Morphological and Functional Neuroradiology of Brain Metastases.

Neuroimaging plays a key role in the diagnosis and differentiation of brain metastases (BM) in patients with known or unknown malignancies. Computed tomography and magnetic resonance imaging are the key imaging modalities used in the detection of BM. Advanced imaging techniques including proton magnetic resonance spectroscopy, magnetic resonance perfusion, diffusion weighted imaging, and diffusion tensor imaging may aid in arriving at the correct diagnosis, in particular cases, such as newly diagnosed solitary enhancing brain lesions in patients without known malignancy. Imaging is also performed to predict and/or assess the efficacy of treatment, and to differentiate residual or recurrent tumors from therapy-related complications. Furthermore, the recent advent of artificial intelligence is opening up a vast scenario for the analysis of quantitative information deriving from neuroimaging. In this image-rich review, we provide an up-to-date overview on the application of imaging in patients with BM. We describe typical and atypical imaging findings of parenchymal and extra-axial BM on Computed tomography, magnetic resonance imaging, and positron emission tomography, focusing on the role of advanced imaging techniques, that can serve as problem-solving tools in the management of patients with BM.

Diagnosis, treatment, and follow-up of patients with cerebral amyloid angiopathy-related inflammation.

PURPOSE: Cerebral amyloid angiopathy-related inflammation (CAA-ri) is a rare potentially reversible encephalopathy associated with an autoimmune process against proteins deposited in the walls of cortical and leptomeningeal brain vessels. Definite diagnosis requires histopathological features of vascular inflammation and amyloid deposition from brain biopsy. Clinical-neuroradiological criteria have been recently introduced and validated to reduce the need for biopsy. The purpose of this paper is to report a historical retrospective review of clinical-neuroradiological follow-up of two patients with probable CAA-ri and five patients with a reasonably probable suspect of CAA-ri (4 females, 3 males, patient's age at admission: 66-79 years) seen at our institution between 2007 and 2021, focusing on clinical and neuroradiological awareness to this entity and variable response to immunotherapy. MATERIALS AND METHODS: Clinical features at presentation included subacute to acute confusion (6/7), seizures (4/7), cognitive impairment (5/7), and focal neurological signs (3/7). Neuroradiology included braincomputed tomography followed by magnetic resonance imaging. Infectious diseases and autoimmune workups were then performed. RESULTS: CSF analysis was performed in two patients. Cerebral angiography was performed in two patients, to rule out vascular malformations. Hemorrhagic posterior reversible encephalopathy syndrome has been suspected in two patients. Four patients underwent immunotherapy with corticosteroids followed by reduction of brain dysfunctions. Three patients did not undergo immunotherapy but underwent clinical and/or neuroradiological remission. CONCLUSIONS: Patients with CAA-ri present a rare steroid-responsive acute to subacute brain dysfunction. Thus, it has to be known and recognized both clinically and neuroradiologically. Spontaneous clinical and/or neuroradiological improvement is possible in patients with mild symptoms.

Central Nervous System Myeloma and Unusual Extramedullary Localizations: Real Life Practical Guidance.

Central nervous system localization of multiple myeloma (CNS-MM) accounts for about 1% of all MM during disease course or even rarer at diagnosis. A difference in the origin, i.e., osteodural or primary dural vs leptomeningeal/intraparenchymal, seems to define two distinct types of intracranial myeloma, with different clinical behavior. CNS-MM may occur also as a presentation of MM. Treatment is still unsatisfactory and many treatments have been reported: chemotherapy, intrathecal therapy, and radiotherapy, with dismal prognosis. Other sites of myeloma localization could be also of interest and deserve description. Because of the rarity and aggressiveness of the disease clinicians are often doubtful on how to treat it since there is no general agreement. Moreover, recent drugs such as the anti CD38 monoclonal antibody, immunomodulatory drugs, and proteasome inhibitors have changed the treatment of patients with MM with a significant improvement in overall response and survival. The role of novel agents in CNS MM management and unusual presentations will be discussed as well as the potential role of other new immunomodulatory drugs and proteasome inhibitors that seem to cross the blood-brain barrier. The purpose of this review is to increase awareness of the clinical unusual presentation and neuroradiological findings, give practical diagnostic advice and treatment options algorithm.

Adult brainstem glioma: a multicentre retrospective analysis of 47 Italian patients.

BACKGROUND AND PURPOSE: Adult brainstem gliomas are rare primary brain tumours with heterogeneous clinical course. The low frequency of these tumours makes it difficult to achieve high-quality evidence regarding prognostic factors, adequate therapeutic approach and outcome in such patients. METHODS: In this retrospective study, we analysed clinical, radiological, molecular, prognostic and therapeutic factors in a series of 47 histologically proven adult brainstem gliomas recruited over a 20-year period (1998-2018). RESULTS: Twenty-two patients were male, 25 female with median age of 39 years. The tumour involved one brainstem segment in 20 cases and 2 or more segments in 27. Contrast enhancement was reported in 28 cases. Surgical procedures included biopsy in 26 cases and partial/total resection in the remaining 21. Histological diagnosis was of low-grade glioma in 23 patients, high-grade glioma in 22 and non-diagnostic in 2 cases. Data regarding molecular biology were available for 22 patients. Median overall survival was 35 months, in particular 16 months in high-grade glioma and 84 months in low-grade glioma. At univariate analysis, tumour grade was the only factor with a statistically significant impact on survival time (p = 0,003), whereas younger age, better performance status and total/subtotal resection showed a trend to more prolonged survival. This study also confirms safety of biopsy/surgery in adult brainstem glioma patients and shows a clear trend to a more frequent assessment of molecular biology data. CONCLUSIONS: Further prospective multicentre efforts, and hopefully clinical trials, are necessary to improve outcome in this neglected glioma patient population.

Assisted coiling of saccular wide-necked unruptured intracranial aneurysms: stent versus balloon.

BACKGROUND AND PURPOSE: Assisted coiling with stents or balloons enables a higher percentage of complete occlusions of saccular unruptured intracranial aneurysms to be achieved with a reasonable complication rate. The aim of this study was to compare stent-assisted coiling and the balloon remodeling technique in terms of efficacy, stability, and safety for the treatment of comparable unruptured saccular intracranial aneurysms. MATERIALS AND METHODS: 268 patients with 286 saccular unruptured wide-necked intracranial aneurysms were treated at our institution with stent- or balloon-assisted coiling and retrospectively reviewed. Statistical analysis was performed to assess significant differences between the two groups. RESULTS: The rate of complete occlusion at the end of the procedure was higher with stent-assisted coiling than with balloon-assisted coiling (86.8% vs 78%) and the same results were also observed after 6 months (92.1% vs 77.6%; p=0.05). About 50% of major recurrences occurred in large to giant aneurysms (p<0.001). The overall complication rate was similar in the stent-assisted and balloon-assisted groups (10.3% vs 9.3%). Independently of the technique, a higher complication rate was observed with bifurcational aneurysms, particularly in the middle cerebral artery (p=0.016). CONCLUSIONS: Stent-assisted coiling achieved better results in terms of complete occlusion and stability than balloon-assisted coiling with a lower rate of recurrence without being associated with a higher risk of intraprocedural complications. Bifurcational and large to giant aneurysms were associated with higher complication rates and higher recurrence rates, respectively, and still represent a challenge for both techniques.

Endovascular treatment of unruptured and ruptured brain arteriovenous malformations with Onyx18: a monocentric series of 84 patients.

BACKGROUND: Brain arteriovenous malformations (AVMs) are a rare pathology, and their treatment is discussed. The development of techniques and materials in endovascular, radiosurgical, and neurosurgical fields led to higher rates of complete occlusions and good clinical outcomes. MATERIALS AND METHODS: 84 patients (52 men, 32 women; mean age 38.2 years; range, 9-70 years) were treated at our institution with Onyx18 from 2001 to 2011. Patients treated with other embolic agents, with micro-AVMs, were not included in the analysis. RESULTS: Complete occlusion was achieved in 27/84 patients (32.2%), in 40/84 (47.6%) brain AVMs occlusion of 80-90% of the nidus was obtained, and in 17/84 (20.3%) cases <80% of the nidus was occluded. Intraprocedural adverse events occurred in 11/84 patients (13.1%), and overall mortality and disabling permanent morbidity were 2.3% (2/84) and 4.7% (4/84), respectively. CONCLUSIONS: Endovascular treatment may be considered a safe and effective approach in superficial small brain AVMs in addition to surgery, mostly in ruptured AVMs. The therapeutic strategy should be to cure small and medium AVMs with endovascular treatment alone or combined treatment. Large unruptured AVMs (Spetzler-Martin grades IV-V) should be treated with target embolization of high flow fistulas or intranidal aneurysms.