Evidence of brain injury in fetuses of mothers with preterm labor with intact membranes and preterm prelabor rupture of membranes

BACKGROUND

Brain injury and poor neurodevelopment have consistently been reported in infants and adults born preterm. These changes occur at least in part prenatally and are associated with intra-amniotic inflammation. The pattern of brain changes has been partially documented by magnetic resonance imaging but not with neurosonography in combination with amniotic fluid brain injury biomarkers.

OBJECTIVES

To evaluate the prenatal features of brain remodeling and injury in fetuses from patients with preterm labor with intact membranes or preterm prelabor rupture of membranes and to investigate the potential influence of intra-amniotic inflammation as a mediator of risk.

STUDY DESIGN

In this prospective cohort study, fetal brain remodeling and injury was evaluated by neurosonography and amniocentesis in singleton pregnant patients with preterm labor with intact membranes or preterm prelabor rupture of membranes between 24.0-34.0 weeks, with (n=41) and without (n=54) intra-amniotic inflammation. Controls for neurosonography were outpatient pregnant patients without preterm labor or preterm prelabor rupture of membranes matched 2:1 by gestational age at ultrasound. Amniotic fluid controls were patients with an amniocentesis performed for indications other than preterm labor or preterm prelabor rupture of membranes without brain or genetic defects whose amniotic fluid was collected in our biobank for research purposes matched by gestational age at amniocentesis. The group with intra-amniotic inflammation included those with intra-amniotic infection (microbial invasion of the amniotic cavity and intra-amniotic inflammation) and those with sterile inflammation. Microbial invasion of the amniotic cavity was defined as a positive amniotic fluid culture and/or positive 16S ribosomal RNA gene. Inflammation was defined by amniotic fluid interleukin-6 >13.4 ng/ml in preterm labor and >1.43 ng/ml in preterm prelabor rupture of membranes. Neurosonography included the evaluation of brain structure biometric parameters and cortical development. As amniotic fluid brain injury biomarkers we selected neuron-specific enolase, protein S100B and glial fibrillary acidic protein. Data was adjusted for cephalic biometrics, fetal growth centile, fetal sex, non-cephalic presentation and preterm prelabor rupture of membranes at admission.

RESULTS

Fetuses from mothers with preterm labor with intact membranes or preterm prelabor rupture of membranes had signs of brain remodeling and injury. First, they had a smaller cerebellum. Thus, in intra-amniotic inflammation, non- intra-amniotic inflammation and control groups, transcerebellar diameter (median (25th; 75th percentile)) was 32.7mm (29.8; 37.6), 35.3mm (31.2;39.6) and 35.0mm (31.3;38.3), respectively (p=0.019); vermian height was 16.9 mm (15.5 ;19.6), 17.2 mm (16.0;18.9) and 17.1mm (15.7;19.0), respectively (p=0.041). Second, they presented a lower corpus callosum area (0.72mm2 (0.59;0. 81), 0.71mm2 (0.63;0.82) and 0.78mm2 (0.71;0. 91), respectively (p=0.006). Third, they showed a delayed cortical maturation (Sylvian fissure depth / biparietal diameter ratio was 0.14 (0.12;0.16), 0.14 (0.13;0.16) and 0.16 (0.15;0.17), respectively (p<0.001), and right parieto-occipital sulci depth ratio was 0.09 (0.07;0.12), 0.11 (0.09;0.14) and 0.11 (0.09;0.14), respectively (p=0.012)). Finally, regarding amniotic fluid brain injury biomarkers, fetuses from mothers with preterm labor with intact membranes or preterm prelabor rupture of membranes, had higher concentrations of neuron-specific enolase (11804.6pg/ml (6213.4;21098.8), 8397.7 pg/ml (3682.1;17398.3) and 2393.7pg/ml (1717.1;3209.3), respectively (p<0.001)); protein S100B (2030.6 pg/ml (993;4883.5), 1070.3pg/ml (365.1-1463.2) and 74.8pg/ml (44.7;93.7), respectively (p<0.001)), and glial fibrillary acidic protein (1.01ng/ml (0.54;3.88), 0.965ng/ml (0.59;2.07) and 0.24mg/ml (0.20;0.28), respectively (p=0.002)).

CONCLUSION

Fetuses with preterm labor with intact membranes or preterm prelabor rupture of membranes had prenatal signs of brain remodeling and injury at the time of clinical presentation. These changes were more pronounced in those with intra-amniotic inflammation.

An accessible deep learning tool for voxel-wise classification of brain malignancies from perfusion MRI

Noninvasive differential diagnosis of brain tumors is currently based on the assessment of magnetic resonance imaging (MRI) coupled with dynamic susceptibility contrast (DSC). However, a definitive diagnosis often requires neurosurgical interventions that compromise patients' quality of life. We apply deep learning on DSC images from histology-confirmed patients with glioblastoma, metastasis, or lymphoma. The convolutional neural network trained on ∼50,000 voxels from 40 patients provides intratumor probability maps that yield clinical-grade diagnosis. Performance is tested in 400 additional cases and an external validation cohort of 128 patients. The tool reaches a three-way accuracy of 0.78, superior to the conventional MRI metrics cerebral blood volume (0.55) and percentage of signal recovery (0.59), showing high value as a support diagnostic tool. Our open-access software, Diagnosis In Susceptibility Contrast Enhancing Regions for Neuro-oncology (DISCERN), demonstrates its potential in aiding medical decisions for brain tumor diagnosis using standard-of-care MRI.

Differentiating IDH-mutant astrocytomas and 1p19q-codeleted oligodendrogliomas using DSC-PWI: high performance through cerebral blood volume and percentage of signal recovery percentiles

OBJECTIVE

Presurgical differentiation between astrocytomas and oligodendrogliomas remains an unresolved challenge in neuro-oncology. This research aims to provide a comprehensive understanding of each tumor's DSC-PWI signatures, evaluate the discriminative capacity of cerebral blood volume (CBV) and percentage of signal recovery (PSR) percentile values, and explore the synergy of CBV and PSR combination for pre-surgical differentiation.

METHODS

Patients diagnosed with grade 2 and 3 IDH-mutant astrocytomas and IDH-mutant 1p19q-codeleted oligodendrogliomas were retrospectively retrieved (2010-2022). 3D segmentations of each tumor were conducted, and voxel-level CBV and PSR were extracted to compute mean, minimum, maximum, and percentile values. Statistical comparisons were performed using the Mann-Whitney U test and the area under the receiver operating characteristic curve (AUC-ROC). Lastly, the five most discriminative variables were combined for classification with internal cross-validation.

RESULTS

The study enrolled 52 patients (mean age 45-year-old, 28 men): 28 astrocytomas and 24 oligodendrogliomas. Oligodendrogliomas exhibited higher CBV and lower PSR than astrocytomas across all metrics (e.g., mean CBV = 2.05 and 1.55, PSR = 0.68 and 0.81 respectively). The highest AUC-ROCs and the smallest p values originated from CBV and PSR percentiles (e.g., PSRp70 AUC-ROC = 0.84 and p value = 0.0005, CBVp75 AUC-ROC = 0.8 and p value = 0.0006). The mean, minimum, and maximum values yielded lower results. Combining the best five variables (PSRp65, CBVp70, PSRp60, CBVp75, and PSRp40) achieved a mean AUC-ROC of 0.87 for differentiation.

CONCLUSIONS

Oligodendrogliomas exhibit higher CBV and lower PSR than astrocytomas, traits that are emphasized when considering percentiles rather than mean or extreme values. The combination of CBV and PSR percentiles results in promising classification outcomes.

CLINICAL RELEVANCE STATEMENT

The combination of histogram-derived percentile values of cerebral blood volume and percentage of signal recovery from DSC-PWI enhances the presurgical differentiation between astrocytomas and oligodendrogliomas, suggesting that incorporating these metrics into clinical practice could be beneficial.

KEY POINTS

• The unsupervised selection of percentile values for cerebral blood volume and percentage of signal recovery enhances presurgical differentiation of astrocytomas and oligodendrogliomas. • Oligodendrogliomas exhibit higher cerebral blood volume and lower percentage of signal recovery than astrocytomas. • Cerebral blood volume and percentage of signal recovery combined provide a broader perspective on tumor vasculature and yield promising results for this preoperative classification.

MR dynamic-susceptibility-contrast perfusion metrics in the presurgical discrimination of adult solitary intra-axial cerebellar tumors

OBJECTIVES

Adult solitary intra-axial cerebellar tumors are uncommon. Their presurgical differentiation based on neuroimaging is crucial, since management differs substantially. Comprehensive full assessment of MR dynamic-susceptibility-contrast perfusion-weighted imaging (DSC-PWI) may reveal key differences between entities. This study aims to provide new insights on perfusion patterns of these tumors and to explore the potential of DSC-PWI in their presurgical discrimination.

METHODS

Adult patients with a solitary cerebellar tumor on presurgical MR and confirmed histological diagnosis of metastasis, medulloblastoma, hemangioblastoma, or pilocytic astrocytoma were retrospectively retrieved (2008-2023). Volumetric segmentation of tumors and normal-appearing white matter (for normalization) was semi-automatically performed on CE-T1WI and coregistered with DSC-PWI. Mean normalized values per patient tumor-mask of relative cerebral blood volume (rCBV), percentage of signal recovery (PSR), peak height (PH), and normalized time-intensity curves (nTIC) were extracted. Statistical comparisons were done. Then, the dataset was split into training (75%) and test (25%) cohorts and a classifier was created considering nTIC, rCBV, PSR, and PH in the model.

RESULTS

Sixty-eight patients (31 metastases, 13 medulloblastomas, 13 hemangioblastomas, and 11 pilocytic astrocytomas) were included. Relevant differences between tumor types' nTICs were demonstrated. Hemangioblastoma showed the highest rCBV and PH, pilocytic astrocytoma the highest PSR. All parameters showed significant differences on the Kruskal-Wallis tests (p < 0.001). The classifier yielded an accuracy of 98% (47/48) in the training and 85% (17/20) in the test sets.

CONCLUSIONS

Intra-axial cerebellar tumors in adults have singular and significantly different DSC-PWI signatures. The combination of perfusion metrics through data-analysis rendered excellent accuracies in discriminating these entities.

CLINICAL RELEVANCE STATEMENT

In this study, the authors constructed a classifier for the non-invasive imaging presurgical diagnosis of adult intra-axial cerebellar tumors. The resultant tool can be a support for decision-making in the clinical practice and enables optimal personalized patient management.

KEY POINTS

• Adult intra-axial cerebellar tumors exhibit specific, singular, and statistically significant different MR dynamic-susceptibility-contrast perfusion-weighted imaging (DSC-PWI) signatures. • Data-analysis, applied to MR DSC-PWI, could provide added value in the presurgical diagnosis of solitary cerebellar metastasis, medulloblastoma, hemangioblastoma, and pilocytic astrocytoma. • A classifier based on DSC-PWI metrics yields excellent accuracy rates and could be used as a support tool for radiologic diagnosis with clinician-friendly displays.

Laryngeal EBV-positive Inflammatory Follicular Dendritic cell/fibroblastic Reticular cell Tumour

Epstein-Barr virus-positive Inflammatory follicular dendritic cell/fibroblastic reticular cell tumour (EBV-IFDC/FRCT) is a rare neoplasm that occurs almost exclusively in the liver or spleen. Extra-hepatosplenic presentation is infrequent and exceptional cases have been described arising in the gastrointestinal tract or in the pharynx. However, EBV-IFDC/FRCT cases have not been previously reported in the larynx. This report describes a case of a 32-year-old woman who arrived to the emergency department due to progressive dyspnea with associated inspiratory stridor and non-productive cough. Direct laryngoscopy showed a nodular tumour arising on the left posterior subglottic mucosa obstructing 90% of the airway. A preoperative dual energy contrast enhanced computed tomography (CECT) was performed demonstrating a low attenuation lesion on virtual non-contrast (VNC) images and vivid iodine uptake on the iodine map. The tumour was excised and the histopathological analysis led to the diagnosis of an EBV-IFDC/FRCT. A fibre-optic laryngoscopy six months after the surgery did not show any abnormalities. Although the vast majority of EBV-IFDC/FRCT occur in the liver or spleen, some extra hepatosplenic tumours have been reported affecting the head and neck region. We describe here the first case arising in the larynx, as well as the usefulness of preoperative dual energy imaging techniques to assess these lesions, thus providing information that could have management implications.

Radiomic-based nonlinear supervised learning classifiers on non-contrast CT to predict functional prognosis in patients with spontaneous intracerebral hematoma

PURPOSE

To evaluate if nonlinear supervised learning classifiers based on non-contrast CT can predict functional prognosis at discharge in patients with spontaneous intracerebral hematoma.

METHODS

Retrospective, single-center, observational analysis of patients with a diagnosis of spontaneous intracerebral hematoma confirmed by non-contrast CT between January 2016 and April 2018. Patients with HIE > 18 years and with TCCSC performed within the first 24 h of symptom onset were included. Patients with secondary spontaneous intracerebral hematoma and in whom radiomic variables were not available were excluded. Clinical, demographic and admission variables were collected. Patients were classified according to the Modified Rankin Scale (mRS) at discharge into good (mRS 0-2) and poor prognosis (mRS 3-6). After manual segmentation of each spontaneous intracerebral hematoma, the radiomics variables were obtained. The sample was divided into a training and testing cohort and a validation cohort (70-30% respectively). Different methods of variable selection and dimensionality reduction were used, and different algorithms were used for model construction. Stratified 10-fold cross-validation were performed on the training and testing cohort and the mean area under the curve (AUC) were calculated. Once the models were trained, the sensitivity of each was calculated to predict functional prognosis at discharge in the validation cohort.

RESULTS

105 patients with spontaneous intracerebral hematoma were analyzed. 105 radiomic variables were evaluated for each patient. P-SVM, KNN-E and RF-10 algorithms, in combination with the ANOVA variable selection method, were the best performing classifiers in the training and testing cohort (AUC 0.798, 0.752 and 0.742 respectively). The predictions of these models, in the validation cohort, had a sensitivity of 0.897 (0.778-1;95%CI), with a false-negative rate of 0% for predicting poor functional prognosis at discharge.

CONCLUSION

The use of radiomics-based nonlinear supervised learning classifiers are a promising diagnostic tool for predicting functional outcome at discharge in HIE patients, with a low false negative rate, although larger and balanced samples are still needed to develop and improve their performance.

Clinicopathological and Neuroimaging Features of Primary Gliosarcoma: A Case Series and Review of Literature

BACKGROUND

Gliosarcoma (GS) is a rare primary high-grade brain neoplasm with a poor prognosis and challenging surgical resection. Although it is now considered a morphologic variant of IDH-wildtype glioblastoma (World Health Organization Classification of Tumours 2021), GS may display peculiarities that hamper both surgical and oncological management.

METHODS

In this retrospective study, we searched our registry for histologically confirmed GS patients between 2006 and 2020. Cases were reviewed for clinical information, pathologic characteristics, imaging findings, management, and outcome.

RESULTS

21 patients with histologically confirmed GS were identified with a median age of 62 years. Twelve were men and 9 women. The temporal lobe was the most common location (9 patients, 42.9%). Nineteen patients underwent surgical resection, and only 4 (19%) demonstrated gross total resection on postsurgical MRI, with an overall median survival of 7 months (range, 0.5-37). Diagnostic MRI demonstrated heterogenous lesions with necrotic-cystic areas and a ring-enhancement pattern. Only 1 case of extracranial extension was seen in our sample, and no patient showed distant metastases.

CONCLUSIONS

The rarity of primary GS and the absence of specific therapeutic guidelines represent a significant clinical challenge. Our study provides a comprehensive analysis of clinical and neuroimaging characteristics in a real-world patient cohort and compares our findings with the available literature.

Texture Analysis of the Apparent Diffusion Coefficient Focused on Contrast-Enhancing Lesions in Predicting Survival for Bevacizumab-Treated Patients with Recurrent Glioblastoma

PURPOSE

Glioblastoma often recurs after treatment. Bevacizumab increases progression-free survival in some patients with recurrent glioblastoma. Identifying pretreatment predictors of survival can help clinical decision making. Magnetic resonance texture analysis (MRTA) quantifies macroscopic tissue heterogeneity indirectly linked to microscopic tissue properties. We investigated the usefulness of MRTA in predicting survival in patients with recurrent glioblastoma treated with bevacizumab.

METHODS

We evaluated retrospective longitudinal data from 33 patients (20 men; mean age 56 ± 13 years) who received bevacizumab on the first recurrence of glioblastoma. Volumes of contrast-enhancing lesions segmented on postcontrast T1-weighted sequences were co-registered on apparent diffusion coefficient maps to extract 107 radiomic features. To assess the performance of textural parameters in predicting progression-free survival and overall survival, we used receiver operating characteristic curves, univariate and multivariate regression analysis, and Kaplan-Meier plots.

RESULTS

Longer progression-free survival (>6 months) and overall survival (>1 year) were associated with lower values of major axis length (MAL), a lower maximum 2D diameter row (m2Ddr), and higher skewness values. Longer progression-free survival was also associated with higher kurtosis, and longer overall survival with higher elongation values. The model combining MAL, m2Ddr, and skewness best predicted progression-free survival at 6 months (AUC 0.886, 100% sensitivity, 77.8% specificity, 50% PPV, 100% NPV), and the model combining m2Ddr, elongation, and skewness best predicted overall survival (AUC 0.895, 83.3% sensitivity, 85.2% specificity, 55.6% PPV, 95.8% NPV).

CONCLUSIONS

Our preliminary analyses suggest that in patients with recurrent glioblastoma pretreatment, MRTA helps to predict survival after bevacizumab treatment.

Persistent lymph nodes after curative chemoradiotherapy for head and neck cancer: imaging predictors of response for decision-making

PURPOSE

To identify response predictors in patients with head and neck squamous cell carcinoma (N + HNSCC) and persistent lymph nodes after curative chemoradiotherapy treatment (CCRT).

MATERIALS AND METHODS

Consecutive patients with N + HNSCC treated with CCRT and persistent lymph nodes at first follow-up between 2015 and 2021 were identified and analyzed. Complete response was defined as the absence of lymph node metastatic involvement in patients with salvage lymphadenectomy or the absence of progression after 1 year of successive follow-ups. Tumour type and location, staging, and human papillomavirus (HPV) status were considered for analysis. The number and size of lymph nodes, type, shape, enhancement and margins on diagnostic and follow-up CT were also analyzed.

RESULTS

The cohort included 46 patients with 134 pathological lymph nodes. Logistic regression models showed the following variables to be significant: performance of salvage lymphadenectomy (OR 0.094, [CI 95% 0.004-0.61], p = 0.037); the type of lymphadenopathy on diagnostic CE-CT (solid vs. cystic) (N1: OR = 4.11, [CI 95% 1.11-17.93], p = 0.042 and N3: OR 6.42, [CI 95% 1.2-42.56], p = 0.036); the change of shape (round to oval) on the follow-up CE-CT (OR 9.76, [CI 95% 1.79-8.57], p = 0.016) and the time in days between CCRT and the first follow-up CE-CT (OR 1.06, [CI 95% 1.004-1.13], p = 0.048).

CONCLUSIONS

In our experience, the presence of solid lymph nodes on pre-treatment CT and the change in shape from round to oval on post-treatment CT are predictors of response to treatment in patients with N + HNSCC persistent lymph nodes after CCRT. Increasing the temporal interval between treatment and follow-up CT should be considered to avoid unnecessary nodal dissections.

Adjunct Thrombolysis Enhances Brain Reperfusion following Successful Thrombectomy

OBJECTIVE

This study was undertaken to investigate whether adjunct alteplase improves brain reperfusion following successful thrombectomy.

METHODS

This single-center, randomized, double-blind, placebo-controlled study included 36 patients (mean [standard deviation] = 70.8 [13.5] years old, 18 [50%] women) with large vessel occlusion undergoing thrombectomy resulting in near-normal (expanded Thrombolysis in Cerebral Infarction [eTICI] b50/67/2c, n = 23, 64%) or normal angiographic reperfusion (eTICI 3, n = 13, 36%). Seventeen patients were randomized to intra-arterial alteplase (0.225mg/kg), and 19 received placebo. At 48 hours, patients had brain perfusion/diffusion-weighted magnetic resonance imaging (MRI) and MRI-spectroscopy. The primary outcome was the difference in the proportion of patients with areas of hypoperfusion on MRI. Secondary outcomes were the infarct expansion ratio (final to initial infarction volume), and the N-acetylaspartate (NAA) peak relative to total creatine as a marker of neuronal integrity.

RESULTS

The prevalence of hypoperfusion was 24% with intra-arterial alteplase, and 58% with placebo (adjusted odds ratio = 0.20, 95% confidence interval [CI] = 0.04-0.91, p = 0.03). Among 14 patients with final eTICI 3 scores, hypoperfusion was found in 1 of 7 (14%) in the alteplase group and 3 of 7 (43%) in the placebo group. Abnormal brain perfusion was associated with worse functional outcome at day 90. Alteplase significantly reduced the infarct expansion ratio compared with placebo (median [interquartile range (IQR)] = 0.7 [0.5-1.2] vs 3.2 [1.8-5.7], p = 0.01) and resulted in higher NAA peaks (median [IQR] = 1.13 [0.91-1.36] vs 1.00 [0.74-1.22], p < 0.0001).

INTERPRETATION

There is a high prevalence of areas of hypoperfusion following thrombectomy despite successful reperfusion on angiography. Adjunct alteplase enhances brain reperfusion, which results in reduced expansion of the infarction and improved neuronal integrity. ANN NEUROL 2022;92:860-870.

Optimizing the Definition of Ischemic Core in CT Perfusion: Influence of Infarct Growth and Tissue-Specific Thresholds

BACKGROUND AND PURPOSE

CTP allows estimating ischemic core in patients with acute stroke. However, these estimations have limited accuracy compared with MR imaging. We studied the effect of applying WM- and GM-specific thresholds and analyzed the infarct growth from baseline imaging to reperfusion.

MATERIALS AND METHODS

This was a single-center cohort of consecutive patients (n = 113) with witnessed strokes due to proximal carotid territory occlusions with baseline CT perfusion, complete reperfusion, and follow-up DWI. We segmented GM and WM, coregistered CTP with DWI, and compared the accuracy of the different predictions for each voxel on DWI through receiver operating characteristic analysis. We assessed the yield of different relative CBF thresholds to predict the final infarct volume and an estimated infarct growth-corrected volume (subtracting the infarct growth from baseline imaging to complete reperfusion) for a single relative CBF threshold and GM- and WM-specific thresholds.

RESULTS

The fixed threshold underestimated lesions in GM and overestimated them in WM. Double GM- and WM-specific thresholds of relative CBF were superior to fixed thresholds in predicting infarcted voxels. The closest estimations of the infarct on DWI were based on a relative CBF of 25% for a single threshold, 35% for GM, and 20% for WM, and they decreased when correcting for infarct growth: 20% for a single threshold, 25% for GM, and 15% for WM. The combination of 25% for GM and 15% for WM yielded the best prediction.

CONCLUSIONS

GM- and WM-specific thresholds result in different estimations of ischemic core in CTP and increase the global accuracy. More restrictive thresholds better estimate the actual extent of the infarcted tissue.

Effect of Intra-arterial Alteplase vs Placebo Following Successful Thrombectomy on Functional Outcomes in Patients With Large Vessel Occlusion Acute Ischemic Stroke: The CHOICE Randomized Clinical Trial

IMPORTANCE

It is estimated that only 27% of patients with acute ischemic stroke and large vessel occlusion who undergo successful reperfusion after mechanical thrombectomy are disability free at 90 days. An incomplete microcirculatory reperfusion might contribute to these suboptimal clinical benefits.

OBJECTIVE

To investigate whether treatment with adjunct intra-arterial alteplase after thrombectomy improves outcomes following reperfusion.

DESIGN, SETTING, AND PARTICIPANTS

Phase 2b randomized, double-blind, placebo-controlled trial performed from December 2018 through May 2021 in 7 stroke centers in Catalonia, Spain. The study included 121 patients with large vessel occlusion acute ischemic stroke treated with thrombectomy within 24 hours after stroke onset and with an expanded Treatment in Cerebral Ischemia angiographic score of 2b50 to 3.

INTERVENTIONS

Participants were randomized to receive intra-arterial alteplase (0.225 mg/kg; maximum dose, 22.5 mg) infused over 15 to 30 minutes (n = 61) or placebo (n = 52).

MAIN OUTCOMES AND MEASURES

The primary outcome was the difference in proportion of patients achieving a score of 0 or 1 on the 90-day modified Rankin Scale (range, 0 [no symptoms] to 6 [death]) in all patients treated as randomized. Safety outcomes included rate of symptomatic intracranial hemorrhage and death.

RESULTS

The study was terminated early for inability to maintain placebo availability and enrollment rate because of the COVID-19 pandemic. Of 1825 patients with acute ischemic stroke treated with thrombectomy at the 7 study sites, 748 (41%) patients fulfilled the angiographic criteria, 121 (7%) patients were randomized (mean age, 70.6 [SD, 13.7] years; 57 women [47%]), and 113 (6%) were treated as randomized. The proportion of participants with a modified Rankin Scale score of 0 or 1 at 90 days was 59.0% (36/61) with alteplase and 40.4% (21/52) with placebo (adjusted risk difference, 18.4%; 95% CI, 0.3%-36.4%; P = .047). The proportion of patients with symptomatic intracranial hemorrhage within 24 hours was 0% with alteplase and 3.8% with placebo (risk difference, -3.8%; 95% CI, -13.2% to 2.5%). Ninety-day mortality was 8% with alteplase and 15% with placebo (risk difference, -7.2%; 95% CI, -19.2% to 4.8%).

CONCLUSIONS AND RELEVANCE

Among patients with large vessel occlusion acute ischemic stroke and successful reperfusion following thrombectomy, the use of adjunct intra-arterial alteplase compared with placebo resulted in a greater likelihood of excellent neurological outcome at 90 days. However, because of study limitations, these findings should be interpreted as preliminary and require replication.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03876119; EudraCT Number: 2018-002195-40.

Transoral laser microsurgery in locally advanced laryngeal cancer: Prognostic impact of anterior versus posterior compartments

BACKGROUND

To evaluate the importance of larynx compartments in the prognosis of T3-T4a laryngeal cancer treated with transoral laser microsurgery.

METHODS

Two hundred and two consecutive pT3-T4a larynx carcinomas. Pre-epiglottic space involvement, anterior and posterior paraglottic space (PGS) involvement, vocal cord, and arytenoid mobility were determined. Local control with laser (LC), overall survival (OS), disease-specific survival (DSS), and laryngectomy-free survival (LFS) were evaluated.

RESULTS

The lowest LC was found in tumors with fixed arytenoid. In the multivariate analysis, positive margins (hazard ratio [HR] = 0.289 [0.085-0.979]) and anterior (HR = 0.278 [0.128-0.605]) and posterior (HR = 0.269 [0.115-0.630]) PGS invasion were independent factors of a reduced LC. Anterior (HR = 3.613 [1.537-8.495]) and posterior (HR = 5.195 [2.167-12.455]) PGS involvement were independent factors of total laryngectomy. Five-year OS, DSS, and LFS rates were 63.9%, 77.5%, and 77.5%, respectively. Patients with posterior PGS presented a reduced 5-year LFS.

CONCLUSIONS

Tumor classification according to laryngeal compartmentalization depicts strong correlation with LC and LFS.

Perinatal post-mortem magnetic resonance imaging (MRI) of the central nervous system (CNS): a pictorial review

Central nervous system (CNS) abnormalities cause approximately 32–37.7% of terminations of pregnancy (TOP). Autopsy is currently the gold standard for assessing dead foetuses and stillborn. However, it has limitations and is sometimes subject to parental rejection. Recent studies have described post-mortem foetal magnetic resonance imaging (MRI) as an alternative and even complementary to autopsy for CNS assessment. Radiologists now play a key role in the evaluation of perinatal deaths. Assessment of foetal CNS abnormalities is difficult, and interpretation of foetal studies requires familiarisation with normal and abnormal findings in post-mortem MRI studies as well as the strengths and limitations of the imaging studies. The purpose of this pictorial review is to report our experience in the post-mortem MRI evaluation of the CNS system, including a description of the protocol used, normal CNS findings related to post-mortem status, abnormal CNS findings in our sample, and the correlation of these findings with histopathological results.

The new Hematoma Maturity Score is highly associated with poor clinical outcome in spontaneous intracerebral hemorrhage

OBJECTIVES

The purpose of this study was to analyze the new combined indicators on noncontrast computed tomography (NCCT) to predict functional outcome at discharge, compared to previously individual radiological NCCT signs.

METHODS

Patients with spontaneous intracerebral hemorrhage (ICH) who underwent baseline CT scan were retrospectively analyzed. Black hole (BH) sign, blend sign (BS), island sign (IS), swirl sign (SwS), Barras classification, any hypodensity, any irregularity, and two combined novel indicators-Combined Barras Total Score (CBTS) and Hematoma Maturity Score-were assessed independently by two radiologists blinded to clinical information. Patients were trichotomized depending on the disability or dependency at discharge according to the Modified Rankin Scale (mRS): no symptoms or no significant/mild disability (mRS 0-2); moderate or severe disability (mRS 3-5); and mortality (mRS 6).

RESULTS

One hundred fourteen patients with spontaneous ICH confirmed by NCCT were included in the analysis. Multivariable statistical analysis was adjusted for anticoagulation, hematoma volume, ventricular expansion, hypertension, blood glucose level at admission, age, and history of atrial fibrillation and demonstrated that any hypodensity (OR 4.768, p 0.006), any irregularity (OR 4.768, p 0.006), CBTS ≥ 4 (OR 3.205, p 0.025), and the new Hematoma Maturity Score (Immature) (OR 5.872, p 0.006) are independent predictors of functional outcome at discharge.

CONCLUSIONS

The new concept of the Hematoma Maturity Score was the radiological sign on NCCT with the highest impact on clinical outcome in comparison with the rest of the evaluated radiological signs.

KEY POINTS

• This is the first manuscript where density and shape characteristics of the ICH had been evaluated together and integrated in a new Hematoma Maturity Score. • The new Hematoma Maturity Score is the radiological sign on NCCT with the highest impact on clinical outcome at discharge.

RadioGraphics Update: White Matter Diseases with Radiologic-Pathologic Correlation

Editor's Note.-Articles in the RadioGraphics Update section provide current knowledge to supplement or update information found in full-length articles previously published in RadioGraphics. Authors of the previously published article provide a brief synopsis that emphasizes important new information such as technologic advances, revised imaging protocols, new clinical guidelines involving imaging, or updated classification schemes. Articles in this section are published solely online and are linked to the original article. ^©RSNA, 2020.

Differential effect of vascularity between long- and short-term survivors with IDH1/2 wild-type glioblastoma

INTRODUCTION

IDH1/2 wt glioblastoma (GB) represents the most lethal tumour of the central nervous system. Tumour vascularity is associated with overall survival (OS), and the clinical relevance of vascular markers, such as rCBV, has already been validated. Nevertheless, molecular and clinical factors may have different influences on the beneficial effect of a favourable vascular signature.

PURPOSE

To evaluate the association between the rCBV and OS of IDH1/2 wt GB patients for long-term survivors (LTSs) and short-term survivors (STSs). Given that initial high rCBV may affect the patient's OS in follow-up stages, we will assess whether a moderate vascularity is beneficial for OS in both groups of patients.

MATERIALS AND METHODS

Ninety-nine IDH1/2 wt GB patients were divided into LTSs (OS ≥ 400 days) and STSs (OS < 400 days). Mann-Whitney and Fisher, uni- and multiparametric Cox, Aalen's additive regression and Kaplan-Meier tests were carried out. Tumour vascularity was represented by the mean rCBV of the high angiogenic tumour (HAT) habitat computed through the haemodynamic tissue signature methodology (available on the ONCOhabitats platform).

RESULTS

For LTSs, we found a significant association between a moderate value of rCBV_mean and higher OS (uni- and multiparametric Cox and Aalen's regression) (p = 0.0140, HR = 1.19; p = 0.0085, HR = 1.22) and significant stratification capability (p = 0.0343). For the STS group, no association between rCBV_mean and survival was observed. Moreover, no significant differences (p > 0.05) in gender, age, resection status, chemoradiation, or MGMT methylation were observed between LTSs and STSs.

CONCLUSION

We have found different prognostic and stratification effects of the vascular marker for the LTS and STS groups. We propose the use of rCBV_mean at HAT as a vascular marker clinically relevant for LTSs with IDH1/2 wt GB and maybe as a potential target for randomized clinical trials focused on this group of patients.

Brain and Lung Imaging Correlation in Patients with COVID-19: Could the Severity of Lung Disease Reflect the Prevalence of Acute Abnormalities on Neuroimaging? A Global Multicenter Observational Study

PURPOSE

Our aim was to study the association between abnormal findings on chest and brain imaging in patients with coronavirus disease 2019 (COVID-19) and neurologic symptoms.

MATERIALS AND METHODS

In this retrospective, international multicenter study, we reviewed the electronic medical records and imaging of hospitalized patients with COVID-19 from March 3, 2020, to June 25, 2020. Our inclusion criteria were patients diagnosed with Severe Acute Respiratory Syndrome coronavirus 2 (SARS-CoV-2) infection with acute neurologic manifestations and available chest CT and brain imaging. The 5 lobes of the lungs were individually scored on a scale of 0-5 (0 corresponded to no involvement and 5 corresponded to >75% involvement). A CT lung severity score was determined as the sum of lung involvement, ranging from 0 (no involvement) to 25 (maximum involvement).

RESULTS

A total of 135 patients met the inclusion criteria with 132 brain CT, 36 brain MR imaging, 7 MRA of the head and neck, and 135 chest CT studies. Compared with 86 (64%) patients without acute abnormal findings on neuroimaging, 49 (36%) patients with these findings had a significantly higher mean CT lung severity score (9.9 versus 5.8, P < .001). These patients were more likely to present with ischemic stroke (40 [82%] versus 11 [13%], P < .0001) and were more likely to have either ground-glass opacities or consolidation (46 [94%] versus 73 [84%], P = .01) in the lungs. A threshold of the CT lung severity score of >8 was found to be 74% sensitive and 65% specific for acute abnormal findings on neuroimaging. The neuroimaging hallmarks of these patients were acute ischemic infarct (28%), intracranial hemorrhage (10%) including microhemorrhages (19%), and leukoencephalopathy with and/or without restricted diffusion (11%). The predominant CT chest findings were peripheral ground-glass opacities with or without consolidation.

CONCLUSIONS

The CT lung disease severity score may be predictive of acute abnormalities on neuroimaging in patients with COVID-19 with neurologic manifestations. This can be used as a predictive tool in patient management to improve clinical outcome.

Oral hydration compared to intravenous hydration in the prevention of post-contrast acute kidney injury in patients with chronic kidney disease stage IIIb: A phase III non-inferiority study (NICIR study)

OBJECTIVE

To evaluate the non-inferiority of oral hydration compared to intravenous (i.v.) hydration in the prevention of post-contrast acute kidney injury (PC-AKI) in patients with stage IIIb chronic kidney disease (CKD) referred for an elective contrast-enhanced computed tomography (CE-CT).

MATERIAL AND METHODS

This is a prospective, randomized, phase 3, parallel-group, open-label, non-inferiority trial. Patients were randomly assigned 1:1 to receive prophylaxis against PC-AKI either with oral hydration: 500 mL of water two hours before and 2000 mL during the 24 h after performing CE-CT or i.v. hydration: sodium bicarbonate (166 mmol/L) 3 mL/kg/h starting one hour before and sodium bicarbonate (166 mmol/L) 1 mL/kg/h during the first hour after CE-CT. 100 mL of non-ionic iodinated contrast was administered in all cases. The primary outcome was the proportion of PC-AKI in the first 48-72 h after CE-CT. Secondary outcomes were persistent PC-AKI, the need for hemodialysis, and the occurrence of adverse events related to prophylaxis.

RESULTS

Of 264 patients randomized between January 2018 and January 2019, 114 received oral hydration, and 114 received i.v. hydration and were evaluable. No significant differences were found (p > 0.05) between arms in clinical characteristics or risk factors. PC-AKI rate was 4.4 % (95 %CI: 1.4-9.9 %) in the oral hydration arm and 5.3 % (95 %CI: 2.0-11.1%) in the i.v. hydration arm. The persistent PC-AKI rate was 1.8 % (95 %CI: 0.2-6.2 %) in both arms. No patient required dialysis during the first month after CE-CT or had adverse effects related to the hydration regime.

CONCLUSION

In those with stage IIIb CKD referred for an elective CE-CT, we provide evidence of non-inferiority of oral hydration compared to i.v. hydration in the prevention of PC-AKI.

Special Report of the RSNA COVID-19 Task Force: Crisis Leadership of Major Health System Radiology Departments during COVID-19

Severe acute respiratory syndrome coronavirus 2 has spread across the world since December 2019, infecting 100 million and killing millions. The impact on health care institutions during the coronavirus disease 2019 pandemic has been considerable, with exhaustion of institutional and personal protective equipment resources during local outbreaks and crushing financial consequences for many institutions. Establishing adaptive principles of leadership is necessary during crises, fostering quick decision-making and workflow modifications, while a rapid review of data must determine necessary course corrections. This report describes concepts of crisis leadership teams that can help maximize their effectiveness during the current and future pandemics.

© RSNA, 2021

RNA sequencing and Immunohistochemistry Reveal ZFN7 as a Stronger Marker of Survival than Molecular Subtypes in G-CIMP-negative Glioblastoma

PURPOSE

Glioblastoma is the most aggressive brain tumor in adults and has few therapeutic options. The study of molecular subtype classifications may lead to improved prognostic classification and identification of new therapeutic targets. The Cancer Genome Atlas (TCGA) subtype classification has mainly been applied in U.S. clinical trials, while the intrinsic glioma subtype (IGS) has mainly been applied in European trials.

EXPERIMENTAL DESIGN

From paraffin-embedded tumor samples of 432 patients with uniformly treated, newly diagnosed glioblastoma, we built tissue microarrays for IHC analysis and applied RNA sequencing to the best samples to classify them according to TCGA and IGS subtypes.

RESULTS

We obtained transcriptomic results from 124 patients. There was a lack of agreement among the three TCGA classificatory algorithms employed, which was not solely attributable to intratumoral heterogeneity. There was overlapping of TCGA mesenchymal subtype with IGS cluster 23 and of TCGA classical subtype with IGS cluster 18. Molecular subtypes were not associated with prognosis, but levels of expression of 13 novel genes were identified as independent prognostic markers in glioma-CpG island methylator phenotype-negative patients, independently of clinical factors and MGMT methylation. These findings were validated in at least one external database. Three of the 13 genes were selected for IHC validation. In particular, high ZNF7 RNA expression and low ZNF7 protein expression were strongly associated with longer survival, independently of molecular subtypes.

CONCLUSIONS

TCGA and IGS molecular classifications of glioblastoma have no higher prognostic value than individual genes and should be refined before being applied to clinical trials.

Assessing Immunotherapy with Functional and Molecular Imaging and Radiomics

Immunotherapy is changing the treatment paradigm for cancer and has introduced new challenges in medical imaging. Because not all patients benefit from immunotherapy, pretreatment imaging should be performed to identify not only prognostic factors but also factors that allow prediction of response to immunotherapy. Follow-up studies must allow detection of nonresponders, without confusion of pseudoprogression with real progression to prevent premature discontinuation of treatment that can benefit the patient. Conventional imaging techniques and classic tumor response criteria are limited for the evaluation of the unusual patterns of response that arise from the specific mechanisms of action of immunotherapy, so advanced imaging methods must be developed to overcome these shortcomings. The authors present the fundamentals of the tumor immune microenvironment and immunotherapy and how they influence imaging findings. They also discuss advances in functional and molecular imaging techniques for the assessment of immunotherapy in clinical practice, including their use to characterize immune phenotypes, assess patient prognosis and response to therapy, and evaluate immune-related adverse events. Finally, the development of radiomics and radiogenomics in these therapies and the future role of imaging biomarkers for immunotherapy are discussed. Online supplemental material is available for this article. ^©RSNA, 2020.

MGMT methylation may benefit overall survival in patients with moderately vascularized glioblastomas

Objectives

To assess the combined role of tumor vascularity, estimated from perfusion MRI, and MGMT methylation status on overall survival (OS) in patients with glioblastoma.

Methods

A multicentric international dataset including 96 patients from NCT03439332 clinical study were used to study the prognostic relationships between MGMT and perfusion markers. Relative cerebral blood volume (rCBV) in the most vascularized tumor regions was automatically obtained from preoperative MRIs using ONCOhabitats online analysis service. Cox survival regression models and stratification strategies were conducted to define a subpopulation that is particularly favored by MGMT methylation in terms of OS.

Results

rCBV distributions did not differ significantly (p > 0.05) in the methylated and the non-methylated subpopulations. In patients with moderately vascularized tumors (rCBV < 10.73), MGMT methylation was a positive predictive factor for OS (HR = 2.73, p = 0.003, AUC = 0.70). In patients with highly vascularized tumors (rCBV > 10.73), however, there was no significant effect of MGMT methylation (HR = 1.72, p = 0.10, AUC = 0.56).

Conclusions

Our results indicate the existence of complementary prognostic information provided by MGMT methylation and rCBV. Perfusion markers could identify a subpopulation of patients who will benefit the most from MGMT methylation. Not considering this information may lead to bias in the interpretation of clinical studies.

Key Points

• MRI perfusion provides complementary prognostic information to MGMT methylation.

• MGMT methylation improves prognosis in glioblastoma patients with moderate vascular profile.

• Failure to consider these relations may lead to bias in the interpretation of clinical studies.

Electronic supplementary material

The online version of this article (10.1007/s00330-020-07297-4) contains supplementary material, which is available to authorized users.

Effectiveness of the clinical decision support tool ESR eGUIDE for teaching medical students the appropriate selection of imaging tests: randomized cross-over evaluation

OBJECTIVES

To evaluate ESR eGUIDE-the European Society of Radiology (ESR) e-Learning tool for appropriate use of diagnostic imaging modalities-for learning purposes in different clinical scenarios.

METHODS

This anonymized evaluation was performed after approval of ESR Education on Demand leadership. Forty clinical scenarios were developed in which at least one imaging modality was clinically most appropriate, and the scenarios were divided into sets 1 and 2. These sets were provided to medical students randomly assigned to group A or B to select the most appropriate imaging test for each scenario. Statistical comparisons were made within and across groups.

RESULTS

Overall, 40 medical students participated, and 31 medical students (78%) answered both sets. The number of correctly chosen imaging methods per set in these 31 paired samples was significantly higher when answered with versus without use of ESR eGUIDE (13.7 ± 2.6 questions vs. 12.1 ± 3.2, p = 0.012). Among the students in group A, who first answered set 1 without ESR eGUIDE (11.1 ± 3.2), there was significant improvement when set 2 was answered with ESR eGUIDE (14.3 ± 2.5, p = 0.013). The number of correct answers in group B did not drop when set 2 was answered without ESR eGUIDE (12.4 ± 2.6) after having answered set 1 first with ESR eGUIDE (13.0 ± 2.7, p = 0.66).

CONCLUSION

The clinical decision support tool ESR eGUIDE is suitable for training medical students in choosing the best radiological imaging modality in typical scenarios, and its use in teaching radiology can thus be recommended.

KEY POINTS

• ESR eGUIDE improved the number of appropriately selected imaging modalities among medical students. • This improvement was also seen in the group of students which first selected imaging tests without ESR eGUIDE. • In the student group which used ESR eGUIDE first, appropriate selection remained stable even without the teaching tool.

The Chemical Optimization of Cerebral Embolectomy trial: Study protocol

RATIONALE

The potential value of rescue intraarterial thrombolysis in patients with large vessel occlusion stroke treated with mechanical thrombectomy has not been assessed in randomized trials.

AIM

The CHemical OptImization of Cerebral Embolectomy trial aims to establish whether rescue intraarterial thrombolysis is more effective than placebo in improving suboptimal reperfusion scores in patients with large vessel occlusion stroke treated with mechanical thrombectomy.

SAMPLE SIZE ESTIMATES

A sample size of 200 patients allocated 1:1 to intraarterial thrombolysis or intraarterial placebo will have >95% statistical power for achieving the primary outcome (5% in the control versus 60% in the treatment group) for a two-sided (5% alpha, and 5% lost to follow-up).

METHODS AND DESIGN

We conducted a multicenter, randomized, placebo-controlled, double blind, phase 2b trial. Eligible patients are 18 or older with symptomatic large vessel occlusion treated with mechanical thrombectomy resulting in a modified treatment in cerebral ischemia score 2b at end of the procedure. Patients will receive 20-30 min intraarterial infusion of recombinant tissue plasminogen activator or placebo (0.5 mg/ml, maximum dose limit 22.5 mg).

STUDY OUTCOME(S)

The primary outcome is the proportion of patients with an improved modified treatment in cerebral ischemia score 10 min after the end of the study treatment. Secondary outcomes include the shift analysis of the modified Rankin Scale, the infarct expansion ratio, the proportion of excellent outcome (modified Rankin Scale 0-1), the proportion of infarct expansion, and the infarction volume. Mortality and symptomatic intracerebral bleeding will be assessed.

DISCUSSION

The study will provide evidence whether rescue intraarterial thrombolysis improves brain reperfusion in patients with large vessel occlusion stroke and incomplete reperfusion (modified treatment in cerebral ischemia 2b) at the end of mechanical thrombectomy.

Presurgical simulation for neuroendoscopic procedures: Virtual study of the integrity of neurological pathways using diffusion tensor imaging tractography

Background:

White matter (WM) transgression is an unexplored concept in neuroendoscopy. Diffusion tensor image (DTI) tractography could be implemented as a planning and postoperative evaluation tool in functional disconnection procedures (FDPs), which are, currently, the subject of technological innovations. We intend to prove the usefulness of this planning method focused on the assessment of WM injury that is suitable for planning FDPs.

Methods:

Ten cranial magnetic resonance studies (20 sides) without pathological findings were processed. Fascicles were defined by two regions of interest (ROIs) using the fiber assignment method by the continuous tracking approach. Using three-dimensional (3D) simulation and DTI tractography, we created an 8-mm virtual endoscope and an uninjured inferior fronto-occipital fasciculus (IFOF) from two ROIs. The injured tract was generated using a third ROI built from the 3D model of the intersection of the oriented trajectory of the endoscope with the fascicle. Data and images were quantitatively and qualitatively analyzed.

Results:

The average percentage of the injured fibers was 32.0% (range: 12.4%–70%). The average intersected volume was 1.1 cm³ (range: 0.3–2.3 cm³). Qualitative analysis showed the inferior medial quadrant of the inferior fronto-occipital fasciculus (IFOF) as the most frequently injured region. No hemispherical asymmetry was found (P > 0.5).

Conclusion:

DTI tractography is a useful surgical planning tool that could be implemented in several endoscopic procedures. Together with a functional atlas, the presented technique provides a noninvasive method to assess the potential sequelae and thus to optimize the surgical route. The suggested method could be implemented to analyze pathological WM fascicles and to assess the surgical results of FDP such as hemispherotomy or amygdalohippocampectomy. More studies are needed to overcome the limitations of the tractography based information and to develop more anatomically and functionally reliable planning systems.

Phase II trial of palbociclib in recurrent RB-positive anaplastic oligodendroglioma: A Spanish group for research in neurooncology (GEINO) trial

2038

Background: The pRB-dependent cell cycle checkpoint is altered in the vast majority of anaplastic oligodendrogliomas (AO), either by homozygous deletion or by hypermethylation of CDKN2A and/or CDKN2B, or by amplification and/or overexpression of CDK4. Palbociclib is an oral inhibitor of CDK4 and 6 that has already been shown to be highly active in breast cancer. Methods: We conducted a multicenter, open-label, phase II trial evaluating efficacy and safety of Palbociclib in patients with AO that progressed to radiotherapy and more than one chemotherapy regimen containing Temozolomide and/or Lomustine. Inclusion criteria included: histologically and molecularly confirmed grade III oligodendroglioma (WHO 2016 classification, IDH1/2 mutation and 1p/19 codeletion were mandatory), recurrence after radiotherapy and 1 or 2 chemotherapy regimens and conserved RB protein expression by immunohistochemistry (IHC). Patients were treated with Palbociclib 125 mg/daily 3 weeks on/1off. The primary objective of the study was progression-free survival at 6 months (6M-PFS). Results: Between October 2015 and September 2018, 34 patients were enrolled across ten hospitals. The study was stopped early secondary to lack of efficacy, with 74% of evaluable patients progressing within 6 months. Number of patients alive and free from progression at 6 months after the enrollment was 9 (26%) out of the first 34 patients, below the minimum number required (18 out of 40) to consider Palbociclib as an active drug in this population. With a median follow-up of 11.2 months, the median PFS was 3 months (95% CI: 2.5-3.5 months). Median overall survival (OS) was 23.1 months (95% CI: 17.2-25 months). There were no partial or complete responses and only 11 patients (32%) achieved stable disease as best response. Palbociclib was well tolerated with neutropenia (Grade 3 or 4: 40%) and thrombocytopenia (Grade 3 or 4: 15%) as the most common adverse effects (AEs). Both AEs had no significant impact since there were no episodes of febrile neutropenia or bleeding. Conclusions: Despite the good tolerance and drug exposure, Palbociclib monotherapy did not show favorable activity in recurrent AO. Clinical trial information: NCT02530320.

Syndrome and outcome of antibody-negative limbic encephalitis

BACKGROUND AND PURPOSE

The aim was to report the clinical characteristics of 12 patients with limbic encephalitis (LE) who were antibody-negative after a comprehensive immunological study.

METHODS

The clinical records of 163 patients with LE were reviewed. Immunohistochemistry on rat brain, cultured neurons and cell-based assays were used to identify neuronal autoantibodies. Patients were included if (i) there was adequate clinical, cerebrospinal fluid (CSF) and magnetic resonance imaging information to classify the syndrome as LE, (ii) magnetic resonance images were accessible for central review and (iii) serum and CSF were available and were confirmed negative for neuronal antibodies.

RESULTS

Twelve (7%) of 163 LE patients [median age 62 years; range 40-79; 9 (75%) male] without neuronal autoantibodies were identified. The most frequent initial complaints were deficits in short-term memory leading to hospital admission in a few weeks (median time 2 weeks; range 0.5-12). In four patients the short-term memory dysfunction remained as an isolated symptom during the entire course of the disease. Seizures, drowsiness and psychiatric problems were unusual. Four patients had solid tumors (one lung, one esophagus, two metastatic cervical adenopathies of unknown primary tumor) and one chronic lymphocytic leukemia. CSF showed pleocytosis in seven (58%) with a median of 13 white blood cells/mm³ (range 9-25). Immunotherapy included corticosteroids, intravenous immunoglobulins and combinations of both drugs or with rituximab. Clinical improvement occurred in six (54%) of 11 assessable patients.

CONCLUSIONS

Despite the discovery of new antibodies, 7% of LE patients remain seronegative. Antibody-negative LE is more frequent in older males and usually develops with predominant or isolated short-term memory loss. Despite the absence of antibodies, patients may have an underlying cancer and respond to immunotherapy.

Pseudoprogression as an adverse event of glioblastoma therapy

We explored predictive factors of pseudoprogression (PsP) and its impact on prognosis in a retrospective series of uniformly treated glioblastoma patients. Patients were classified as having PsP, early progression (eP) or neither (nP). We examined potential associations with clinical, molecular, and basal imaging characteristics and compared overall survival (OS), progression‐free survival (PFS), post‐progression survival (PPS) as well as the relationship between PFS and PPS in the three groups. Of the 256 patients studied, 56 (21.9%) were classified as PsP, 70 (27.3%) as eP, and 130 (50.8%) as nP. Only MGMT methylation status was associated to PsP. MGMT methylated patients had a 3.5‐fold greater possibility of having PsP than eP (OR: 3.48; 95% CI: 1.606–7.564; P = 0.002). OS was longer for PsP than eP patients (18.9 vs. 12.3 months; P = 0.0001) but was similar for PsP and nP patients (P = 0.91). OS was shorter–though not significantly so—for PsP than nP patients (OS: 19.5 vs. 27.9 months; P = 0.63) in methylated patients. PPS was similar for patients having PsP, eP or nP (PPS: 7.2 vs. 5.4 vs. 6.7; P = 0.43). Neurological deterioration occurred in 64.3% of cases at the time they were classified as PsP and in 72.8% of cases of eP (P = 0.14). PsP confounds the evaluation of disease and does not confer a survival advantage in glioblastoma.

White Matter Diseases with Radiologic-Pathologic Correlation

White matter diseases include a wide spectrum of disorders that have in common impairment of normal myelination, either by secondary destruction of previously myelinated structures (demyelinating processes) or by primary abnormalities of myelin formation (dysmyelinating processes). The pathogenesis of many white matter diseases remains poorly understood. Demyelinating disorders are the object of this review and will be further divided into autoimmune, infectious, vascular, and toxic-metabolic processes. Autoimmune processes include multiple sclerosis and related diseases: tumefactive demyelinating lesions, Balo concentric sclerosis, Marburg and Schilder variants, neuromyelitis optica (Devic disease), acute disseminated encephalomyelitis, and acute hemorrhagic leukoencephalopathy (Hurst disease). Infectious processes include Lyme disease (neuroborreliosis), progressive multifocal leukoencephalopathy, and human immunodeficiency virus (HIV) encephalopathy. Vascular processes include different types of small-vessel disease: arteriolosclerosis, cerebral amyloid angiopathy, cerebral autosomal-dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL), primary angiitis of the central nervous system, Susac syndrome, and neurolupus. Toxic-metabolic processes include osmotic myelinolysis, methotrexate leukoencephalopathy, and posterior reversible encephalopathy syndrome. The imaging spectrum can vary widely from small multifocal white matter lesions to confluent or extensive white matter involvement. Understanding the pathologic substrate is fundamental for understanding the radiologic manifestations, and a systematic approach to the radiologic findings, in correlation with clinical and laboratory data, is crucial for narrowing the differential diagnosis. (©)RSNA, 2016.

Vessel Wall Enhancement and Blood–Cerebrospinal Fluid Barrier Disruption After Mechanical Thrombectomy in Acute Ischemic Stroke

Background and Purpose—

Less than half of acute ischemic stroke patients treated with mechanical thrombectomy obtain permanent clinical benefits. Consequently, there is an urgent need to identify mechanisms implicated in the limited efficacy of early reperfusion. We evaluated the predictors and prognostic significance of vessel wall permeability impairment and its association with blood–cerebrospinal fluid barrier (BCSFB) disruption after acute stroke treated with thrombectomy.

Methods—

A prospective cohort of acute stroke patients treated with stent retrievers was analyzed. Vessel wall permeability impairment was identified as gadolinium vessel wall enhancement (GVE) in a 24- to 48-hour follow-up contrast-enhanced magnetic resonance imaging, and severe BCSFB disruption was defined as subarachnoid hemorrhage or gadolinium sulcal enhancement (present across >10 slices). Infarct volume was evaluated in follow-up magnetic resonance imaging, and clinical outcome was evaluated with the modified Rankin Scale at day 90.

Results—

A total of 60 patients (median National Institutes of Health Stroke Scale score, 18) were analyzed, of whom 28 (47%) received intravenous alteplase before mechanical thrombectomy. Overall, 34 (57%) patients had GVE and 27 (45%) had severe BCSFB disruption. GVE was significantly associated with alteplase use before thrombectomy and with more stent retriever passes, along with the presence of severe BCSFB disruption. GVE was associated with poor clinical outcome, and both GVE and severe BCSFB disruption were associated with increased final infarct volume.

Conclusions—

These findings may support the clinical relevance of direct vessel damage and BCSFB disruption after acute stroke and reinforce the need for further improvements in reperfusion strategies. Further validation in larger cohorts of patients is warranted.

[Asymptomatic skull base metastases: clinical course and therapeutic alternatives]

INTRODUCTION

Skull base metastases (SBM) are an infrequent and late type of cancer progression that are associated to poor prognosis. Its clinical manifestations may be grouped in five clinical syndromes and radiotherapy is its more frequent treatment. Because of the improvement in imaging tests and the close follow up of cancer patients, SBM can be diagnosed incidentally. In this group the best option of treatment has not been established.

AIM

To analyze the clinical features and outcomes of patients with SBM diagnosed incidentally.

PATIENTS AND METHODS

Between January 2012 and December 2015, 31 patients with diagnoses of SBM from solid primary tumor were reviewed.

RESULTS

SBM were diagnosed due to skull base syndromes (n = 24) or incidentally (n = 7). Symptomatic patients were treated with radiotherapy. Patients diagnosed incidentally remained without symptoms of craneal base involvement during the follow up, although they frequently had other types of intracranial progression. A statistically significant difference in survival was observed between symptomatic and asymptomatic patients (p = 0.001).

CONCLUSIONS

The incidentally diagnosed SBM were frequently associated to other types of intracranial progression, limiting the options of treatment.

Proton magnetic resonance spectroscopy in oncology: the fingerprints of cancer?

Abnormal metabolism is a key tumor hallmark. Proton magnetic resonance spectroscopy (1H-MRS) allows measurement of metabolite concentration that can be utilized to characterize tumor metabolic changes. 1H-MRS measurements of specific metabolites have been implemented in the clinic. This article performs a systematic review of image acquisition and interpretation of 1H-MRS for cancer evaluation, evaluates its strengths and limitations, and correlates metabolite peaks at 1H-MRS with diagnostic and prognostic parameters of cancer in different tumor types.

Neuroanatomical correlates of stroke-associated infection and stroke-induced immunodepression

BACKGROUND

Infections represent the most frequent medical complications in stroke patients. Their main determinants are dysphagia and a transient state of immunodepression. We analyzed whether distinct anatomical brain regions were associated with the occurrence of stroke-associated infections or immunodepression.

MATERIALS AND METHODS

In 106 patients with acute ischemic stroke, we evaluated the incidence of pneumonia, urinary tract infection, or other infections together with the characterization of biomarkers of immunodepression. Twenty control subjects served to provide reference values. Using voxel-based lesion-symptom mapping, the involvement of gray and white matter structures was correlated with clinical and laboratory findings in crude analyses and in volume adjusted models to rule out associations reflecting differences in the size of the infarction.

RESULTS

Stroke-associated infection occurred in 22 (21%) patients and prevailed in patients with larger infarcts. Volume adjusted voxel-based lesion-symptom mapping revealed the involvement of the superior and middle temporal gyri, the orbitofrontal cortex, the superior longitudinal fasciculus and the inferior fronto-occipital fasciculus amongst infected patients. These associations were similar for pneumonia but not for urinary tract infections. Lymphopenia was associated with lesions of the superior and middle temporal gyri. Laterality did not influence stroke-associated infections or the presence of immunodepressive traits after volume control. The greatest overlap in the neuroanatomical correlates occurred between pneumonia and dysphagia.

CONCLUSION

Infarct volume plays a relevant role in the occurrence of stroke-associated infections, but lesions in specific brain locations such as the superior and lateral temporal lobe and the orbitofrontal cortex are also associated with increased infectious risk, especially pneumonia.

Brain hemorrhage after endovascular reperfusion therapy of ischemic stroke: a threshold-finding whole-brain perfusion CT study

Endovascular reperfusion therapy is increasingly used for acute ischemic stroke treatment. The occurrence of parenchymal hemorrhage is clinically relevant and increases with reperfusion therapies. Herein we aimed to examine the optimal perfusion CT-derived parameters and the impact of the duration of brain ischemia for the prediction of parenchymal hemorrhage after endovascular therapy. A cohort of 146 consecutive patients with anterior circulation occlusions and treated with endovascular reperfusion therapy was analyzed. Recanalization was assessed at the end of reperfusion treatment, and the rate of parenchymal hemorrhage at follow-up neuroimaging. In regression analyses, cerebral blood volume and cerebral blood flow performed better than Delay Time maps for the prediction of parenchymal hemorrhage. The most informative thresholds (receiver operating curves) for relative cerebral blood volume and relative cerebral blood flow were values lower than 2.5% of normal brain. In binary regression analyses, the volume of regions with reduced relative cerebral blood volume and/or relative cerebral blood flow was significantly associated with an increased risk of parenchymal hemorrhage, as well as delayed vessel recanalization. These results highlight the relevance of the severity and duration of ischemia as drivers of blood-brain barrier disruption in acute ischemic stroke and support the role of perfusion CT for the prediction of parenchymal hemorrhage.

Assessment of White Matter Transgression During Neuroendoscopic Procedures Using Diffusion Tensor Image Fiber Tracking

BACKGROUND

Presurgical planning allows anticipating intraoperative difficulties, increasing efficiency, and reducing risks. Neuroendoscopy is a minimally invasive technique whose related complications have been focused on cortical function and surface vessels injury. However, white matter disruption has been insufficiently acknowledged.

OBJECTIVE

To present a new surgical planning method based on diffusion tensor image that allows quantifying subcortical transgression and optimizing neuroendoscopic trajectories.

METHODS

Ten cranial magnetic resonance studies (20 sides) without pathologic findings were anonymized and processed. A standard transcortical approach to the frontal horn was used to study the transgression of the corpus callosum (CC) and cingulum (Ci) caused by a virtual endoscope (VE) oriented from the Kocher point to the foramen of Monro. An 8-mm VE model was created, oriented, and coregistered. VE-CC and VE-Ci intersections were segmented. The number and volume of injured fibers were measured, intersections were quantified, and the percentage of tract transgression was calculated. The areas damaged by the VE were also recorded.

RESULTS

Among the CC fibers, 16.4% were injured (range: 3.3%-37%) and 26.7% of fibers on Ci (rank: 0%-73.4%). The average intersected volumes were 19.1% (range: 4.2%-53.2%) for CC and 33.2% for Ci (range: 0%-73.7%). Qualitative analysis showed the lateral aspect of both tracts as the most frequently injured region. No hemispherical asymmetry was found (P > 0.05).

CONCLUSION

This method using tractography and oriented models of surgical instruments allows assessing white matter transgression, both qualitatively and quantitatively, for a deep brain trajectory. Thus our method permits surgeons to optimize safety and avoid transgression of eloquent tracts during surgical planning. Nevertheless, more studies are necessary.

Oropharyngeal Syphilis: Imaging and Pathologic Findings in Two Patients

Syphilis is a widespread infection with increasing frequency in developed countries, especially among men who have sex with men. We present two cases of oropharyngeal syphilis in two middle-aged men who presented with a painless tonsillar ulcer and progressive enlargement of cervical lymph nodes suspected of being a tonsillar tumour. A pathologic analysis of the ulcer led to an accurate diagnosis. We review the imaging and pathologic findings to emphasize the importance of taking syphilis into account in the differential diagnosis.

Increased signal intensity in FLAIR sequences in the resection cavity can predict progression and progression-free survival in gliomas

OBJECTIVE

To determine if hyperintense fluid in the postsurgical cavity on follow-up fluid-attenuated inversion recovery (FLAIR) sequences can predict progression in gliomas.

MATERIAL AND METHODS

Observational study of magnetic resonance imaging signal of fluid within the post-surgical cavity in patients with glioma (grade II-IV), with surgery and follow-up between 2007 and 2012. Qualitative comparison between the signal of fluid in the cavity and of the ventricular cerebrospinal fluid (CSF) was performed on FLAIR sequences. Fluid in the cavity was classified as isointense or hyperintense compared to CSF. Double-blind reading was performed. The signal intensity was correlated with tumour progression, assessed using Response Assessment in Neuro-Oncology criteria.

RESULTS

A total of 107 patients were included, of whom 90 had high-grade gliomas. Inter-rater agreement was excellent, and intra-rater complete (k=0.94 and 1, p<.001). Hyperintense fluid in the resection cavity occurred more commonly (58.9% versus 29.4%, p=.025) and earlier (mean 4.5 versus 9.9 months, p<.001) in high-grade than in low-grade gliomas. Hyperintense fluid was associated with progression in high-grade gliomas, with a sensitivity of 65.7% (95%CI, 54.3-75.6%) and a specificity of 70.6% (95%CI, 46.6-87%), and in low-grade gliomas with a sensitivity of 50% (95%CI, 18.7-81.2%), and a specificity of 81.8% (95%CI, 51.1-96%). The positive predictive value of this sign was 90.6% (95%CI, 79.3-96.3%) for high-grade gliomas, and was higher for grade IV (93.2%, 95%CI, 87.3-99.1%) and lower for grade III (77.8%, 95%CI, 59.6-96%), and low-grade gliomas (60%, 95%CI, 22.9-88.4%). False-positives were identified in 7 patients, due to bleeding or infection. Hyperintense fluid in high-grade gliomas preceded progression in 22 patients (30.1%), with a mean of 4.1 months (SD 2.1, 95% CI, 3.2-5), and associated with poorer progression-free survival (mean 6.8 versus 11.7 months, p=.004).

CONCLUSIONS

Hyperintense fluid in the resection cavity on follow-up FLAIR sequences occurs more frequently and earlier in high-grade gliomas, and is associated with poorer progression-free survival. Hyperintense fluid is associated with disease progression, and can predict the progression of resected gliomas. False-positives due to bleeding and infection can be observed, and are easily recognizable.