MR imaging of human herpesvirus-6-associated encephalitis in 4 patients with anterograde amnesia after allogeneic hematopoietic stem-cell transplantation.

MR imaging is typically obtained during the work-up of patients who have undergone allogeneic hematopoietic stem-cell transplant who present with unexplained change in mental status, amnesia, or seizures. Although the differential diagnosis is broad in this setting, the presence of T2 prolongation limited to the medial aspect of one or both temporal lobes with or without associated reduced water diffusion may help limit the possible diagnoses. A frequent etiology seen in this context is human herpesvirus-6 (HHV6) infection. We report the evolution of MR imaging findings and clinical course in 4 patients with limbic encephalitis probably related to HHV6.

On the interpretation and use of neutron calibration coefficients.

Calibration laboratories provide measurement services that include determining the calibration coefficients for neutron survey meters and personal dosemeters. While there are numerous documents dealing with the procedures for calibration of neutron measuring devices, the purpose of this paper is to clarify the use of the particular dose equivalent conversion coefficients used at the National Institute of Standards and Technology and the Pacific Northwest National Laboratory for these calibrations.

Calibration of neutron albedo dosemeters.

It is shown that by calibrating neutron albedo dosemeters under the proper conditions, two complicating effects will essentially cancel out, allowing accurate calibrations with no need for explicit corrections. The 'proper conditions' are: a large room (> or = 8 m on a side). use of a D2O moderated 252Cf source, and a source-to-phantom calibration distance of approximately 70 cm.

Use of night vision goggles and low-level light source in obtaining intravenous access in tactical conditions of darkness.

OBJECTIVE: The tactical environment of the nighttime battlefield precludes the use of white light to perform medical procedures. This study sought differences between two alternatives to white light used to facilitate intravenous access. A comparison was made between night vision goggles (NVG) and a low level light source (Fingerlite). METHODS: Fifty-eight volunteers were paired. Each member of the pair attempted intravenous access on his or her partner in darkness using both techniques. One attempt per method was allowed. Success was confirmed by the free flow of blood from the catheter. RESULTS: Of the 58 attempts using NVG, 32 were successful and 26 failed. In the Fingerlite group, there were 46 successful attempts and 12 failures. These differences reached statistical significance (p < 0.02). CONCLUSION: This study suggests that in conditions requiring darkness, a Fingerlite offers a clinical advantage over NVG in obtaining intravenous access.

Orotrachial intubation in darkness using night vision goggles.

OBJECTIVE: Securing the airway of a wounded soldier while operating in a light-restricted combat environment may be required of forward-deployed military medical personnel. The best method of obtaining such an airway has not been addressed. In this pilot study, the objective was to examine the use of endotracheal intubation using an infrared filtered laryngoscope and night vision goggles. METHODS: The investigators performed endotracheal intubation, using an infrared filter light source laryngoscope, on patients undergoing elective surgical procedures. All intubations took place in a completely darkened operating room. RESULTS: Twenty-one patients (91.3%) were intubated successfully as defined in the study. No adverse outcomes or complications occurred. CONCLUSIONS: This study demonstrates that endotracheal intubation can be performed using a laryngoscope with an infrared filter and night vision goggles with a high success rate in a select population in a darkened environment.

Serial intraoperative magnetic resonance imaging of brain shift.

OBJECTIVE: A major shortcoming of image-guided navigational systems is the use of preoperatively acquired image data, which does not account for intraoperative changes in brain morphology. The occurrence of these surgically induced volumetric deformations ("brain shift") has been well established. Maximal measurements for surface and midline shifts have been reported. There has been no detailed analysis, however, of the changes that occur during surgery. The use of intraoperative magnetic resonance imaging provides a unique opportunity to obtain serial image data and characterize the time course of brain deformations during surgery. METHODS: The vertically open intraoperative magnetic resonance imaging system (SignaSP, 0.5 T; GE Medical Systems, Milwaukee, WI) permits access to the surgical field and allows multiple intraoperative image updates without the need to move the patient. We developed volumetric display software (the 3D Slicer) that allows quantitative analysis of the degree and direction of brain shift. For 25 patients, four or more intraoperative volumetric image acquisitions were extensively evaluated. RESULTS: Serial acquisitions allow comprehensive sequential descriptions of the direction and magnitude of intraoperative deformations. Brain shift occurs at various surgical stages and in different regions. Surface shift occurs throughout surgery and is mainly attributable to gravity. Subsurface shift occurs during resection and involves collapse of the resection cavity and intraparenchymal changes that are difficult to model. CONCLUSION: Brain shift is a continuous dynamic process that evolves differently in distinct brain regions. Therefore, only serial imaging or continuous data acquisition can provide consistently accurate image guidance. Furthermore, only serial intraoperative magnetic resonance imaging provides an accurate basis for the computational analysis of brain deformations, which might lead to an understanding and eventual simulation of brain shift for intraoperative guidance.

Intraoperative diffusion imaging on a 0.5 Tesla interventional scanner.

Intraoperative line scan diffusion imaging (LSDI) on a 0.5 Tesla interventional MRI was performed during neurosurgery in three patients. Diffusion trace images were obtained in acute ischemic cases. Scan time per slice was 46 seconds and 94 seconds, respectively, for diffusion tensor images. Diagnosis of acutely developed vascular occlusion was confirmed with follow-up scans. White matter tracts were displayed with the principal eigenvectors and provided guidance for the tumor surgery. In all cases, the diagnostic utility of LSDI was established. J. Magn. Reson. Imaging 2001;13:115-119.

Intra-operative MR guidance during trans-sphenoidal pituitary resection: preliminary results.

The use of intra-operative MR image guidance has the potential to improve the precision, extent, and safety of trans-sphenoidal pituitary resections. The trans-sphenoidal approach to pituitary surgery has been performed for some time (1--3). Until now these surgeries have relied on direct visualization without the aid of image guidance. An open-bore configuration 0.5T SIGNA SP MR system (GE Medical Systems, Milwaukee, Wisconsin) has been used to provide image guidance for seventeen trans-sphenoidal pituitary adenoma resections (4). The intra-operative MRI system allowed the radiologist to successfully direct the surgeon toward the sella turcica while avoiding the cavernous sinus, optic chiasm and other critical structures. Imaging performed during the surgery monitored the extent of resection and allowed for removal of tumor beyond the surgeon's view in seven cases. Dynamic MR imaging was used to distinguish residual tumor from normal gland and postoperative changes, permitting more precise tumor localization. A heme-sensitive long TE gradient echo sequence was used to find the presence of hemorrhagic debris. All patients tolerated the procedure well without significant complications. J. Magn. Reson. Imaging 2001;13:136-141.

Intraoperative MR systems. Midfield approaches.

Intraoperative MR imaging provides an unrestricted view of intracranial structures and lesions that has revolutionized the way that neurosurgery is performed in the authors' institution. Intraoperative imaging allows the practitioner to update and adjust the approach to intracranial lesions continuously. With this system, important anatomic and vascular structures can be successfully avoided; boundaries of low-grade tumors can be accurately defined, and foci of possible higher grade within these lesions can be identified; foci of high-grade astrocytomas can be differentiated from radiated brain; hyperacute hemorrhage or infarction during and after procedures can be determined; and the possible communication of cystic collections with CSF can be ascertained. These advantages provide a level of comfort to the surgeon and a presumptive margin of safety to the patient that is unattainable during conventional surgical approaches, and given the choice, the authors' neurosurgeons would prefer to operate in the interventional magnet. Preliminary reports concerning the efficacy and usefulness of MR-guided navigational tools for the performance of neurosurgery are encouraging, as noted earlier, Wirtz et al have shown that the more extensive removal of glioblastomas afforded by intraoperative MR leads to significantly prolonged patient survival compared with conventional surgery. Further outcomes analysis must be performed, however, to determine whether these new techniques significantly decrease overall long-term morbidity or increase survival in those patients who have low-grade astrocytomas.

A comparison of carbon monoxide levels during the use of a multi-fuel camp stove.

OBJECTIVE: The use of camp stoves in an enclosed or poorly ventilated space is clearly not recommended due to the risk of carbon monoxide (CO) poisoning. Instances may arise, however, when use for a limited time is necessary. We sought to find differences in CO levels between various fuels used to power a commercially available camp stove. METHODS: A comparison was made between unleaded gasoline, kerosene, and white gas (Coleman fuel). The stove, fuels, and CO detector were all purchased from local retailers. A 0.4-m3 space was constructed with a cardboard box. Three trials were performed using each fuel in which water was heated over the stove for 5 minutes. Measurement of the CO level within the box was taken every 30 seconds. RESULTS: Kerosene created CO levels of 714 (SD = 113.5) parts per million (ppm) at 2 1/2 minutes but was out of the measurable range of >999 ppm within 4 minutes on each of its trials. White gas burned the cleanest, with an average of 212 ppm (SD = 27.8) at 2 1/2 minutes and 348 ppm (SD = 76.0) at 5 minutes. Unleaded gasoline created 305 ppm (SD = 27.1) at 2 1/2 minutes and 464 ppm (SD = 31.6) at 5 minutes. CONCLUSION: All of the fuels created a high level of CO in a short period of time. White gas burned the cleanest and would be preferred to unleaded gasoline or kerosene in the event that the unvented use of a camp stove was necessary.

Preeclampsia-eclampsia: clinical and neuroradiographic correlates and insights into the pathogenesis of hypertensive encephalopathy.

PURPOSE: To investigate the clinical parameters that are associated with the development of brain edema of hypertensive encephalopathy in patients with preeclampsia-eclampsia. MATERIALS AND METHODS: Twenty-eight patients with preeclampsia-eclampsia and neurologic symptoms underwent magnetic resonance (MR) imaging. Clinical parameters recorded at the time of MR imaging included serum electrolytes and various indices of hematologic, renal, and hepatic function. Several data were available 1 week prior to the development of neurologic symptoms in 11 patients. Univariate analysis and multivariate logistic regression analyses were performed to study possible associations between these parameters and brain edema at MR imaging. RESULTS: The 20 patients with brain edema at MR imaging had a significantly greater incidence of abnormal red blood cell morphology (14 [82%] of 17 patients vs two [25%] of eight, P: <.005) and higher levels of lactic dehydrogenase (LDH) (339 U/L +/- 65 [SD] vs 258 U/L +/- 65, P: =.007) than the eight with normal MR imaging findings; multivariate logistic regression analysis showed a strong association with red blood cell morphology only. Moreover, LDH levels were elevated before the development of neurologic abnormalities (P: <.05). Blood pressures were not significantly different between groups at any time. CONCLUSION: Brain edema at MR imaging in patients with preeclampsia-eclampsia was associated with abnormalities in endothelial damage markers and not with hypertension level.

Frameless stereotactic neurosurgery using intraoperative magnetic resonance imaging: stereotactic brain biopsy.

OBJECTIVE: To assess the application accuracy of intraoperative magnetic resonance imaging for frameless stereotactic surgery, and to evaluate the performance of intraoperative magnetic resonance imaging for the brain biopsy, a standard stereotactic procedure. METHODS: A series of spatial coordinate and phantom experiments were performed to analyze the application accuracy of the system. A prospective analysis of 68 consecutive patients undergoing stereotactic brain biopsy was then performed. RESULTS: The spatial coordinate experiments revealed a mean overall error in acquisition of 0.2 mm. The phantom experiments demonstrated a 1:1 correlation between the magnetic resonance image of a stereotactically guided probe and its relationship to a target and the actual relationship of the probe and target. Sixty-eight brain biopsies were successfully performed in all intracranial compartments except the sella. The radiographic abnormality was localized successfully in all patients (100%). Sixty-six (97.1%) of the biopsies yielded diagnostic tissue. Two biopsies (2.9%) were complicated by intraparenchymal hemorrhage. One expanding temporal lobe hemorrhage was evacuated by immediate craniotomy in the magnet with no postoperative sequelae. A deep hemorrhage from a lymphoma was managed conservatively with interval resolution of symptoms. There were no infections. There was no perioperative mortality. CONCLUSION: Intraoperative magnetic resonance imaging allows excellent target localization, provides true real-time imaging to account for anatomic changes during surgery, and permits intraoperative confirmation that the biopsy needle has reached the targeted lesion. Immediate postoperative imaging in the operating room allows assessment of adverse events and the potential for immediate management of hemorrhagic complications.

Cortical blindness in severe preeclampsia: computed tomography, magnetic resonance imaging, and single-photon-emission computed tomography findings.

BACKGROUND: Cortical blindness is a complication of severe preeclampsia, but it is unclear whether it results from cerebral vasospasm and ischemic injury or vasogenic (hydrostatic) edema due to increased capillary permeability. CASE: Reversible cortical blindness in a 33-year-old gravida 2, para 1, with severe postpartum preeclampsia after evacuation of a partial molar pregnancy at 19 weeks' gestation is presented. Initial neuroimaging studies showed hyperperfusion on head single-photon-emission computed tomography scan, which corresponded with lesions found on head computed tomography and magnetic resonance imaging scans. Follow-up neuroimaging studies 2 weeks later, by which time the patient's visual acuity had returned to normal, showed complete resolution of radiologic abnormalities. CONCLUSION: Neuroimaging studies in a woman with severe postpartum preeclampsia complicated by reversible cortical blindness showed that blindness resulted from vasogenic (hydrostatic) cerebral edema and not cerebral vasospasm.

Interventional and intraoperative magnetic resonance imaging.

The goal of the Image Guided Therapy Program, as the name implies, is to develop the use of imaging to guide minimally invasive therapy. The program combines interventional and intraoperative magnetic resonance imaging (MRI) with high-performance computing and novel therapeutic devices. In clinical practice the multidisciplinary program provides for the investigation of a wide range of interventional and surgical procedures. The Signa SP 0.5 T superconducting MRI system (GE Medical Systems, Milwaukee, WI) has a 56-cm-wide vertical gap, allowing access to the patient and permitting the execution of interactive MRI-guided procedures. This system is integrated with an optical tracking system and utilizes flexible surface coils and MRI-compatible displays to facilitate procedures. Images are obtained with routine pulse sequences. Nearly real-time imaging, with fast gradient-recalled echo sequences, may be acquired at a rate of one image every 1.5 s with interactive image plane selection. Since 1994, more than 800 of these procedures, including various percutaneous procedures and open surgeries, have been successfully performed at Brigham and Women's Hospital (Boston, MA).

Craniotomy for tumor treatment in an intraoperative magnetic resonance imaging unit.

OBJECTIVE: The complex three-dimensional anatomic features of the brain and its vulnerability to surgical intervention make the surgical treatment of intracranial tumors challenging. We evaluated the surgical treatment of supratentorial tumors using intraoperative magnetic resonance imaging (MRI), which provides real-time guidance, allows localization of intracranial tumors and their margins, and facilitates continuous assessment of surgical progress. METHODS: Sixty patients underwent craniotomies for tumor treatment in the General Electric intraoperative MRI unit at the Brigham and Women's Hospital (Boston, MA) during a 1-year period. The patients selected were those with intracranial tumors that were considered difficult to resect because of their locations or previous incomplete operations. Twenty-nine low-grade and 19 high-grade gliomas, 8 metastatic lesions, 2 meningiomas, 1 pineoblastoma, and 1 astroblastoma were resected. RESULTS: Tumors were accurately localized and targeted, and the extent of resection, as well as any intraoperative complications, could be immediately assessed during surgery. Marked brain shifting occurred during the procedures, and repeated intraoperative imaging allowed surgical accommodation for this shifting. In more than one-third of the cases, intraoperative imaging showed residual tumor when resection appeared complete on the basis of surgical observation alone. CONCLUSION: Intraoperative MRI is a revolutionary tool for the surgical treatment of brain tumors, providing observation of the procedure as it is being performed. With intraoperative MRI, tumor resection is safer, the extent of resection can be directly evaluated, and intraoperative complications can be noted if they occur. Outcomes after resection depend on minimizing injury to normal brain tissue and achieving maximal tumor resection. The use of intraoperative MRI directly affects these factors.

Partial wavelet encoding: a new approach for accelerating temporal resolution in contrast-enhanced MR imaging.

We propose a new approach using wavelet encoding to improve temporal resolution in contrast-enhanced magnetic resonance (MR) imaging. Exploiting the unique property of wavelets localized in space and frequency, we construct an efficient encoding scheme to capture signal changes due to contrast agent uptake, which in general is spatially localized with low- and mid-range frequency components. On the basis of space-frequency analysis, we describe mathematical formulations of our method and discuss its theoretical advantages over Fourier-based phase-encoding methods (the keyhole and reduced-encoding imaging by generalized-series reconstruction [RIGR] techniques). The results obtained in computer simulations and a phantom study demonstrate the feasibility and practical advantages of our approach.

Hypertensive encephalopathy as a complication of hyperdynamic therapy for vasospasm: report of two cases.

OBJECTIVE AND IMPORTANCE: After developing subarachnoid hemorrhage, patients may deteriorate from a variety of well-known causes, including rebleeding, hydrocephalus, and vasospasm. Many patients now undergo empirical hyperdynamic vasospasm therapy with hypervolemia, induced hypertension, and nimodipine. CLINICAL PRESENTATION: We report two cases of iatrogenic hypertensive encephalopathy occurring during hyperdynamic therapy for cerebral vasospasm after subarachnoid hemorrhage. Hypertensive encephalopathy is a syndrome of rapidly evolving generalized or focal cerebral symptoms occurring in the setting of severe hypertension, which is reversible with antihypertensive therapy. INTERVENTION: The syndrome can be diagnosed in the appropriate clinical setting with computed tomographic or magnetic resonance imaging that demonstrates characteristic findings. In both cases, decreasing the blood pressure resulted in neurological improvement. CONCLUSION: In the setting of induced hypertensive/hypervolemic therapy for vasospasm, hypertensive encephalopathy should be considered as a potentially reversible cause of delayed neurological decline.

Intraoperative MR imaging guidance for intracranial neurosurgery: experience with the first 200 cases.

PURPOSE: To review preliminary experience with an open-bore magnetic resonance (MR) imaging system for guidance in intracranial surgical procedures. MATERIALS AND METHODS: A vertically oriented, open-configuration 0.5-T MR imager was housed in a sterile procedure room. Receive and transmit surface coils were wrapped around the patient's head, and images were displayed on monitors mounted in the gap of the magnet and visible to surgeons. During 2 years, 200 intracranial procedures were performed. RESULTS: There were 111 craniotomies, 68 biopsies, 12 intracranial cyst evaluations, four subdural drainages, and five transsphenoidal pituitary resections performed with the intraoperative MR unit. In each case, the intraoperative MR system yielded satisfactory results by allowing the radiologist to guide surgeons toward lesions and to assist in treatment. In two patients, hyperacute hemorrhage was noted and removed. The duration of the procedure and the complication rate were similar to those of conventional surgery. CONCLUSION: Intraoperative MR imaging was successfully implemented for a variety of intracranial procedures and provided continuous visual feedback, which can be helpful in all stages of neurosurgical intervention without affecting the duration of the procedure or the incidence of complications. This system has potential advantages over conventional frame-based and frameless stereotactic procedures with respect to the safety and effectiveness of neurosurgical interventions.

Computer-based imaging and interventional MRI: applications for neurosurgery.

Advances in computer technology and the development of open MRI systems definitely enhanced intraoperative image-guidance in neurosurgery. Based upon the integration of previously acquired and processed 3D information and the corresponding anatomy of the patient, this requires computerized image-processing methods (segmentation, registration, and display) and fast image integration techniques. Open MR systems equipped with instrument tracking systems, provide an interactive environment in which biopsies and minimally invasive interventions or open surgeries can be performed. Enhanced by the integration of multimodal imaging these techniques significantly improve the available treatment options and can change the prognosis for patients with surgically treatable diseases.