis in asymptomatic people and will help to establish a more personalized management of medical care.

Cardiac Insulin Resistance in Subjects With Metabolic Syndrome Traits and Early Subclinical Atherosclerosis.

OBJECTIVE: Experimental evidence suggests that metabolic syndrome (MetS) is associated with changes in cardiac metabolism. Whether this association occurs in humans is unknown. RESEARCH DESIGN AND METHODS: 821 asymptomatic individuals from the Progression of Early Subclinical Atherosclerosis (PESA) study (50.6 [46.9-53.6] years, 83.7% male) underwent two whole-body 18F-fluorodeoxyglucose positron emission tomography-magnetic resonance (18F-FDG PET-MR) 4.8 ± 0.6 years apart. Presence of myocardial 18F-FDG uptake was evaluated qualitatively and quantitatively. No myocardial uptake was grade 0, while positive uptake was classified in grades 1-3 according to target-to-background ratio tertiles. RESULTS: One hundred fifty-six participants (19.0%) showed no myocardial 18F-FDG uptake, and this was significantly associated with higher prevalence of MetS (29.0% vs. 13.9%, P < 0.001), hypertension (29.0% vs. 18.0%, P = 0.002), and diabetes (11.0% vs. 3.2%, P < 0.001), and with higher insulin resistance index (HOMA-IR, 1.64% vs. 1.23%, P < 0.001). Absence of myocardial uptake was associated with higher prevalence of early atherosclerosis (i.e., arterial 18F-FDG uptake, P = 0.004). On follow-up, the associations between myocardial 18F-FDG uptake and risk factors were replicated, and MetS was more frequent in the group without myocardial uptake. The increase in HOMA-IR was associated with a progressive decrease in myocardial uptake (P < 0.001). In 82% of subjects, the categorization according to presence/absence of myocardial 18F-FDG uptake did not change between baseline and follow-up. MetS regression on follow-up was associated with a significant (P < 0.001) increase in myocardial uptake. CONCLUSIONS: Apparently healthy individuals without cardiac 18F-FDG uptake have higher HOMA-IR and higher prevalence of MetS traits, cardiovascular risk factors, and early atherosclerosis. An improvement in cardiometabolic profile is associated with the recovery of myocardial 18F-FDG uptake at follow-up.

Early perfusion changes in multiple sclerosis patients as assessed by MRI using arterial spin labeling.

BACKGROUND: Gadolinium-perfusion magnetic resonance (MR) identifies gray matter abnormalities in early multiple sclerosis (MS), even in the absence of structural differences. These perfusion changes could be related to the cognitive disability of these patients, especially in the working memory. Arterial spin labeling (ASL) is a relatively recent perfusion technique that does not require intravenous contrast, making the technique especially attractive for clinical research. PURPOSE: To verify the perfusion alterations in early MS, even in the absence of cerebral volume changes. To introduce the ASL sequence as a suitable non-invasive method in the monitoring of these patients. MATERIAL AND METHODS: Nineteen healthy controls and 28 patients were included. The neuropsychological test EDSS and SDMT were evaluated. Cerebral blood flow and bolus arrival time were collected from the ASL study. Cerebral volume and cortical thickness were obtained from the volumetric T1 sequence. Spearman's correlation analyzed the correlation between EDSS and SDMT tests and perfusion data. Differences were considered significant at a level of P < 0.05. RESULTS: Reduction of the cerebral blood flow and an increase in the bolus arrival time were found in patients compared to controls. A negative correlation between EDSS and thalamus transit time, and between EDSS and cerebral blood flow in the frontal cortex, was found. CONCLUSION: ASL perfusion might detect changes in MS patients even in absent structural volumetric changes. More longitudinal studies are needed, but perfusion parameters could be biomarkers for monitoring these patients.

Correlation between apparent diffusion coefficient values in breast magnetic resonance imaging and prognostic factors of breast invasive ductal carcinoma.

BACKGROUND: We wanted to examine whether the apparent diffusion coefficient values obtained by diffusion-weighted imaging techniques could indicate an early prognostic assessment for patients with Invasive Ductal Carcinoma and, therefore, influence the treatment decision making. OBJECTIVE: The main objective was to evaluate the correlation between the apparent diffusion coefficient values obtained by diffusion-weighted imaging and the key prognostic factors in breast invasive ductal carcinoma. Secondary objectives were to analyze the eventual correlations between magnetic resonance imaging findings and prognostic factors in breast cancer; and to perform a comparison between results in 1.5 and 3.0 T scanners. METHODS: Breast magnetic resonance imaging with diffusion-weighted imaging sequence was performed on 100 patients, who were proven histopathologically to have breast invasive ductal carcinoma. We compared the apparent diffusion coefficient values, obtained previous to biopsy, with the main prognostic factors in breast cancer: tumor size, histologic grade, hormonal receptors, Ki67 index, human epidermal growth factor receptor type 2, and axillary lymph node status. The Mann-Whitney U test and the Kruskal-Wallis analysis were used to establish these correlations. RESULTS: The mean apparent diffusion coefficient value was inferior in the estrogen receptor-positive group than in the estrogen receptor-negative group (1.04 vs 1.17 × 10-3 mm2/s, P = .004). Higher histologic grade related to larger tumor size (P = .002). We found association between spiculated margins and positive axillary lymph node status [odds ratio = 4.35 (1.49-12.71)]. There were no differences in apparent diffusion coefficient measurements between 1.5 and 3.0 T magnetic resonance imaging scanners (P = .513). CONCLUSIONS: Low apparent diffusion coefficient values are related with positive expression of estrogen receptor. Larger tumors and spiculated margins are associated to worse prognosis. Rim enhancement is more frequently observed in estrogen receptor-negative tumors. There are no differences in apparent diffusion coefficient measurements between different magnetic resonance imaging scanners.

The Multiple Faces of Nervous System Lymphoma. Atypical Magnetic Resonance Imaging Features and Contribution of the Advanced Imaging.

Primary central nervous system lymphoma (PCNSL) is an uncommon variant of extranodal non-Hodgkin lymphoma, which involves the brain, leptomeninges, eyes, or spinal cord without evidence of systemic disease. In addition to a detailed history and physical examination, the evaluation of patients suspected of having a PCNSL should include a contrast-enhanced magnetic resonance imaging. Occassionaly, PCNSL shows peculiarities on magnetic resonance imaging, which delay the diagnosis and thus the start of treatment. It is essential that radiologists be aware of these less common presentations such as isolated spine or meningeal lymphoma, angiocentric lymphoma, ocular lymphoma, and Epstein-Barr virus-associated lymphoma. Advanced neuroimaging (diffusion and perfusion sequences, spectroscopy-magnetic resonance, and positron emission tomography metabolic imaging) are useful techniques for the differential diagnosis of PCNSL with processes such as brain glioblastoma, multiple sclerosis, and metastases and brain abscesses, especially in atypical presentations. In this article, a review of unusual radiological findings for PCNSL in immunocompetent patients is made, highlighting the usefulness of functional and metabolic imaging for establishing an early presumptive diagnosis, which reduces delays in treatment.