Spinal subependymoma surgery: do no harm. Little may be more!

OBJECTIVE:  Outline the reported diagnostic and operative findings, and evaluate the surgical treatment outcome to clarify the best available recommendations. METHODS:  Ovid Medline, Embase and PubMed central databases were searched from inception until January 2019 using the terms (subependymoma and (spinal or cervical or thoracic)). The articles were reviewed for reported spinal subependymoma cases perioperative management and treatment outcomes. RESULTS:  A total of 49 papers provided data on 105 cases. 47 cases were reported in the last 5 years. The reported cases were two medullary-cervical, 35 cervical, 32 cervicothoracic, 21 thoracic, 12 thoracolumbar and three lumbar. Spinal subependymomas typically arise from within the central spinal canal, giving the appearance of an intramedullary mass, usually eccentric to one side. Symptoms at presentation ranged between 1 month to 17 years, (mean 3.5 years, median 2 years) and were over 3 years in 36, and over 8 years in 12 cases. Sensory symptoms are the most frequent 75(80%), followed by weakness in 60(64%), pain in 45(48%) and sphincter disturbance in 24(25%). Postoperative neurological function was reported in 78 cases, and worsening was reported in 40 cases (51%), of which, 29 (72%) had complete resection, 6 (15%) had subtotal resection and 5 (12%) had partial resection. Neurological status remained the same in 24 (30%) and improved in 14 (18%). CONCLUSION:  The reviewed cases report a rate of 65% total resection of which 57% had worsened function after surgery. There were no reports of malignant transformation; therefore, long-term survival is expected, and surgical caution should be exercised where there is minimal symptom progression.

Magnetic resonance imaging acquisition techniques intended to decrease movement artefact in paediatric brain imaging: a systematic review.

Attaining paediatric brain images of diagnostic quality can be difficult because of young age or neurological impairment. The use of anaesthesia to reduce movement in MRI increases clinical risk and cost, while CT, though faster, exposes children to potentially harmful ionising radiation. MRI acquisition techniques that aim to decrease movement artefact may allow diagnostic paediatric brain imaging without sedation or anaesthesia. We conducted a systematic review to establish the evidence base for ultra-fast sequences and sequences using oversampling of k-space in paediatric brain MR imaging. Techniques were assessed for imaging time, occurrence of movement artefact, the need for sedation, and either image quality or diagnostic accuracy. We identified 24 relevant studies. We found that ultra-fast techniques had shorter imaging acquisition times compared to standard MRI. Techniques using oversampling of k-space required equal or longer imaging times than standard MRI. Both ultra-fast sequences and those using oversampling of k-space reduced movement artefact compared with standard MRI in unsedated children. Assessment of overall diagnostic accuracy was difficult because of the heterogeneous patient populations, imaging indications, and reporting methods of the studies. In children with shunt-treated hydrocephalus there is evidence that ultra-fast MRI is sufficient for the assessment of ventricular size.

A case of chronic dysaesthesia in the torso and upper limbs: lessons from a cervical spinal cord subependymoma.

INTRODUCTION: Subependymomas are slow growing WHO grade 1 tumours, typically attached to the ventricular wall of the fourth or lateral ventricles. Spinal subependymomas are rarer still and experience of their biological characteristics remains limited. CASE PRESENTATION: A 29-year-old lady presented with chronic attacks of itchy dysaesthesia involving the left hand, neck and trunk, and associated with ipsilateral leg spasms. Recent symptomatic change involved occasional limping and left sided facial numbness but no pain. MRI showed an intradural mass surrounding most of the cervical spinal cord, which appeared scalloped extrinsically, rather than diffusely expanded, by a seemingly extramedullary lesion. At operation, the cord appeared expanded, with no clear margin or distinction between tumour and cord tissue; and the tumour was found to be intramedullary with an exophytic component, rather than extramedullary. Moderate reduction of the left abductor pollicis brevis evoked potential led to a pause in surgery. There was transient hand weakness postoperatively with full recovery, and no radiological change in the tumour morphology for a further 6 years. DISCUSSION: An intramedullary tumour such as a spinal cord subependymoma can be mistaken radiologically for an extramedullary tumour, such as an epidermoid. If a subependymoma is suspected, given its indolent course and long-term survival, caution in the extent of surgical resection is advisable in order to avoid surgical morbidity.

Case report: Eastern equine encephalitis virus imported to the UK.

Eastern equine encephalitis (EEE) is rare, but the most severe of the mosquito-borne encephalitides in the United States with a high case fatality rate of 30%. Here, we present a patient with EEE. EEE virus causes sporadic human disease in the Eastern parts of the United States, but the case we describe was a Scottish tourist who acquired the disease from mosquito bites while in holiday in the United States. This is a first report of an imported case to Europe.

Correlation of relative permeability and relative cerebral blood volume in high-grade cerebral neoplasms.

OBJECTIVE: The purpose of this study was to correlate the degree of contrast enhancement on dynamic contrast-enhanced T1-weighted MRI and the relative cerebral blood volume (rCBV) values on T2*-weighted MRI in patients with high-grade brain neoplasms. SUBJECTS AND METHODS: Ten patients with biopsy-proven high-grade gliomas underwent dynamic contrast-enhanced MRI using T1-weighted fast spoiled gradient-echo technique (TR/TE, 8.3/1.5) during i.v. infusion of 0.1 mmol/kg of MR contrast medium. This sequence was followed within 5 minutes by dynamic susceptibility contrast (DSC) imaging (1,500/80) during i.v. infusion of 0.2 mmol/kg of MR contrast medium. Dynamic contrast-enhanced analysis was performed using the maximum-signal-intensity algorithm, and DSC analysis was performed using the negative enhancement integral program. For each tumor, we performed two comparisons: first, the average dynamic contrast-enhanced and rCBV values within a region of interest drawn around the entire contrast-enhancing tumor on a single image through the center of the lesion and, second, the highest dynamic contrast-enhanced and highest rCBV values within each tumor. Statistical analyses of the first comparison were performed using Pearson's correlation coefficient, R2 correlation coefficient, and Spearman's rank correlation and for the second comparison using Kendall's tau correlation. RESULTS: The mean signal intensity values ranged between 3.48 and 7.16 SDs above baseline values (mean, 4.89 SDs). The mean rCBV values ranged between 57.9% and 122.7% of the normal lentiform nucleus (mean, 76.6%). The Pearson's correlation coefficient was 0.867, the R2 correlation coefficient was 0.752, and the Spearman's rank correlation was 0.794 (p = 0.001). Dynamic contrast-enhanced values from the region of highest signal intensity ranged between 7.7 and 48.6 SDs above baseline values (mean, 17.3 SDs). The highest rCBV values ranged between 105% and 400% of the normal lentiform nucleus (mean, 292%). The correlation was estimated to be 0.7778 and was statistically significant at the 0.01 level of statistical significance (p = 0.0035). CONCLUSION: We found a high correlation between degree of contrast enhancement on dynamic contrast-enhanced images and rCBV values in whole tumors and in regions having the highest degree of contrast enhancement in this small study. Our findings, which suggest that relative permeability and rCBV values may be correlated in high-grade glial neoplasms, deserve further study in a larger patient population.

Determination of multiple sclerosis plaque size with diffusion-tensor MR Imaging: comparison study with healthy volunteers.

PURPOSE: To use diffusion-tensor magnetic resonance (MR) imaging to measure involvement of normal-appearing white matter (WM) immediately adjacent to multiple sclerosis (MS) plaques and thus redefine actual plaque size on diffusion-tensor images through comparison with T2-weighted images of equivalent areas in healthy volunteers. MATERIALS AND METHODS: Informed consent was not required given the retrospective nature of the study on an anonymized database. The study complied with requirements of the Health Insurance Portability and Accountability Act. Twelve patients with MS (four men, eight women; mean age, 35 years) and 14 healthy volunteers (six men, eight women; mean age, 25 years) were studied. The authors obtained fractional anisotropy (FA) values in MS plaques and in the adjacent normal-appearing WM in patients with MS and in equivalent areas in healthy volunteers. They placed regions of interest (ROIs) around the periphery of plaques and defined the total ROIs (ie, plaques plus peripheral ROIs) as abnormal if their mean FA values were at least 2 standard deviations below those of equivalent ROIs within equivalent regions in healthy volunteers. The combined area of the plaque and the peripheral ROI was compared with the area of the plaque seen on T2-weighted MR images by means of a Student paired t test (P = .05). RESULTS: The mean plaque size on T2-weighted images was 72 mm2 +/- 21 (standard deviation). The mean plaque FA value was 0.285 +/- 0.088 (0.447 +/- 0.069 in healthy volunteers [P < .001]; mean percentage reduction in FA in MS plaques, 37%). The mean plaque size on FA maps was 91 mm2 +/- 35, a mean increase of 127% compared with the size of the original plaque on T2-weighted images (P = .03). CONCLUSION: A significant increase in plaque size was seen when normal-appearing WM was interrogated with diffusion-tensor MR imaging. This imaging technique may represent a more sensitive method of assessing disease burden and may have a future role in determining disease burden and activity.

Assessment of apparent diffusion coefficient in normal and degenerated intervertebral lumbar disks: initial experience.

PURPOSE: To determine prospectively the diffusibility of water in normal lumbar disks in adults by using the mean apparent diffusion coefficient (ADC) and to determine if a relationship exists between disk ADC and magnetic resonance (MR) findings of disk degeneration. MATERIALS AND METHODS: The study was approved by the Institutional Review Board, and all participants gave written informed consent prior to enrollment. Diffusion-weighted MR imaging of the lumbar spine was performed in 39 patients (all men; mean age, 53 years) and five volunteers (all men; mean age, 31 years). ADC values were recorded for each disk. All disks were visually graded by two independent observers as being normal or as showing at least one of three MR findings of degeneration on sagittal T2-weighted images. Mean ADC values of normal disks were compared with those of degenerated disks and were correlated with age and anatomic location. Data were analyzed by using Kendall correlation statistics, Mantel-Haenszel statistics, and a paired two-tailed Student t test. RESULTS: The mean ADC value was 2.27 x 10(-3) mm(2)/sec +/- 0.58 (+/- standard deviation) in normal disks and 2.06 x 10(-3) mm(2)/sec +/- 0.47 in abnormal disks (9% reduction, P = .006). A statistically significant dependence of lumbar disk ADC on anatomic location was reported (analysis of variance, P < .001), with lower ADC values seen in more caudal disks. There was no association between age and mean disk ADC. CONCLUSION: A statistically significant decrease was seen in the ADC values of degenerated lumbar disks when compared with ADC values of normal disks. More caudal disks, even when normal, showed lower ADC values than more cephalic disks.

Tensor diffusion imaging in B12 leukoencephalopathy.

Anisotropy measurements were obtained from periventricular foci of T2 prolongation and adjacent normal-appearing white matter in a case of B12 leukoencephalopathy. Measurements were compared with mean values from two age-matched control subjects. Anisotropy was greatly reduced in the lesions evident on T2-weighted images and in the normal-appearing adjacent white matter (WM), indicating that the extent of WM tract disruption was greater than could be identified on routine MR sequences.

Redefinition of multiple sclerosis plaque size using diffusion tensor MRI.

OBJECTIVE: We used diffusion tensor MRI to redefine the size of multiple sclerosis (MS) plaques on fractional anisotropy (FA) maps. MATERIALS AND METHODS: Thirty-six white matter (WM) plaques were identified in 20 patients with MS. Plaque FA was measured by placing regions of interest (ROIs) on plaques on diffusion tensor images. We compared FA values in identical mirror-image ROIs placed on normal-appearing WM in the contralateral hemisphere. This comparison showed a mean decrease in FA of 41% in plaques, serving as the threshold for outlining abnormal regions in normal-appearing WM surrounding plaques. ROIs were placed around each plaque and FA values were compared with those in the mirror-image ROIs. Combined areas of perilesional normal-appearing WM with 40% or more FA reduction plus plaque were compared with the areas of abnormality on T2-weighted images using a paired Student's t test. A p value of 0.05 or less was considered significant. RESULTS: Mean plaque area was 60 mm(2) (range, 15-103 mm(2)), mean plaque FA was 0.251 (range, 0.133-0.436), and mean FA of contralateral normal-appearing WM was 0.429 (range, 0.204-0.712). Applying a threshold of 40% FA reduction, mean combined area of abnormal WM (including plaque seen on T2-weighted sequences) was 87 mm(2) (range, 30-251 mm(2)) or 145% of the mean plaque area that was seen on T2-weighted images (p < 0.001). CONCLUSION: Using an operator-defined threshold of abnormal FA values based on plaque anisotropy characteristics, we saw a statistically significant increase in plaque size.

User-defined vascular input function curves: influence on mean perfusion parameter values and signal-to-noise ratio.

The authors reviewed 40 computed tomographic (CT) perfusion studies to determine the effect of arterial and venous input function properties on perfusion parameter values and tissue signal-to-noise ratio (SNR). A 10-subject subset was analyzed to evaluate the effect of varying venous region of interest (ROI) locations. Venous peak enhancement correlated significantly with mean tissue cerebral blood flow (CBF) and cerebral blood volume (CBV); venous and arterial peak enhancement correlated significantly with SNR of perfusion maps. Different ROI locations within the same vein resulted in significantly different CBV and CBF values. Perfusion map parameters are related to peak enhancement within user-selected ROIs. Optimal ROI selection should limit variability and increase quality of CT perfusion images.

Management of visceral interventional radiology catheters: a troubleshooting guide for interventional radiologists.

Visceral interventional radiology catheters can be difficult to exchange or remove for a variety of reasons. These reasons include exit of the guide wire through the side holes of the catheter, blockage of the catheter, difficulty unlocking the pigtail, retention of the string after catheter removal, migration of the string ahead of the guide wire, catheter fracture, and snaring of an adjacent stent by the pigtail. Secure fixation of the catheter to the skin is important. A technique that allows secure fixation without direct puncture and suturing of the catheter to the skin is recommended. If a catheter falls out or is inadvertently removed, access can occasionally be regained and the catheter can be replaced without repuncture. The timing of catheter removal is based on the clinical condition of the patient and the daily output from the catheter. "Tractography" is a useful study before removal of any catheter that requires a mature tract for removal, particularly cholecystostomy catheters and transpleural catheters. In biliary catheter exchange, the most vital issue is the position of the side holes of the catheter. If an abscess cavity remains large after catheter drainage, the catheter can be repositioned or a second catheter can be placed.