Advanced MRI imaging of nerve roots in lumbar radiculopathy due to discoradicular conflict: DWI, DTI, and T2 mapping with clinical and neurophysiological correlations.

PURPOSE: To evaluate the lumbar nerve root alterations in patients with lumbar disc herniation sciatica using advanced multimodality MRI sequences and the correlations with clinical and neurophysiological findings. MATERIAL AND METHODS: We prospectively evaluated 45 patients suffering from unilateral lumbar radiculopathy due to disco radicular conflict. All patients underwent MRI examinations using a standard MRI protocol and additional advanced MRI sequences (DWI, DTI, and T2 mapping sequences). Relative metrics of ADC, FA, and T2 relaxation times were recorded by placing ROIs at the pre-, foraminal, and post-foraminal level, either at the affected side or the contralateral side, used as control. All patients were also submitted to electromyography testing, recording the spontaneous activity, voluntary activity, F wave amplitude, latency, and motor evoked potentials (MEP) amplitude and latency, both at the level of the tibialis anterior and the gastrocnemius. Clinical features (diseases duration, pain, sensitivity, strength, osteotendinous reflexes) were also recorded. RESULTS: Among clinical features, we found a positive correlation of pain intensity with ADC values of the lumbar nerve roots. The presence of spontaneous activity was correlated with lower ADC values of the affected lumbar nerve root. F wave and MEP latency were correlated with decreased FA values at the foraminal level and increased values at the post-foraminal level. The same neurophysiological measures correlated positively with pre-foraminal T2 mapping values and negatively with post-foraminal T2 mapping values. Increased T2 mapping values at the foraminal level were correlated with disease duration. CONCLUSIONS: Evaluation of lumbar nerve roots using advanced MRI sequences may provide useful clinical information in patients with lumbar radiculopathy, potentially indicating active inflammation/myelinic damage (DTI, T2 mapping) and axonal damage/chronicity (DWI).

Choroidal Thickness Changes After Intravitreal Aflibercept Injections in Treatment-Naïve Neovascular AMD.

INTRODUCTION: Choroidal thickness (CT) plays an important role in the pathogenesis of various ocular diseases, including neovascular age-related macular degeneration (nAMD). Previous studies evaluated the CT variations after anti-vascular endothelial growth factor (VEGF) injections in patients with nAMD, but the results are still controversial. The present study aimed to evaluate the CT at different times (15, 30, 60, 90, and 365 days) after intravitreal aflibercept injections and its correlation with the baseline CT in treatment-naïve patients with nAMD. Secondly, the study evaluated the correlation between CT variation at 365 days and the number of intravitreal injections received. METHODS: This was a prospective, open-label, single-arm pilot study. Twenty-one treatment-naïve nAMD eyes were enrolled. The study population underwent three monthly aflibercept injections (loading phase) and additional injections as needed (pro re nata regimen). A complete ophthalmological examination, including optical coherence tomography (OCT) was performed at each visit. CT was measured manually by two independent observers. All patients were evaluated at baseline and at 15, 30, 60, 90, and 365 days after the first intravitreal injection. RESULTS: CT showed a statistically significant reduction at days 15, 90, and 365 in comparison to baseline. However, the major reduction of CT was observed at day 15 and in eyes with a thicker choroid at baseline. No significant correlation between CT variation and the number of injections performed was found. CONCLUSION: Our findings contribute to clarifying the role of aflibercept injections in choroidal vasculature, confirming its effect after the first 2 weeks. Moreover, CT can be considered as a potential biomarker, as it reflects the pharmacological effect of anti-VEGF drugs.

Evaluation of Cerebral Volume Changes in Patients with Tremor Treated by MRgFUS Thalamotomy.

The purpose of the study is to quantify volumetric variations of cortical and subcortical brain structures after Vim ablation using MRgFUS, and correlate them with the patients' clinical features and treatment outcomes. For this pilot retrospective study we enrolled 31 patients with a mean age of 70.86 years who were eligible for unilateral Vim thalamotomy. Clinical evaluation included tremor severity assessment using the FTM scale and cognitive assessment using the MoCA score. MRI data were acquired with a 3T scanner, using a dedicated 32-channel coil and acquiring a volumetric sequence of T1 3D IR FSPGR (BRAVO), before treatment and one year after MRgFUS thalamotomy. Image processing and volume data extraction were conducted with dedicated software. A volumetric analysis showed a significant reduction (p < 0.05) of the left thalamus 1 year after the treatment in patients with ET. Other significant results were found on the same side in the other nuclei of the basal ganglia and in the cerebellar cortex. In confronting the two groups (ET, PD), no significant differences were found in terms of age, FTM, MoCA scores, or brain volumes. Similarly, no significant correlations were found between the FTM and MoCA scores and the brain volumes before the treatment.

Comprehensive Evaluation of Factors Affecting Tremor Relapse after MRgFUS Thalamotomy: A Case-Control Study.

OBJECTIVE: To identify possible relevant factors contributing to tremor relapse after MRgFUS thalamotomy in patients with essential tremor (ET) and Parkinson's disease (PD). METHODS: We identified patients with tremor relapse from a series of 79 treatments in a single institution. The demographic and clinical characteristics of the study group patients were compared to those of patients who did not relapse in the same follow-up period. Imaging and procedural factors were compared using a control group matched for clinical and demographic characteristics. RESULTS: Concerning clinical and demographic characteristics, we did not find statistically significant differences in gender and age. Seventy-three percent of patients with tremor relapse were Parkinson's disease patients. Using MRI, we found larger thalamotomy lesions at the 1-year follow-up in the control group with stable outcomes, compared to patients with tremor relapse. In the tractography evaluation, we found a more frequent eccentric position of the DRTt in patients with tremor relapse. CONCLUSIONS: The most relevant determining factors for tremor relapse after MRgFUS thalamotomy appear to be tremor from Parkinson's disease and inaccurate thalamic targeting. Size of the thalamotomy lesion can also influence the outcome of treatment.

When to perform vertebroplasty? A retrospective analysis from a single center and a review of the literature.

BACKGROUND AND AIM: To establish an optimal timing for vertebroplasty in order to obtain a clinically important pain reduction and improving quality of live in patients with osteoporotic or traumatic vertebral fractures. METHODS: This study includes 22 vertebroplasty procedures performed from October 2018 to July 2020 in 21 patients with traumatic or osteoporotic vertebral fractures (19 female, two men; age between 53 and 89 years). All treatments were executed under fluoroscopic guidance using 11 or 13 G needle through transpedicular or costovertebral unilateral approach. Each patient underwent conscious sedation, continuously monitored by an anesthesiologist. Preoperative MRI images, obtained by 3T or 1.5T MRI scanner, always showed bone marrow edema. The VAS scale and Roland Morris disability questionnaire (RMdq) were administered to patients before and after the treatment to evaluate pain and life quality. RESULTS: 7 patients were treated in the first month after the injury, one was treated twice; 8 patients in the second month, 6 in the third. We observed a reduction of: 5.5 points in the vas scale, 10.3 in the RMdq in the first month; 5.6 points vas, 11.6 points RMdq in the second month; 4 points vas and 9.75 points RMdq in the third month. CONCLUSIONS: This study demostrated that, in our preliminary experience, vertebroplasty has the best outcome if performed at 2 months from injury.

Cervical spine trauma: impact of different imaging classification systems in the clinical decision-making.

BACKGROUND AND AIM: Considering the high rate of mortality and permanent disability related to vertebral traumas, an early and detailed diagnosis of the trauma and subsequently an immediate and effective intervention are crucial. Cervical vertebral injury classifications guide treatment choice through a severity grade based on radiological information. The purpose of the present study was to define which imaging classification system could provide the best morphological and clinical-surgical correlations for cervical spine traumas. METHODS: We retrospectively analyzed patients evaluated for cervical spine trauma at our Institution in the period 2015-2020. Information regarding the morphological examination (using CT and MRI), the neurological evaluation, and the therapeutic management were collected. C3-C7 fractures were classified according to the SLIC and AOSpine criteria; axial lesions were classified according to the modified AOSpine for the C1-C2 compartment and through the Roy-Camille and the Anderson D'Alonzo system for the odontoid process of the axis. RESULTS: 29 patients were included in the final study population. Nine patients with axial spine trauma and 21 with subaxial cervical spine trauma. A conservative approach was applied in 16 patients while nine patients underwent neurosurgery. Considering the therapeutical indications provided by the SLIC system, a 76.9% accordance was found for patients with a <4 score, while a 100% concordance was calculated for patients with a >4 score undergoing neurosurgery. Regarding the AOSspine classification, a 28.6% concordance was observed for patients classified group B being treated with a posterior neurosurgical approach, while for patients belonging to subgroup C, considered for anterior neurosurgical approach, a 66.7% accordance was calculated. CONCLUSIONS: The study demonstrated a better morphological correlation for the AOSpine classification in subaxial trauma and the AOSpine and Anderson D'Alonzo in axial trauma. The therapeutic indication found a better correlation in the SLIC classification for subaxial trauma and the Anderson D'Alonzo for axial ones.

A time-dependent study of nano-mechanical and ultrastructural properties of internal limiting membrane under ocriplasmin treatment.

Vitreomacular traction (VMT) syndrome has only been surgically treated for a long time. Recently, enzymatic vitreolysis with ocriplasmin has emerged as a possible option to release VMT and, in some cases, close full thickness macular holes (FTMHs). Despite its clinical relevance, gathering information about the ocriplasmin-induced alterations of the Inner Limiting Membrane (ILM) of the retina in a clinical study is a complex task, mainly because of the inter-individual variability among patients. To obtain more insights into the mechanism underlying the drug action, we studied in-vitro the mechanical and morphological changes of the ILM using Atomic Force Microscopy (AFM). To this aim, we measured the ILM average Young's modulus (YM), hysteresis (H) and adhesion work (A) over time under ocriplasmin treatment. Our data unveil a time-dependent increase in the membrane YM of 19% of its initial value, along with changes in its adhesive and dissipative behavior. Such modifications well correlate with the morphological alterations detected in the AFM imaging mode. Taken all together, the results here presented provide more insights into the mechanism underlying the ocriplasmin action in-vivo, suggesting that it is only able to alter the top-most layer of the vitreal side of the membrane, not compromising the inner ILM structure.

Nanomechanical mapping helps explain differences in outcomes of eye microsurgery: A comparative study of macular pathologies.

Many ocular diseases are associated with an alteration of the mechanical and the material properties of the eye. These mechanically-related diseases include macular hole and pucker, two ocular conditions due to the presence of abnormal physical tractions acting on the retina. A complete relief of these tractions can be obtained through a challenging microsurgical procedure, which requires the mechanical peeling of the internal limiting membrane of the retina (ILM). In this paper, we provide the first comparative study of the nanoscale morphological and mechanical properties of the ILM in macular hole and macular pucker. Our nanoscale elastic measurements unveil a different bio-mechanical response of the ILM in the two pathologies, which correlates well to significant differences occurring during microsurgery. The results here presented pave the way to the development of novel dedicated microsurgical protocols based on the material ILM properties in macular hole or pucker. Moreover, they contribute to clarify why, despite a common aetiology, a patient might develop one disease or the other, an issue which is still debated in literature.

Macular Impairment in Fabry Disease: A Morpho-functional Assessment by Swept-Source OCT Angiography and Focal Electroretinography.

Purpose: Fabry disease (FD) is a multiorgan X-linked condition characterized by a deficiency of the lysosomal enzyme alpha-galactosidase A, resulting in a progressive intralysosomal deposit of globotriaosylceramide. The aim of this study was to evaluate the macular ultrastructure of the vascular network using optical coherence tomography angiography (OCTA) and to evaluate macular function using focal electroretinography (fERG) in Fabry patients (FPs). Methods: A total of 20 FPs (38 eyes, mean age 57 ± 2.12 SD, range of 27-80 years) and 17 healthy controls (27 eyes, mean age 45 years ± 20.50 SD, range of 24-65 years) were enrolled in the study. Color fundus photography, swept-source optical coherence tomography (SS-OCT), OCTA and fERG were performed in all subjects. The OCTA foveal avascular zone (FAZ), vasculature structure, superficial and deep retinal plexus densities (images of 4.5 × 4.5 mm) and fERG amplitudes were measured. Group differences were statistically assessed by Student's t-test and ANOVA. Results: In the FP group, the FAZ areas of the superficial and deep plexuses were enlarged (P = 0.036, t = 2.138; P < 0.001, t = -3.889, respectively), the vessel density was increased in the superficial plexus, and the fERG amplitude was reduced (P < 0.001, t = -10.647) compared with those in healthy controls. No significant correlations were found between the structural and functional data. Conclusions: OCTA vascular abnormalities and reduced fERG amplitudes indicate subclinical signs of microangiopathy with early retinal dysfunction in FPs. This study highlights the relevance of OCTA imaging analysis in the identification of abnormal macular vasculature as an ocular hallmark of FD.

Short-Term Assessment of Intravitreal Dexamethasone Implant Using Enhanced-Depth Image Optical Coherence Tomography and Optical Coherence Tomography Angiography in Patients with Retinal Vascular Diseases.

INTRODUCTION: To evaluate the short-term efficacy and safety of intravitreal dexamethasone implant (IDI) in patients with macular oedema associated with diabetic retinopathy (DR) and retinal vein occlusion (RVO) using enhanced-depth image optical coherence tomography (EDI-OCT) and to estimate the effect of dexamethasone on the choroid and the retinal vascular network using OCT angiography (OCTA). METHODS: Fifteen eyes in 15 patients with macular oedema secondary to diabetes (DR, n = 8) or retinal vein occlusion (RVO, n = 7) were treated with intravitreal injection of sustained-release IDI. Primary efficacy end points were changes in best corrected visual acuity and central macular thickness (CMT). Secondary end points were changes in choroidal thickness and choroidal and retinal vascular networks as determined by OCTA. RESULTS: CMT was significantly reduced from baseline by 3 h after injection (p < 0.01) and improved further during the 3-month follow-up. Visual acuity improvement was consistent with CMT reduction. No alterations in IOP or systemic side effects were observed. OCTA showed improvement from baseline in terms of decreased number and size of cysts and restoration of the retinal vascular network; flow choroidal thickness did not change significantly. CMT and visual acuity variations were similar in the two groups. CONCLUSIONS: CMT reduced as early as 3 h after the injection of IDI, with further reduction during follow-up. Choroidal thickness was unchanged, whereas the vascular retinal network improved from baseline to the end of study. Both EDI-OCT and OCTA were useful in demonstrating the early beneficial effects of IDI on the macula and the perifoveal vascular network. FUNDING: The article processing charges, the open access fee and the medical writing and editorial assistance was funded by Allergan.

Swept source optical coherence tomography and optical coherence tomography angiography in pediatric enhanced S-cone syndrome: a case report.

BACKGROUND: Enhanced S-cone syndrome is an autosomal recessive retinal dystrophy related to a defect in a nuclear receptor gene (NR2E3) that leads to alteration in cells development from rod to S-cone. This retinal dystrophy may be associated with retinal schisis. The aim of this report is to describe structural optical coherence tomography and optical coherence tomography angiography features in a case of enhanced S-cone syndrome associated with macular schisis. CASE PRESENTATION: A Caucasian 13-year-old girl underwent measurement of best corrected visual acuity, ophthalmoscopic evaluation, and fundus autofluorescence examination. Photopic and scotopic electroretinography were carried out as well. Enhanced S-cone syndrome was suspected on the basis of clinical and electrophysiological findings. Structural optical coherence tomography and optical coherence tomography angiography allowed the further characterization of the associated macular schisis. Genetic analysis not only confirmed the diagnosis but increased the clinical novelty of this case report by showing two variations in the NR2E3 gene probably related to the phenotype: a missense variation c.1118T>C which leads to the substitution of leucine with proline in amino acid position 373, and c.349+5G>C, which involves a gene sequence near a splicing site. CONCLUSIONS: Swept source structural optical coherence tomography (B scans and "en face" images) and optical coherence tomography angiography allowed the observation of retinal structural details and the involvement of each retinal layer and capillary plexus in enhanced S-cone syndrome. Of interest, neither of the two NR2E3 gene variants found in this case report have been linked to any form of retinopathy.

Effect of intravitreal dexamethasone on macular edema in von Hippel-Lindau disease assessed using swept-source optical coherence tomography: a case report.

BACKGROUND: Von Hippel-Lindau disease is a rare hereditary syndrome caused by germinal mutations in a von Hippel-Lindau tumor-suppressing gene. Retinal hemangioblastoma is the ocular hallmark lesion of von Hippel-Lindau disease. CASE PRESENTATION: A 20-year-old Caucasian woman presented to our institution with painless visual impairment in the right eye. A fundus ophthalmoscopic evaluation and swept-source optical coherence tomographic examination revealed a retinal hemangioblastoma associated with cystoid macular edema. On the basis of the clinical ocular findings and genetic analysis, von Hippel-Lindau disease was diagnosed. Following an intravitreal injection of ranibizumab, off-label administration of intravitreal dexamethasone was considered to reduce the edema. An almost complete resolution of the edema in the macular area was observed 1 week after the injection. Finally, laser photocoagulation and transconjunctival cryotherapy were performed; the patient developed "ablatio fugax" after cryotherapy. CONCLUSIONS: In our experience, intravitreal dexamethasone administration has proven to be a useful tool for reducing retinal hemangioblastoma-related macular edema in von Hippel-Lindau disease and may be considered a potentially valuable treatment that can be used in combination with other therapies.