[Headache in puerperium]. / Een kraamvrouw met hoofdpijn.

BACKGROUND: Sheehan's syndrome is a rare complication of excessive postpartum hemorrhage with impaired function of the pituitary gland (hypopituitarism). Clinical presentation includes headache, fatigue, nausea, symptoms due to electrolyte imbalance and pituitary hormone insufficiency. Cranial imaging can support the diagnosis if pituitary gland ischemia or empty sella sign is detected. Therapy is based on correction of hypovolemia in the acute setting, symptom reduction and chronic hormone replacement treatment. CASE: We report a case of a patient who developed Sheehan's syndrome as a result of severe blood loss during cesarean section. Brain imaging in this case was initially performed with an alternative differential diagnosis in mind. CONCLUSION: Differential diagnosis of headache in puerperium is comprised of a spectrum of syndromes, in which attention for medical and patient history are key. In Sheehan's syndrome early diagnosis is of crucial prognostic importance.

Brain miliary enhancement.

PURPOSE: Miliary enhancement refers to the presence of multiple small, monomorphic, enhancing foci on T1-weighted post-contrast MRI images. In the absence of a clear clinical presentation, a broad differential diagnosis may result in invasive procedures and possibly brain biopsy for diagnostic purposes. METHODS: An extensive review of the literature is provided for diseases that may present with miliary enhancement on T1-weighted brain MR images. Additional disease-specific findings, both clinical and radiological, are summarized and categorized by the presence or absence of perivascular space involvement. RESULTS: Miliary pattern of enhancement may be due to a variety of underlying causes, including inflammatory, infectious, nutritional or neoplastic processes. The recognition of disease spread along the perivascular spaces in addition to the detection or exclusion of disease-specific features on MRI images, such as leptomeningeal enhancement, presence of haemorrhagic lesions, spinal cord involvement and specific localisation or systemic involvement, allows to narrow the potential differential diagnoses. CONCLUSION: A systematic approach to disease-specific findings from both clinical and radiological perspectives might facilitate diagnostic work-up, and recognition of disease spread along the perivascular spaces may help narrowing down differential diagnoses and may help to minimize the use of invasive diagnostic procedures.

Repeatability and reproducibility of relative cerebral blood volume measurement of recurrent glioma in a multicentre trial setting.

BACKGROUND: Measurement of relative cerebral blood volume (rCBV) with dynamic susceptibility contrast (DSC) magnetic resonance imaging (MRI) is used extensively for brain tumour diagnosis and follow-up. The aim of this pilot study was to assess the robustness of rCBV measurement in patients with enhancing recurrent glioma in a European multicentre trial setting. METHODS: We included pre-treatment postcontrast T1 weighted (T1w) and DSC scans of 20 patients with recurrent glioma from 2 European Organisation for Research and Treatment of Cancer trials (26101 and 26091). Three reviewers independently placed a fixed circular region of interest of 70 mm2 in the tumour area of highest rCBV (rCBVmax). To calculate the normalised rCBVmax (nrCBVmax), three ROIs were placed in the anterior, middle and posterior centrum semiovale normal-appearing white matter of the contralateral hemisphere. After several months, each observer repeated the assessments blinded for initial findings. Repeatability and reproducibility were estimated with a mixed model. Each measurement was also classified according to 4 clinically meaningful categories. RESULTS: Three patients were post hoc excluded from analysis because of lack of enhancing tumour. The mean nrCBVmax repeatability was 49.5%, and reproducibility was 5.5%. In 14 of 17 patients, at least 2 reviewers classified the patient into the same category. CONCLUSIONS: Our results indicate that a well-established review process needs to be applied upfront to assess perfusion in a multicentre trial setting. While awaiting further validation, we propose as a strategy to measure rCBV in the context of recurrent glioma trials to use two central reviewers and an adjudicator in case of disagreement.

Visual inspection of MR relative cerebral blood volume maps has limited value for distinguishing progression from pseudoprogression in glioblastoma multiforme patients.

AIM: We examined whether visual interpretation of relative cerebral blood volume (rCBV) color maps made with dynamic susceptibility-weighted perfusion MRI can reliably distinguish progressive disease (PD) from pseudoprogression (PsPD) in glioblastoma patients during treatment with temozolomide chemoradiation. MATERIALS & METHODS: Magnetic resonance (MR) perfusion-weighted images were evaluated based on visual inspection of rCBV maps. Sensitivity and specificity were calculated to assess if rCBV can reliably differentiate between PD and PsPD, during standard chemoradiation therapy. RESULTS: Evaluation of dynamic susceptibility-weighted contrast-enhanced perfusion MRI by visual interpretation of rCBV maps did not differentiate PD from PsPD (sensitivity = 72%; specificity = 23%). Furthermore, the interpretation of the rCBV maps had no prognostic value regarding survival. CONCLUSION: Qualitative rCBV-based dynamic susceptibility-weighted contrast-enhanced perfusion MRI does not reliably differentiate PD from PsPD, and is not prognostic for survival in glioblastoma multiforme patients during treatment with temozolomide chemoradiation.

Changes in brain electrical activity during extended continuous word recognition.

Twenty healthy subjects (10 men, 10 women) participated in an EEG study with an extended continuous recognition memory task, in which each of 30 words was randomly shown 10 times and subjects were required to make old vs. new decisions. Both event-related brain potentials (ERPs) and induced band power (IBP) were investigated. We hypothesized that repeated presentations affect recollection rather than familiarity. For the 300- to 500-ms time window, an 'old/new' ERP effect was found for the first vs. second word presentations. The correct recognition of an 'old' word was associated with a more positive waveform than the correct identification of a new word. The old/new effect was most pronounced at and around the midline parietal electrode position. For the 500- to 800-ms time window, a linear repetition effect was found for multiple word repetitions. Correct recognition after an increasing number of repetitions was associated with increasing positivity. The multiple repetitions effect was most pronounced at the midline central (Cz) and fronto-central (FCz) electrode positions and reflects a graded recollection process: the stronger the memory trace grows, the more positive the ERP in the 500- to 800-ms time window. The ERP results support a dual-processing model, with familiarity being discernable from a more graded recollection state that depends on memory strengths. For IBP, we found 'old/new' effects for the lower-2 alpha, theta, and delta bands, with higher bandpower during 'old' words. The lower-2 alpha 'old/new' effect most probably reflects attentional processes, whereas the theta and delta effects reflect encoding and retrieval processes. Upon repeated word presentations, the magnitude of induced delta power in the 375- to 750-ms time window diminished linearly. Correlation analysis suggests that decreased delta power is moderately associated with faster decision speed and higher accuracy.

Determination of individual stimulus--response curves in the visual cortex.

Activation in the visual cortex is typically studied using group average changes in an on-off paradigm for a single flicker frequency. We used functional magnetic resonance imaging (fMRI) to characterize the stimulus-response curve in the visual cortex as a function of flicker frequency in individual subjects, using LED goggles with 17 frequency steps between 0 and 30 Hz. Ten healthy young individuals were studied on two different occasions (mean interval; 22 days). In all but one subject, a third-order polynomial curve could be fitted to the data. From the response curve we calculated the peak response (the frequency where the response amplitude was maximal), the percentage change (relative difference) of the response amplitudes between 8 Hz and the peak frequency, and the average slope of response (towards the peak). On both occasions we could determine a peak response for each subject with small within-subject variability. The average absolute difference in peak response between both sessions was 1.37 Hz (range, 0.2-4.3 Hz), indicating that the peak frequency is rather stable for a given individual. In conclusion, our study illustrates the ability of fMRI to examine the stimulus-response curve in individual subjects in the visual cortex. Based on our findings, the peak response and the slope of response seem highly reproducible within subjects. A similar analysis of the stimulus-response curve may be applicable to other types of stimuli.

Left-right and upper-lower visual field asymmetries for face matching, letter naming, and lexical decision.

The relation between left-right and upper-lower visual field (VF) asymmetries was examined for face matching, letter naming, and lexical decision. Stimuli were flashed in the VF quadrants. Face matching resulted in a lower left and upper right VF advantage. Letter-naming resulted in a distinct upper-right VF advantage. For lexical decision, no upper/lower asymmetries were found. Words were processed faster in the right than in the left VF, while nonwords were processed equally fast in both VFs. The results are discussed in terms of hypothesized structural connections of the lower versus upper visual field to dorsal versus ventral visual pathways and in terms of attentional mechanisms related to the processing of visual information in the VF quadrants.