Extraventricular Neurocytoma of the Sellar Region Presenting With Syndrome of Inappropriate Antidiuresis.

Neurocytomas are neuronal tumors that are usually intraventricular. Rare cases can arise from extraventricular sites. To our knowledge, only 29 cases of extraventricular neurocytoma of the sellar region (EVNSR) have been reported in the literature. We describe a case of a 39-year-old woman who presented with a one-month history of refractory headache, nausea and vomiting. Magnetic resonance imaging (MRI) showed a 5.1 × 3.1 × 2.2 cm sellar and suprasellar mass, suggestive of a pituitary adenoma (PA). She had hyponatremia, obstructive hydrocephalus, and panhypopituitarism at presentation (hypogonadism, adrenal insufficiency). After glucocorticoid replacement therapy and ventriculoperitoneal shunt, the vomiting and headache resolved, but she remained with nausea and hyponatremia. She was submitted to surgery, and histopathological analysis revealed a neurocytoma with positive immunostaining for arginine vasopressin. Syndrome of inappropriate antidiuresis (SIAD) was diagnosed but did not resolve after surgery due to residual tumor, despite fluid restriction and saline replacement. SIAD later resolved with empagliflozin. In conclusion, EVNSR is extremely rare and can be misdiagnosed as PA on MRI. In the context of SIAD and extraventricular neurocytoma, a secreting arginine vasopressin tumor must be considered. SIAD can be challenging to treat, with excision of the EVNSR the treatment choice and, alternatively, empagliflozin associated with fluid restriction.

Loss of ATRX Protein Expression in an Aggressive Null Cell Pituitary Tumor.

Somatic alpha thalassemia/mental retardation syndrome X-linked (ATRX) pathogenic variants have been shown to predict a malignant phenotype in neuroendocrine tumors. They were recently identified in aggressive pituitary tumors and carcinomas, mainly of corticotrophic origin. To our knowledge, these tumors are rare in a general cohort of pituitary tumors, with no cases described in null cell tumors. These variants can lead to loss of protein expression as revealed by immunohistochemistry. We describe a case of an aggressive null cell pituitary tumor with loss of ATRX expression. The patient underwent two transsphenoidal surgeries and radiotherapy and exhibited tumor growth despite conventional therapy. Analysis of the tumor samples revealed loss of ATRX expression in both surgical specimens, suggesting that ATRX may be a useful biomarker for the early identification of aggressive pituitary tumors.

The dark side of T2: central nervous system lesions with low signal intensity on T2-weighted imaging.

The majority of central nervous system diseases show high signal intensity on T2-weighted magnetic resonance imaging. Diseases of the central nervous system with low signal intensity are less common, which makes it a finding that helps narrow the differential diagnosis. This was a retrospective analysis of brain and spine magnetic resonance imaging examinations in which that finding was helpful in the diagnostic investigation. We selected the cases of patients examined between 2015 and 2022. All diagnoses were confirmed on the basis of the clinical-radiological correlation or the histopathological findings. We obtained images of 14 patients with the following central nervous system diseases: arteriovenous malformation; cavernous malformation; metastasis from lymphoma; medulloblastoma; embryonal tumor; metastasis from melanoma; Rathke's cleft cyst; Erdheim-Chester disease; aspergillosis; paracoccidioidomycosis; tuberculosis; syphilis; immunoglobulin G4-related disease; and metastasis from a pulmonary neuroendocrine tumor. We described lesions of different etiologies in which the T2-weighted imaging profile helped narrow the differential diagnosis and facilitated the definitive diagnosis.

A grande maioria das doenças do sistema nervoso central apresenta alto sinal em ponderações T2 na ressonância magnética. As alterações com baixo sinal são menos comuns, de forma que essa característica permite estreitar o diagnóstico diferencial. Analisamos, retrospectivamente, pacientes com imagens de ressonância magnética de crânio e/ou coluna em que este achado foi útil na investigação diagnóstica. Os pacientes foram selecionados no período entre 2015 e 2022 e todos tiveram seus diagnósticos confirmados por estudo clinicorradiológico ou por estudo histopatológico. Obtivemos imagens de 14 pacientes com as seguintes afecções: malformação arteriovenosa, cavernoma, metástase de linfoma, meduloblastoma, tumor embrionário, metástase de melanoma, cisto da bolsa de Rathke, doença de Erdheim-Chester, aspergilose, paracoccidioidomicose, tuberculose, sífilis, doença relacionada à IgG4 e metástase de tumor neuroendócrino de pulmão. Descrevemos lesões de diversas origens etiológicas que, a partir de suas características nas imagens ponderadas em T2, foi possível reduzir o quadro de diagnósticos diferenciais e chegar mais facilmente à hipótese final.

Diffusion-weighted imaging does not seem to be a predictor of consistency in pituitary adenomas.

PURPOSE: To prospectively evaluate the usefulness of T1-weighted imaging (T1WI) and diffusion-weighted imaging (DWI) sequences in predicting the consistency of macroadenomas. In addition, to determine their values ​​as prognostic factors of surgical outcomes. METHODS: Patients with pituitary macroadenoma and surgical indication were included. All patients underwent pre-surgical magnetic resonance imaging (MRI) that included the sequences T1WI before and after contrast administration and DWI with the apparent diffusion coefficient (ADC) map. Post-surgical MRI was performed at least 3 months after surgery. The consistency of the macroadenomas was evaluated at surgery, and they were grouped into soft and intermediate/hard adenomas. Mean ADC values, signal on T1WI and the ratio of tumor ADC values ​​to pons (ADCR) were compared with tumor consistency and grade of surgical resection. RESULTS: A total of 80 patients were included. A softened consistency was found at surgery in 53 patients and hardened in 27 patients. The median ADC in the soft consistency group was 0.532 × 10-3 mm2/sec (0.306 - 1.096 × 10-3 mm2/sec), and in the intermediate/hard consistency group was 0.509 × 10-3 mm2/sec (0.308 - 0.818 × 10-3 mm2/sec). There was no significant difference between the median values ​​of ADC, ADCR and signal on T1W between the soft and hard tumor groups, or between patients with and without tumor residue. CONCLUSION: Our results did not show usefulness of the DWI and T1WI for assessing the consistency of pituitary macroadenomas, nor as a predictor of the degree of surgical resection.

Integrating Osteopathic Principles for Enhanced Dermatological Outcomes: A Literature Review.

This paper explores the impact of osteopathic medicine's principles and philosophy on dermatology conditions, focusing specifically on atopic dermatitis (AD), bullous pemphigoid (BP), and acne scars. The aim is to investigate how integrating osteopathic principles into dermatology can improve patient outcomes by addressing visible and internal health factors. The review was conducted through a literature search utilizing PubMed and Journal Storage. By focusing on the interconnectedness of mind, body, and spirit, osteopathic medicine could contribute to the effective treatment of AD. Stress management techniques have been found to significantly aid in the treatment of AD, as stress levels and social stress have a significant impact on the exacerbation of AD symptoms. Micro-needling is a promising treatment for atrophic acne scars, reducing scar severity scores by up to 68.3%. Combining micro-needling with trichloroacetic acid or non-ablative fractional laser technology further enhances treatment efficacy. The development of BP has been linked to alterations in the epidermis. Granzyme B has been identified as a contributing factor in dermal-epidermal junction separation and autoantibody formation, leading to BP. However, the specific link between osteopathic manipulation and Granzyme B levels in BP is not yet firmly established. Although osteopathic manipulation may impact the immune system and inflammation, further investigation is required to determine its precise effects on granzyme B and BP. Nonetheless, integrating osteopathic principles and philosophy into dermatology can improve patient outcomes by addressing visible and internal health factors. The benefits of such integration include improved patient-provider relationships, innovative treatments, better stress management, and individualized care plans. Practitioners should be educated on the significance of complete skin examinations for all patients, and future research should focus on exploring the benefits of osteopathic manipulation for dermatologic conditions. Further investigations into new dermatological treatment methods rooted in osteopathic principles are encouraged. The foundation of dermatology and osteopathic medicine share the importance of physical touch for diagnosis and treatment. An osteopathic approach to dermatology considers the link between cutaneous diseases and systemic health. This approach aligns with the four fundamental osteopathic beliefs: the body functions as a whole unit; a person is an integration of body, mind, and spirit that cannot be separated. The body can regulate itself, heal itself, and maintain its health. The body's structure and function are interdependent and work together. Rational treatment is based upon an understanding of the basic principles of body unity, self-regulation, and the interrelationship of structure and function.

The dark side of T2: central nervous system lesions with low signal intensity on T2-weighted imaging / The dark side of T2: lesões do sistema nervoso central com baixo sinal em ponderações T2

Abstract The majority of central nervous system diseases show high signal intensity on T2-weighted magnetic resonance imaging. Diseases of the central nervous system with low signal intensity are less common, which makes it a finding that helps narrow the differential diagnosis. This was a retrospective analysis of brain and spine magnetic resonance imaging examinations in which that finding was helpful in the diagnostic investigation. We selected the cases of patients examined between 2015 and 2022. All diagnoses were confirmed on the basis of the clinical-radiological correlation or the histopathological findings. We obtained images of 14 patients with the following central nervous system diseases: arteriovenous malformation; cavernous malformation; metastasis from lymphoma; medulloblastoma; embryonal tumor; metastasis from melanoma; Rathke's cleft cyst; Erdheim-Chester disease; aspergillosis; paracoccidioidomycosis; tuberculosis; syphilis; immunoglobulin G4-related disease; and metastasis from a pulmonary neuroendocrine tumor. We described lesions of different etiologies in which the T2-weighted imaging profile helped narrow the differential diagnosis and facilitated the definitive diagnosis.

Resumo A grande maioria das doenças do sistema nervoso central apresenta alto sinal em ponderações T2 na ressonância magnética. As alterações com baixo sinal são menos comuns, de forma que essa característica permite estreitar o diagnóstico diferencial. Analisamos, retrospectivamente, pacientes com imagens de ressonância magnética de crânio e/ou coluna em que este achado foi útil na investigação diagnóstica. Os pacientes foram selecionados no período entre 2015 e 2022 e todos tiveram seus diagnósticos confirmados por estudo clinicorradiológico ou por estudo histopatológico. Obtivemos imagens de 14 pacientes com as seguintes afecções: malformação arteriovenosa, cavernoma, metástase de linfoma, meduloblastoma, tumor embrionário, metástase de melanoma, cisto da bolsa de Rathke, doença de Erdheim-Chester, aspergilose, paracoccidioidomicose, tuberculose, sífilis, doença relacionada à IgG4 e metástase de tumor neuroendócrino de pulmão. Descrevemos lesões de diversas origens etiológicas que, a partir de suas características nas imagens ponderadas em T2, foi possível reduzir o quadro de diagnósticos diferenciais e chegar mais facilmente à hipótese final.

Insights into Magnetic Resonance Imaging Findings in Central Nervous System Paracoccidioidomycosis: A Comprehensive Review.

Paracoccidioidomycosis (PCM) is a infection caused by the thermodimorphic fungus Paracoccidioides spp. (P. lutzii and, mainly, P. brasiliensis). This infection predominantly affects rural male workers aged between 30 and 50 years old who deal with soil on daily activities. Clinically, the disease is classified as acute/subacute phase, which evolves rapidly, secondary to dissemination of the fungus through to the phagocytic-mononuclear system, leading to fever, weight loss, and anorexia, associated with hepatosplenomegaly and lymphadenopathy, which can be complicated with suppuration and fistulization; and chronic phase, which corresponds to 74% to 95% of symptomatic cases, with a common pulmonary involvement. Central nervous system involvement is almost always a characteristic of the chronic form. Inhalation is the most common route of primary infection, usually affecting the lungs, forming the primary complex. From the primary complex, hematogenic dissemination can occur to any organ, including the brain and spinal cord. Although PCM of the central nervous system diagnosis is usually based on histopathological analysis and the imaging features are not specific for PCM, computed tomography and magnetic resonance imaging can demonstrate evidences of granuloma, abscess, meningitis, or a combination of these lesions, contributing to a preoperative diagnosis, especially when considered in conjunction with epidemiology. In this article, we review the pathophysiology, clinical manifestations and imaging aspects of neuro-PCM.

Case report: Regression of Glioblastoma after flavivirus infection.

Glioblastoma is the most frequent and aggressive primary brain cancer. In preclinical studies, Zika virus, a flavivirus that triggers the death of glioblastoma stem-like cells. However, the flavivirus oncolytic activity has not been demonstrated in human patients. Here we report a glioblastoma patient who received the standard of care therapy, including surgical resection, radiotherapy and temozolomide. However, shortly after the tumor mass resection, the patient was clinically diagnosed with a typical arbovirus-like infection, during a Zika virus outbreak in Brazil. Following the infection resolution, the glioblastoma regressed, and no recurrence was observed. This clinical response continues 6 years after the glioblastoma initial diagnosis.

The Hypoglossal Nerve.

The hypoglossal nerve is the 12th cranial nerve, exiting the brainstem in the preolivary sulcus, passing through the premedullary cistern, and exiting the skull through the hypoglossal canal. This is a purely motor nerve, responsible for the innervation of all the intrinsic tongue muscles (superior longitudinal muscle, inferior longitudinal muscle, transverse muscle, and vertical muscle), 3 extrinsic tongue muscles (styloglossus, hyoglossus, and genioglossus), and the geniohyoid muscle. Magnetic resonance imaging (MRI) is the best imaging exam to evaluate patients with clinical signs of hypoglossal nerve palsy, and computed tomography may have a complementary role in the evaluation of bone lesions affecting the hypoglossal canal. A heavily T2-weighted sequence, such as fast imaging employing steady-state acquisition (FIESTA) or constructive interference steady state (CISS) is important to evaluate this nerve on MRI. There are multiple causes of hypoglossal nerve palsy, being neoplasia the most common cause, but vascular lesions, inflammatory diseases, infections, and trauma can also affect this nerve. The purpose of this article is to review the hypoglossal nerve anatomy, discuss the best imaging techniques to evaluate this nerve and demonstrate the imaging aspect of the main diseases that affect it.

Measuring head circumference using visual impressions or cross-sectional volumetric imaging: a comparison.

BACKGROUND: Head circumference (HC) correlates with brain growth and development. However, radiologists typically use their visual impressions to evaluate head dimensions, which is a purely subjective assessment. OBJECTIVE: The first objective of this paper was to analyze whether it is possible to obtain HC measurements by CT and MRI cross-sectional volumetric imaging using parameters similar to the tape measurement method, which is considered the gold standard. The second objective was to determine the most accurate method for characterizing head size: visual impression or imaging measurement. MATERIALS AND METHODS: Children who underwent HC measurement by tape and with volumetric imaging exams were selected from the Paulo Niemeyer State Brain Institute, Brazil. Two radiologists classified the children's heads using their visual impressions and by direct measurement on imaging. We used anatomical parameters similar to the tape measurement method and appropriate head growth charts and compared the absolute values obtained. RESULTS: The concordance between tape and imaging ranged 52.3-72.7% for visual impression (kappa 0.27-0.55), ≥ 95.5% for CT and ≥ 93.1% for MRI (kappa ≥ 0.92 and ≥ 0.88, respectively). Intraclass correlation coefficients ≥ 0.997 and ≥ 0.996, absolute technical error measurements of 0.20-0.31 cm and 0.24-0.29 cm, and relative technical error measurements of 0.49-0.73% and 0.58-0.70% were evidenced in the intra- and inter-rater evaluations, respectively. The means between the methods were not significantly different (P > 0.05), with high values of Pearson correlation coefficient (≥ 0.99) and Lin concordance correlation coefficient (≥ 0.99). CONCLUSION: Head circumference values obtained by cross-sectional volumetric imaging are similar to those obtained using the tape measurement method (gold standard), with high repeatability and reproducibility. Head size characterization by visual impression is less accurate than head circumference measurement by imaging and plotting the values obtained on World Health Organization normative charts.

Characterization of sporadic somatotropinomas with high GIP receptor expression.

PURPOSE: To analyze the expression of glucose-dependent insulinotropic polypeptide receptor (GIPR) in somatotropinomas specimens and compare clinical, biochemical, radiological, therapeutic, molecular, and pathological data among those who overexpressed (GIPR +) and those who did not overexpress (GIPR - ) GIPR. METHODS: Clinical, biochemical, radiological, molecular, and pathological data were collected. GNAS1 sequencing was performed with the Sanger method. Protein expression of somatostatin receptor subtypes 2 and 5 and CAM 5.2 were analyzed by immunohistochemistry. Quantitative real-time PCR was performed to analyze the mRNA expression of GIPR with the TaqMan® method. Positive expression was considered when the fold change (FC) was above 17.2 (GIPR +). RESULTS: A total of 74 patients (54% female) were included. Eighteen tumors (24%) were GIPR + . Gsp mutation was detected in 30 tumors (40%). GIPR + tumors were more frequently densely granulated adenomas (83% vs 47%, p = 0.028). There was no difference in clinical, biochemical, radiological, therapeutic (surgical cure or response to medical therapy), or other pathological features between GIPR + and GIPR -  tumors. Twenty-eight out of 56 (50%) GIPR -  tumors harbored a gsp mutation, whereas two out of 18 (11%) GIPR + tumors harbored a gsp mutation (p = 0.005). CONCLUSION: We described, for the first time, that GIPR + and gsp mutations are not mutually exclusive, but gsp mutations are less common in GIPR + tumors. GIPR + and GIPR -  tumors have similar clinical, biochemical, radiological, therapeutic, and pathological features, with the exception of a high frequency of densely granulated adenomas among GIPR + tumors.

Approach to the Patient: Differential Diagnosis of Cystic Sellar Lesions.

Cystic lesions arising in the sellar region are not uncommon and encompass cystic pituitary adenomas, Rathke cleft cysts, craniopharyngiomas, and arachnoid cysts. Their clinical presentation may be similar, including headache, visual field defects, and anterior pituitary hormone deficits, which makes differential diagnosis challenging. On the other hand, imaging features may indicate certain pathologies. In this approach to the patient, we describe the case of a patient who presented with right temporal hemianopsia and a sellar/suprasellar cystic lesion, which was determined to be Rathke cleft cyst. We discuss the imaging characteristics that may suggest a particular diagnosis between Rathke cleft cyst, cystic pituitary adenoma, craniopharyngioma, and arachnoid cyst and propose a flowchart for aiding in the imaging differential diagnosis.

Pituitary MRI Standard and Advanced Sequences: Role in the Diagnosis and Characterization of Pituitary Adenomas.

Pituitary adenomas (PAs) represent the most frequently found lesions in the sellar region; however, several other lesions may be encountered in this region, such as meningiomas, craniopharyngiomas, and aneurysms. High-quality imaging is fundamental for diagnosis, characterization, and guidance of treatment planning of PAs. Sellar magnetic resonance imaging (MRI) is considered the imaging modality of choice for the evaluation of lesions in the sella turcica. The sellar MRI standard protocol includes coronal and sagittal T1-weighted spin-echo sequencing with and without gadolinium-based contrast agent and coronal T2-weighted (T2w) fast-spin echo sequencing. A systematic MRI approach to the pituitary region generally provides information that includes the size and shape of the PA, the presence of cysts or hemorrhage within the tumor, its relationship with the optic pathways and surrounding structures, potential cavernous sinus invasion, sphenoid sinus pneumatization type, and differential diagnosis with other sellar lesions. The standard protocol is sufficient for the evaluation of most cases; however, some advanced techniques (susceptibility imaging, diffusion-weighted imaging, 3D T2w high-resolution sequences, magnetic resonance elastography, perfusion-weighted imaging) may render additional information, which may be important for some cases. In this "approach to the patient" manuscript, we will discuss the use of standard and advanced MRI sequences in the diagnosis and characterization of PAs, including MRI features associated with treatment response that may aid in presurgical evaluation and planning, and red flags that may point to an alternative diagnosis.

Computed tomography features of cerebrovascular complications in intensive care unit patients with severe COVID-19.

OBJECTIVE: To report the computed tomography (CT) features of acute cerebrovascular complications in severely ill patients with confirmed coronavirus disease 2019 (COVID-19) in the intensive care unit. MATERIALS AND METHODS: We conducted a retrospective analysis of 29 intensive care unit patients with confirmed COVID-19 who underwent CT of the brain. We describe the CT features of the cerebrovascular complications of COVID-19, as well the demographic characteristics and clinical features, together with the results of laboratory tests, such as complete blood cell count, coagulation testing, renal function testing, and C-reactive protein assay. RESULTS: Two patients were excluded because of brain death. Among the remaining 27 patients, CT revealed acute cerebrovascular complications in six (three men and three women; 49-81 years of age), whereas no such complications were seen in 21 (15 men and six women; 36-82 years of age). CONCLUSION: Radiologists should be aware of the risks of cerebrovascular complications of COVID-19 and the potential underlying etiologies. COVID-19-associated coagulopathy is likely multifactorial and may increase the risk of ischemic and hemorrhagic infarction.

OBJETIVO: Relatar as características da tomografia computadorizada (TC) das complicações cerebrovasculares agudas em pacientes com doença do coronavírus 2019 (COVID-19) grave, internados em unidade de terapia intensiva. MATERIAIS E MÉTODOS: Foi realizada análise retrospectiva de 29 pacientes com COVID-19 confirmada, internados em unidade de terapia intensiva, que realizaram TC de crânio. Descrevemos as alterações tomográficas das complicações cerebrovasculares, bem como as características demográficas, clínicas e exames laboratoriais, tais como hemograma completo, teste de coagulação, função renal e proteína C reativa desses pacientes. RESULTADOS: Seis pacientes (três homens e três mulheres; faixa etária de 49-81 anos) apresentaram alterações cerebrovasculares reveladas por TC e 21 pacientes (15 homens e 6 mulheres; faixa etária de 36-82 anos) não apresentaram complicações cerebrovasculares agudas. Dois pacientes foram excluídos por morte encefálica. CONCLUSÃO: Os radiologistas devem estar cientes dos riscos de complicações cerebrovasculares da COVID-19 e das possíveis etiologias subjacentes. A coagulopatia relacionada à COVID-19 é provavelmente multifatorial e pode aumentar os riscos de infarto isquêmico e hemorrágico.

Computed tomography features of cerebrovascular complications in intensive care unit patients with severe COVID-19 / Alterações na tomografia computadorizada das complicações cerebrovasculares em pacientes com COVID-19 grave na unidade de terapia intensiva

Abstract Objective: To report the computed tomography (CT) features of acute cerebrovascular complications in severely ill patients with confirmed coronavirus disease 2019 (COVID-19) in the intensive care unit. Materials and Methods: We conducted a retrospective analysis of 29 intensive care unit patients with confirmed COVID-19 who underwent CT of the brain. We describe the CT features of the cerebrovascular complications of COVID-19, as well the demographic characteristics and clinical features, together with the results of laboratory tests, such as complete blood cell count, coagulation testing, renal function testing, and C-reactive protein assay. Results: Two patients were excluded because of brain death. Among the remaining 27 patients, CT revealed acute cerebrovascular complications in six (three men and three women; 49-81 years of age), whereas no such complications were seen in 21 (15 men and six women; 36-82 years of age). Conclusion: Radiologists should be aware of the risks of cerebrovascular complications of COVID-19 and the potential underlying etiologies. COVID-19-associated coagulopathy is likely multifactorial and may increase the risk of ischemic and hemorrhagic infarction.

Resumo Objetivo: Relatar as características da tomografia computadorizada (TC) das complicações cerebrovasculares agudas em pacientes com doença do coronavírus 2019 (COVID-19) grave, internados em unidade de terapia intensiva. Materiais e Métodos: Foi realizada análise retrospectiva de 29 pacientes com COVID-19 confirmada, internados em unidade de terapia intensiva, que realizaram TC de crânio. Descrevemos as alterações tomográficas das complicações cerebrovasculares, bem como as características demográficas, clínicas e exames laboratoriais, tais como hemograma completo, teste de coagulação, função renal e proteína C reativa desses pacientes. Resultados: Seis pacientes (três homens e três mulheres; faixa etária de 49-81 anos) apresentaram alterações cerebrovasculares reveladas por TC e 21 pacientes (15 homens e 6 mulheres; faixa etária de 36-82 anos) não apresentaram complicações cerebrovasculares agudas. Dois pacientes foram excluídos por morte encefálica. Conclusão: Os radiologistas devem estar cientes dos riscos de complicações cerebrovasculares da COVID-19 e das possíveis etiologias subjacentes. A coagulopatia relacionada à COVID-19 é provavelmente multifatorial e pode aumentar os riscos de infarto isquêmico e hemorrágico.