The contribution of enhancing lesions in monitoring multiple sclerosis treatment: is gadolinium always necessary?

BACKGROUND: MRI is highly sensitive for monitoring of disease activity and treatment efficacy in MS. Patients treated with disease modifying therapy (DMT), who experience MRI activity, including contrast-enhancing lesions (CEL) or new/enlarged T2 lesions, should be evaluated for a switch to more effective treatment. Due to recent evidence of gadolinium (Gd) accumulation in the brain after repeated administration of Gd-based contrast agents, FDA recommended to limit its use. AIM: To investigate the proportion of cases in which MRI activity would be detectable only using contrast-enhanced T1-weighted sequences.Secondary aims were to assess the presence of clinical or demographic variables associated with reactivation of pre-existing lesions and to analyse therapeutic consequences of different types of MRI lesions. METHODS: We retrospectively evaluated brain MRI scans, performed between 2014 and 2018, in patients treated with DMT for at least 6 months. RESULTS: We analysed 906 scans in 255 patients. New/enlarged T2 lesions were detected in 13.7% of cases, CEL in 3.5%, CEL without new T2 lesions (old lesions reactivated) in 1.1%. No variables were associated with old lesions reactivated. CEL with T2 equivalent were at higher risk of DMT switch, compared with new/enlarged T2 lesions without corresponding CEL (OR 4.0, 95% CI 1.5-10.4, p  = 0.005). CONCLUSIONS: Reactivation of pre-existing lesions is limited to a tiny fraction of MRI studies. Gd + T1-weighted images could be omitted, in patients treated with DMT for at least 6 months, without relevant loss of information.

Pattern of care and effectiveness of treatment for glioblastoma patients in the real world: Results from a prospective population-based registry. Could survival differ in a high-volume center?

BACKGROUND: As yet, no population-based prospective studies have been conducted to investigate the incidence and clinical outcome of glioblastoma (GBM) or the diffusion and impact of the current standard therapeutic approach in newly diagnosed patients younger than aged 70 years. METHODS: Data on all new cases of primary brain tumors observed from January 1, 2009, to December 31, 2010, in adults residing within the Emilia-Romagna region were recorded in a prospective registry in the Project of Emilia Romagna on Neuro-Oncology (PERNO). Based on the data from this registry, a prospective evaluation was made of the treatment efficacy and outcome in GBM patients. RESULTS: Two hundred sixty-seven GBM patients (median age, 64 y; range, 29-84 y) were enrolled. The median overall survival (OS) was 10.7 months (95% CI, 9.2-12.4). The 139 patients ≤aged 70 years who were given standard temozolomide treatment concomitant with and adjuvant to radiotherapy had a median OS of 16.4 months (95% CI, 14.0-18.5). With multivariate analysis, OS correlated significantly with KPS (HR = 0.458; 95% CI, 0.248-0.847; P = .0127), MGMT methylation status (HR = 0.612; 95% CI, 0.388-0.966; P = .0350), and treatment received in a high versus low-volume center (HR = 0.56; 95% CI, 0.328-0.986; P = .0446). CONCLUSIONS: The median OS following standard temozolomide treatment concurrent with and adjuvant to radiotherapy given to (72.8% of) patients aged ≤70 years is consistent with findings reported from randomized phase III trials. The volume and expertise of the treatment center should be further investigated as a prognostic factor.

Influenza A H1N1 Related Acute Necrotizing Encephalopathy: Radiological Findings in Adulthood.

In 2009 a novel swine-origin Influenza A H1N1 virus was identified in Mexico and Southern California. Since it was first recognized, neurological complications including acute necrotizing encephalopathy (ANE) have been globally documented in association with this viral infection. ANE is mostly known to occur in the paediatric population. We describe a fatal case of ANE in a previously healthy 40-year-old man infected with influenza A H1N1 virus presenting with severe neurologic decline. Computed tomography (CT) scan and magnetic resonance imaging (MRI) findings were consistent with ANE. CT and MR findings typically documented in paediatric cases of ANE - including bilateral thalamic necrosis with petechial hemorrhage - have been seldom described in adulthood.

(1)H MR Spectroscopy of Meningiomas at 3.0T: the Role of Glutamate-Glutamine Complex and Glutathione.

Proton magnetic resonance spectroscopy ((1)H MRS) has been used extensively for the characterization of the intracranial meningiomas. A major emphasis is placed on identification of an alanine (Ala) content within these tumors. Less attention is given to other metabolites such as glutamine and glutamate (Glx). Our objective was to assess the incidence and the relevance of the Glx content in meningiomas, to evaluate their usefulness versus Ala in the diagnosis of intracranial meningiomas and to indicate a potential role of other biochemical compounds such as glutathione (GSH). We performed a retrospective review of the (1)H MRS spectra at 3.0T of 16 intracranial meningiomas in 16 consecutive patients with newly diagnosed tumors. All meningiomas were evaluated with single- voxel (1)H MRS at short echo time using an automatic quantitation of the metabolites by linear combination model (LCModel) fitting. Detailed analysis of the spectra showed that the Glx content was a more common result (100%) than the Ala content (44%). The Glx content can be considered in high concentrations within these tumors resulting in overall levels comparable to normal brain values (P > 0.2). A glutathione (GSH) spectrum was added to the LCModel basis set in six meningiomas and in all of them a GSH peak was detected at 2.95 ppm (100%). Other metabolites such as guanidinoacetate (Gua) were detected in six meningiomas (38%) and this was not reported previously. Our data indicate that Glx and GSH are far more likely to be biochemical predictors than Ala in the (1)H MRS evaluation of intracranial meningiomas. The significance of Gua as another potential marker of the meningioma cell metabolism needs to be further investigated.

Acute necrotizing encephalopathy in a child during the 2009 influenza A(H1N1) pandemia: MR imaging in diagnosis and follow-up.

The recently emerged novel influenza A(H1N1) virus continues to spread globally. The clinical disease generally appears mild, but unfavorable outcomes have been reported. We describe a case of a 3-year-old Italian girl infected with influenza A(H1N1) virus presenting with neurologic deterioration. CT findings were negative, but MR imaging findings were consistent with ANE. To our knowledge, this is the first case reported in Europe and the second in worldwide pediatric radiology literature.

Basilar Dependence on a Persistent Hypoglossal Artery Visualized at CT Angiography. A Case Report.

The persistent hypoglossal artery is a rare perseverance of an embryonic vessel connecting the anterior and posterior circulations and is generally considered an incidental finding. This report describes a patient with a basilar dependence on a persistent hypoglossal artery visualized at CT angiography. The pertinent findings and clinical implications of this anomalous vessel are discussed.

Desmoplastic Fibroma of the Mandible: Usefulness of CT and MR Imaging in Diagnosis and Treatment. A Case Report.

Desmoplastic fibroma (DF) is a rare non-metastasizing benign neoplasm of the bone characterized by aggressive local infiltration, also known as desmoid tumour. Desmoplastic fibroma of the mandible may recur locally when incompletely excised. In particular it can occur adjacent to and display contiguous extension along the mandibular nerve. This case report describes the imaging findings of a histopathologically proven desmoplastic fibroma involving the right mandibular region in a three-year-old Italian girl. We also discuss the usefulness of different imaging modalities (CT and MRI) in DF diagnosis and treatment.

MR and Diffusion Tensor Imaging of Vein of Galen Aneurysmal Malformation in an Infant Presenting with Spastic Diplegia and Seizures. A Case Report.

A three-year-old girl developed spastic diplegia to the right and irregular tonc-clonic movements. Phenobarbital was started because of suspected seizure activity. The Pediatric unit asked for brain MR imaging to investigate neurological symptoms. MR and diffusion tensor imaging showed a haemorrhagic vein of Galen aneurysmal malformation (choroidal type) that shifted the corticospinal tract fibres to one side and the corpus callosum was moved forward. Vein of Galen aneurysmal malformations (VGAM) are characterized by multiple arteriovenous connections draining into a markedly enlarged median draining vein. This ectatic vein is not the vein of Galen, but its embryonic precursor, the median prosencephalic vein of Markowski. During normal development, the posterior portion of the median prosencephalic vein persists as the vein of Galen, while its anterior portion regresses in parallel with the formation of the internal cerebral veins (ICV). With the advent of endovascular neurointerventional techniques, the prospects for successful treatment of these lesions, once dismal, are now much improved. MR and diffusion tensor imaging can help in diagnosis and to guide endovascular interventional procedures.

Diffusion Tensor MR Imaging Tractography of the Pyramidal Tracts and Corpus Callosum in Children with Right-Sided Congenital Hemiparesis. A Case Report.

This study used diffusion tensor tractography to evaluate the diffusion parameters of the corpsus callosum and asymmetry in the diffusion parameters of the corticospinal tracts in children with congenital hemiparesis. Precision moving critically correlates with the integrity of the pyramidal tracts as evidenced in congenital hemiparesis by the correlation found between corticospinal lesions and motor deficits. Therefore we hypothesize that diffusion parameters correlate with the severity of hemiparesis measured using the Bayley Scales of Infant Development.

Occasional finding of a dural arteriovenous fistula in a newborn with orbital lymphangioma. A case report.

Dural arteriovenous fistulas (DAVF) are vascular malformations rarely occurring in the paediatric population (1,2,3). Prompt diagnosis and treatment are mandatory to prevent life-threatening complications including congestive heart failure and severe brain injury (1,2). We describe the case of a female newborn with an orbital lymphangioma treated for a posterior fossa DAVF. We emphasize the role of MR imaging as a useful non-invasive tool in the diagnosis of these malformations and in the evaluation of associated brain parenchymal lesions.

Bilateral Hippocampal DWI Lesions in Transient Global Amnesia. A Case Report.

Transient global amnesia (TGA) is characterized by anterograde memory disturbance of sudden onset that lasts for 1 to 24 hours. The etiology and pathogenesis of TGA are still uncertain, although an hypoxic-ischemic origin has been recently suggested on the basis of infarct-like diffusion-weighted imaging (DWI) lesions in the hippocampus of some affected individuals. Recent diffusion-weighted imaging (DWI) studies have indicated the presence of focal hyperintensities involving the hippocampus in TGA patients. These lesions detected by DWI, which peak at 48 to 72 hours, are small and punctate (1-3 mm) and in most studies are reported as unilateral. We describe one TGA patient with high signal-intensity lesions in the bilateral hippocampus on DWI at the acute stage. The mechanisms related to the pathophysiology are discussed with emphasis on the hypoxic-ischemic origin underlying the observation of infarct-like diffusion-weighted imaging (DWI) abnormalities.

Non-von Hippel-Lindau Hemangioblastoma in the Hippocampus: Characterization with Time-Resolved MRA Using TRICKS Sequence at 3T. A Case Report.

Supratentorial hemangioblastomas (HBs) are exceedingly rare tumors accounting for 5%-10% of all HBs and usually present in the setting of von Hippel-Lindau (VHL) disease. Isolated HBs of the central nervous system also occur as a result of spontaneous mutation in the absence of any clinical manifestations of VHL disease. Of 13 temporal lobe HBs, only one non-VHL case was reported in the hippocampus. We describe the TRICKS findings in a case of isolated hemangioblastoma in the hippocampus without VHL disease. To our knowledge, this is the second case report of a hippocampal non-VHL hemangioblastoma.

Stress-ECG vs. CT coronary angiography for the diagnosis of coronary artery disease: a "real-world" experience.

PURPOSE: This study aimed to evaluate the diagnostic accuracy of stress electrocardiogram (ECG) and computed tomography coronary angiography (CTCA) for the detection of significant coronary artery stenosis (> or =50%) in the real world using conventional CA as the reference standard. MATERIALS AND METHODS: A total of 236 consecutive patients (159 men, 77 women; mean age 62.8+/-10.2 years) at moderate risk and with suspected coronary artery disease (CAD) were enrolled in the study and underwent stress ECG, CTCA and CA. The CTCA scan was performed after i.v. administration of a 100-ml bolus of iodinated contrast material. The stress ECG and CTCA reports were used to evaluate diagnostic accuracy compared with CA in the detection of significant stenosis > or =50%. RESULTS: We excluded 16 patients from the analysis because of the nondiagnostic quality of stress ECG and/or CTCA. The prevalence of disease demonstrated at CA was 62% (n=220), 51% in the population with comparable stress ECG and CTCA (n=147) and 84% in the population with equivocal stress ECG (n=73). Stress ECG was classified as equivocal in 73 cases (33.2%), positive in 69 (31.4%) and negative in 78 (35.5%). In the per-patient analysis, the diagnostic accuracy of stress ECG was sensitivity 47%, specificity 53%, positive predictive value (PPV) 51% and negative predictive value (NPV) 49%. On stress ECG, 40 (27.2%) patients were misclassified as negative, and 34 (23.1%) patients with nonsignificant stenosis were overestimated as positive. The diagnostic accuracy of CTCA was sensitivity 96%, specificity 65%, PPV 74% and NPV 94%. CTCA incorrectly classified three (2%) as negative and 25 (17%) as positive. The difference in diagnostic accuracy between stress ECG and CTCA was significant (p<0.01). CONCLUSIONS: CTCA in the real world has significantly higher diagnostic accuracy compared with stress ECG and could be used as a first-line study in patients at moderate risk.

Formation of intracerebral cavernous malformation after radiation treatment for medulloblastoma in a child.

Cavernous malformations (CMs) are one of the four major types of vascular malformations of the central nervous system (CNS). Literature reports also term them cavernomas, cavernous angiomas, angiographically occult vascular malformations and cavernous hemangiomas.CMs are composed of well-circumscribed vascular channels containing blood at various stages of evolution and show a low-flow vascular pattern. They have usually been considered developmental lesions of the intracranial vasculature, but recently the de novo appearance of these malformations has been observed with increasing frequency.We describe a case of sporadic de novo formation of a CNS cavernous malformation following radiation treatment in a child with medulloblastoma. We review the patient's clinical course and the literature focusing on the role of radiation therapy in the pathogenesis of CMs.

Refractures in cemented vertebrae after percutaneous vertebroplasty and pain relief after a second procedure: a retrospective analysis.

Refractures of cemented vertebrae occasionally occur after vertebroplasty. It is unclear whether such fractures are procedure-related or part of the natural course of osteoporosis and neoplasy. Our aim was to identify why there is an increased risk of subsequent fracture in cemented vertebrae. We retrospectively analyzed the incidence and possible causative mechanism of refracture in patients who had received vertebroplasty for multiple levels of vertebral compression fracture and the reduction of pain after a subsequent vertebroplasty procedure. A total of 356 patients were evaluated with follow-up from June 2003 to September 2008. We identified 59 refractured patients (54 osteoporotic and four neoplastic). Refractures of cemented vertebrae after vertebroplasty occurred in 59 patients (16%: 98% osteoporotic and 2% neoplastic). Refractures occurred in 8% at the same level as the first vetebroplasty, 31% at an inferior level, 19% at a superior level, 41% at superior and inferior levels and 1% at superior and same levels. Pain was significantly reduced after retreatment in 45 patients (76%) with a moderate reduction in 14 patients (24 %). In conclusion, significant anterior vertebral height restoration increases the risk of subsequent fracture in cemented vertebrae.

MRA Evidence of Superior Sagittal Sinus - Torcular Herophili Divisions in a New Type of Occipital Sinus. A Case Report.

We describe a new type of occipital sinus: absence (or hypoplasy) of the right transverse sinus, patent right sigmoid sinus and a well formed left occipital sinus draining into the left marginal sinus. The lateral and occipital sinus variations were classified into five groups by Kalbag. This classification was modified in 1980 by Dora and Zileli. We speculate on the possible MRA evidence of "divisions" of the superior sagittal sinus (SSS), as reported by Shao et Al (2009) who examined the lumen of the SSS and torcular Herophili with the aid of an endoscope.

Pseudotumoural Hemicerebellitis: Conventional MR Imaging and MR Spectroscopy Evolution. A Case Report.

Acute cerebellitis is an inflammatory process commonly involving both cerebellar hemispheres. Bilateral cerebellar hemispheres involvement is the most common finding. It typically occurs as a primary infectious, post-infectious or post-vaccination disorder, but is also a disease entity with heterogeneous pathogenesis including paraneoplasia. Acute cerebellitis is usually a benign, self-limiting and rarely fatal disease. Typically, cerebellar atrophy is a late consequence of the syndrome. We describe the radiological features of a case of pseudotumoural hemicerebellitis with emphasis on MRI and spectroscopy findings as non-invasive diagnostic tools to avoid unnecessary surgical procedures.

Listerial Rhombencephalitis MR Findings. A Case Report.

We describe a case of listerial rhombencephalitis in a previously healthy 37-year-old woman. The diagnosis was based on the clinical findings, results of cerebrospinal fluid analysis, blood culture and MR imaging. The specific treatment was started after culture results were available, and the patient made a full clinical recovery.

Noninvasive evaluation of the celiac trunk and superior mesenteric artery with multislice CT in patients with chronic mesenteric ischaemia.

PURPOSE: This study sought to assess the role of multislice computed tomography (MSCT) in patients with suspected chronic mesenteric ischaemia (CMI). MATERIALS AND METHODS: Forty-five patients (29 men; mean age 68) underwent MSCT angiography of the abdomen for suspected CMI (main clinical finding: postprandial abdominal pain). The scan protocol was detectors/collimation 16/0.75 mm; feed 36 mm/s; rotation time 500 ms; increment 0.4 mm; 120-150 mAs and 120 kVp. A volume of 80 ml of contrast material was administered through an antecubital vein (rate 4 ml/s), followed by 40 ml of saline (rate 4 ml/s). Images were analysed on the workstation with different algorithms (axial image scrolling, multiplanar reconstructions, maximum intensity projection, volume rendering). Targeted central lumen-line reconstructions (curved reconstructions) were obtained along the celiac trunk (CeT) and superior mesenteric artery (SMA). Vessel occlusions and significant (>50%) stenosis were recorded. RESULTS: Image generation and interpretation required 25 min. Stenosis and/or occlusions were detected in 29 (65%) cases on the CeT and in 32 (71%) on the SMA. Of those lesions (n=61), 44 (49%) were classified as not significant. In 16 (35%) cases, there was a simultaneous stenosis and/or occlusion of the CeT and SMA (confirmed by conventional angiography). In six (13%) cases, there were no lesions affecting the CeT, SMA or their branches (confirmed by clinical follow-up). CONCLUSIONS: MSCT angiography can play a major role in the detection of stenosis of the abdominal arteries in patients with suspected CMI.