The "central vein sign": is there a place for susceptibility weighted imaging in possible multiple sclerosis?

OBJECTIVES: Susceptibility weighted imaging (SWI) may have the potential to depict the perivenous extent of white matter lesions (WMLs) in multiple sclerosis (MS). We aimed to assess the discriminatory value of the "central vein sign" (CVS). METHODS: In a 3-T magnetic resonance imaging (MRI) study, 28 WMLs in 14 patients with at least one circumscribed lesion >5 mm and not more than eight non-confluent lesions >3 mm were prospectively included. Only WMLs in FLAIR images with a maximum diameter of >5 mm were correlated to their SWI equivalent for CVS evaluation. RESULTS: Five patients fulfilled the revised McDonald criteria for MS and nine patients were given alternative diagnoses. Nineteen MS-WMLs and nine non-MS-WMLs >5 mm were detected. Consensus reading found a central vein in 16 out of 19 MS-WMLs (84 %) and in one out of nine non-MS-WMLs (11 %), respectively. The CVS proved to be a highly significant discriminator (P < 0.001) between MS-WMLs and non-MS-WMLs with a sensitivity, specificity, positive and negative predictive value and accuracy of 84 %, 89 %, 94 %, 73 % and 86 %, respectively. Inter-rater agreement was good (κ = 0.77). CONCLUSIONS: Even though the CVS is not exclusively found in MS-WMLs, SWI may be a useful adjunct in patients with possible MS. KEY POINTS: • MRI continues to yield further information concerning MS lesions. • SWI adds diagnostic information in patients with possible MS. • The "central vein sign" was predominantly seen in MS lesions. • The "central vein sign" helps discriminate between MS and non-MS lesions.

Cerebral infarction in bacterial meningitis: predictive factors and outcome.

In this study, we analysed the frequency, morphological patterns and clinical characteristics of cerebral ischaemia in bacterial meningitis. We sought to determine predictors for the development of vasculopathy and ischaemic infarction in patients with bacterial meningitis. Consecutive adult patients admitted between March 1998 and February 2009 to a neurological intensive care unit at a university hospital in Germany with the diagnosis of bacterial meningitis were included in the study. Standard criteria were used to define bacterial meningitis. From 68 patients with bacterial meningitis, six patients suffered from cerebral ischaemia (8.8%). In our cohort, reduced level of consciousness on admission (p = 0.01) and lower white blood cell (WBC) count in cerebrospinal fluid (CSF) (p = 0.012) were associated with development of ischaemic cerebrovascular complications. The short-term outcome of all patients was poor (median modified Rankin scale 4.5). In patients presenting with reduced level of consciousness on admission and/or low WBC count in CSF early cerebral imaging including MR angiography or CT angiography are warranted to detect impending cerebrovascular complications.

When coughing can cause stroke--a case-based update on cerebral air embolism complicating biopsy of the lung.

Introducing gas to the circulation is a largely iatrogenic problem which can result in serious morbidity and even death. We report a case of CT-guided needle biopsy of a pulmonary lesion complicated by acute stroke. The English literature on cerebral air embolism is reviewed, including an update of current opinions on its pathomechanism, diagnostic findings, therapeutic strategies, and means of prevention.

Severe Guillain-Barré syndrome associated with chromosome 17p11.2-12 duplication.

We report a patient with Guillain-Barré syndrome (GBS), characterized by severe tetraparesis, bulbar syndrome, and ophthalmoparesis. The nadir was reached within 1 day, followed by respiratory insufficiency requiring mechanical ventilation. Molecular analysis revealed a duplication at chromosome 17p11.2-12, which is a known genetic cause of Charcot-Marie-Tooth disease type 1A (CMT1A). We suggest that this genotype may comprise a previously unrecognized genetic risk factor for GBS.

A new paraclinical CSF marker for hypoxia-like tissue damage in multiple sclerosis lesions.

Recent studies on the immunopathology of multiple sclerosis revealed a heterogeneity in the patterns of demyelination, suggesting interindividual differences in the mechanism responsible for myelin destruction. One of these patterns of demyelination, characterized by oligodendrocyte dystrophy and apoptosis, closely mimics myelin destruction in acute white matter ischaemia. In the course of a systematic screening for virus antigen expression in multiple sclerosis brains, we identified a monoclonal antibody against canine distemper virus, which detects a cross-reactive endogenous brain epitope, highly expressed in this specific subtype of actively demyelinating multiple sclerosis lesions with little or no immunoreactivity in other active multiple sclerosis cases. The respective epitope, which is a phosphorylation-dependent sequence of one or more proteins of 50, 70 and 115 kDa, is also expressed in a subset of active lesions of different virus-induced inflammatory brain diseases, but is present most prominently and consistently in acute lesions of white matter ischaemia. Its presence is significantly associated with nuclear expression of hypoxia-inducible factor-1 alpha within the lesions of both inflammatory and ischaemic brain diseases. The respective epitope is liberated into the CSF and, thus, may become a useful diagnostic tool to identify clinically a defined multiple sclerosis subtype.