Consensus Recommendations of the Multiple Sclerosis Study Group and the Portuguese Neuroradiological Society for the Use of Magnetic Resonance Imaging in Multiple Sclerosis in Clinical Practice: Part 2.

INTRODUCTION: Magnetic resonance imaging is recognized as the most important diagnostic test in the diagnosis of multiple sclerosis, differential diagnosis and evaluation of progression/therapeutic response. However, to make optimal use of magnetic resonance imaging in multiple sclerosis, the use of a standard, reproducible and comparable imaging protocol is of uttermost importance. In this context, the Portuguese Society of Neuroradiology and the Group of Studies of Multiple Sclerosis, after a joint discussion, appointed a committee of experts to create recommendations adapted to the national reality on the use of magnetic resonance imaging in multiple sclerosis. This document represents the second part of the first Portuguese consensus recommendations on the use of magnetic resonance imaging in multiple sclerosis in clinical practice. MATERIAL AND METHODS: The Portuguese Society of Neuroradiology and the Group of Studies of Multiple Sclerosis, after discussing the topic in national meetings and after a working group meeting held in Figueira da Foz, May 2017, appointed a committee of experts that have developed several standard protocols on the use of magnetic resonance imaging on multiple sclerosis by consensus. The document obtained was based on the best scientific evidence and expert opinion. Portuguese multiple sclerosis consultants and departments of neuroradiology scrutinized and reviewed the consensus paper; comments and suggestions were considered. Standardized strategies of magnetic resonance imaging referral in clinical practice for diagnosis and follow-up of multiple sclerosis were published in the first part of this paper. RESULTS: We provide magnetic resonance imaging acquisition protocols regarding multiple sclerosis diagnostic and monitoring and the information to be included in the report for application across Portuguese healthcare institutions. CONCLUSION: We hope that these first Portuguese magnetic resonance imaging guidelines will contribute to optimize multiple sclerosis management and improve patient care in Portugal.

Introdução: A ressonância magnética é considerada o exame complementar mais importante para o diagnóstico de esclerose múltipla, seus diagnósticos diferenciais e avaliação da sua progressão/resposta terapêutica. No entanto, para um uso ótimo desta ferramenta na esclerose múltipla, é essencial a aplicação de um protocolo de imagem padronizado, reprodutível e comparável. Neste contexto, o Grupo de Estudos de Esclerose Múltipla e a Sociedade Portuguesa de Neurorradiologia, após discussão conjunta, designaram um comité de peritos para a criação de recomendações adaptadas à realidade nacional sobre a utilização da ressonância magnética na esclerose múltipla. Este documento corresponde à segunda parte das primeiras recomendações de consenso portuguesas sobre a utilização da ressonância magnética na esclerose múltipla na prática clínica. Material e Métodos: O Grupo de Estudos de Esclerose Múltipla e a Sociedade Portuguesa de Neurorradiologia após discussão do tema em reuniões de âmbito nacional e de uma reunião do grupo de trabalho que teve lugar na Figueira da Foz em maio de 2017, designaram um comité de peritos que elaboraram por método de consenso protocolos padronizados sobre o uso da ressonância magnética na esclerose múltipla. O documento teve como base a melhor evidência científica e a opinião dos peritos. Posteriormente, o documento foi enviado para escrutínio à maioria dos responsáveis de consulta de esclerose múltipla e dos departamentos de neurorradiologia; tendo sido considerados os seus comentários e sugestões. As estratégias padronizadas de referenciação imagiológica na prática clínica para o diagnóstico e seguimento da esclerose múltipla foram publicadas na primeira parte deste artigo. Resultados: Neste artigo são propostos os protocolos de aquisição de ressonância magnética adequados para o diagnóstico e monitorização da esclerose múltipla, bem como a informação a constar do relatório imagiológico, tendo em vista a sua aplicação nas várias instituições de saúde portuguesas. Conclusão: Os autores esperam que estas primeiras orientações portuguesas sobre a utilização da ressonância magnética na esclerose múltipla na prática clínica contribuam para otimizar a gestão desta patologia e melhorar o tratamento destes doentes em Portugal.

[Anatomy and variants of the cerebral venous system--fact or defect?]. / Anatomia e variantes do sistema venoso cerebral--defeito ou feitio?

UNLABELLED: The anatomy of the cerebral venous system (CVS) is based on a known variable three-dimensional structure. For a correct recognition and characterization of its elements, a detailed knowledge of its anatomy and potential variants is essential. However, this structural changes, commonly named as variants, may appear in asymptomatic situations as well as associated to certain pathological syndromes with diagnostic and therapeutic consequences. PURPOSE: The authors present a brief summary of the CVS anatomy, highlight the potential structural changes and discuss their ethiology as constitutional or pathological. METHOD AND RESULTS: Based on clinical cases, the most frequent anatomical modifications will be presented and their ethiology discussed,whether constitutional or pathological. CONCLUSION: The CVS is characterized by its various presentations. These changes are classically named as anatomic variants. However,they may appear associated to certain pathological situations. Only a profound recognition of the normal CVS anatomy allows a correct definition of the ethiology of the structural change as constitutional or pathologic.

[The development of the cerebral venous system--from the embryo to the adult definitive structure]. / O desenvolvimento do sistema venoso cerebral--do embrião à estrutura definitiva no adulto.

INTRODUCTION: The human development consists of a continuous process where an uninterrupted pattern of extremely complex repetitive cycles of growth, modulation and modification take place. Despite this extreme complexity, the normal development is ordered by an impressive regularity, namely, in chronological, anatomical, topographic and physiological trends. In some organic systems, this development will not be totally ended by the time of birth. In this situation, further changes will have to take place until the adult definitive pattern is achieved. The cerebral venous system (CVS) is such a paradigm. PURPOSE: The authors pretend to present a synopsis of the specific organogenesis of the cerebral venous system in order to allow a correct interpretation of the vascular structures, recognise the anatomical variations and better comprehend the topographic correlations between neighbouring structures. METHOD AND RESULTS: Following a structured and synthetic order, the main guiding lines of the principal evolutional steps will be presented from the first embryological stages until the final and definitive adult pattern. CONCLUSION: The detailed study of the continuous development stages of the CVS constitutes a fundamental tool for the whole recognition of the anatomical structures, their correct interpretation and detection of possible variants as well as a better comprehension of topographic relationship between neighbouring structures. In other words and following KL Moore, Embryology illuminates anatomy.

[Mesial-temporal lesions in patients with neurosyphilis]. / Alterações mesiotemporais em doentes com neurossífilis.

BACKGROUND AND PURPOSE: Evaluate and describe clinical and imaging findings in two patients with mesial-temporal changes in a context of Neurosyphilis. METHODS: The clinical files of two patients with mesial-temporal lesions in the context of Neurosyphilis were reviewed, gathering information about sex, age, clinical presentation, laboratory and EEG changes, treatment and clinical outcome. An emphasis was placed in the initial and follow-up MR studies. RESULTS: Two male caucasian patients, aged 43 and 45, with a normal immunological status, with no prior known history of syphilis. Both presented a history of behavioral changes, disorientation and mnesic changes. Laboratorial results were compatible with neurosyphilis(TPHA and VDRL were detected in blood and LCR) and the HSV serology was negative. MR studies revealed changes of signal indicating lesions in the temporal white matter, amygdala, hippocampus, gyri parahipocampi and insulas. CONCLUSIONS: Neurosyphilis is a challenging diagnosis due to the variability of clinical and imaging findings. Precocious therapy significantly improves prognosis and outcome, stressing the need for an early diagnosis. In imaging studies Neurosyphilis should be considered as a differential diagnosis when mesial-temporal lesions are detected, prompting adequate laboratorial investigation.

Posterior Reversible Encephalopathy Syndrome and Anti-Angiogenic Agents: A Case Report.

Posterior reversible encephalopathy syndrome is an increasingly recognised clinico-radiological entity, associated with several medical conditions (such as systemic arterial hypertension) and characterised by seizures, altered mental status, headaches, and visual symptoms. Magnetic resonance imaging is a key component in this diagnosis, with hyperintense foci in T2-weighted images, corresponding to vasogenic oedema. The pathophysiology is not fully understood but probably involves loss of auto-regulation of cerebral vasculature or endothelial dysfunction or both. A 56-year-old male, suffering from a gastro-intestinal stromal tumour with hepatic metastasis resistant to imatinib, on therapy with sunitinib, came to the Emergency Department because of headaches, hallucinations, and loss of vision. There was no previous history of high blood pressure. A hypertensive crisis was diagnosed; ophthalmological examination on admission showed no light perception bilaterally. Brain imaging displayed bilateral parieto-occipital and frontal vasogenic oedema, consistent with the clinical diagnosis of posterior reversible encephalopathy syndrome. After treatment of hypertension and suspension of sunitinib, the patient recovered from his symptoms. Control imaging showed no oedema. Angiogenesis inhibitors, such as sunitinib and bevacizumab, can cause hypertension, one of the many medical conditions associated with the posterior reversible encephalopathy syndrome. This syndrome should be considered in cases of acute visual loss, particularly in view of its reversible nature when diagnosed and treated promptly.

Neuroimaging findings in alcohol-related encephalopathies.

OBJECTIVE: Our aim was to review the emergent neuroimaging findings of alcohol-related CNS nontraumatic disorders. Alcohol (ethanol) promotes inflammatory processes, increases DNA damage, and creates oxidative stress. In addition, the accompanying thiamine deficiency may lead to Wernicke encephalopathy. Associated changes in serum osmolarity may lead to acute demyelination. CONCLUSION: Alcohol-related encephalopathies can be life-threatening conditions but can be prevented or treated, if recognized.