Patterns of Contrast Enhancement in the Brain and Meninges

Early Detection of Malignant Transformation in Resected WHO II Low-Grade Glioma Using Diffusion Tensor-Derived Quantitative Measures

OBJECTIVE

Here, we retrospectively investigate the value of voxel-wisely plotted diffusion tensor-derived (DTI) axial, radial and mean diffusivity for the early detection of malignant transformation (MT) in WHO II glioma compared to contrast-enhanced images.

MATERIALS AND METHODS

Forty-seven patients underwent brain magnetic resonance imaging follow-up between 2006-2014 after gross-tumor resection of intra-axial WHO II glioma. Axial/Mean/Radial diffusivity maps (AD/MD/RD) were generated from DTI data. ADmin/MDmin/RDmin values were quantified within tumor regions-of-interest generated by two independent readers including tumor contrast-to-noise (CNR). Sensitivity/specificity and area-under-the-curve (AUC) were calculated using receiver-operating-characteristic analysis. Inter-reader agreement was assessed (Cohen's kappa).

RESULTS

Eighteen patients demonstrated malignant transformation (MT) confirmed in 8/18 by histopathology and in 10/18 through imaging follow-up. Twelve of 18 patients (66.6%) with MT showed diffusion restriction timely coincidental with contrast-enhancement (CE). In the remaining six patients (33.3%), the diffusion restriction preceded the CE. The mean gain in detection time using DTI was (0.8±0.5 years, p = 0.028). Compared to MDmin and RDmin, ROC-analysis showed best diagnostic value for ADmin (sensitivity/specificity 94.94%/89.7%, AUC 0.96; p<0.0001) to detect MT. CNR was highest for AD (1.83±0.14), compared to MD (1.31±0.19; p<0.003) and RD (0.90±0.23; p<0.0001). Cohen's Kappa was 0.77 for ADmin, 0.71 for MDmin and 0.65 for RDmin (p<0.0001, respectively).

CONCLUSION

MT is detectable at the same time point or earlier compared to T1w-CE by diffusion restriction in diffusion-tensor-derived maps. AD demonstrated highest sensitivity/specificity/tumor-contrast compared to radial or mean diffusivity (= apparent diffusion coefficient) to detect MT.

Orbital Metastasis of Breast Cancer Mimicking Invasive Fungal Rhinosinusitis

Introduction. A range of traumatic, vascular, inflammatory, infectious, and neoplastic processes can affect the orbit and its structures. In the area of otolaryngology, the rhino-orbital-cerebral involvement of invasive fungal rhinosinusitis can affect the orbit, which may look like initially a rhinosinusitis or even mimic malignancy. Case Presentation. Female patient, 32 years old, with headache and ocular proptosis. She was using prednisone in immunosuppressive doses for a year and had breast cancer treated three years earlier. The initial CT scan showed opacification of the sphenoid and ethmoid sinuses, left intraorbital involvement and contrast impregnation in the cavernous sinus. The biopsy resulted positive for invasive ductal carcinoma of the breast. Discussion. The initial CT scan of our patient showed both signs of early changes of invasive fungal rhinosinusitis (IFR) and possible metastatic involvement. The intracranial extension and ocular involvement are usually the most common signs of IFR (first hypothesis). Among metastases at the orbit and the eye, breast and lung carcinomas are the most frequent. Conclusion. Although several studies on the differential diagnosis of orbital lesions exist, especially when it concerns the involvement of the nasal cavity, the diagnosis by imaging is still a challenge.

Perilesional Inflammation in Neurocysticercosis - Relationship Between Contrast-Enhanced Magnetic Resonance Imaging, Evans Blue Staining and Histopathology in the Pig Model

Background

Disease manifestations in neurocysticercosis (NCC) are frequently due to inflammation of degenerating Taenia solium brain cysts. Exacerbated inflammation post anthelmintic treatment is associated with leakage of the blood brain barrier (BBB) using Evans blue (EB) staining. How well EB extravasation into the brain correlates with magnetic resonance imaging (MRI) using gadolinium (Gd) enhancement as a contrast agent and pericystic inflammation was analyzed in pigs harboring brain cysts of Taenia solium.

Methodology/Principal Findings

Three groups of 4 naturally infected pigs were assessed. The first and second groups were treated with both praziquantel plus albendazole and sacrificed two and five days post treatment, respectively. A third untreated group remained untreated. Pigs were injected with EB two hours prior to evaluation by Gd-enhanced T1-MRI, and euthanized. The EB staining for each cyst capsule was scored (EB grades were 0: 0%; 1: up to 50%; 2: over 50% but less than 100%; 3: 100%). Similarly, the Gd enhancement around each cyst was qualitatively and quantitatively scored from the MRI. The extent of pericystic inflammation on histology was scored in increasing severity as IS1, IS2, IS3 and IS4. Grade 3 EB staining and enhancement was only seen in treated capsules. Also, treated groups had higher Gd intensity than the untreated group. Grades of enhancement correlated significantly with Gd enhancement intensity. EB staining was correlated with Gd enhancement intensity and with IS4 in the treated groups. These correlations were stronger in internally located cysts compared to superficial cysts in treated groups.

Significance

EB staining and Gd enhancement strongly correlate. The intensity of enhancement determined by MRI is a good indication of the degree of inflammation. Similarly, EB staining highly correlates with the degree of inflammation and may be applied to study inflammation in the pig model of NCC.

Neurocysticercosis (NCC) is a frequent parasitic infection of the human brain in developing countries. The symptomatology of human NCC after antiparasitic treatment is generally related to inflammation. The presence and degree of enhancement after intravascular injection of the contrast agent gadolinium in magnetic resonance imaging (MRI) is commonly considered an evidence of blood brain barrier (BBB) leakage. Experimentally, the presence and degree of extravasation of Evans blue (EB) after intravascular injection into the tissues of the brain is a direct measure of blood brain barrier leakage. The BBB leakage of gadolinium in neurocysticercosis is commonly used as an indirect measure of inflammation but has never been experimentally proven. Here we evaluated the relationship between contrast T1-MRI, EB staining and histology findings in naturally infected pigs. There was a strong correlation between EB staining, contrast MRI and histopathology findings after antiparasitic treatment. This correlation was stronger when cysts were internally located in the brain than in superficial cysts partly located in the subarachnoid space (meninges). Contrast-enhanced MRI is a non invasive tool used in diagnosis and follow up of NCC patients. This study shows that the use of EB staining allows for the same conclusions as when using MRI post-treatment, and that both techniques correlate with histopathology findings. These results support the use of EB staining to study NCC using the porcine model as well as validate MRI enhancement to assess brain inflammation in patients.

Incidence of meningeal enhancement on brain MRI secondary to lumbar puncture

Background

Concern for reactive meningeal enhancement after lumbar puncture (LP) is a common reason for performing brain MRI prior to LP. We sought to determine actual incidence of unexplained meningeal enhancement after LP.

Methods

We collected results from all contrasted brain MRIs in patients admitted to adult neurology at a New York City hospital over a 3-year period. We used electronic medical records to determine whether an LP had been done within 30 days prior to brain MRI. The control group comprised those brain MRIs not preceded by an LP within 30 days prior to imaging. Number of cases of unexplained meningeal enhancement was compared between groups using a Fisher exact test. We recorded variables such as number of LP attempts, needle size, amount of fluid removed, and days from LP to brain MRI.

Results

From 2011 to 2013, there were 77 cases of LP prior to brain MRI and 707 controls (n = 784). Of the cases, 3 had meningeal enhancement, 1 (1.2%) of which was unexplained. Of the 707 controls, 36 had enhancement, and none was unexplained. The p value comparing unexplained enhancement in the cases vs controls was 0.098.

Conclusions

Iatrogenic meningeal enhancement from prior LP that is not attributable to traumatic LP or intracranial hypotension is rare and not more common than in cases without a prior LP. Results suggest that the practice of delaying LP until after brain MRI might not be supported in cases where LP is necessary.

Dilemmas surrounding the diagnosis of deep brain stimulation electrode infection without associated wound complications: A series of two cases

Background:

When wounds are benign, diagnosis of deep brain stimulation (DBS) electrode infection and associated intraparenchymal infection can be challenging. Only a couple, such cases exist in literature. Since infections of the central nervous system can be life-threatening, prompt diagnosis is necessary to prevent neurological injury. Employed within the appropriate context, magnetic resonance imaging (MRI) of the brain, as well as laboratory data and clinical presentation, may help guide diagnosis.

Case Descriptions:

Case 1 - A 55-year-old male with bilateral DBS electrodes and generators (49 days from last procedure), who presented with confusion and fever. Pertinent positive laboratory was white blood cell 20.5K. MRI of the brain showed edema with enhancement along the right DBS electrode. Wound exploration revealed gross purulence in the subgaleal space. The entire system was removed; cultures from subgaleal space revealed Propionibacterium acnes; cultures from electrode were negative. The patient was sent home on antibiotics. Case 2 - A 68-year-old male with a right DBS electrode (11 days from placement), who presented after an unwitnessed fall, followed by confusion and amnesia. Pertinent laboratory examinations were negative. MRI of the brain showed edema with enhancement along the DBS electrode. Wound exploration revealed no infection. The DBS system was left in place; final cultures were negative; no antibiotics were prescribed. Repeat MRI showed resolving fluid-attenuated inversion recovery (FLAIR) signal and contrast enhancement.

Conclusions:

Contrast enhancement, T2 FLAIR, and diffusion weighted imaging are influenced by postoperative changes. Caution is stressed regarding dependence on these features for acute diagnosis of infection and indication for electrode removal. Timing of the imaging after surgery must be considered. Other factors, such as systemic signs and abnormal laboratory data, should be evaluated. Based on these guidelines, retrospectively, the patient in Case 2 should not have been rushed for a wound exploration; close observation with serial imaging and laboratory data may have prevented an unnecessary procedure.

"Comet tail sign": A pitfall of post-gadolinium magnetic resonance imaging findings for metastatic brain tumors

A highly enhanced cap attached to the surface of metastatic tumors in the brain parenchyma is occasionally encountered on magnetic resonance (MR) images. This atypical enhanced cap tends to occur in severe peritumoral edema and may produce the characteristic bulge of a metastatic mass lesion termed the "comet tail sign" (CTS). The purpose of this study was to demonstrate the features of the CTS using MR imaging and pathological findings, and to clarify its clinical relevance. We selected 21 consecutive cases of newly diagnosed metastases from MR imaging studies that demonstrated the CTS; all had diffuse peritumoral edema. The MR T2-weighted images showed similarly homogenous and high intensity signals in both the tail and peritumoral edema. Fourteen of the 21 patients underwent surgical resection of their tumors, and 12 tails were separately removed for pathological examination, no tumor cells which revealed. We speculate that the CTS does not contain neoplastic tissues but is observed as a result of the leakage of contrast medium from the tumor body into the interstitial space of the white matter. Although CTS is a peculiar and uncommon enhancement pattern, it has clinical significance in determining the extent of the margin for invasive local treatments, such as surgical resection or stereotactic radiotherapy; this is particularly true in and near the eloquent areas.

Performance of Apparent Diffusion Coefficient Values and Conventional MRI Features in Differentiating Tumefactive Demyelinating Lesions From Primary Brain Neoplasms

OBJECTIVE

Tumefactive demyelinating lesions (TDLs) remain one of the most common brain lesions to mimic a brain tumor, particularly primary CNS lymphoma (PCNSL) and high-grade gliomas. The purpose of our study was to evaluate the ability of apparent diffusion coefficient (ADC) values and conventional MRI features to differentiate TDLs from PCNSLs and high-grade gliomas.

MATERIALS AND METHODS

Seventy-five patients (24 patients with TDLs, 28 with PCNSLs, and 23 with high-grade gliomas) with 168 brain lesions (70 TDLs, 68 PCNSLs, and 30 high-grade gliomas) who underwent DWI before surgery or therapy were included in the study. Minimum ADC (ADC(min)) and average ADC (ADC(avg)) values were calculated for each lesion. ANOVA and ROC analyses were performed. ROC analyses were also performed for the presence of incomplete rim enhancement and for the number of lesions. Multiple-variable logistic regression with ROC analysis was then performed to evaluate performance in multiple-variable models.

RESULTS

ADC(min) was statistically significantly higher (p < 0.01) in TDLs (mean, 0.886; 95% CI, 0.802-0.931) than in PCNSLs (0.547; 95% CI, 0.496-0.598) and high-grade gliomas (0.470; 95% CI, 0.385-0.555). (All ADC values in this article are reported in units of × 10(-3) mm(2)/s.) ADC(avg) was statistically significantly higher (p < 0.01) in TDLs (mean, 1.362; 95% CI, 1.268-1.456) than in PCNSLs (0.990; 95% CI, 0.919-1.061) but not in high-grade gliomas (1.216; 95% CI, 1.074-1.356). Multiple-variable models showed statistically significant individual effects and superior diagnostic performance on ROC analysis.

CONCLUSION

TDLs can be diagnosed on preoperative MRI with a high degree of specificity; MRI features of incomplete rim enhancement, high ADC values, and a large number of lesions individually increase the probability and diagnostic confidence that a lesion is a TDL.

Quantifying brain volumes for Multiple Sclerosis patients follow-up in clinical practice - comparison of 1.5 and 3 Tesla magnetic resonance imaging

INTRODUCTION

There is emerging evidence that brain atrophy is a part of the pathophysiology of Multiple Sclerosis (MS) and correlates with several clinical outcomes of the disease, both physical and cognitive. Consequently, brain atrophy is becoming an important parameter in patients' follow-up. Since in clinical practice both 1.5Tesla (T) and 3T magnetic resonance imaging (MRI) systems are used for MS patients follow-up, questions arise regarding compatibility and a possible need for standardization.

METHODS

Therefore, in this study 18 MS patients were scanned on the same day on a 1.5T and a 3T scanner. For each scanner, a 3D T1 and a 3D FLAIR were acquired. As no atrophy is expected within 1 day, these datasets can be used to evaluate the median percentage error of the brain volume measurement for gray matter (GM) volume and parenchymal volume (PV) between 1.5T and 3T scanners. The results are obtained with MSmetrix, which is developed especially for use in the MS clinical care path, and compared to Siena (FSL), a widely used software for research purposes.

RESULTS

The MSmetrix median percentage error of the brain volume measurement between a 1.5T and a 3T scanner is 0.52% for GM and 0.35% for PV. For Siena this error equals 2.99%. When data of the same scanner are compared, the error is in the order of 0.06-0.08% for both MSmetrix and Siena.

CONCLUSIONS

MSmetrix appears robust on both the 1.5T and 3T systems and the measurement error becomes an order of magnitude higher between scanners with different field strength.

The Direct Effects of Fingolimod in the Central Nervous System: Implications for Relapsing Multiple Sclerosis

Fingolimod, a structural analog of sphingosine derived from fungal metabolites, is a functional antagonist of the G-protein-coupled sphingosine 1-phosphate (S1P) receptors S1P(1,3,4,5). In the treatment of relapsing forms of multiple sclerosis (RMS), fingolimod acts by reversibly retaining central memory T cells and naïve T cells in lymph nodes, thereby reducing the recirculation of autoreactive lymphocytes to the central nervous system (CNS). Fingolimod also has differential effects on the trafficking and function of B-cell subtypes and natural killer (NK) cells in peripheral blood and the CNS. Fingolimod also crosses the blood-brain barrier (BBB) and accumulates in the CNS. Experimental evidence increasingly supports a direct action of fingolimod within the CNS on brain cells, providing protection against the neurodegenerative component of RMS. We review the direct influence of this compound on CNS pathogenesis in RMS, including the central effects of fingolimod in animal models of MS and on neural cell types that express S1P receptors, such as astrocytes, BBB endothelial cells, microglia, neurones, and oligodendrocytes, which are all involved in RMS pathology.

Nonenhancing Leptomeningeal Metastases: Imaging Characteristics and Potential Causative Factors

The diagnosis of leptomeningeal metastasis (LM) has increased in frequency, as new therapies have lengthened the survival of patients with cancer. Early diagnosis and intervention help improve quality of life and prevent further neurological deterioration in LM. The detection of LM is often established by magnetic resonance imaging examinations, cerebrospinal fluid analysis, or both. We present a series of cases where LM was identified on fluid-attenuated inversion recovery or T2-weighted image but was nonenhancing on the traditionally more sensitive postcontrast T1-weighted sequences. Nonenhancing LM is unusual and not yet fully understood but should be considered in the appropriate clinical context and may become more common with increased utilization of antiangiogenic therapies.

Importance of Contrast-Enhanced Fluid-Attenuated Inversion Recovery Magnetic Resonance Imaging in Various Intracranial Pathologic Conditions

Intracranial lesions may show contrast enhancement through various mechanisms that are closely associated with the disease process. The preferred magnetic resonance sequence in contrast imaging is T1-weighted imaging (T1WI) at most institutions. However, lesion enhancement is occasionally inconspicuous on T1WI. Although fluid-attenuated inversion recovery (FLAIR) sequences are commonly considered as T2-weighted imaging with dark cerebrospinal fluid, they also show mild T1-weighted contrast, which is responsible for the contrast enhancement. For several years, FLAIR imaging has been successfully incorporated as a routine sequence at our institution for contrast-enhanced (CE) brain imaging in detecting various intracranial diseases. In this pictorial essay, we describe and illustrate the diagnostic importance of CE-FLAIR imaging in various intracranial pathologic conditions.

Infections

"Children are not little adults," and while this is a well-worn aphorism, it is especially true in the context of infection, where the same organism may evoke a different immune response in the pediatric central nervous system (CNS) and clinical presentation may be clouded by the lack of a good history or paucity of clinical information. The chronology and natural history of different organisms/infections will be laid out together with the preferred use of different imaging modalities. This chapter will use illustrative examples of some of the more common infections and their complications, in addition to several more rare conditions as well as mimics of childhood CNS infection. Challenges in the imaging of children, including strategies to minimize the use of radiation, are discussed. Some of the more recently voiced concerns regarding the use of anesthetic agents in children are also addressed, along with the contrast agents that are typically required for imaging. With a global increase in worldwide travel the anticipation is that pediatricians will increasingly see unusual organisms presenting with CNS infection while dealing with the ever-present risk of drug resistance with inappropriately treated common or garden infections.

Utility and Significance of Gadolinium-Based Contrast Enhancement in Posterior Reversible Encephalopathy Syndrome

BACKGROUND AND PURPOSE

Posterior reversible encephalopathy syndrome is a clinicoradiologic syndrome. Literature regarding associated factors and the prognostic significance of contrast enhancement in posterior reversible encephalopathy syndrome is sparse. This study set out to evaluate an association between the presence of enhancement in posterior reversible encephalopathy syndrome and various clinical factors in a large series of patients with this syndrome.

MATERIALS AND METHODS

From an MR imaging report search that yielded 176 patients with clinically confirmed posterior reversible encephalopathy syndrome between 1997 and 2014, we identified 135 patients who had received gadolinium-based contrast. The presenting symptoms, etiology, clinical follow-up, and maximum systolic and diastolic blood pressures within 1 day of MR imaging were recorded. MRIs were reviewed for parenchymal hemorrhage, MR imaging severity, and the presence and pattern of contrast enhancement. Statistical analyses evaluated a correlation between any clinical features and the presence or pattern of enhancement.

RESULTS

Of 135 included patients (67.4% females; age range, 7-82 years), 59 (43.7%) had contrast enhancement on T1-weighted MR imaging, the most common pattern being leptomeningeal (n = 24, 17.8%) or leptomeningeal plus cortical (n = 21, 15.6%). Clinical outcomes were available in 96 patients. No significant association was found between the presence or pattern of enhancement and any of the variables, including sex, age, symptom, MR imaging severity, blood pressure, or outcome (all P > .05 after Bonferroni correction).

CONCLUSIONS

The presence or pattern of enhancement in posterior reversible encephalopathy syndrome is not associated with any of the tested variables. However, an association was found between MR imaging severity and clinical outcome.

Polyradiculopathy and Gastroparesis due to Cytomegalovirus Infection in AIDS: A Case Report and Review of Literature

Patient: Female, 46

Final Diagnosis: CMV gastroparesis and radiculopathy

Symptoms: Nausea • paraplegia • urinary retention • vomiting

Medication: —

Clinical Procedure: Lumbar puncture

Specialty: Infectious Diseases

Granulomatous disease in the head and neck: developing a differential diagnosis

Granulomatous diseases have a varied etiology that includes autoimmune, infectious, idiopathic, and hereditary causes. The unifying factor in these diseases is the formation of granulomas, which histologically are mononuclear inflammatory cells or macrophages surrounded by lymphocytes. Granulomatous diseases often have systemic manifestations that affect organs throughout the body. Granulomatous diseases with head and neck manifestations include granulomatosis with polyangiitis, Churg-Strauss syndrome, Behçet disease, chronic granulomatous disease, and sarcoidosis. Infectious causes include tuberculosis, cat-scratch disease, syphilis, leprosy, actinomycosis, rhinoscleroma, and fungal infections. In the head and neck, granulomatous disease may affect the orbits, sinonasal cavities, salivary glands, aerodigestive tract, temporal bone, or skull base. Imaging findings include sinonasal opacification, ocular and other soft-tissue masses, osseous erosion, airway narrowing, lymphadenopathy, and salivary gland infiltration. Vascular involvement may also be evident, with displacement, narrowing, or occlusion of arteries and veins. Some radiologic findings of granulomatous processes have a considerable overlap with findings of malignancy, and a radiologic differential diagnosis inclusive of both is critical to avoid incorrect clinical treatment. Without the benefit of a prior clinical diagnosis, laboratory findings, or suggestive clinical signs and symptoms, granulomatous diseases may be difficult to differentiate radiologically. Although individual granulomatous diseases may have overlapping findings at imaging, certain radiologic findings should prompt the inclusion of granulomatous diseases in the differential diagnosis, thus facilitating appropriate clinical management.

MRI/MRS in neuroinflammation: methodology and applications

Neuroinflammation encompasses a wide range of humoral and cellular responses, not only enabling the CNS to fight various noxious events, including infections and trauma, but also playing a critical role in autoimmune as well as in neurodegenerative diseases. The complex interactions of immune, endothelial, and neuronal cells that take place during inflammation require an equivalent complexity of imaging approaches to be appropriately explored in vivo. Magnetic Resonance provides several complementary techniques that allow to study most mechanisms underlying the brain/immune interaction. In this review, we discuss the MR approaches to the study of endothelial activation, blood-brain barrier permeability alterations, intercellular compartment modifications, immune cell trafficking, and of metabolic alterations linked to immune cell activity. The main advantages and limitations of these techniques are assessed, in view of their exploitation in the clinical arena, where the complementarity of the information that can be obtained has the potential to change our way of studying neuroinflammation, with implications for the management of several CNS diseases.

Cranial base manifestations of neurosarcoidosis: a review of 305 patients

OBJECTIVE

Neurosarcoidosis is a rare granulomatous disease that can result in cranial neuropathy, chronic meningitis, and intracranial granuloma formation. Meningeal involvement may cause focal nodular enhancement that can simulate common cranial base tumors. The objective of the current study is to further define the clinical features of neurosarcoidosis in a large cohort of patients, focusing on characteristics relevant to the skull base surgeon.

STUDY DESIGN

Retrospective series.

SETTING

Two tertiary academic referral centers.

PATIENTS

Consecutive patients diagnosed with neurosarcoidosis.

INTERVENTION(S)

Review of clinical presentation, physical examination, radiologic findings, biopsy results, and laboratory testing.

MAIN OUTCOME MEASURES

Prevalence and distribution of cranial neuropathy, radiologic features of meningeal enhancement, and patterns of simulated tumors.

RESULTS

A total of 305 patients met study criteria. The mean age at diagnosis was 47 years and 53% were female. The optic nerve was the most commonly involved cranial nerve, followed by the trigeminal and the facial nerve. Meningeal enhancement was present in 67% of cases with 17% demonstrating focal or multicentric nodular enhancement simulating tumor. The most common locations of inflammatory tumor development included the cavernous sinus, petrous temporal bone, and sphenoid wing; six patients had bilateral internal auditory canal lesions, several mimicking neurofibromatosis type II.

CONCLUSION

Establishing the diagnosis of neurosarcoidosis remains challenging. Meningeal involvement and cranial neuropathy often mimic other more common conditions. Careful review of patient history and clinical imaging can reveal important clues toward the diagnosis of neurosarcoidosis. The clinician must maintain a high index of suspicion in patients with atypical presentation to avoid misdiagnosis and facilitate early medical treatment.

Pachymeningeal enhancement-a comprehensive review of literature

Pachymeningeal enhancement, synonymous with dural enhancement, is a radiological feature best appreciated on a contrast-enhanced magnetic resonance imaging (MRI). The vasculature of the dura mater is permeable, facilitating avid uptake of contrast agent and subsequent enhancement. Thin, discontinuous enhancement can be normal, seen in half the normal population. In patients complaining of postural headaches worse on sitting, gadolinium-enhanced MRI findings of diffuse pachymeningeal enhancement is highly suggestive of benign intracranial hypotension. In these cases, the process of pachymeningeal enhancement is explained by the Monro-Kellie doctrine as compensatory volume changes by vasocongestion and interstitial oedema of the dura mater due to decreased cerebrospinal fluid (CSF) pressure. Focal and diffuse pachymeningeal enhancement can also be attributed to infectious or inflammatory, neoplastic and iatrogenic aetiologies. Correction of the underlying pathology often results in spontaneous resolution of the pachymeningeal enhancement. There have also been reports of pachymeningeal enhancement associated with cerebral venous sinus thrombosis, temporal arteritis, baroreceptor reflex failure syndrome and arteriovenous fistulae.

Susceptibility-weighted imaging in stroke-like migraine attacks after radiation therapy syndrome

INTRODUCTION

Stroke-like migraine attacks after radiation therapy (SMART) syndrome has a characteristic clinical presentation and postcontrast T1WI MRI appearance. Susceptibility-weighted imaging (SWI) may help distinguish SMART from other disorders that may have a similar postcontrast MRI appearance.

METHODS

The MRI examinations of four patients with SMART syndrome are described herein, each of which included SWI, FLAIR, DWI, and postcontrast T1WI on the presenting and follow-up MRI examinations.

RESULTS

In each, the initial SWI MRI demonstrated numerous susceptibility hypointensities <5 mm in size throughout the cerebrum, particularly within the periventricular white matter (PVWM), presumably related to radiation-induced cavernous hemangiomas (RICHs). By follow-up MRI, each postcontrast examination had demonstrated resolution of the gyriform enhancement on T1WI, without susceptibility hypointensities on SWI within those previously enhancing regions.

CONCLUSION

These preliminary findings suggest that SWI may help identify SMART syndrome or at least help discriminate it from other disorders, by the findings of numerous susceptibility hypointensities on SWI likely representing RICHs, gyriform enhancement on T1WI, and postsurgical findings or appropriate clinical history.

Errors in neuroradiology

Approximately 4 % of radiologic interpretation in daily practice contains errors and discrepancies that should occur in 2-20 % of reports. Fortunately, most of them are minor degree errors, or if serious, are found and corrected with sufficient promptness; obviously, diagnostic errors become critical when misinterpretation or misidentification should significantly delay medical or surgical treatments. Errors can be summarized into four main categories: observer errors, errors in interpretation, failure to suggest the next appropriate procedure, failure to communicate in a timely and a clinically appropriate manner. Misdiagnosis/misinterpretation percentage should rise up in emergency setting and in the first moments of the learning curve, as in residency. Para-physiological and pathological pitfalls in neuroradiology include calcification and brain stones, pseudofractures, and enlargement of subarachnoid or epidural spaces, ventricular system abnormalities, vascular system abnormalities, intracranial lesions or pseudolesions, and finally neuroradiological emergencies. In order to minimize the possibility of error, it is important to be aware of various presentations of pathology, obtain clinical information, know current practice guidelines, review after interpreting a diagnostic study, suggest follow-up studies when appropriate, communicate significant abnormal findings appropriately and in a timely fashion directly with the treatment team.

Transcranial MRI-Guided Focused Ultrasound: A Review of the Technologic and Neurologic Applications

OBJECTIVE

This article reviews the physical principles of MRI-guided focused ultra-sound and discusses current and potential applications of this exciting technology.

CONCLUSION

MRI-guided focused ultrasound is a new minimally invasive method of targeted tissue thermal ablation that may be of use to treat central neuropathic pain, essential tremor, Parkinson tremor, and brain tumors. The system has also been used to temporarily disrupt the blood-brain barrier to allow targeted drug delivery to brain tumors.

Bacterial, Fungal, and Parasitic Infections of the Central Nervous System: Radiologic-Pathologic Correlation and Historical Perspectives

Despite remarkable progress in prevention and treatment, infectious diseases affecting the central nervous system remain an important source of morbidity and mortality, particularly in less-developed countries and in immunocompromised persons. Bacterial, fungal, and parasitic pathogens are derived from living organisms and affect the brain, spinal cord, or meninges. Infections due to these pathogens are associated with a variety of neuroimaging patterns that can be appreciated at magnetic resonance imaging in most cases. Bacterial infections, most often due to Streptococcus, Haemophilus, and Neisseria species, cause significant meningitis, whereas the less common cerebritis and subsequent abscess formation have well-documented progression, with increasingly prominent altered signal intensity and corresponding contrast enhancement. Atypical bacterial infections are characterized by the development of a granulomatous response, classically seen in tuberculosis, in which the tuberculoma is the most common parenchymal form of the disease; spirochetal and rickettsial diseases are less common. Fungal infections predominate in immunocompromised hosts and are caused by yeasts, molds, and dimorphic fungi. Cryptococcal meningitis is the most common fungal infection, whereas candidiasis is the most common nosocomial infection. Mucormycosis and aspergillosis are characterized by angioinvasiveness and are associated with high morbidity and mortality among immunocompromised patients. In terms of potential exposure in the worldwide population, parasitic infections, including neurocysticercosis, toxoplasmosis, echinococcosis, malaria, and schistosomiasis, are the greatest threat. Rare amebic infections are noteworthy for their extreme virulence and high mortality. The objective of this article is to highlight the characteristic neuroimaging manifestations of bacterial, fungal, and parasitic diseases, with emphasis on radiologic-pathologic correlation and historical perspectives.

Delayed Occurrence of Escherichia coli Subdural Empyema Following Head Injury in an Elderly Patient: A Case Report and Literature Review

Subdural empyema is a rare but serious intracranial infection that warrants prompt management to reduce morbidity and avoid mortality. However, clinical and radiologic features may be subtle or ambivalent. Thus a diagnosis of subdural empyema should not be discounted, especially in a patient with a history of head trauma. Treatment consists of surgery to establish bacteriologic identification and subsequently guide antibiotic therapy. Here we present a case of delayed Escherichia coli subdural empyema following a head injury in an elderly patient without significant risk factors. Computed tomography imaging was equivocal for subdural empyema. The patient underwent surgery and was treated with intravenous antibiotic therapy. Although initial improvement in the patient's clinical condition was observed, he eventually succumbed to nosocomial pneumonia. In this article, we discuss the presentation, diagnostic tools, and treatment options for subdural empyema with an emphasis on the challenges. The management conundrum that follows prompted us subsequently to review the literature.

Differentiation of Leptomeningeal and Vascular Enhancement on Post-contrast FLAIR MRI Sequence: Role in Early Detection of Infectious Meningitis

OBJECTIVE

To qualitatively and quantitatively differentiate leptomeningeal and vascular enhancement on Post-contrast Fluid Attenuated Inversion Recovery (PCFLAIR) sequence compared to post-contrast T1-weighted (PCT1W) sequence with fat suppression (FS) and evaluate its role in early detection of infectious meningitis.

MATERIALS AND METHODS

Thirty-one patients with diagnosis of meningitis were evaluated with pre and post-contrast FLAIR and T1-weighted sequences with fat suppression (FS). Qualitative assessment was done by two observers for presence, absence or equivocal status of leptomeningeal enhancement. Further, quantitative estimation of single pixel signal intensities (SPSI) for meningeal and vascular enhancement was undertaken. A statistical comparison was performed using Kappa coefficient and t-test.

RESULTS

The overall qualitative accuracy was 90.3% for PCFLAIR compared to 54.8% for PCT1W with FS sequence. PCFLAIR was found to be 100% accurate in the detection of tubercular and pyogenic meningitis and 70% accurate in the detection of viral meningitis while PCT1W with FS sequence showed the corresponding accuracy to be 76.2% and 0% respectively. Both observers rated PCFLAIR images better than PCT1W with FS at detecting meningitis (p<0.05). The quantitative assessment revealed that the SPSI difference between the average meningeal and vascular enhancement on PCFLAIR was significantly greater than that on PCT1W with FS sequence (t= 6.31, p<0.01).

CONCLUSION

PCFLAIR sequence has insignificant component of vascular enhancement compared to meningeal enhancement. This makes meningeal inflammation easily discernable and aids in early detection of infectious meningitis.

Evolution of a Pediatric Primary Cerebral ALK-1-Positive Anaplastic Large Cell Lymphoma on Serial MRI

BACKGROUND

Primary central nervous system lymphoma (PCNSL) is a rare central nervous system tumor, especially in the pediatric population. There are fewer than 20 described cases of pediatric primary central nervous system anaplastic large cell lymphoma. The child described in our case report demonstrated a dramatic evolution of this tumor in the first 4 weeks on serial imaging.

METHODS

Serial MRI imaging was performed followed by biopsy and chemotherapy.

RESULTS

Initial imaging revealed a T2 hyperintense lesion in the frontal lobe with abnormally enhancing sulci and minimal surrounding edema and diffusion restriction. Serial imaging revealed progressive increase in the degree of gadolinium enhancement, and the hyperintense T2 edema progressed markedly to exert mass effect. The lesion itself grew marginally. Biopsy revealed an anaplastic large cell lymphoma, only described in 14 previous pediatric patient case reports. The patient was successfully treated with chemotherapy and autologous stem cell transplant.

CONCLUSIONS

Our case demonstrates the rapidity with which a PCNSL lesion can develop, and the evolution of the imaging characteristics prior to definitive diagnosis and treatment. Serial imaging by MRI may help differentiate the behavior of a PCNSL from other imitating lesions.

Convection enhanced delivery of carmustine to the murine brainstem: a feasibility study

BACKGROUND

Systemic delivery of therapeutic agents remains ineffective against diffuse intrinsic pontine glioma (DIPG), possibly due to an intact blood-brain-barrier (BBB) and to dose-limiting toxicity of systemic chemotherapeutic agents. Convection-enhanced delivery (CED) into the brainstem may provide an effective local delivery alternative for DIPG patients.

NEW METHOD

The aim of this study is to develop a method to perform CED into the murine brainstem and to test this method using the chemotherapeutic agent carmustine (BiCNU). To this end, a newly designed murine CED catheter was tested in vitro and in vivo. After determination of safety and distribution, mice bearing VUMC-DIPG-3 and E98FM-DIPG brainstem tumors were treated with carmustine dissolved in DW 5% or carmustine dissolved in 10% ethanol.

RESULTS

Our results show that CED into the murine brainstem is feasible and well tolerated by mice with and without brainstem tumors. CED of carmustine dissolved in 5% DW increased median survival of mice with VUMC-DIPG-3 and E98FM-DIPG tumors with 35% and 25% respectively. Dissolving carmustine in 10% ethanol further improved survival to 45% in mice with E98FM-DIPG tumors.

COMPARISON WITH EXISTING METHODS

Since genetically engineered and primary DIPG models are currently only available in mice, murine CED studies have clear advantages over CED studies in other animals.

CONCLUSION

CED in the murine brainstem can be performed safely, is well tolerated and can be used to study efficacy of chemotherapeutic agents orthotopically. These results set the foundation for more CED studies in murine DIPG models.

Neuroimaging of infectious disease

This article provides an imaging overview of several of the common central nervous system (CNS) infections. Neurologic clinicians who provide acute care for patients should be familiar with the range of imaging findings for patients with acute neurologic infections, including knowledge of the appropriate study and the best protocol and views to show the disorder, and the ability to properly interpret them. This requirement applies particularly for CNS infections, as in stroke, in which a rapid appreciation of the exact cause of a patient's infection may play a major role in reducing mortality and morbidity.

Differences in vascular endothelial growth factor receptor expression and correlation with the degree of enhancement in medulloblastoma

OBJECT

Vascular endothelial growth factor (VEGF) is the major proangiogenic factor in many solid tumors. Vascular endothelial growth factor receptor (VEGFR) is expressed in abundance in pediatric patients with medulloblastoma and is associated with tumor metastasis, poor prognosis, and proliferation. Gadolinium enhancement on MRI has been suggested to have prognostic significance for some tumors. The association of VEGF/VEGFR and Gd enhancement in medulloblastoma has never been closely examined. The authors therefore sought to evaluate whether Gd-enhancing medulloblastomas have higher levels of VEGFR and CD31. Outcomes and survival in patients with enhancing and nonenhancing tumors were also compared.

METHODS

A retrospective analysis of patients with enhancing, nonenhancing, and partially enhancing medulloblastomas was performed. Primary end points included risk stratification, extent of resection, and perioperative complications. A cohort of 3 enhancing and 3 nonenhancing tumors was selected for VEGFR and CD31 analysis as well as microvessel density measurements.

RESULTS

Fifty-eight patients were analyzed, and 20.7% of the medulloblastomas in these patients were nonenhancing. Enhancing medulloblastomas exhibited strong VEGFR1/2 and CD31 expression relative to nonenhancing tumors. There was no significant difference in perioperative complications or patient survival between the 2 groups.

CONCLUSIONS

These results suggest that in patients with medulloblastoma the presence of enhancement on MRI may correlate with increased vascularity and angiogenesis, but does not correlate with worse patient prognosis in the short or long term.

Contrast-enhanced FLAIR (fluid-attenuated inversion recovery) for evaluating mild traumatic brain injury

PURPOSE

To evaluate whether adding a contrast-enhanced fluid-attenuated inversion recovery (FLAIR) sequence to routine magnetic resonance imaging (MRI) can detect additional abnormalities in the brains of symptomatic patients with mild traumatic brain injury.

MATERIALS AND METHODS

Fifty-four patients with persistent symptoms following mild closed head injury were included in our retrospective study (M ∶ F =  32 ∶ 22, mean age: 59.8 ± 16.4, age range: 26-84 years). All MRI examinations were obtained within 14 days after head trauma (mean: 3.2 ± 4.1 days, range: 0.2-14 days). Two neuroradiologists recorded (1) the presence of traumatic brain lesions on MR images with and without contrast-enhanced FLAIR images and (2) the pattern and location of meningeal enhancement depicted on contrast-enhanced FLAIR images. The number of additional traumatic brain lesions diagnosed with contrast-enhanced FLAIR was recorded. Correlations between meningeal enhancement and clinical findings were also evaluated.

RESULTS

Traumatic brain lesions were detected on routine image sequences in 25 patients. Three additional cases of brain abnormality were detected with the contrast-enhanced FLAIR images. Meningeal enhancement was identified on contrast-enhanced FLAIR images in 9 cases while the other routine image sequences showed no findings of traumatic brain injury. Overall, the additional contrast-enhanced FLAIR images revealed more extensive abnormalities than routine imaging in 37 cases (p<0.001). In multivariate logistic regression analysis, subdural hematoma and posttraumatic loss of consciousness showed a significant association with meningeal enhancement on contrast-enhanced FLAIR images, with odds ratios 13.068 (95% confidence interval 2.037 to 83.852), and 15.487 (95% confidence interval 2.545 to 94.228), respectively.

CONCLUSION

Meningeal enhancement on contrast-enhanced FLAIR images can help detect traumatic brain lesions as well as additional abnormalities not identified on routine unenhanced MRI. Therefore contrast-enhanced FLAIR MR imaging is recommended when a contrast MR study is indicated in a patient with a symptomatic prior closed mild head injury.

Appearance of the canine meninges in subtraction magnetic resonance images

The canine meninges are not visible as discrete structures in noncontrast magnetic resonance (MR) images, and are incompletely visualized in T1-weighted, postgadolinium images, reportedly appearing as short, thin curvilinear segments with minimal enhancement. Subtraction imaging facilitates detection of enhancement of tissues, hence may increase the conspicuity of meninges. The aim of the present study was to describe qualitatively the appearance of canine meninges in subtraction MR images obtained using a dynamic technique. Images were reviewed of 10 consecutive dogs that had dynamic pre- and postgadolinium T1W imaging of the brain that was interpreted as normal, and had normal cerebrospinal fluid. Image-anatomic correlation was facilitated by dissection and histologic examination of two canine cadavers. Meningeal enhancement was relatively inconspicuous in postgadolinium T1-weighted images, but was clearly visible in subtraction images of all dogs. Enhancement was visible as faint, small-rounded foci compatible with vessels seen end on within the sulci, a series of larger rounded foci compatible with vessels of variable caliber on the dorsal aspect of the cerebral cortex, and a continuous thin zone of moderate enhancement around the brain. Superimposition of color-encoded subtraction images on pregadolinium T1- and T2-weighted images facilitated localization of the origin of enhancement, which appeared to be predominantly dural, with relatively few leptomeningeal structures visible. Dynamic subtraction MR imaging should be considered for inclusion in clinical brain MR protocols because of the possibility that its use may increase sensitivity for lesions affecting the meninges.

Exclusion of a brain lesion: is intravenous contrast administration required after normal precontrast magnetic resonance imaging?

Background

No evidence‐based guidelines are available for the administration of gadolinium‐based contrast media to veterinary patients.

Objective

To investigate whether administration of intravenous (IV) contrast media alters the likelihood of identifying a brain lesion in dogs and cats.

Animals

Four hundred and eighty‐seven client‐owned animals referred for investigation of intracranial disease.

Methods

Two reviewers retrospectively analyzed precontrast transverse and sagittal T1‐weighted (T1W), T2‐weighted, and fluid‐attenuated inversion recovery low‐field MRI sequences from each patient for the presence of a clinically relevant brain lesion. All sequences subsequently were reviewed in the same manner with additional access to postcontrast T1W images.

Results

Of the 487 precontrast MRI studies, 312 were judged to be normal by 1 or both reviewers. Of these 312 studies, a previously undetected lesion was identified in only 6 cases (1.9%) based on changes observed on postcontrast sequences. Final diagnoses included meningoencephalitis of unknown origin (n = 1), feline infectious peritonitis (n = 1), and neoplasia (n = 2). All 4 of these cases had persistent neurological deficits suggestive of an underlying brain lesion. Contrast enhancement observed in the 2 other cases was considered falsely positive based on the results of further investigations.

Conclusions and Clinical Importance

In patients with normal neurological examination and normal precontrast MRI, the subsequent administration of IV gadolinium‐based contrast media is highly unlikely to disclose a previously unidentified lesion, calling into question the routine administration of contrast media to these patients. However, administration still should be considered in animals with persistent neurological deficits suggestive of an underlying inflammatory or neoplastic brain lesion.

Radiologic and histologic consequences of radiosurgery for brain tumors

Progressively enlarging encephalopathic changes are now well-documented effects of gamma knife radiosurgery (GKRS) occurring ~3-30 months after treatment of both benign and malignant brain lesions. These changes can be variably associated with inflammatory demyelination and necrosis and/or recurrent tumor. While radiographic differentiation between encephalopathic changes and recurrent tumor is of high clinical relevance, confident interpretation of post-radiosurgery imaging changes can be challenging or even impossible in some cases. Gadolinium-enhanced MRI of these lesions reveals variable amounts of enhancing and non-enhancing components within these lesions that have not been clearly correlated with structural-pathologic change. The goal of this study is to characterize the histopathological changes associated with enhancing versus non-enhancing regions of GKRS-treated lesions. MRI images of patients with progressive, etiologically ambiguous brain lesions following GKRS were reviewed prior to explorative neurosurgery. Chosen for this study were lesions in which distinct areas of enhancement and non-enhancement of at least 5 mm in size could be identified (n = 16). Distinctly enhancing and non-enhancing areas were separately biopsied and histologically evaluated. Only cases with uniform histological results are presented in this study. Enhancing and non-enhancing areas in post GKRS lesions represent separate pathological changes. Radiographically enhancing areas correlate either with recurrent tumor growth or inflammatory demyelinating changes. Lack of radiographic enhancement correlates with coagulative necrosis if the sample is taken from the center of the lesion, or with reactive astrocytosis if the sample is taken from the periphery. Separate biopsy of enhancing and non-enhancing regions of post-GKRS encephalopathy was able to confirm that the pathologies in these areas are distinct. These findings allow for better-informed correlation of histological and radiological changes and a better understanding of post-treatment tissue pathology.

A small noncoding RNA signature found in exosomes of GBM patient serum as a diagnostic tool

BACKGROUND

Glioblastoma multiforme (GBM) is the most frequent malignant brain tumor in adults, and its prognosis remains dismal despite intensive research and therapeutic advances. Diagnostic biomarkers would be clinically meaningful to allow for early detection of the tumor and for those cases in which surgery is contraindicated or biopsy results are inconclusive. Recent findings show that GBM cells release microvesicles that contain a select subset of cellular proteins and RNA. The aim of this hypothesis-generating study was to assess the diagnostic potential of miRNAs found in microvesicles isolated from the serum of GBM patients.

METHODS

To control disease heterogeneity, we used patients with newly diagnosed GBM. In the discovery stage, PCR-based TaqMan Low Density Arrays followed by individual quantitative reverse transcriptase polymerase chain reaction were used to test the differences in the miRNA expression levels of serum microvesicles among 25 GBM patients and healthy controls paired by age and sex. The detected noncoding RNAs were then validated in another 50 GBM patients.

RESULTS

We found that the expression levels of 1 small noncoding RNA (RNU6-1) and 2 microRNAs (miR-320 and miR-574-3p) were significantly associated with a GBM diagnosis. In addition, RNU6-1 was consistently an independent predictor of a GBM diagnosis.

CONCLUSIONS

Altogether our results uncovered a small noncoding RNA signature in microvesicles isolated from GBM patient serum that could be used as a fast and reliable differential diagnostic biomarker.

Imaging findings in MR imaging-guided focused ultrasound treatment for patients with essential tremor

BACKGROUND AND PURPOSE

MR imaging-guided focused sonography surgery is a new stereotactic technique that uses high-intensity focused sonography to heat and ablate tissue. The goal of this study was to describe MR imaging findings pre- and post-ventralis intermedius nucleus lesioning by MR imaging-guided focused sonography as a treatment for essential tremor and to determine whether there was an association between these imaging features and the clinical response to MR imaging-guided focused sonography.

MATERIALS AND METHODS

Fifteen patients with medication-refractory essential tremor prospectively gave consent; were enrolled in a single-site, FDA-approved pilot clinical trial; and were treated with transcranial MR imaging-guided focused sonography. MR imaging studies were obtained on a 3T scanner before the procedure and 24 hours, 1 week, 1 month, and 3 months following the procedure.

RESULTS

On T2-weighted imaging, 3 time-dependent concentric zones were seen at the site of the focal spot. The inner 2 zones showed reduced ADC values at 24 hours in all patients except one. Diffusion had pseudonormalized by 1 month in all patients, when the cavity collapsed. Very mild postcontrast enhancement was seen at 24 hours and again at 1 month after MR imaging-guided focused sonography. The total lesion size and clinical response evolved inversely compared with each other (coefficient of correlation = 0.29, P value = .02).

CONCLUSIONS

MR imaging-guided focused sonography can accurately ablate a precisely delineated target, with typical imaging findings seen in the days, weeks, and months following the treatment. Tremor control was optimal early when the lesion size and perilesional edema were maximal and was less later when the perilesional edema had resolved.

Hypertrophic pachymeningitis associated with cerebral spinal fluid hypovolemia as initial presentation of systemic lupus erythematous

We report a case of a 61-year-old man with thickening of the dura mater associated with the presence of subdural collections as a consequence of cerebral spinal fluid hypovolemia (CSFH) and hypertrophic pachymeningitis (HP) as presentation of systemic lupus erythematous (SLE). The patient complained about fatigue, musculoskeletal pain, headache and skin lesions. In the laboratory tests minimal normocytic anemia, mild leukopenia, polyclonal hypergammaglobulinemia and antinuclear antibodies (ANA), anti-double-stranded DNA antibodies (dsDNA), antibodies against extractable nuclear antigens (ENA) type SSA-Ro, anti-Smith antigen antibodies (anti-Sm) and anti-ribonucleoprotein antibodies (anti-RNP) were detected. Cranial magnetic resonance imaging (MRI), with and without gadolinium enhancement, revealed generalized thickening of the dura mater more severe at the right parieto-occipital lobes with the presence of subdural collections. The patient was diagnosed with SLE associated both with CSFH and HP. A conservative treatment with prednisone 60 mg daily, mycophenolate mofetil (MMF) 1 g daily and hydroxychloroquine 200 mg twice a day was started with significant clinical and radiological improvement (almost complete resolution of the subdural collections and clear decrease of meningeal thickness).

The authors emphasize that HP associated with CSFH in the context of SLE is a rare entity, which makes this case unique.

Spontaneous intracranial hypotension with magnetic resonance localisation of spinal cerebrospinal fluid leak

To increase the awareness of spontaneous intracranial hypotension (SIH), we report in this paper a middle-aged woman who presented with an intractable headache that worsened in sitting and standing positions (a postural headache). Magnetic resonance imaging (MRI) of the spine demonstrated a cerebrospinal fluid (CSF) leak at the level of the cervical spine, in addition to typical features in a brain MRI, including symmetrical subdural collections, circumferential dural enhancement and features of midbrain sagging. The patient underwent a surgical repair of the cervical CSF leak which resulted in a dramatic symptomatic improvement that was confirmed by follow-up imaging.

Hypertrophic pachymeningitis: significance of myeloperoxidase anti-neutrophil cytoplasmic antibody

The aim of this study was to elucidate the characteristics, pathogenesis and treatment strategy of hypertrophic pachymeningitis that is associated with myeloperoxidase anti-neutrophil cytoplasmic antibody (ANCA). We retrospectively investigated clinical, radiological, immunological and pathological profiles of 36 patients with immune-mediated or idiopathic hypertrophic pachymeningitis, including 17 patients with myeloperoxidase-ANCA, four patients with proteinase 3-ANCA, six patients with other immune-mediated disorders, and nine patients with 'idiopathic' variety. Myeloperoxidase-ANCA-positive hypertrophic pachymeningitis was characterized by: (i) an elderly female predominance; (ii) 82% of patients diagnosed with granulomatosis with polyangiitis (previously known as Wegener's granulomatosis) according to Watts' algorithm; (iii) a high frequency of patients with lesions limited to the dura mater and upper airways, developing headaches, chronic sinusitis, otitis media or mastoiditis; (iv) a low frequency of patients with the 'classical or generalized form' of granulomatosis with polyangiitis involving the entire upper and lower airways and kidney, or progressing to generalized disease, in contrast to proteinase 3-ANCA-positive hypertrophic pachymeningitis; (v) less severe neurological damage according to the modified Rankin Scale and low disease activity according to the Birmingham Vasculitis Activity Score compared with proteinase 3-ANCA-positive hypertrophic pachymeningitis; (vi) increased levels of CXCL10, CXCL8 and interleukin 6 in cerebrospinal fluids, and increased numbers of T cells, neutrophils, eosinophils, plasma cells and monocytes/macrophages in autopsied or biopsied dura mater with pachymeningitis, suggesting TH1-predominant granulomatous lesions in hypertrophic pachymeningitis, as previously reported in pulmonary or renal lesions of granulomatosis with polyangiitis; and (vii) greater efficacy of combination therapy with prednisolone and cyclophosphamide compared with monotherapy with prednisolone. Proteinase 3-ANCA may be considered a marker for more severe neurological damage, higher disease activity and a higher frequency of the generalized form compared with myeloperoxidase-ANCA-positive hypertrophic pachymeningitis. However, categorization into 'granulomatosis with polyangiitis' according to Watts' algorithm and immunological or pathological features were common in both proteinase 3- and myeloperoxidase-ANCA-positive hypertrophic pachymeningitis. These data indicate that most patients with myeloperoxidase-ANCA-positive hypertrophic pachymeningitis should be categorized as having the central nervous system-limited form of ANCA-associated vasculitis, consistent with the concept of ophthalmic-, pulmonary- or renal-limited vasculitis.

Mass spectrometry imaging as a tool for surgical decision-making

Despite significant advances in image-guided therapy, surgeons are still too often left with uncertainty when deciding to remove tissue. This binary decision between removing and leaving tissue during surgery implies that the surgeon should be able to distinguish tumor from healthy tissue. In neurosurgery, current image-guidance approaches such as magnetic resonance imaging (MRI) combined with neuronavigation offer a map as to where the tumor should be, but the only definitive method to characterize the tissue at stake is histopathology. Although extremely valuable information is derived from this gold standard approach, it is limited to very few samples during surgery and is not practically used for the delineation of tumor margins. The development and implementation of faster, comprehensive, and complementary approaches for tissue characterization are required to support surgical decision-making--an incremental and iterative process with tumor removed in multiple and often minute biopsies. The development of atmospheric pressure ionization sources makes it possible to analyze tissue specimens with little to no sample preparation. Here, we highlight the value of desorption electrospray ionization as one of many available approaches for the analysis of surgical tissue. Twelve surgical samples resected from a patient during surgery were analyzed and diagnosed as glioblastoma tumor or necrotic tissue by standard histopathology, and mass spectrometry results were further correlated to histopathology for critical validation of the approach. The use of a robust statistical approach reiterated results from the qualitative detection of potential biomarkers of these tissue types. The correlation of the mass spectrometry and histopathology results to MRI brings significant insight into tumor presentation that could not only serve to guide tumor resection, but that is also worthy of more detailed studies on our understanding of tumor presentation on MRI.