[Neurological involvement of sarcoidosis: current diagnostic and therapeutic strategies]

Neurosarcoidosis (NS) is a rare but severe form of sarcoidosis. NS is associated with significant morbidity and mortality. Mortality is about 10% at 10 years with more than 30% of patients who have a significant disability. The most frequent features are cranial neuropathy (the facial and optic nerve most commonly affected), cranial parenchymal lesions, meningitis, spinal corn abnormalities (20-30%) and more rarely peripheral neuropathy (approximately 10-15%). The challenge of diagnosis is to eliminate other diagnoses. Atypical presentations should make to discuss the need for cerebral biopsy in order to highlight the presence of granulomatous lesions while eliminating alternative diagnosis. Therapeutic management is based on corticosteroid therapy and immunomodulators. There are no comparative prospective study to allow us to define the first-line immunosuppressive treatment and the therapeutic strategy in refractory patients. Conventional immunosuppressants such as methotrexate, mycophenolate mofetil and cyclophosphamide are commonly used. Data on the efficacy of anti-TNFα (including infliximab) in refractory and/or severe forms are increasing during the last ten years. Additional data is necessary to assess their interest in first line in patients with severe involvement and a significant risk of relapse.

Human pegivirus identified in severe myelitis and optic neuritis in immunocompromised patients: A pathogenic role for a forgotten virus?

The role of Human pegivirus (HPgV) in patients with encephalitis has been recently questioned. We present cases of 4 patients with similar clinical, biological, and radiological characteristics, including a past history of transplantation with long-term immunosuppression and a progressive course of severe and predominantly myelitis, associated in 3 cases with optic neuropathy causing blindness. Extensive workup was negative but analysis of the CSF by use of pan-microorganism DNA- and RNA-based shotgun metagenomics was positive for HPgV. This case series further supports the hypothesis of HPgV CNS infection and highlights the utility of metagenomic next-generation sequencing of CSF in immunocompromised patients.

MRI characteristics of MOG-Ab associated disease in adults: An update

Our knowledge of the radiological spectrum of myelin oligodendrocyte glycoprotein antibody associated disease (MOGAD) is growing rapidly. An update on the radiological features of the disease, and its evolution is thus necessary. Magnetic resonance imaging (MRI) has an increasingly important role in the differential diagnosis of MOGAD particularly from aquaporin-4 antibody-positive neuromyelitis optica spectrum disorder (AQP4-NMOSD), and multiple sclerosis (MS). Differentiating these conditions is of prime importance because the management is different between the three inflammatory diseases, and thus could prevent further attack-related disability. Therefore, identifying the MRI features suggestive of MOGAD has diagnostic and prognostic implications. We herein review optic nerve, spinal cord and the brain MRI findings from MOGAD adult patients, and compare them to AQP4-NMOSD and MS.

Atypical Deep Cerebral Vein Thrombosis with Hemorrhagic Venous Infarction in a Patient Positive for COVID-19

There is growing evidence that Severe Acute Respiratory Syndrome coronavirus 2 (SARS-CoV-2) has a neurotropic and neuroinvasive potential. In particular, neurologic complications associated with the infection by SARS-CoV-2 include strokes that may result from a dysregulated inflammatory response to the infection. We report an atypical deep cerebral vein thrombosis complicated with hemorrhagic venous infarction in a patient positive for SARS-CoV-2 with no risk factors for thrombosis.

Advanced multiparametric magnetic resonance imaging of multinodular and vacuolating neuronal tumor

BACKGROUND AND PURPOSE

Multinodular and vacuolating neuronal tumor (MVNT) of the cerebrum is a rare brain lesion with suggestive imaging features. The aim of our study was to report the largest series of MVNTs so far and to evaluate the utility of advanced multiparametric magnetic resonance (MR) techniques.

METHODS

This multicenter retrospective study was approved by our institutional research ethics board. From July 2014 to May 2019, two radiologists read in consensus the MR examinations of patients presenting with a lesion suggestive of an MVNT. They analyzed the lesions' MR characteristics on structural images and advanced multiparametric MR imaging.

RESULTS

A total of 64 patients (29 women and 35 men, mean age 44.2 ± 15.1 years) from 25 centers were included. Lesions were all hyperintense on fluid-attenuated inversion recovery and T2-weighted imaging without post-contrast enhancement. The median relative apparent diffusion coefficient on diffusion-weighted imaging was 1.13 [interquartile range (IQR), 0.2]. Perfusion-weighted imaging showed no increase in perfusion, with a relative cerebral blood volume of 1.02 (IQR, 0.05) and a relative cerebral blood flow of 1.01 (IQR, 0.08). MR spectroscopy showed no abnormal peaks. Median follow-up was 2 (IQR, 1.2) years, without any changes in size.

CONCLUSIONS

A comprehensive characterization protocol including advanced multiparametric magnetic resonance imaging sequences showed no imaging patterns suggestive of malignancy in MVNTs. It might be useful to better characterize MVNTs.

Multinodular and Vacuolating Posterior Fossa Lesions of Unknown Significance

Multinodular and vacuolating neuronal tumor of the cerebrum is a rare supratentorial brain tumor described for the first time in 2013. Here, we report 11 cases of infratentorial lesions showing similar striking imaging features consisting of a cluster of low T1-weighted imaging and high T2-FLAIR signal intensity nodules, which we referred to as multinodular and vacuolating posterior fossa lesions of unknown significance. No relationship was found between the location of the lesion and clinical symptoms. A T2-FLAIR hypointense central dot sign was present in images of 9/11 (82%) patients. Cortical involvement was present in 2/11 (18%) of patients. Only 1 nodule of 1 multinodular and vacuolating posterior fossa lesion of unknown significance showed enhancement on postcontrast T1WI. DWI, SWI, MRS, and PWI showed no malignant pattern. Lesions did not change in size or signal during a median follow-up of 3 years, suggesting that multinodular and vacuolating posterior fossa lesions of unknown significance are benign malformative lesions that do not require surgical intervention or removal.

Coronary stent deployment without predilation in acute myocardial infarction: a feasible, safe, and effective technique

Direct percutaneous transcatheter revascularization (PTCR) is becoming an acceptable therapy for acute myocardial infarction (AMI). Stenting in the setting of AMI, once considered contraindicated, is emerging as a suitable option in this situation. Coronary stenting without predilation (SWOP) may potentially shorten the procedure and radiation time, reduce costs, and decrease procedural complications such as coronary dissection and distal embolization. It is expected to cause less vascular injury, with a reduction in the rate of in-stent restenosis. In this preliminary study the authors evaluated the feasibility of the SWOP procedure in 22 selected patients with AMI. Indications for catheter-based myocardial reperfusion were the following: extensive anterior wall MI (68%), inferior wall and right ventricular MI (23%), and inferior wall MI with contraindication for thrombolytic therapy (9%). Patients with cardiogenic shock or with contraindications for aspirin or ticlopidine were excluded. SWOP was successful in 21 attempts (95%), and final procedural success was achieved in all. Proximal or distal dissections were seen in three cases and were treated by additional three stents. Thrombolysis in myocardial infarction (TIMI) flow 3 was restored in all patients. There were no distal embolizations, side branch occlusions, coronary perforations, procedure-related emergency bypass operations, or deaths. It is concluded that in selected patients with AMI, coronary artery stenting without predilation is feasible and safe and does not introduce additional risk to the patients.

Effectiveness of coronary stent deployment without predilation

The feasibility of coronary stenting without predilation is demonstrated in 240 patients. In all, 249 stents were placed. Primary implantation was successful in 93% of cases. In 17 lesions the stents could not be advanced through the stenotic lesion. The unexpanded stents were removed through the guiding catheter, and stenting was performed after prediction. Minor complications (side branch compromise and intimal dissection), which were successfully treated, occurred in 26 patients (10.6%).

Coronary stent deployment without predilation: prevention of complications of venous graft angioplasty

Saphenous vein graft stenting without predilation may potentially decrease procedural complications such as distal embolization and no-reflow phenomenon. In this report the authors describe the deployment of stents (three Wallstents, one Palmaz-Schatz, one Multilink, and one NIR) without predilation in five patients with unstable angina pectoris due to high-grade stenosis in old saphenous vein grafts. Stent deployment was successful in all patients without procedure-related complications. Stenting without predilation appears to be feasible in old bypass grafts with significant stenosis. The potential of this new stenting technique to reduce the risk of stenting complications should be tested by a randomized trial.

Coronary wallstent implantation by the transradial artery approach. A case report

The authors report the implantation of two wallstents in a patient by use of the transradial artery approach. This approach for coronary wallstent implantation allows for intensive anticoagulation therapy with less risk of bleeding.