Utilidad de la resonancia magnética cerebral con secuencia de difusión y valor b alto en el diagnóstico de la enfermedad de Creutzfeldt-Jakob / Usefulness of high b-value diffusion-weighted MRI in the diagnosis of Creutzfeldt-Jakob disease

Introducción: los criterios diagnósticos actuales de la enfermedad de Creutzfeldt-Jakob (ECJ) probable incluyen la combinación de datos clínicos, electroencefalográficos y analíticos. En los últimos años se ha demostrado que la RM craneal con el uso de secuencias FLAIR y difusión (DWI) puede ser una herramienta útil en el diagnóstico de esta enfermedad. Describimos nuestra experiencia en la utilización de la DWI convencional (b: 1000s/mm2) y DWI con valor b alto (3000s/mm2) en el diagnóstico de la ECJ probable o definitiva. Pacientes y métodos: realizamos un análisis retrospectivo de los pacientes atendidos en nuestro hospital diagnosticados de ECJ probable o definitiva, desde el año 2002 al 2008. A todos ellos se les realizó una RM craneal con un protocolo que incluyó secuencias potenciadas en T1, T2, FLAIR y dos secuencias DWI, una con valor b convencional (1000s/mm2) y otra con valor b alto (3000s/mm2). Resultados: se atendieron a 7 pacientes con diagnóstico de ECJ probable o definitiva. En tres de ellos (43%) la secuencia FLAIR mostró cambios de señal compatibles con ECJ. En todos los pacientes en la secuencia DWI con valor b alto se observaron alteraciones características de la enfermedad, incluyendo dos casos (28%) en los que todas las secuencias realizadas, incluida la DWI convencional, fueron normales. Adicionalmente en los 7 casos (100%) las alteraciones radiológicas fueron más fáciles de identificar y más extensas con valores altos b de DWI (AU). Conclusión: la utilización de un valor b alto (3000s/mm2) en la secuencia DWI puede aumentar la sensibilidad de la RM craneal en el diagnóstico de la ECJ, permitiendo la detección de casos en los que la DWI convencional es normal

Background: current diagnostic criteria of probable Creutzfeldt-Jakob disease (CJD) include a combination of clinical, EEG and analytic data. Recent data indicate that brain MRI including fluid-attenuated inversion recovery (FLAIR) and diffusion-weighted imaging (DWI) sequences can be a valid and reliable tool for the diagnosis of CJD. We describe our experience with high b-value (3000s/mm2) diffusion-weighted imaging (DWI) in patients with probable or definite CJD and compare it with standard b-value (1000s/mm2) DWI. Methods: we performed a retrospective analysis of patients admitted to our Hospital Service between 2002 and 2008 with a final diagnosis of probable or definite CJD. Patients were examined using either a 1.5 Tesla or a 3 Tesla MRI. The MRI protocol included T1-weigthed spin-echo sequences, T2-weighted fast spin-echo, FLAIR and DWI sequences with high b-value and standard b-value. Results: during the study period there were 7 patients with probable or definite CJD. Only 3 patients (43%) showed changes on FLAIR sequence consistent with CJD. All the cases were detected with high b-value DWI, including 2 cases (28%) that would have been missed using standard b-value (1000s/mm2) DWI. In all the patients the changes were more conspicuous and extensive at high b-value DWI (b=3000s/mm2). Conclusion;: our data indicate that high b-value DWI may improve the sensitivity of brain MRI for the diagnosis of CJD, allowing the detection of some cases that would have been overlooked by conventional sequences (AU)

Usefulness of high b-value diffusion-weighted MRI in the diagnosis of Creutzfeldt-Jakob disease.

BACKGROUND: current diagnostic criteria of probable Creutzfeldt-Jakob disease (CJD) include a combination of clinical, EEG and analytic data. Recent data indicate that brain MRI including fluid-attenuated inversion recovery (FLAIR) and diffusion-weighted imaging (DWI) sequences can be a valid and reliable tool for the diagnosis of CJD. We describe our experience with high b-value (3000s/mm(2)) diffusion-weighted imaging (DWI) in patients with probable or definite CJD and compare it with standard b-value (1000s/mm(2)) DWI. METHODS: we performed a retrospective analysis of patients admitted to our Hospital Service between 2002 and 2008 with a final diagnosis of probable or definite CJD. Patients were examined using either a 1.5 Tesla or a 3 Tesla MRI. The MRI protocol included T1-weigthed spin-echo sequences, T2-weighted fast spin-echo, FLAIR and DWI sequences with high b-value and standard b-value. RESULTS: during the study period there were 7 patients with probable or definite CJD. Only 3 patients (43%) showed changes on FLAIR sequence consistent with CJD. All the cases were detected with high b-value DWI, including 2 cases (28%) that would have been missed using standard b-value (1000s/mm(2)) DWI. In all the patients the changes were more conspicuous and extensive at high b-value DWI (b=3000s/mm(2)). CONCLUSION: our data indicate that high b-value DWI may improve the sensitivity of brain MRI for the diagnosis of CJD, allowing the detection of some cases that would have been overlooked by conventional sequences.

[Spinal leptomeningeal metastasis from cerebral glioblastoma: case report]. / Metástasis leptomeníngeas espinales y glioblastoma multiforme: caso clínico.

INTRODUCTION: Glioblastoma multiforme (GBM) is the most common primary malignant tumor of the central nervous system. Its tendency to infiltrate and recur locally is well known. Spinal leptomeningeal metastasis (SLM) due to a GBM are well documented at autopsy in patients previously diagnosed of GBM, however, systemic dissemination with symptomatic leptomeningeal metastasis is quite rare. Most of the time it is diagnosed late and misdiagnosis is a common problem. CASE REPORT: We present a case of a 65-year-old man with a right temporal GBM treated by surgical resection, radiotherapy and chemotherapy, who is readmitted 10 months later as he developed an ataxic gait. A new cerebral magnetic resonance imaging (MRI) showed multiple cerebellar metastasis. He also reported intense lumbar pain on the new admission, increasing in intensity and that was followed by flaccid paraparesis two weeks later. Multiple spinal metastasis deposits were documented by a contrast enhanced spinal MRI. CONCLUSIONS: SLM need to be suspected in patients with a past history of intracranial GBM, who present with clinical features that can not been explained by the primary lesion. Awareness of this complication might facilitate more rapid diagnosis and treatment. A discussion is made regarding SLM in patients with GBM with reference to the medical literature.

Metástasis leptomeníngeas espinales y glioblastoma multiforme: caso clínico / Spinal leptomeningeal metástasis fromcerebral glioblastoma: case report

Introducción. El glioblastoma multiforme (GBM) es el tumor cerebral primario más frecuente en adultos. Presenta una gran capacidad de invasión y recidiva local. Se han documentado metástasis leptomeníngeas espinales (MLE) en las autopsias de pacientes con GBM; no obstante, la diseminación sistémica con afectación leptomeníngea espinal sintomática es rara, diagnosticándose en muchas ocasiones de forma errónea o tardíamente. Caso clínico. Presentamos el caso de un paciente de 65 años diagnosticado de un GBM temporal derecho, que es tratado quirúrgicamente con radioterapia y quimioterapia adyuvante y que 10 meses después vuelve a ingresar tras desarrollar una alteración de la marcha. Se realizó una nueva resonancia magnética cerebral, objetivándose múltiples metástasis en el cerebelo. Posteriormente el paciente presentó dolor lumbar intenso y 2 semanas después una paraparesia flácida. Se realizó una resonancia magnética espinal en la que aparecieron múltiples depósitos metastásicos. Conclusiones. Las MLE se deben sospechar en todos los pacientes con antecedentes de GBM cerebral que presentan clínica no justificable por la lesión primaria. El conocimiento de esta complicación puede facilitar un diagnóstico y tratamiento más precoz. Realizamos una revisión bibliográfica en relación con las MLE en los pacientes con GBM (AU)

Introduction: Glioblastoma multiforme (GBM) is the most common primary malignant tumor of the central nervous system. Its tendency to infiltrate and recur locally is well known. Spinal leptomeningeal metastasis (SLM) due to a GBM are well documented at autopsy in patients previously diagnosed of GBM, however, systemic dissemination with symptomatic leptomeningeal metastasis is quite rare. Most of the time it is diagnosed late and misdiagnosis is a common problem. Case report: We present a case of a 65-year-old man with a right temporal GBM treated by surgical resection, radiotherapy and chemotherapy, who is readmitted 10 months later as he developed an ataxic gait. A new cerebral magnetic resonance imaging (MRI) showed multiple cerebellar metastasis. He also reported intense lumbar pain on the new admission, increasing in intensity and that was followed by flaccid paraparesis two weeks later. Multiple spinal metastasis deposits were documented by a contrast enhanced spinal MRI. Conclusions: SLM need to be suspected in patients with a past history of intracranial GBM, who present with clinical features that can not been explained by the primary lesion. Awareness of this complication might facilitate more rapid diagnosis and treatment. A discussion is made regarding SLM in patients with GBM with reference to the medical literatura (AU)

[Spontaneous intracranial hypotension due to a broken dorsal perineural cyst]. / Rotura de un quiste perirradicular dorsal como causa de síndrome de hipotensión intracraneal espontánea.

INTRODUCTION: It is now recognized that most, if not all, cases of spontaneous intracraneal hypotension result from spontaneous cerebrospinal fluid (CSF) leaks. The exact cause of spontaneous leak often remains unclear. However, two factors are typically considered: trivial trauma and weakness of the dural sac. CLINICAL CASE: A 61-year-old woman came with a one week history of orthostatic headache. The neurologic examination and funduscopy were normal. Brain contrast- enhanced magnetic resonance imaging (MRI) showed subdural fluid collections and diffuse pachymeningeal enhancement. Cervical-dorsal-lumbar MRI showed a dilated spinal venous plexus throughout the canal. Computed tomography (CT) myelography demonstrated perineural cysts at the level of D7, D8, D9 and D10. The right D10 cysts was broken with extravasation of contrast medium into the extradural space. Three months later, after rest and hydration, the patient was asymptomatic. The brain and dorsal MRI, four months later were normal. CONCLUSIONS: Spontaneous CSF leaks from broken perineural cysts has been exceptionally demonstrated. CT myelography should be employed to detect the involved site.

Rotura de un quiste perirradicular dorsal como causa de síndrome de hipotensión intracraneal espontánea / Spontaneous intracranial hypotension due to a broken dorsal perineural cyst

Introducción. El síndrome de hipotensión intracraneal espontánea (SHIE) está producido en la mayoría de los casos por fugas de liquido cefalorraquídeo (LCR). Sin embargo, la causa exacta de éstas no suele objetivarse, considerándose fundamentalmente dos factores: traumatismos craneoencefálicos banales y adelgazamiento del saco dural. Caso clínico. Mujer de 61 años que acude por cefalea ortostática de 1 semana de evolución. El fondo de ojo y la exploración neurológica fueron normales. La resonancia magnética (RM) craneal mostró colecciones subdurales bilaterales en la convexidad y realce paquimeningeo difuso tras la inyección de gadolinio. La RM de columna cervical-dorsallumbar mostró un engrosamiento de los plexos venosos epidurales a lo largo de todo el canal. En la mielo- TC (presión de apertura: 7 cm H2O) se observaron quistes durales derechos perirradiculares a nivel D7, D8, D9 Y DIO, con rotura de este último y fuga de LCR a nivel del espacio epidural. La paciente quedó asintomática tras permanecer 3 meses en reposo relativo y con hidratación abundante. La RM craneal y de la columna dorsal realizadas a los 4 meses fueron normales. Conclusiones. La rotura de un quiste dural perirradicular espinal es una causa de fuga de LCR en el SHIE que raramente ha sido demostrada, siendo la mielo-TC la técnica de elección para su diagnóstico

Introduction: It is now recognized that most, if not all, cases of spontaneous intracraneal hypotension result from spontaneous cerebrospinal fluid (CSF) leaks. The exact cause of spontaneous leak often remains unclear. However, two factors are typically considered: trivial trauma and weakness of the dural sac. Clinical case: A 61-year-old woman came with a one week history of orthostatic headache. The neurologic examination and funduscopy were normal. Brain contrast- enhanced magnetic resonance imaging (MRI) showed subdural fluid collections and diffuse pachymeningeal enhancement. Cervical-dorsal-lumbar MRI showed a dilated spinal venous plexus throughout the canal. Computed tomography (CT) myelography demonstrated perineural cysts at the level of D7, D8, D9 and D10. The right D10 cysts was broken with extravasation of contrast medium into the extradural space. Three months later, after rest and hydration, the patient was asymptomatic. The brain and dorsal MRI, four months later were normal. Conclusions: Spontaneous CSF leaks from broken perineural cysts has been exceptionally demonstrated. CT myelography should be employed to detect the involved site

Dolor abdominal, disfagia y oftalmoparesia / Abdominal pain, dysphagia, and ophthalmoparesis

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