Posterior fossa abnormalities in high-risk term infants: comparison of ultrasound and MRI.

OBJECTIVES: We aimed to assess the characteristics of posterior fossa (PF) abnormalities in a cohort of high-risk term neonates, as well as the diagnostic performance of cranial ultrasound (CUS) with additional mastoid fontanelle (MF) views for the detection of these abnormalities, with magnetic resonance imaging (MRI) being the reference standard. METHODS: In this retrospective study, 113 term neonates with CUS and subsequent MRI were included. Sensitivity, specificity, and predictive values of routine CUS and CUS with MF views were calculated. RESULTS: Posterior fossa abnormalities were diagnosed on CUS in 46 of 113 infants. MRI confirmed these findings in 43 and showed additional abnormalities in 32 infants. The sensitivity and specificity of anterior fontanelle views for major PF abnormalities as seen on MRI were 16% and 99%. Adding MF views increased the sensitivity of US to 82%. The sensitivity and specificity of MF views for the detection of any (major or minor) PF abnormality were 57% and 95%. Especially acute hypoxic-ischemic injury and small subdural and punctate cerebellar haemorrhage remained undetected by CUS. CONCLUSIONS: PF abnormalities are frequent in high-risk term infants. MF-CUS enables early diagnosis of major PF abnormalities. We therefore advocate to perform MF-CUS in high-risk term neonates. KEY POINTS: • Posterior fossa abnormalities are a frequent finding in high-risk term infants. • Adding mastoid fontanelle views improves ultrasound detection of clinically relevant abnormalities. • Hypoxic-ischemic injury and small posterior fossa haemorrhages are better detected with MRI. • Cranial ultrasound examination should include mastoid fontanelle views in high-risk term neonates.

Lenticulostriate vasculopathy in very preterm infants.

OBJECTIVE: To assess for lenticulostriate vasculopathy (LSV) on cranial ultrasound (cUS) scans of very preterm infants: incidence and aetiology, evolution during neonatal period, association with clinical parameters, and MRI equivalent. DESIGN: Prospective study. SETTING: Tertiary neonatal referral centre. PATIENTS: Very preterm infants (<32 weeks) underwent sequential cUS throughout the neonatal period and MRI around term age. cUS were evaluated for LSV and other changes, and MRI for changes in signal and myelination in deep grey matter. LSV was divided into early-onset (7 postnatal days). Perinatal clinical parameters were collected for all infants and compared between groups. RESULTS: In 22/111 (20%) infants LSV was detected: early-onset in 5 and late-onset in 17. LSV mostly presented some weeks after birth and persisted for several months. There were no associations between LSV and other changes on cUS or deep grey matter changes on MRI. Infants with late-onset LSV were younger and smaller at birth than infants with early-onset LSV. Postmenstrual age at first detection was comparable for both LSV groups. There were no associations between LSV and perinatal clinical parameters, but infants with LSV had less episodes of hypotension than infants without LSV. CONCLUSIONS: LSV is a frequent finding on cUS in very preterm infants, but does not show on MRI. The postmenstrual age, rather than gestational and postnatal age, seems important in LSV development. LSV is not associated with clinical parameters. When encountered in otherwise healthy preterm infants, LSV is probably a benign temporary phenomenon.

[Transsphenoidal resection of pituitary adenomas: long-term results from the Leiden University Medical Center]. / Transsfenoïdale resectie van hypofyseadenomen: langetermijnresultaten van het Leids Universitair Medisch Centrum.

OBJECTIVE: To evaluate the long-term outcome of transsphenoidal resection of pituitary adenomas at the Leiden University Medical Center (LUMC), The Netherlands. DESIGN: Retrospective, descriptive. METHOD: 416 consecutive patients undergoing surgery for pituitary adenoma at the LUMC between 1978 and 2004 were included; 174 patients with non-functioning macroadenomas (NFMA), 164 patients with acromegaly and 78 patients with Cushing's disease. RESULTS: Biochemical remission was achieved in 66% of patients with acromegaly, and 72% of patients with Cushing's disease; incidence of pituitary failure was low in these patients (5% and 18% respectively). In 82% of the patients with NFMA visual function improved whereas the percentage with any degree of pituitary failure increased from 85% (preoperatively) to 95% (postoperatively). During follow-up of 10-15 years, the recurrence rate for acromegaly and Cushing's disease was 9% and for NFMA it was 15%. CONCLUSION: Transsphenoidal resection is an effective treatment in most, but not all, patients with pituitary adenomas. The surgical results at the LUMC are comparable with those obtained in important international centres. All patients cured by surgery need lifelong follow-up, because of the real risk of recurrent disease.

Pituitary magnetic resonance imaging is not required in the postoperative follow-up of acromegalic patients with long-term biochemical cure after transsphenoidal surgery.

After successful transsphenoidal surgery for acromegaly, life-long follow-up is required, because 10-15% of patients develop recurrence of disease. We assessed whether it is safe to perform postoperative follow-up with only biochemical evaluation in acromegalic patients initially cured by transsphenoidal surgery. We studied 32 patients cured after transsphenoidal surgery for acromegaly during a follow-up of 8.7 +/- 6.4 yr (mean +/- sd). Serial measurements of serum GH during glucose tolerance test and magnetic resonance imaging (MRI) scans were performed. Serial MRI scans were reevaluated by three independent neuroradiologists, who were blinded for the clinical and biochemical data, for growth of suspected tumor tissue. Twenty-three patients remained biochemically cured in the long term, whereas nine of the 32 patients developed recurrence of disease, indicated by elevated serum GH concentrations during glucose tolerance test and clinical symptoms/signs. None of the 23 patients with long-term biochemical cure showed growth of tumor tissue according to two neuroradiologists, whereas the third neuroradiologist assessed three of 23 patients as having tumor growth despite continuing biochemical cure. In the nine patients with biochemical recurrence, no tumor growth was found in the series of postoperative MRI scans, according to two of the three independent radiologists, whereas the third radiologist found tumor growth in four patients with recurrent disease. In conclusion, in patients with acromegaly, initially cured by transsphenoidal surgery, it appears safe to check for recurrent disease during long-term follow-up of these patients by biochemical markers only.

MR angiography of the intracranial venous system.

PURPOSE: To compare the effectiveness of different imaging planes at time-of-flight (TOF) magnetic resonance (MR) angiography and phase-contrast MR angiography in the visualization of the normal intracranial venous system. MATERIALS AND METHODS: In 12 healthy volunteers, two-dimensional (2D) TOF MR angiography and three-dimensional (3D) phase-contrast MR angiography were performed in transverse, sagittal, and coronal planes. All data were displayed as maximum intensity projection (MIP) images. Four neuroradiologists assessed the visibility of 28 intracranial venous structures on the MIP images. Statistical analysis was performed by using the Friedman two-way analysis of variance and the Cochran Q test. RESULTS: Visualization of the normal intracranial venous system was better with 3D phase-contrast and coronal 2D TOF MR angiography than with transverse or sagittal 2D TOF MR angiography (P < .05, Friedman test) for each observer and the group of observers. Differences were found between each of the 2D TOF and 3D phase-contrast MR angiographic sequences in the visualization of individual venous structures (Cochran Q test). The kappa values ranged from 0.36 to 0.71, which indicated a moderate to good agreement between observers. CONCLUSION: The normal intracranial venous system is adequately visualized with 3D phase-contrast and coronal 2D TOF MR angiography.

Hereditary cerebral hemorrhage with amyloidosis-Dutch type: better correlation of cognitive deterioration with advancing age than with number of focal lesions or white matter hyperintensities.

The relationship between cognitive deterioration and abnormalities detected by magnetic resonance imaging (MRI) was investigated to determine the radiological correlates of cognitive deterioration in hereditary cerebral hemorrhage with amyloidosis-Dutch type (HCHWA-D). Twenty HCHWA-D subjects (12 patients who had suffered one or more strokes and eight who had not suffered a stroke) were studied with MRI and underwent extensive neuropsychological examination. On MRI the number of focal lesions was counted, and white matter hyperintensities (WMHs) were scored semiquantitatively. A significant correlation between cognitive deterioration and WMH score and number of focal lesions was found. However, cognitive deterioration, WMH score, and the number of focal lesions all increase with age, and therefore their mutual correlation can be explained as an age effect. This study shows that cognitive deterioration in HCHWA-D is not correlated with abnormalities detected by MRI (number of focal lesions and subcortical WMHs) independently of age. Although a contribution of white matter changes and/or focal lesions, possibly in combination with age, to cognitive deterioration cannot be excluded. Cognitive deterioration in these HCHWA-D patients is probably primarily the result of chronic damage of amyloid angiopathy to the brain, to which may be superimposed cognitive impairment from focal cerebral hemorrhage or infarction.

Spinal chordoma: radiologic features in 14 cases.

The radiologic appearance of chordoma of the cervical (three patients), thoracic (four patients), and lumbar spine (seven patients) was studied. Eleven patients were over 50 years old and presented with long-standing back pain. All were examined with conventional radiographs; three cases also had CT examinations. In thirteen patients, the tumor originated in the vertebral body and, in one patient, in the posterior element of a vertebra. In nine (64%) of the 14 cases, osteosclerosis was a prominent feature. In the remaining five cases (36%), the bone lesion was purely osteolytic. Involvement of the intervertebral disk was found in three patients; in two of these the tumor extended to an adjacent vertebra. In nine patients, a soft-tissue mass was a distinctive additional feature. A sclerotic and/or osteolytic lesion in a vertebral body with a large, paraspinal soft-tissue mass in an older patient with long-standing back pain should raise the possibility of a chordoma.

Pulmonary complications of cytosine-arabinoside therapy: radiographic findings.

Sixty-four patients underwent 66 remission induction courses with intermediate-dose cytosine-arabinoside (Ara-C) for treatment of acute myelogenous leukemia, acute lymphoblastic leukemia, or high-grade malignant non-Hodgkin's lymphoma. The Ara-C was administered in combination with amsacrine with or without VP16-213 and prednisone. After complete remission was achieved, 27 patients received 38 consolidation courses consisting of high-dose Ara-C either alone or in combination with amsacrine with or without VP16-213 and prednisone. Seven (11%) of 66 induction courses and eight (21%) of 38 consolidation courses were complicated by respiratory failure that was considered a pulmonary reaction to Ara-C therapy. The initial findings on chest radiographs in the 15 cases included a diffuse interstitial pattern (two), a mixed interstitial-alveolar pattern (eight), an alveolar pattern (three), and a normal pattern (two). In 11 cases, the abnormalities were diffuse throughout both lungs with a preference for the lower lobes in five. The changes were localized in two cases. A small pleural effusion was observed in two patients. In the majority of cases, the initial radiographic changes progressed to a predominantly alveolar pattern. Thirteen patients recovered clinically within 2-9 days, and two patients died of pulmonary complications. Radiologic recovery took 7-21 days. Rapid regression of alveolar consolidations within 3-7 days was the first sign of radiologic improvement. The interstitial pattern gradually regressed. We conclude that the spectrum of radiologic abnormalities in cases of pulmonary reaction to Ara-C therapy includes diffuse interstitial, mixed interstitial-alveolar, or alveolar pulmonary changes.