Imaging score for differentiation of meningioma grade.

PURPOSE: We sought to establish a comprehensive imaging score indicating the likelihood of higher WHO grade meningiomas pre-operatively. METHODS: All surgical intracranial meningioma patients at our institution between 2014 and 2018 underwent retrospective chart review. Preoperative MRI sequences were reviewed, and imaging features were included in the score based on statistical and clinical significance. Point values for each significant feature were assigned based on the beta coefficients obtained from multivariate analysis. The imaging score was calculated by adding up the points, for a total score of 0 to 5. The predictive ability of the score to identify higher-grade meningiomas was evaluated. RESULTS: Ninety patients, 50% of whom had a postoperative diagnosis of WHO grade II meningioma, were included. The mean age for the population was 59.9 years and 70% were female. Tumor volume ≥ 36.0 cc was assigned 2 points, presence of irregular tumor borders was assigned 2 points, and presence of peritumoral edema was assigned 1 point. The probability of having a WHO grade II meningioma was 0% with a score of 0, 25.0% with a score of 1, 38.5% with a score of 2, 65.4% with a score of 3, and 83.3% with a score of 4 or greater. A threshold of ≥ 3 points achieved a recall of 0.80, precision of 0.73, F1-score of 0.77, accuracy of 0.76, and AUC of 0.82. CONCLUSION: The proposed imaging scoring system had good predictive capability for WHO grade II meningiomas with good discrimination and calibration. External validation is needed.

Pituitary Metastasis Presenting With Central Diabetes Insipidus and Panhypopituitarism.

OBJECTIVE: We report a case of pituitary metastasis (PM) presenting with acute anterior and posterior pituitary dysfunction following a two-decade-long oncologic course marked by disease progression. CASE REPORT: An elderly woman with a history of stage IIA invasive ductal carcinoma of the breast presented with confusion. Her laboratory evaluation was significant for panhypopituitarism and central diabetes insipidus, and magnetic resonance imaging findings were suggestive of PM. She was treated with hormone replacement, resulting in the reversal of her metabolic and cognitive derangements. DISCUSSION: PM is a rare complication of advanced malignancy. Although several malignancies may spread to the pituitary, the most common are breast cancer in women and lung cancer in men. Unlike pituitary adenomas, which predominantly involve the anterior pituitary, PM has a predilection for the posterior lobe and infundibulum due to direct access via systemic circulation. The clinical presentation of PM depends on the size of the metastatic deposit and other structures involved in the vicinity of the sella. Magnetic resonance imaging with gadolinium is the gold standard for the evaluation of sellar masses. The diagnosis of PM involves a thorough history, physical examination, biochemical evaluation of the hypothalamic-pituitary axis, and imaging studies. CONCLUSION: Metastatic involvement of the pituitary is a rare condition seen in <2% of resected pituitary masses. The clinical presentation is heterogeneous and can include headache, visual impairment, and panhypopituitarism. Unfortunately, the presence of PM portends a poor prognosis, and the median survival rate after diagnosis is 6 to 13.6 months.

ACR Appropriateness Criteria® Suspected Spine Infection.

Spine infection is both a clinical and diagnostic imaging challenge due to its relatively indolent and nonspecific clinical presentation. The diagnosis of spine infection is based upon a combination of clinical suspicion, imaging evaluation and, when possible, microbiologic confirmation performed from blood cultures or image-guided percutaneous or open spine biopsy. With respect to the imaging evaluation of suspected spine infection, MRI without and with contrast of the affected spine segment is the initial diagnostic test of choice. As noncontrast MRI of the spine is often used in the evaluation of back or neck pain not responding to conservative medical management, it may show findings that are suggestive of infection, hence this procedure may also be considered in the evaluation of suspected spine infection. Nuclear medicine studies, including skeletal scintigraphy, gallium scan, and FDG-PET/CT, may be helpful in equivocal or select cases. Similarly, radiography and CT may be appropriate for assessing overall spinal stability, spine alignment, osseous integrity and, when present, the status of spine instrumentation or spine implants. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Posterior Reversible Encephalopathy Syndrome and Reversible Cerebral Vasoconstriction Syndrome: Distinct Clinical Entities with Overlapping Pathophysiology.

The clinical and radiologic manifestations of posterior reversible encephalopathy syndrome and reversible cerebral vasoconstriction syndrome are reviewed. The relationship between these entities is discussed. A hypothesis of a common underlying pathophysiology is proposed and substantiated based on the current medical literature.

Pharmacological protection of hearing loss in the mouse model of endolymphatic hydrops.

OBJECTIVES/HYPOTHESIS: Excitotoxic and related inflammatory injury are implicated in the spiral ganglion degeneration seen with Meniere's disease and endolymphatic hydrops (ELH). Excitotoxicity is initiated with glutamate elevation and associated with downstream increases in reactive oxygen species resulting in inflammation-mediated neuronal degeneration. This study tests the hypothesis that interruption of the initial and/or downstream aspects of excitotoxicity should provide hearing protection in ELH-associated hearing loss. STUDY DESIGN: This study tests whether riluzole, a glutamate release inhibitor, and dimethylsulfoxide (DMSO), an anti-inflammatory and antioxidant solvent with favorable properties at the level of glutamate receptors, can protect against early-stage hearing loss in a mouse model of ELH. METHODS: The Phex(Hyp-Duk) mouse spontaneously develops ELH and postnatal hearing loss. Starting at postnatal day 6 (P6), daily injections of riluzole + DMSO or just DMSO were administered. Untreated mutants served as controls. At P21, P25, and P30, hearing function was assessed by recording auditory brainstem responses. A cochlear function index was developed to assess global cochlear function at each time point. RESULTS: Compared to no treatment, DMSO provided significant hearing protection (P < .05). The riluzole + DMSO also showed protection, but it was statistically indistinguishable from DMSO alone; a synergistic increase in protection with riluzole was not observed. CONCLUSIONS: This study demonstrates pharmacological hearing protection in an animal model of ELH. The results support the assertion that inflammatory (reactive oxygen species) injury, which is part of the excitotoxic pathway, contributes to the development of ELH-associated hearing loss.

Roman arch, keystone fixation for facial bipartition with monobloc distraction.

BACKGROUND: Patients with craniofacial dysostosis may require correction for hypertelorbitism and midface hypoplasia. Traditionally, these procedures were sequential or staged, and used acute advancement with bone grafting and rigid fixation. The authors reviewed a series of combined, one-stage facial bipartition and monobloc distraction procedures using internal devices. They describe the Roman arch, keystone fixation modification to maximize the stability of the bipartition segments and support the vertical load of the distraction forces. METHODS: Patients diagnosed at the University of California, Los Angeles as having craniofacial dysostosis with hypertelorbitism and midface hypoplasia who underwent the Roman arch, keystone fixation procedure were included in the study (n = 13). Reduction of interdacryon and intercanthal distances and the lateral cephalometric horizontal change of the forehead, midface, and maxilla were studied postoperatively and at 1-year follow-up. RESULTS: There were no serious complications (e.g., cerebrospinal fluid leak, meningitis, frontal bone loss); there was a 10 percent rate of total complications (wound infection). Facial bipartition successfully narrowed the interdacryon distance by a mean of 55 percent (21 mm), with only a 3-mm relapse. The mean distraction advancement/relapse was as follows: forehead, +16 mm/-2 mm; midface, 14 mm/-1 mm; and maxilla, 13 mm/-1 mm. Only one of 13 patients required a repeated monobloc procedure. Of the seven patients who reached skeletal maturity, 86 percent underwent a subsequent Le Fort I and/or III procedure. CONCLUSION: The Roman arch, keystone fixation modification of a combined facial bipartition with monobloc distraction using internal devices provided a stable construct for advancement, with minimal relapse.