Evaluation of cortical superficial siderosis in patients with cognitive dysfunction using 3D FLAIR and 3D DIR.

OBJECTIVES: Our aim was to evaluate the detectability of cortical superficial siderosis (cSS) by 3D FLAIR and 3D DIR images in comparison with the SWI images in patients with cognitive dysfunction. METHODS: We studied 246 patients with cognitive dysfunction (144 women, 102 men; mean age: 75.5 ± 7.53 years) who visited a memory clinic at our hospital and underwent MR examinations at 3 T. Specifically, 16 patients with Alzheimer disease (AD) (n = 11) and AD with cerebrovascular disease (n = 5) manifested cSS based on SWI. Each set of MR images (3D FLAIR and 3D DIR) was reviewed by two reviewers separately for the detection of sulcal hyperintensity that suggested cSS. RESULTS: SWI detected a greater number of cSS sulci than 3D DIR and 3D FLAIR. The sensitivity and specificity for the detection of sulcal hyperintensity were the same between 3D FLAIR and 3D DIR (87.5%/100%). However, 3D DIR detected a greater number of cSS sulci than 3D FLAIR (p = .005). CONCLUSIONS: Our study showed that 3D DIR and 3D FLAIR can detect sulcal hyperintensity related to cSS although they are less sensitive to cSS lesions than SWI. KEY POINTS: • 3D FLAIR and 3D DIR can show sulcal signal abnormalities related to cSS in patients with cognitive dysfunction. • 3D FLAIR and 3D DIR detect sulcal hyperintensity of cSS, although they are less sensitive to cSS than SWI. • Signal alterations due to cSS are more detectable in 3D DIR than in 3D FLAIR.

Association between cortical microinfarcts and total small vessel disease burden in cerebral amyloid angiopathy on 3-Tesla magnetic resonance imaging.

BACKGROUND AND PURPOSE: Cortical microinfarcts (CMIs) are frequently found in the brains of patients with advanced cerebral amyloid angiopathy (CAA) at autopsy. The small vessel disease (SVD) score for CAA (i.e., the CAA-SVD score) has been proposed to evaluate the severity of CAA-associated vasculopathic changes by a combination of magnetic resonance imaging (MRI) markers. The aim of this study was to examine the association between total CAA-SVD score and features of CMIs on in vivo 3-Tesla MRI. METHODS: Eighty patients with probable CAA were retrospectively analyzed. Lobar cerebral microbleeds, cortical superficial siderosis, enlargement of perivascular space in the centrum semiovale and white matter hyperintensity were collectively assessed, and the total CAA-SVD score was calculated. The presence of CMI was also examined. RESULTS: Of the 80 patients, 13 (16.25%) had CMIs. CMIs were detected more frequently in the parietal and occipital lobes. A positive correlation was found between total CAA-SVD score and prevalence of CMI (ρ = 0.943; p = 0.005). Total CAA-SVD score was significantly higher in patients with CMIs than in those without (p = 0.009). In a multivariable logistic regression analysis, the presence of CMIs was significantly associated with total CAA-SVD score (odds ratio 2.318 [95% confidence interval 1.228-4.376]; p = 0.01, per each additional point). CONCLUSIONS: The presence of CMIs with a high CAA-SVD score could be an indicator of more severe amyloid-associated vasculopathic changes in patients with probable CAA.

Evaluation of Intradural Ecchordosis Physaliphora With Three-Dimensional Fluid-Attenuated Inversion Recovery.

OBJECTIVE: This study evaluated the efficacy of 3-dimensional fluid-attenuated inversion recovery (3D FLAIR) for detecting intradural ecchordosis physaliphora (EP). METHODS: We retrospectively determined the presence or absence of intradural EP on 3D FLAIR for 3888 consecutive patients, classifying the EP as "classical" or "possible" and analyzing the prevalence, size, and presence or absence of an intraosseous stalk. Where available, magnetic resonance cisternography images were compared with the 3D FLAIR images. RESULTS: Intradural EP was identified in 50 patients (1.3%): 36 (0.9%) classical and 14 (0.4%) possible. The classical EPs were significantly larger than the possible EPs (P < 0.01). Nine EPs (18.0%) showed an osseous stalk. Magnetic resonance cisternography was performed for 19 EPs (16 classical, 3 possible), detecting all 16 classical EPs but none of the possible EPs. CONCLUSIONS: Classical EPs were detected by 3D FLAIR as with magnetic resonance cisternography. The 3D FLAIR findings suggested a new type of possible EP variant previously unreported.

Evaluation of a high-signal lesion posterior to the intracranial vertebral artery using 3D balanced fast-field echo imaging.

Previous reports have identified a small, benign, high-signal lesion (HSL) posterior to the intracranial vertebral artery and associated with the ipsilateral spinal accessory nerve (SAN) using 3D fluid-attenuated inversion recovery (3D FLAIR) imaging as an emerging new entity. To elucidate the relationship between HSLs and SAN, 76 patients with 86 HSLs were evaluated using 3D FLAIR and 3D balanced fast-field echo (3D bFFE imaging). All HSLs showed contact with ipsilateral SAN on both the sequences. 3D bFFE imaging clearly distinguished between the two structures unlike 3D FLAIR. Moreover, SAN was surrounded by HSLs on 3D bFFE images, which may be a characteristic of this entity.

Small high-signal lesions posterior to the intracranial vertebral artery incidentally identified by 3D FLAIR: retrospective study of 127 patients.

PURPOSE: A small, benign high-signal lesion (HSL) posterior to the intracranial vertebral artery (VA) at the foramen magnum is a new entity revealed by a 3D FLAIR sequence. However, this entity has not been sufficiently investigated. We aimed to investigate the MR imaging findings of HSLs posterior to the intracranial VA that were incidentally detected by 3D FLAIR. METHODS: We retrospectively evaluated 3717 patients using a 3-T MR unit. HSLs on 3D FLAIR were assessed for prevalence, size, contact with the spinal accessory nerve (SAN), and size changes on follow-up images. RESULTS: Of 3717 patients, 127 (3.4%) (58 males and 69 females; age, 60.0 ± 18.9 years) showed 142 HSLs posterior to the intracranial VA. In total, 114 patients (89.8%) had a single lesion, whereas 13 patients (10.2%) had multiple lesions. The mean lesion size was 3.8 ± 1.6 mm. All HSLs showed contact with the ipsilateral SAN. Of 69 HSLs that were imaged during follow-up, the size was stable in 91.3% and increased in 8.7%. CONCLUSION: HSLs posterior to the intracranial VA were incidentally detected in 3.4% of patients by 3D FLAIR. Our results indicated a possible association between HSLs and SAN. These lesions appear to be benign in etiology and thus would not require any surgical intervention without continuous growth in a short period or relevant signs and symptoms.

Cortical Brush Sign: A Novel Finding on Thin-slice 3T Susceptibility-weighted Imaging in Acute Cerebral Infarct and Cerebral Venous Thrombosis.

We observed a new SWI finding, "cortical brush sign," that represents prominent venous structures in the cortex of patients with acute cerebral infarct with or without moyamoya disease and cerebral venous thrombosis. The cortical brush sign disappeared on follow-up SWI in all cases. Cortical brush sign may help to understand the pathophysiology of venous structures in the cortex at acute phase.

A Combination of Amide Proton Transfer, Tumor Blood Flow, and Apparent Diffusion Coefficient Histogram Analysis Is Useful for Differentiating Malignant from Benign Intracranial Tumors in Young Patients: A Preliminary Study.

PURPOSE: To evaluate the amide proton transfer (APT), tumor blood flow (TBF), and apparent diffusion coefficient (ADC) combined diagnostic value for differentiating intracranial malignant tumors (MTs) from benign tumors (BTs) in young patients, as defined by the 2021 World Health Organization classification of central nervous system tumors. METHODS: Fifteen patients with intracranial MTs and 10 patients with BTs aged 0-30 years underwent MRI with APT, pseudocontinuous arterial spin labeling (pCASL), and diffusion-weighted imaging. All tumors were evaluated through the use of histogram analysis and the Mann-Whitney U test to compare 10 parameters for each sequence between the groups. The diagnostic performance was evaluated using receiver operating characteristic (ROC) curve analysis. RESULTS: The APT maximum, mean, 10th, 25th, 50th, 75th, and 90th percentiles were significantly higher in MTs than in BTs; the TBF minimum (min) was significantly lower in MTs than in BTs; TBF kurtosis was significantly higher in MTs than in BTs; the ADC min, 10th, and 25th percentiles were significantly lower in MTs than in BTs (all p < 0.05). The APT 50th percentile (0.900), TBF min (0.813), and ADC min (0.900) had the highest area under the curve (AUC) values of the parameters in each sequence. The AUC for the combination of these three parameters was 0.933. CONCLUSIONS: The combination of APT, TBF, and ADC evaluated through histogram analysis may be useful for differentiating intracranial MTs from BTs in young patients.

Superficial small cerebellar infarcts in cerebral amyloid angiopathy on 3 T MRI: A preliminary study.

BACKGROUND: Strictly superficial cerebellar microbleeds and cerebellar superficial siderosis have been considered markers of advanced cerebral amyloid angiopathy (CAA), but there are few studies on cerebellar ischemic lesions in CAA. We investigated the presence of superficial small cerebellar infarct (SCI) ≤15 mm and its relation to magnetic resonance imaging (MRI) markers in patients with probable CAA. METHODS: Eighty patients with probable CAA were retrospectively evaluated. The presence of superficial SCIs was examined, along with cerebellar microbleeds and cerebellar superficial siderosis, using 3-T MRI. Lobar cerebral microbleeds, cortical superficial siderosis (cSS), enlargement of the perivascular space in the centrum semiovale, and white matter hyperintensity were assessed and the total CAA-small vessel disease (SVD) score was calculated. RESULTS: Nine of the 80 patients (11.3%) had a total of 16 superficial SCIs. By tentatively defining SCI <4 mm as cerebellar microinfarcts, 8 out of 16 (50%) superficial SCIs corresponded to cerebellar microinfarcts. The total CAA-SVD score was significantly higher in patients with superficial SCIs (p = 0.01). The prevalence of cSS (p = 0.018), cortical cerebral microinfarct (p = 0.034), and superficial cerebellar microbleeds (p = 0.006) was significantly higher in patients with superficial SCIs. The number of superficial cerebellar microbleeds was also significantly higher in patients with superficial SCIs (p = 0.001). CONCLUSIONS: Our results suggest that in patients with CAA, superficial SCIs (including microinfarcts) on MRI may indicate more severe, advanced-stage CAA. These preliminary findings should be verified by larger prospective studies in the future.

Advanced multiparametric MRI and FDG-PET/CT in multinodular and vacuolating neuronal tumor: A pathologically confirmed case.

Multinodular and vacuolating neuronal tumor (MVNT) is a relatively new disease concept proposed in 2013 and was classified as a separate tumor type in 2021 by the World Health Organization (WHO) classification. MVNT can cause seizures but is a benign disease, with no cases of enlargement or postoperative recurrence reported. Recent reports described advanced MRI features in MVNT cases, but the diagnosis of MVNT is usually based on characteristic MRI findings of clusters of nodules. Here, we report advanced multiparametric MRI and FDG-PET/CT findings in a case of MVNT with epileptiform symptoms that was pathologically confirmed by surgery.

Pseudocontinuous Arterial Spin Labeling: Clinical Applications and Usefulness in Head and Neck Entities.

As functional magnetic resonance imaging, arterial spin labeling (ASL) techniques have been developed to provide quantitative tissue blood flow measurements, which can improve the performance of lesion diagnosis. ASL does not require contrast agents, thus, it can be applied to a variety of patients regardless of renal impairments and contrast agent allergic reactions. The clinical implementation of head and neck lesions is limited, although, in recent years, ASL has been increasingly utilized in brain lesions. Here, we review the development of the ASL techniques, including pseudocontinuous ASL (pCASL). We compare readout methods between three-dimensional (3D) turbo spin-echo and 2D echo planar pCASL for the clinical applications of pCASL to head and neck lesions. We demonstrate the clinical usefulness of 3D pCASL for diagnosing various entities, including inflammatory lesions, hypervascular lesions, and neoplasms; for evaluating squamous cell carcinoma (SCC) treatment responses, and for predicting SCC prognosis.

Tumor blood flow and apparent diffusion coefficient histogram analysis for differentiating malignant salivary tumors from pleomorphic adenomas and Warthin's tumors.

We aimed to assess the combined diagnostic value of apparent diffusion coefficient (ADC) and tumor blood flow (TBF) obtained by pseudocontinuous arterial spin labeling (pCASL) for differentiating malignant tumors (MTs) in salivary glands from pleomorphic adenomas (PAs) and Warthin's tumors (WTs). We used pCASL imaging and ADC map to evaluate 65 patients, including 16 with MT, 30 with PA, and 19 with WT. We evaluated all tumors by histogram analyses and compared various characteristics by one-way analysis of variance followed by Tukey post-hoc tests. Diagnostic performance was evaluated by receiver operating characteristic (ROC) curve analysis. There were significant differences in the mean, 50th, 75th, and 90th percentiles of TBF among the tumor types, in the mean TBFs (mL/100 g/min) between MTs (57.47 ± 35.14) and PAs (29.88 ± 22.53, p = 0.039) and between MTs and WTs (119.31 ± 50.11, p < 0.001), as well as in the mean ADCs (× 10-3 mm2/s) between MTs (1.08 ± 0.28) and PAs (1.60 ± 0.34, p < 0.001), but not in the mean ADCs between MTs and WTs (0.87 ± 0.23, p = 0.117). In the ROC curve analysis, the highest areas under the curves (AUCs) were achieved by the 10th and 25th percentiles of ADC (AUC = 0.885) for differentiating MTs from PAs and the 50th percentile of TBF (AUC = 0.855) for differentiating MTs from WTs. The AUCs of TBF, ADC, and combination of TBF and ADC were 0.850, 0.885, and 0.950 for MTs and PAs differentiation and 0.855, 0.814, and 0.905 for MTs and WTs differentiation, respectively. The combination of TBF and ADC evaluated by histogram analysis may help differentiate salivary gland MTs from PAs and WTs.

Central nervous system involvement of systemic ALK-positive histiocytosis with KIF5B-ALK fusion.

ALK-positive histiocytosis is an emerging histiocytic entity that can involve a single organ or multiple organs. This disease frequently involves the central nervous system, and the importance of immunohistochemical and genetic analyses is emphasized for the accurate diagnosis of this rare entity. However, radiological findings of this disease have not been sufficiently described. Here, we report a case of a 3-year-old boy with ALK-positive histiocytosis with systemic masses that was identified to harbor KIF5B-ALK gene fusion.

Cerebral Microbleeds With Atrial Fibrillation After Ablation Therapy.

BACKGROUND: The prevalence of cerebral microbleeds (CMBs) is significantly higher in patients with atrial fibrillation (AF) than in those without AF. CMBs in patients with AF have been reported to be primarily of the lobar type, but the exact cause of this remains unknown. We investigated the possibility that hemorrhagic transformation of embolic microinfarction can account for de novo lobar CMBs. METHODS: A total of 101 patients who underwent ablation therapy for AF were prospectively registered, and 72 patients completed the assessment with MRI 6 months after catheter ablation. Brain MRI, including diffusion-weighted imaging (DWI) and susceptibility-weighted imaging (SWI), were examined at 1-3 days (baseline) and 6 months after catheter ablation. We quantitatively evaluated the spatial and temporal distribution of embolic microinfarctions and de novo CMBs. RESULTS: Of the 101 patients, 68 were enrolled in this study. Fifty-nine patients (86.8%) showed embolic microinfarctions on baseline DWI immediately after catheter ablation. There were 137 CMBs in SWI, and 96 CMBs were of the lobar type. Six months later, there were 208 CMBs, including 71 de novo CMBs, and 60 of 71 (84.5%) were of the lobar type. Of the 71 de novo CMBs, 56 (78.9%) corresponded to the location of previous embolic microinfarctions found on baseline DWI. The platelet count was significantly lower and hematocrit/hemoglobin and Fazekas score were higher in the group with de novo CMBs than in the group without de novo CMBs. CONCLUSION: De novo CMBs frequently appeared after catheter ablation therapy. Our results suggest that embolic microinfarction can cause lobar CMBs.

Hemangioblastoma of the Cerebellopontine Angle Evaluated with Pseudocontinuous Arterial Spin Labeling.

Hemangioblastomas of the cerebellopontine angle (CPA) that emerge extra-axially from the peripheral nervous system are extremely rare. We report a case of hemangioblastoma of the CPA evaluated by pseudocontinuous arterial spin labeling (pCASL). The high rate of tumor blood flow determined using pCASL provided additional useful information for the differential diagnosis of the CPA tumors in this patient.

A case of a rosette-forming glioneuronal tumor arising from the pons with disappearance of contrast enhancement.

A rosette-forming glioneuronal tumor (RGNT) is a rare and slow-growing central nervous system tumor. This tumor is usually assessed by MRI during the follow-up period. RGNT can show alteration of contrast enhancement regardless of tumor growth. Here, we report a case of RGNT arising from pons which shows partial enhancement on initial MRI, smaller enhancement on follow-up MRI at 10 months, and totally disappeared at 18 months without any therapy.

Ipilimumab-induced hypophysitis involving the optic tracts and tuber cinereum evaluated using 3D fluid-attenuated inversion recovery.

Ipilimumab, a human monoclonal antibody against cytotoxic T-lymphocyte antigen 4, was approved by the U.S. FDA (Food and Drug Administration) in 2011 for the treatment of unresectable or metastatic malignant melanoma. Occurrence of hypophysitis, an immune-related adverse event due to ipilimumab use, has been frequently reported. We report a case of ipilimumab-induced hypophysitis involving the optic tracts and tuber cinereum, identified using 3D fluid-attenuated inversion recovery.