Tumor or not a tumor: Pitfalls and differential diagnosis in neuro-oncology.

The majority of intracranial expansive lesions are tumors. However, a wide range of lesions can mimic neoplastic pathology. Differentiating pseudotumoral lesions from brain tumors is crucial to patient management. This article describes the most common intracranial pseudotumors, with a focus on the imaging features that serve as clues to detect pseudotumors.

Aging modulates fronto-temporal cortical interactions during lexical production. A dynamic causal modeling study.

In this dynamic causal modeling (DCM) study, we evaluated the effect of age on the effective connectivity of a cerebral network involved in lexical production. Younger and older adults performed an object naming task during fMRI. The DCM was used to explore the interactions between four regions of interest: the occipital cortex, OC; the lateral temporal cortex, LTC; the medial temporal cortex, MTC; and the inferior frontal cortex, IFC. We mainly focused on the modulation of the fronto-temporal interaction, according to the hypothesis that aging requires strategies that modulate the access to the semantic knowledge, either through a neural reserve mechanism (increased MTC-LTC connectivity) or through a neural compensation mechanism (supplementary IFC-MTC connectivity). For younger adults, our results indicated a bi-directional interaction between the left IFC and LTC suggesting a typical activation related to lexico-semantic representations. For older adults, our results reveal the existence of bi-directional interaction between the IFC and MTC, but not between the IFC and LTC - which in turn suggests that older adults adapt a new strategy, via supplemental access to conceptual access and semantic retrieval processes. This neural compensation strategy would be facilitated by a top-down mechanism from the IFC to the MTC. We discuss our results in the context of the possible additional strategies used by older compared to younger adults, to retrieve and produce words.

Endolymphatic hydrops imaging: Differential diagnosis in patients with Meniere disease symptoms.

PURPOSE: The goal of this retrospective study was to investigate the differential diagnosis of endolymphatic hydrops in patients with Meniere's disease (MD) symptoms by using magnetic resonance imaging (MRI) with intravenous injection of gadolinium chelate and delayed acquisition. MATERIAL AND METHOD: Two hundred patients (133 women, 67 men; mean age=67.2±11 ([SD] years) with unilateral MD underwent MRI at 3-T, between 4.5 and 5.5hours after intravenous administration of gadoterate meglumine at a dose of 0.1mmol/kg. MR images were analyzed for the presence of saccular hydrops, perilymphatic fistulae, inner ear malformations, semicircular canal (SCC) abnormal enhancement and brain lesions. We also tested the potential relationship between past history of gentamicin intratympanic administration and perilymphatic fistula presence and SCC aspect. RESULTS: Saccular hydrops were found in 96/200 patients with MD (48%). Three patients (1.5%) had perilymphatic fistulas associated with saccular hydrops, as confirmed by surgery. There was a correlation between the presence of perilymphatic fistula and past history of intratympanic gentamicin administration (P=0.02). We detected inner ear malformations in 5 patients (2.5%), SCC local enhancement in 15 patients (7.5%) always on the same side than the clinical symptoms of MD. There was a correlation between the presence of SCC abnormal enhancement and past intratympanic gentamicin administration (P=0.001). Five patients (2.5%) had brain lesions along central cochleovestibular pathways. CONCLUSION: MRI may reveal brain lesions, SCC abnormalities and perilymphatic fistulae in patients with clinical MD.

The Central Bright Spot Sign: A Potential New MR Imaging Sign for the Early Diagnosis of Anterior Ischemic Optic Neuropathy due to Giant Cell Arteritis.

BACKGROUND AND PURPOSE: A rapid identification of the etiology of anterior ischemic optic neuropathy is crucial because it determines therapeutic management. Our aim was to assess MR imaging to study the optic nerve head in patients referred with anterior ischemic optic neuropathy, due to either giant cell arteritis or the nonarteritic form of the disease, compared with healthy subjects. MATERIALS AND METHODS: Fifteen patients with giant cell arteritis-related anterior ischemic optic neuropathy and 15 patients with nonarteritic anterior ischemic optic neuropathy from 2 medical centers were prospectively included in our study between August 2015 and May 2016. Fifteen healthy subjects and patients had undergone contrast-enhanced, flow-compensated, 3D T1-weighted MR imaging. The bright spot sign was defined as optic nerve head enhancement with a 3-grade ranking system. Two radiologists and 1 ophthalmologist independently performed blinded evaluations of MR imaging sequences with this scale. Statistical analysis included interobserver agreement. RESULTS: MR imaging scores were significantly higher in patients with giant cell arteritis-related anterior ischemic optic neuropathy than in patients with nonarteritic anterior ischemic optic neuropathy (P ≤ .05). All patients with giant cell arteritis-related anterior ischemic optic neuropathy (15/15) and 7/15 patients with nonarteritic anterior ischemic optic neuropathy presented with the bright spot sign. No healthy subjects exhibited enhancement of the anterior part of the optic nerve. There was a significant relationship between the side of the bright spot and the side of the anterior ischemic optic neuropathy (P ≤ .001). Interreader agreement was good for observers (κ = 0.815). CONCLUSIONS: Here, we provide evidence of a new MR imaging sign that identifies the acute stage of giant cell arteritis-related anterior ischemic optic neuropathy; patients without this central bright spot sign always had a nonarteritic pathophysiology and therefore did not require emergency corticosteroid therapy.

Diffusion MRI: literature review in salivary gland tumors.

Surgical resection is currently the best treatment for salivary gland tumors. A reliable magnetic resonance imaging mapping, encompassing tumor grade, location, and extension may assist safe and effective tumor resection and provide better information for patients regarding potential risks and morbidity after surgical intervention. However, direct examination of the tumor grade and extension using conventional morphological MRI remains difficult, often requiring contrast media injection and complex algorithms on perfusion imaging to estimate the degree of malignancy. In addition, contrast-enhanced MRI technique may be problematic due to the recently demonstrated gadolinium accumulation in the dentate nucleus of the cerebellum. Significant developments in magnetic resonance diffusion imaging, involving voxel-based quantitative analysis through the measurement of the apparent diffusion coefficient, have enhanced our knowledge on the different histopathological salivary tumor grades. Other diffusion imaging-derived techniques, including high-order tractography models, have recently demonstrated their usefulness in assessing the facial nerve location in parotid tumor context. All of these imaging techniques do not require contrast media injection. Our review starts by outlining the physical basis of diffusion imaging, before discussing findings from diagnostic studies testing its usefulness in assessing salivary glands tumors with diffusion MRI.

Evaluation of tumour vascular distribution and function using immunohistochemistry and BOLD fMRI with carbogen inhalation.

AIM: To evaluate oxygenation changes in rat subcutaneous C6 gliomas using blood-oxygen-level dependent (BOLD) functional magnetic resonance imaging (fMRI) combined with non-haemodynamic response function (non-HRF) analysis. MATERIALS AND METHODS: BOLD fMRI were performed during carbogen inhalation in 20 Wistar rats bearing gliomas. Statistical maps of spatial oxygenation changes were computed by a dedicated non-HRF analysis algorithm. Three types of regions of interest (ROIs) were defined: (1) maximum re-oxygenation zone (ROImax), (2) re-oxygenation zones that were less than the maximum re-oxygenation (ROInon-max), and (3) zones without significant re-oxygenation (ROInone). The values of percent BOLD signal change (PSC), percent enhancement (ΔSI), and significant re-oxygenation (T) were extracted from each ROI. Tumours were sectioned for histology using the fMRI scan orientation and were stained with haematoxylin and eosin and CD105. The number of microvessels (MVN) in each ROI was counted. Differences and correlations among the values for T, PSC, ΔSI, and MVN were determined. RESULTS: After carbogen inhalation, the PSC significantly increased in the ROImax areas (p<0.01) located in the tumour parenchyma. No changes occurred in any of the ROInone areas (20/20). Some changes occurred in a minority of the ROInon-max areas (3/60) corresponding to tumour necrosis. MVN and PSC (R=0.59, p=0.01) were significantly correlated in the ROImax areas. In the ROInon-max areas, MVN was significantly correlated with PSC (R=0.55, p=0.00) and ΔSI (R=0.37, p=0.00). CONCLUSIONS: Statistical maps obtained via BOLD fMRI with non-HRF analysis can assess the re-oxygenation of gliomas.

Value of brain MRI in infective endocarditis: a narrative literature review.

The nervous system is frequently involved in patients with infective endocarditis (IE). A systematic review of the literature was realized in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA). This study sought to systematically evaluate the published evidence of the contribution of brain magnetic resonance imaging (MRI) in IE. The aim was to identify studies presenting the incidence and type of MRI brain lesions in IE. Fifteen relevant studies were isolated using the Medline, Embase, and Cochrane databases. Most of them were observational studies with a small number of patients. MRI studies demonstrated a wide variety and high frequency of cerebral lesions, around 80 % of which were mostly clinically occult. This review shows MRI's superiority compared to brain computed tomography (CT) for the diagnosis of neurologic complications. Recent developments of sensitive MRI sequences can detect microinfarction and cerebral microhemorrhages. However, the clinical significance of these microhemorrhages, also called cerebral microbleeds (CMBs), remains uncertain. Because some MRI neurological lesions are a distinctive IE feature, they can have a broader involvement in diagnosis and therapeutic decisions. Even if cerebral MRI offers new perspectives for better IE management, there is not enough scientific proof to recommend it in current guidelines. The literature remains incomplete regarding the impact of MRI on concerted decision-making. The long-term prognosis of CMBs has not been evaluated to date and requires further studies. Today, brain MRI can be used on a case-by-case basis based on a clinician's appraisal.

Functional MRI evidence for the decline of word retrieval and generation during normal aging.

This fMRI study aimed to explore the effect of normal aging on word retrieval and generation. The question addressed is whether lexical production decline is determined by a direct mechanism, which concerns the language operations or is rather indirectly induced by a decline of executive functions. Indeed, the main hypothesis was that normal aging does not induce loss of lexical knowledge, but there is only a general slowdown in retrieval mechanisms involved in lexical processing, due to possible decline of the executive functions. We used three tasks (verbal fluency, object naming, and semantic categorization). Two groups of participants were tested (Young, Y and Aged, A), without cognitive and psychiatric impairment and showing similar levels of vocabulary. Neuropsychological testing revealed that older participants had lower executive function scores, longer processing speeds, and tended to have lower verbal fluency scores. Additionally, older participants showed higher scores for verbal automatisms and overlearned information. In terms of behavioral data, older participants performed as accurate as younger adults, but they were significantly slower for the semantic categorization and were less fluent for verbal fluency task. Functional MRI analyses suggested that older adults did not simply activate fewer brain regions involved in word production, but they actually showed an atypical pattern of activation. Significant correlations between the BOLD (Blood Oxygen Level Dependent) signal of aging-related (A > Y) regions and cognitive scores suggested that this atypical pattern of the activation may reveal several compensatory mechanisms (a) to overcome the slowdown in retrieval, due to the decline of executive functions and processing speed and (b) to inhibit verbal automatic processes. The BOLD signal measured in some other aging-dependent regions did not correlate with the behavioral and neuropsychological scores, and the overactivation of these uncorrelated regions would simply reveal dedifferentiation that occurs with aging. Altogether, our results suggest that normal aging is associated with a more difficult access to lexico-semantic operations and representations by a slowdown in executive functions, without any conceptual loss.

Fibromuscular dysplasia: what the radiologist should know: a pictorial review.

UNLABELLED: Fibromuscular dysplasia (FMD) is an idiopathic, segmentary, non-inflammatory and non-atherosclerotic disease that can affect all layers of both small- and medium-calibre arteries. The prevalence of FMD is estimated between 4 and 6 % in the renal arteries and between 0.3 and 3 % in the cervico-encephalic arteries. FMD most frequently affects the renal, carotid and vertebral arteries, but it can theoretically affect any artery. Radiologists play an important role in the diagnosis of FMD, and good knowledge of FMD's signs will certainly help reduce the delay between the first symptoms and diagnosis. The common string-of-beads aspect is well known, but less common presentations also have to be considered. These less common imaging findings include vascular loops, fusiform vascular ectasia, arterial dissection, aneurysm and subarachnoid haemorrhage. These radiologic presentations should be known by radiologists in order to diagnose possible FMD, particularly when present in young females or when associated with personal or familial hypertension, to reduce the delay between the onset of the first symptom and the final diagnosis. The patients have to be referred to specialised FMD centres for dedicated management. TEACHING POINTS: • Fibromuscular dysplasia is not a rare disease. • Radiologists should recognise less common presentations to orient specific management. • Vascular loops, fusiform vascular ectasia and a "string-of-beads" aspect are typical presentations. • Arterial dissection, aneurysm and subarachnoid haemorrhage are less typical radiologic presentations.

Recurrent peripheral vestibulopathy: Is MRI useful for the diagnosis of endolymphatic hydrops in clinical practice?

OBJECTIVES: Recurrent peripheral vestibulopathy (RPV) is a public health problem, yet the aetiology remains unclear. Recent developments in MRI of endolymphatic hydrops (EH) allow for a better understanding of inner ear disorders. We intended to study the prevalence of EH in patients with RPV, in comparison to those with Meniere's disease (MD). METHODS: MRI examinations were performed 4 hours after intravenous injection of gadoteric acid in 132 patients with RPV (n = 64) and MD (n = 68). Two radiologists retrospectively studied the prevalence and localization of EH in RPV and MD groups. Patients were graded based on the number and localization of hydrops, between 1 (EH in either cochlea or vestibule on one side) and 4 (EH in cochlea and vestibule on both ears). RESULTS: We identified EH in 31 out of 64 patients and in 61 out of 68 patients in the RPV and MD groups, respectively. There was a significant difference regarding the number of subjects with EH between the two groups (p ≤ 0.01), with a higher average number of hydrops localization in MD group (p ≤ 0.01). CONCLUSION: MRI may reveal EH in some cases among patients with RPV, suggesting a similar pathophysiological mechanism in comparison with MD. KEY POINTS: • MRI may reveal endolymphatic hydrops in some patients with recurrent peripheral vestibulopathy. • We suggest a similar pathophysiological mechanism in recurrent vestibulopathy and Meniere's Disease. • MRI with delayed acquisition helps clinicians to assess patients with recurrent vestibulopathy. • The outcome would be to aid the development of adapted therapeutic strategies. • MRI of endolymphatic hydrops should probably be included in future diagnostic protocols.

Inhibitory control and error monitoring by human subthalamic neurons.

The subthalamic nucleus (STN) has been shown to be implicated in the control of voluntary action, especially during tasks involving conflicting choice alternatives or rapid response suppression. However, the precise role of the STN during nonmotor functions remains controversial. First, we tested whether functionally distinct neuronal populations support different executive control functions (such as inhibitory control or error monitoring) even within a single subterritory of the STN. We used microelectrode recordings during deep brain stimulation surgery to study extracellular activity of the putative associative-limbic part of the STN while patients with severe obsessive-compulsive disorder performed a stop-signal task. Second, 2-4 days after the surgery, local field potential recordings of STN were used to test the hypothesis that STN oscillations may also reflect executive control signals. Extracellular recordings revealed three functionally distinct neuronal populations: the first one fired selectively before and during motor responses, the second one selectively increased their firing rate during successful inhibitory control, and the last one fired selectively during error monitoring. Furthermore, we found that beta band activity (15-35 Hz) rapidly increased during correct and incorrect behavioral stopping. Taken together, our results provide critical electrophysiological support for the hypothesized role of the STN in the integration of motor and cognitive-executive control functions.

The different faces of central nervous system metastases.

Cerebral metastases are the commonest central nervous system tumors. The MR assessment should include T1-weighted images with and without enhancement and T2/FLAIR images. They usually appear as multiple lesions with nodular or annular enhancement and are surrounded by edema. They are hypervascularized and have no restriction of their diffusion coefficient in their necrotic area and contain lipids on 1H spectroscopy. Metastases can be distinguished from primary tumors by the lack of malignant cell infiltration around the tumor. Stereotactic radiotherapy may temporarily increase tumor volume, although this is not of adverse oncological value. Less commonly, spinal disease may be asymptomatic and should be examined by MR.

Neurological imaging of brain damages after radiotherapy and/or chimiotherapy.

Radiotherapy and chemotherapy may induce neurological toxicities with different appearances on CT and MRI scans. While optimized radiotherapy techniques have reduced some complications, new unwanted effects have occurred on account of therapeutic protocols involving the simultaneous use of radiotherapy and chemotherapy. Advances in radio-surgery, innovative anti-angiogenic therapies, as well as prolonged patient survival have led to the emergence of new deleterious side effects. In this report, we describe the early, semi-delayed, and late encephalic complications, while specifying how to identify the morphological lesions depending on the therapeutic protocol.

Functional imaging of cerebral perfusion.

The functional imaging of perfusion enables the study of its properties such as the vasoreactivity to circulating gases, the autoregulation and the neurovascular coupling. Downstream from arterial stenosis, this imaging can estimate the vascular reserve and the risk of ischemia in order to adapt the therapeutic strategy. This method reveals the hemodynamic disorders in patients suffering from Alzheimer's disease or with arteriovenous malformations revealed by epilepsy. Functional MRI of the vasoreactivity also helps to better interpret the functional MRI activation in practice and in clinical research.

Perfusion imaging in brain disease.

Perfusion CT or MRI have been extensively developed over the last years and are accessible on most imaging machines. Perfusion CT has taken a major place in the assessment of a stroke. Its role has to be specified for the diagnosis and treatment of the vasospasm, complicating a subarachnoid hemorrhage. Perfusion MRI should be included in the assessment of any brain tumor, both at the time of the diagnosis as well as in the post-treatment monitoring. It is included in the multimodal approach required for the optimum treatment of this disease. The applications in epilepsy and the neurodegenerative diseases are in the evaluation process.

Evaluation of dual-source parallel RF excitation technology in MRI of thoraco-lumbar spine at 3.0 T.

High-field 3 T magnetic resonance imaging (MRI) has entered standard clinical practice over the past decade, and its advantages have already been suggested in areas such as neural, musculoskeletal, pelvic and angiographic imaging. However, high-field systems still pose challenges in terms of their specific absorption rate (SAR) and radiofrequency (RF) excitation uniformity. Thus, the aim of the present study was to evaluate the impact, on both these factors, of standard quadrature against parallel RF transmission technology (dual-source parallel RF excitation [DSPE]) in spinal examination at 3 T. The thoracolumbar spine was examined with three different sequences: T1-weighted (T1w); T2-weighted (T2w); and T2w short tau inversion recovery (STIR). Each was acquired with and without DSPE. The manufacturer's implementation of this technology has been associated with optimized handling of patient SAR exposure, resulting in a 38.4% reduction in acquisition time. On comparing sequences with equal repetition times (TRs), the acquisition time reduction was 44.4%. Thus, DSPE allows a reduction in acquisition time. This gain is accompanied by augmentation of the whole-body SAR and diminution of the local SAR. Image quality improvement due to more homogeneous effective transmit B1 was mainly observed at the junction of the thoracolumbar spine.

Per-subject characterization of bolus width in pulsed arterial spin labeling using bolus turbo sampling.

Quantification of cerebral blood flow using QUIPSSII pulsed arterial spin labeling requires that the QUIPSS saturation delay TI1 is shorter than the natural temporal bolus width. Yet the duration of the bolus of tagged spins entering the region of interest varies during vasoactive stimuli such as gaseous challenges or across subjects due to differences in blood velocity or vessel geometry. A new technique, bolus turbo sampling, to rapidly measure the duration of the inflowing bolus is presented. It allows to optimize the arterial spin labeling acquisition to ensure reliable quantification of perfusion while maximizing the arterial spin labeling signal by avoiding the use of unnecessarily short label durations. The average bolus width measured in the right and left middle cerebral artery territories using the bolus turbo sampling technique has a repeatability coefficient of 75 ms and correlates significantly with the TI1,max determined from a novel multi-TI1 protocol (R=0.65, P<0.05). The possibility to measure the bolus width under hypercapnia is demonstrated.

Impaired cerebral vasoreactivity to CO2 in Alzheimer's disease using BOLD fMRI.

OBJECTIVE: To evaluate the cerebral vasoreactivity using blood oxygenation level dependent functional MRI during carbogen inhalation with 7% CO(2) in Alzheimer's disease and amnestic mild cognitive impairment. PARTICIPANTS AND METHODS: Thirty nine subjects were included to be investigated using blood oxygenation level dependent (BOLD) functional MRI at 1.5T during a block-design carbogen inhalation paradigm, with a high concentration face-mask under physiological monitoring. Basal cerebral perfusion was measured using pulsed arterial spin labeling. Image analyses were conducted using Matlab® and SPM5 with physiological regressors and corrected for partial volume effect. RESULTS: Among selected participants, 12 subjects were excluded because of incomplete protocol, leaving for analysis 27 subjects without significant microangiopathy diagnosed for Alzheimer's disease (n=9), amnestic mild cognitive impairment (n=7), and matched controls (n=11). No adverse reaction related to the CO(2) challenge was reported. Carbogen inhalation induced a whole-brain signal increase, predominant in the gray matter. In patients, signal changes corrected for gray matter partial volume were decreased (0.36±0.13% BOLD/mmHg in Alzheimer's disease, 0.36±0.12 in patients with mild cognitive impairment, 0.62±0.20 in controls). Cerebral vasoreactivity impairments were diffuse but seemed predominant in posterior areas. The basal hypoperfusion in Alzheimer's disease was not significantly different from patients with mild cognitive impairment and controls. Among clinical and biological parameters, no effect of apoE4 genotype was detected. Cerebral vasoreactivity values were correlated with cognitive performances and hippocampal volumes. Among age and hippocampal atrophy, mean CVR was the best predictor of the mini-mental status examination. CONCLUSION: This BOLD functional MRI study on CO(2) challenge shows impaired cerebral vasoreactivity in patients with Alzheimer's disease and amnestic mild cognitive impairment at the individual level. These preliminary findings using a new MRI approach may help to better characterize patients with cognitive disorders in clinical practice and further investigate vaso-protective therapeutics.