Cerebral cortical thickness and gyrification changes in first-episode psychoses and multi-episode schizophrenia.

Cortical thickness (CT) and local gyrification index (LGI) in psychotic disorders may show modifications that relate to clinical course. This observational study aimed to analyse such variables in patients with schizophrenia, compared to healthy controls (HCs). We compared CT and LGI of 18 patients with first-episode psychosis with that of 21 with multi-episode schizophrenia and 16 HCs. CT corrected for false-positive cases (Family-Wise Error Rate) showed a reduction in the multi-episode group compared to HCs in left temporal and parietal, and right temporal, parietal, occipital, and hippocampal cortices. Family-wise corrected LGI was increased in the left inferior and middle frontal cortices, and in the right fusiform gyrus, cingulate, lingual, and parahippocampal gyri in first onset patients compared to HCs. Increased LGI was absent from later stages of psychosis, suggesting that specific CT and LGI alterations may underlie different stages of illness.

The role of time-resolved imaging of contrast kinetics (TRICKS) magnetic resonance angiography (MRA) in the evaluation of head-neck vascular anomalies: a preliminary experience.

OBJECTIVES: In this preliminary report, we describe our experience with time-resolved imaging of contrast kinetics-MR angiography (TRICKS-MRA) in the assessment of head-neck vascular anomalies (HNVAs). METHODS: We prospectively studied six consecutive patients with clinically suspected or diagnosed HNVAs. All of them underwent TRICKS-MRA of the head and neck as part of the routine for treatment planning. A digital subtraction angiography (DSA) was also performed. RESULTS: TRICKS-MRA could be achieved in all cases. Three subjects were treated based on TRICKS-MRA imaging findings and subsequent DSA examination. In all of them, DSA confirmed the vascular architecture of HNVAs shown by TRICKS-MRA. In the other three patients, a close follow up to assess the evolution of the suspected haemangioma was preferred. CONCLUSIONS: TRICKS sequences add important diagnostic information in cases of HNVAs, helpful for therapeutic decisions and post-treatment follow up. We recommend TRICKS-MRA use (if technically possible) as part of routine MRI protocol for HNVAs, representing a possible alternative imaging tool to conventional DSA.

Apparent diffusion coefficient obtained by magnetic resonance imaging as a prognostic marker in glioblastomas: correlation with MGMT promoter methylation status.

OBJECTIVE: To evaluate whether apparent diffusion coefficient (ADC) values can predict the status of MGMT of glioblastoma multiforme (GBM) and correlate with overall survival (OS) and progression-free survival (PFS). METHODS: This retrospective study included 47 patients with pathologically proven glioblastoma. All of them underwent MR DWI study before surgery (mean time 1 week) and the status of methylguanine-DNA-methyltransferase (MGMT) promoter methylation was searched for. Minimum apparent diffusion coefficient (ADC) values were evaluated. OS and PSF parameters were calculated, and Student's t-test, Kaplan-Meier curves, linear and Cox regression were performed. RESULTS: Twenty-five patients showed positive methylation of the MGMT promoter. Patients showing MGMT promoter methylation had higher minimum ADC values, and they survived longer than those without MGMT promoter methylation. The median ADCmin value of 0.80 represents the cutoff value able to distinguish between methylated and un-methylated patients. Patients showing minimum ADC values higher than 0.80 survived longer than patients with minimum ADC values lower than 0.80. A linear correlation between minimum ADC values vs. the OS and PFS was observed. CONCLUSIONS: Minimum ADC values in glioblastoma multiforme could be used as a preoperative parameter to estimate the status of MGMT promoter methylation and the survival of patients.

Anatomical substrates of cognitive and clinical dimensions in first episode schizophrenia.

OBJECTIVE: To explore gray (GM) and white matter (WM) abnormalities and the relationships with neuropsychopathology in first-episode schizophrenia (FES). METHOD: Nineteen patients with first episode of non-affective psychosis and 18 controls underwent a magnetic resonance voxel-based morphometry. Additionally, WM fractional anisotropy (FA) was calculated. For correlative analysis, symptoms and neuropsychological performances were scored by PANSS and by a comprehensive neuropsychological assessment respectively. RESULTS: Patients showed significantly decreased volume of left temporal lobe and disarray of all major WM tracts. Disorganized PANSS factor was inversely related to left cerebellar GM volume (corrected P = 0.03) and to WM FA of the left cerebellum, inferior fronto-occipital fasciculi (IFOF), and inferior longitudinal fasciculi (corrected P < 0.05). PANSS negative factor was inversely related to FA in the IFOF and superior longitudinal fasciculi (corrected P < 0.05). Impairment in facial emotion identification showed associations with temporo-occipital GM volume decrease (corrected P = 0.003) and WM disarray of superior and middle temporal gyri, anterior thalamic radiation, and superior longitudinal fasciculi (corrected P < 0.05). Speed of processing and visual memory correlated with WM abnormalities in fronto-temporal tracts. CONCLUSION: These results confirm how the structural development of key brain regions is related to neuropsychopathological dysfunction in FES, consistently with a neurodevelopmentally derived misconnection syndrome.

Transcranial Doppler and diffusion-weighted magnetic resonance evaluation of cerebral embolization occurring during transfemoral carotid stenting with proximal flow blockage.

AIM: Transfemoral carotid artery stenting (CAS) with endovascular proximal flow blockage is deemed able to reduce the cerebral embolization observed during filter-protected CAS. We evaluated clinical outcome and intraoperative embolization rates, measured by diffusion-weighted magnetic resonance imaging (DW-MRI) and transcranial Doppler monitoring, in a series of patients undergoing CAS with proximal flow blockage. METHODS: A series of 35 consecutive patients with symptomatic or asymptomatic internal carotid artery stenosis ≥70% were included to undergo CAS with proximal flow blockage, obtained with the Mo.Ma system. All patients underwent preoperative and postoperative DW-MRI in order to detect new ischemic lesions. Of the 35 patients, 31 (89%) underwent intraoperative transcranial Doppler monitoring to record the microembolic signals (MES) produced during each procedure. RESULTS: The MoMa system was successfully used in 34 patients (technical success: 97%). Intolerance to balloon occlusion was observed in 4 patients (12%), but never compromised the completion of the procedure. No deaths or neurological events occurred in the postoperative period. DW-MRI disclosed 74 new ischemic lesions in 8 patients (8/34, 23.5%). All lesions except one were ipsilateral to the treated carotid artery. MES were detected in all procedures, with a mean number of 33.2±23.2 (range 3-103). In 20 procedures (20/31, 65%), MES were detected also during flow blockage (mean: 9.1±7; range 2-28). CONCLUSION: While achieving good technical and clinical results, CAS with proximal flow blockage is still accompanied by a non-negligible cerebral embolization. The detection of MES during ICA flow blockage suggests the need for a better selection of patients.

Bilateral inflammatory pseudotumour of the trigeminal nerve: a diagnostic challenge.

Inflammatory pseudotumour (IPT) is an uncommon disease with undefined pathogenesis. It is often characterized by local aggressiveness with compressive and displacing effects on surrounding structures. It may appear in different regions of the body, rarely involving perineural structures unilaterally. We present a case of a bilateral IPT around trigeminal branches in a patient with a long-term history of periorbital swelling and proptosis.

Clinical applications of dynamic susceptibility contrast perfusion-weighted MR imaging in brain tumours.

Magnetic resonance imaging (MRI) with a dynamic susceptibility contrast perfusion-weighted imaging (DSC-PWI) sequence to study brain tumours provides information on the haemodynamic characteristics of the neoplastic tissue. Brain perfusion maps and calculation of perfusion parameters, such as relative cerebral blood flow (rCBF), relative cerebral blood volume (rCBV) and mean transit time (MTT) allow assessment of vascularity and angiogenesis within tumours of the central nervous system (CNS), thus providing additional information to conventional MRI sequences. Although DSC-PWI has long been used, its clinical use in the study of brain tumours in daily clinical practice is still to be defined. The aim of this review was to analyse the application of perfusion MRI in the study of brain tumours by summarising our personal experience and the main results reported in the literature.

Stereotactic radiosurgery plus whole-brain radiotherapy for treatment of multiple metastases from non-small cell lung cancer.

BACKGROUND: The aim of this study was to evaluate local control and survival rates after stereotactic radiosurgery (SRS) plus whole-brain radiotherapy (WBRT) for the treatment of multiple brain metastases from non-small cell lung cancer (NSCLC). PATIENTS AND METHODS: Between June 2004 and September 2008, sixty-six patients with multiple brain metastases from NSCLC were enrolled in this prospective study. All patients were required to have 2-3 brain metastases and Karnofsky performance status (KPS) > or = 70. WBRT treatment dose was 30 Gy in 10 fractions followed by SRS. A matched control population treated with WBRT alone to a dose of 30 Gy in 10 fractions was used for comparison. RESULTS: The median survival was 10.3 months in the WBRT plus SRS group and 7.2 months in the WBRT group (p=0.005). The 6-month and 12-month survival rates were 90% and 38% in the SRS plus WBRT group and 84% and 19% in the WBRT group (p=0.01). Stable extracranial disease and KPS were significant predictive factors of survival in both groups (p=0.001). Death due to neurological causes occurred in 18% and 35% of patients treated with WBRT plus SRS and WBRT (p=0.02), respectively. Disease control in the brain was 10 months in the SRS plus WBRT group and 7 months in the WBRT group (p=0.001); the 6-month and 12-month control rates were 82% and 42% for WBRT plus SRS, and 75% and 18% for WBRT (p=0.001), respectively. The 6-month and 12-month control rates of treated lesions (local control) were 90% and 47% in the WBRT group, and 100% and 93% in the WBRT plus SRS group (p=0.001). CONCLUSION: WBRT plus SRS is a safe, minimally invasive and well-tolerated treatment for patients with up to three brain metastases from NSCLC. The treatment is associated with longer survival and better disease control in comparison with WBRT alone. Survival benefits need to be confirmed by large randomized studies.

Intracranial hypotension and PRES: case report.

We report a case of a woman presenting, 7 days after epidural analgesia for a caesarean section, to the emergency room for a worsening of the headache and tonico-clonic seizures. MRI showed alterations suggestive of the presence of intracranial hypotension (IH) as well as evidence of posterior reversible encephalopathy syndrome (PRES). She was treated with a blood patch which leads to the prompt regression of the clinical symptoms and follow-up MRI, after 15 days, showed complete resolution of radiological alterations. The possible pathogenetic relationship between IH, secondary to the inadvertent dural puncture, and PRES is discussed. We suggest that venous stagnation and hydrostatic edema, secondary to intracranial hypotension, probably played a crucial role in the pathogenesis of PRES.

Cervical access for filter-protected carotid artery stenting: a useful tool to reduce cerebral embolisation.

BACKGROUND: Filter-protected transcervical carotid artery stenting (CAS) has been suggested to reduce the intraoperative cerebral embolisation observed during transfemoral CAS. We therefore evaluated clinical outcome and incidence of ischaemic lesions at diffusion-weighted magnetic resonance imaging (DW-MRI) after transcervical and transfemoral CAS. METHODS: From March 2007 to May 2009, we performed filter-protected CAS in 135 patients with symptomatic (30%) or asymptomatic (70%) carotid stenosis above 70% and below 95%. In 44 patients with risky femoral access or unfavourable aortic arch anatomy, access to common carotid artery was achieved by a small cervical incision. In another 91 procedures we used a classic percutaneous femoral access. Preoperative and postoperative DW-MRI scans were obtained after 111 procedures (82%) - 35 transcervical and 76 transfemoral. RESULTS: The incidence of clinical events (transient ischaemic attack (TIA) and stroke) was 2.3% after transcervical CAS and 19.8% after transfemoral CAS (P<0.01), without any deaths. DW-MRI disclosed new ischaemic lesions in five patients (5/35, 14.3%) after transcervical CAS and in 28 patients (28/76, 36.8%) after transfemoral CAS (P=0.015). All ischaemic lesions depicted after transcervical procedures were ipsilateral to the treated artery. CONCLUSIONS: Transcervical filter-protected CAS, compared with classic percutaneous procedures, seems to reduce clinical events and DW-MRI ischaemic damage and may be useful in selected patients.

Pre-surgical planning and MR-tractography utility in brain tumour resection.

The purposes of this study were (1) to evaluate the possible identification of trajectories of fibre tracts, (2) to examine the useful of a neuronavigation system for presurgical planning, (3) to assess pre- and post-surgery patients' clinical condition and (4) to evaluate the impact of this information on surgical planning and procedure. Twenty-eight right-handed patients were prospectively and consecutively studied. All the patients were clinically assessed by a neurologist in both pre- and postsurgical phases. Separately the pyramidal tract, optic radiation and arcuate fasciculus were reconstructed. The trajectories were considered suitable for surgical planning if there were no interruptions of any of the layers at the level of the lesion. Dedicated software 'merged' the acquired images with the tractographic processing, and the whole dataset was sent to the neuronavigation system. The assessment of the 37 visualised trajectories close to the tumour resulted in a modification of the surgical approach to corticotomy in six patients (21%); the impact on the definition of the resection margins during surgery was 64%(18 cases). The overall impact percentage on the surgical procedure was 82%. In 27 cases, the symptoms had not changed. MR-tractography provides the neurosurgeon with a new anatomical view that has an impact on the surgical resection planning for brain neoplasms.

Headache and visual symptoms in two patients with MRI alterations in posterior cerebral artery territory.

Posterior cerebral artery (PCA) territory infarcts account for only 5-10% of all infarcts in stroke registries. Moreover, the clinical features and etiology of such infarcts have not been studied as extensively as those in other vascular territories.We describe two patients with recurrent episodes of visual symptoms and headache due to probable transitory PCA vasospasm. MR angiography in the acute phase revealed incomplete visualization of PCA, conventional MRI showed mild T2 signal alterations and MR perfusion showed the presence of marked hypoperfusion in the same regions. Diffusion weighted MR images were normal. All these findings resolved after therapy. These cases suggest that reversible signal alterations associated with reversible vessel and perfusion abnormalities may be observed in patients with visual symptoms and headache. Normal DWI-MR may help distinguish these patients from those affected by non-reversible ischemic attacks.

Hypofractionated radiotherapy followed by adjuvant chemotherapy with temozolomide in elderly patients with glioblastoma.

OBJECTIVES: The optimal treatment for elderly patients (age >70 years) with glioblastoma (GBM) remains controversial. We conducted a prospective trial in 43 consecutive elderly patients with GBM treated with hypofractionated radiotherapy (RT) followed by adjuvant temozolomide. PATIENTS AND METHODS: Forty-three patients 70 years of age or older with a newly diagnosed GBM and a Karnofsky performance status (KPS) > or = 60 were treated with hypofractionated RT (6 fractions of 5 Gy each for a total of 30 Gy over 2 weeks) followed by up to 12 cycles of adjuvant temozolomide (150-200 mg/m(2) for 5 days during each 28 day cycle). The HRQOL was assessed with the EORTC Quality of Life Questionnaire C30. The primary endpoint was overall survival (OS). Secondary endpoints included progression free survival (PFS), toxicity and quality of life. RESULTS: The median OS was 9.3 months and the median PFS was 6.3 months. The 6 and 12 month survival rates were 86% and 35%, respectively. The 6 and 12 month PFS rates were 55% and 12%, respectively. In multivariate analysis KPS was the only significant independent predictive factor of survival (P = 0.008). Neurological deterioration occurred during or after RT in 16% of patients and was resolved in most cases with the use of steroids. Grade 3-4 hematologic toxicity occurred in 28% of patients during the adjuvant chemotherapy treatment with temozolomide. The treatment had no negative effect on HRQOL, however, fatigue (P = 0.02) and constipation (P = 0.01) scales worsened over time. CONCLUSIONS: Hypofractionated RT followed by temozolomide may provide survival benefit maintaining a good quality of life in elderly patients with GBM. It may represent a reasonable therapeutic approach especially in patients with less favourably prognostic factors.

Late evaluation of silent cerebral ischemia detected by diffusion-weighted MR imaging after filter-protected carotid artery stenting.

BACKGROUND AND PURPOSE: Postoperative diffusion-weighted MR imaging (DWI) often discloses new lesions after carotid artery stent placement (CAS), most of them asymptomatic. Our aim was to investigate the fate of these silent ischemic lesions. MATERIALS AND METHODS: We prospectively studied 110 patients undergoing protected transfemoral CAS, 98 of whom underwent DWI before and after the intervention. Patients in whom DWI disclosed silent postoperative lesions also had delayed MR imaging. Preoperative, postoperative, and delayed scans were compared. RESULTS: Of the 92 patients without postoperative symptoms, DWI disclosed 33 new silent ischemic lesions in 14 patients (15.2%), 13 of whom (30 lesions) underwent delayed MR imaging after a mean follow-up of 6.2 months. In 8 of these 13 patients (61%), MR imaging disclosed 12 persistent lesions (12/30, 40%). The reversibility rate depended significantly on the location (cortical versus subcortical) and size (0-5 versus 5-10 mm) of the lesions (P < .05 by chi(2) test). CONCLUSIONS: Because many silent ischemic lesions seen on postoperative DWI after CAS reverse within months, the extent of permanent CAS-related cerebral damage may be overestimated.

Radiotherapy plus concomitant and adjuvant temozolomide for glioblastoma in elderly patients.

OBJECTIVES: The optimal treatment for elderly patients (age > 70 years) with glioblastoma remains controversial. We conducted a prospective trial in 32 consecutive elderly patients with glioblastoma who underwent surgery followed by radiotherapy (RT) plus concomitant and adjuvant temozolomide. PATIENTS AND METHODS: 32 patients 70 years of age or older with a newly diagnosed glioblastoma and a Karnofsky performance status (KPS) > or = 70 were treated with RT (daily fractions of 2 Gy for a total of 60 Gy) plus temozolomide at the dose of 75 mg/m(2) per day followed by six cycles of adjuvant temozolomide (150-200 mg/m(2) for 5 days during each 28-day cycle). The primary endpoint was overall survival (OS). Secondary endpoints included progression free survival (PFS) and toxicity. RESULTS: The median OS was 10.6 months and the median PFS was 7 months. The 6-month and 12-month survival rates were 91% and 37%, respectively. The 6-month and 12-month PFS rates were 56% and 16%, respectively. In multivariate analysis KPS was the only significant independent predictive factor of survival (P = 0.01). Adverse effects were mainly represented by neurotoxicity (40%), which resolved in most cases with the use of steroids, and Grade 3-4 hematologic toxicity in 28% of patients. Chemotherapy was stopped in 2 patients, delayed in 9 patients and reduced in 4 patients. CONCLUSIONS: Standard RT plus concomitant and adjuvant temozolomide is a feasible treatment for elderly patients with newly diagnosed glioblastoma who present with good prognostic factors.

Primary intradural extramedullary ependymoma: imaging findings and review of the literature. A case report.

We describe a 32-year-old woman who presented with progressive dorsal back pain. Neither sensory nor motor deficit was reported. Magnetic resonance imaging (MRI) of the dorsal spine revealed a primary intradural extramedullary lesion with severe spinal cord compression. No other lesion was found in the central nervous system. During surgery an intradural extramedullary tumor was found without medullary infiltration and a total removal was achieved under microscopic guidance. The histological diagnosis revealed a benign extramedullary ependymoma. The patient recovery completely after surgery and at a follow-up of 24 months MRI showed no evidence of tumor recurrence. Ependymoma should be taken in account in the differential diagnosis on intradural extramedullary tumours.

Cerebral embolization in patients undergoing protected carotid-artery stenting and carotid surgery.

AIM: Intraoperative cerebral embolization is a greater concern in patients undergoing carotid-artery stenting (CAS) than in those undergoing the reference standard treatment carotid endarterectomy (CEA). We evaluated cerebral embolism with diffusion-weighted magnetic resonance imaging (DW-MRI) and transcranial Doppler monitoring during CAS and CEA. METHODS: A series of 75 patients with carotid stenosis, 40 undergoing CEA and 35 transfemoral protected CAS, underwent preoperative and postoperative cerebral DW-MRI. Of the 75 patients, 64 (85%) underwent intraoperative transcranial Doppler monitoring to evaluate the mean number of microembolic signals (MES) recorded in each procedure. RESULTS: None of the patients died. No patient in the CEA but two in the CAS group had strokes (5.7%, P=NS). The mean MES count on transcranial Doppler monitoring was higher in the CAS than in the CEA group (330.0 MES, range 2754 vs 13.2, range 0-49 MES; P<0.01). DW-MRI disclosed a significantly larger number of new ischemic lesions in the CAS than in the CEA group (40 lesions in 12/35 patients, 34.3% vs 4 lesions in 3/40 patients, 7.5%; P<0.01). In the CEA group, all patients with ischemic lesions were asymptomatic whereas in the CAS group 5 were symptomatic (14.3%) and 7 asymptomatic (20%). The cerebral distribution also differed in the two groups: no CEA but 20% of CAS lesions were contralateral. CONCLUSION: CAS is associated with a significantly higher rate of cerebral embolization than CEA. Even though the clinical meaning of new postoperative ischemic lesions remains debatable, it seems prudent to reduce the embolic load by improving procedural techniques and cerebral protection devices.

Role of magnetic resonance tractography in the preoperative planning and intraoperative assessment of patients with intra-axial brain tumours.

PURPOSE: This study was conducted to assess the possibility of identifying precise white matter tracts situated in proximity to intracranial tumours, to define the anatomical and topographical relations between the same white matter tracts and the tumour, to verify the possibility of integrating tractographic images in the context of a package of three-dimensional anatomical images to send to the neuronavigation system, to assess the impact of this information on surgical planning, and to analyse, both pre-and postoperatively, the patient's clinical conditions as an index of the functional integrity of the fibres themselves. MATERIALS AND METHODS: Twenty-five patients underwent diffusion tensor study prior to neurosurgery. With the use of dedicated software, relative colour maps were obtained and the trajectories of the white matter tracts adjacent to the tumour were reconstructed in three dimensions. These were then processed for preoperative planning. Planning, which was performed with the neuronavigator, was based on analysis of the location of the course of the main white matter tracts adjacent to the lesion (pyramidal tract, optic radiation and arcuate fasciculus). Two neurosurgeons were asked whether the tractography images had modified the access and/or intraoperative approach to the tumour. All patients were clinically assessed both pre-and postoperatively 1 month after the procedure to define the presence of symptoms related to the involvement of the white matter tracts studied and therefore to assess the integrity of the fibres after the operation. RESULTS: In one patient, the tumour was situated away from all the tracts studied and did not compress them in any way. Overall, 40/75 tracts studied had no anatomical relation with the tumour, were not displaced by the tumour or could not be visualised in their entire course. Analysis of the remaining 35 white matter tracts led to an a priori change in the surgical approach for corticotomy in four patients (16%), with no disagreement between the two neurosurgeons and an impact on the extent of resection during surgery in 17 (68%), thus an overall impact on the surgical procedure in 80% of cases. Eight patients showed no symptoms related to the involvement of the white matter tracts studied. In the remaining 17 patients, the symptoms were related to involvement of the pyramidal tract, arcuate fasciculus or optic radiation. At 1-month follow-up, one previously asymptomatic patient reported a speech disorder (transcortical sensory dysphasia); in the remaining 24, symptoms remained unchanged, with a tendency to improvement in 14/17 with symptoms related to involvement of white matter tracts studied. CONCLUSIONS: Magnetic resonance (MR) tractography offers the neurosurgeon an anatomical panoramic view that can improve surgical planning for the resection of intracranial tumours. Despite the high incidence of cases in which the lesion is responsible for changes that hinder the reconstruction of white matter tracts, the technique can change the surgical approach for corticotomy, defines the extent of resection and leads to some change in the procedure in 80% of cases. The improvement of pre-existing symptoms and the absence of new symptoms in the postoperative phase, in our opinion, confirms the value of the technique.

Emerging patterns of diffusion, perfusion-weighted MRI and spectroscopy in creutzfeldt-jacob disease.

Sporadic Creutzfeldt-Jacob disease (CJD) is a transmissible, progressive, fatal spongiform encephalopathy. Routine MR imaging sequences may show abnormalities in the basal ganglia and cerebral cortex. Recently, several reports claimed that diffusion weighted MRI (DWI) could demonstrate early brain lesions in CJD patients when conventional MR images are normal on T2-weighted sequences. We evaluated the usefulness of DWI, perfusion-weighted MRI (PWI) and spectroscopy to confirm the clinical diagnosis and assess lesion progression in two patients with suspected CJD. We noted a diffuse hypoperfusion in the basal ganglia where ADC values were reduced but spectroscopy values were normal. A strong hypoperfusion was observed in the right head of the caudate nucleus in patient n° 2 where spectroscopy values were abnormal. A typical distribution of hypoperfusion followed the posterior progression of disease. We suggest the hypoperfusion in the areas presenting restricted diffusion probably reflects spongiform degeneration and moderate mass effects from cytotoxic edema.