Posterior reversible encephalopathy and Guillain-Barré syndrome in a single patient: coincidence or causative relation?

We report 62-year-old female patient with coincident posterior reversible encephalopathy syndrome (PRES) and Guillain-Barré syndrome (GBS). The first presentation of PRES was a generalised tonic-clonic seizure. A risk factor for PRES was acute arterial hypertension. The diagnosis of PRES was established by MRI (magnetic resonance imaging) and hypertension was treated with labetalol 800mg daily followed by regression of symptoms of PRES. Two days after the seizure the first motor signs of GBS presented with a weakness in both upper arms. The diagnosis of GBS was finally established 6 days after the seizure by clinical evolution, lumbar puncture and electrophysiological findings. After treatment of GBS with intravenous immunoglobulins (IVIg), antihypertensive therapy could be phased out and finally stopped. The patient was discharged after 25 days without any medication. At that time she was completely recovered from PRES and recovering well from GBS. The acute arterial hypertension, the provoking factor of PRES, was probably caused by an autonomic dysfunction in the context of GBS before motor signs of GBS were present but we speculate also that there are other GBS related factors playing a role in PRES. This hypothesis is based on the relatively high coincidence of these two rare syndromes which appears from a review of the literature. One other possible mechanism can be the influence of cytokines, produced in the context of a GBS, on the permeability of blood brain barrier.

Functional MRI of the cervical spinal cord on 1.5 T with fingertapping: to what extent is it feasible?

INTRODUCTION: Until recently, functional magnetic resonance imaging (fMRI) with blood oxygen level-dependent (BOLD) contrast, was mainly used to study brain physiology. The activation signal measured with fMRI is based upon the changes in the concentration of deoxyhaemoglobin that arise from an increase in blood flow in the vicinity of neuronal firing. Technical limitations have impeded such research in the human cervical spinal cord. The purpose of this investigation was to determine whether a reliable fMRI signal can be elicited from the cervical spinal cord during fingertapping, a complex motor activity. Furthermore, we wanted to determine whether the fMRI signal could be spatially localized to the particular neuroanatomical location specific for this task. METHODS: A group of 12 right-handed healthy volunteers performed the complex motor task of fingertapping with their right hand. T2*-weighted gradient-echo echo-planar imaging on a 1.5-T clinical unit was used to image the cervical spinal cord. Motion correction was applied. Cord activation was measured in the transverse imaging plane, between the spinal cord levels C5 and T1. RESULTS: In all subjects spinal cord responses were found, and in most of them on the left and the right side. The distribution of the activation response showed important variations between the subjects. While regions of activation were distributed throughout the spinal cord, concentrated activity was found at the anatomical location of expected motor innervation, namely nerve root C8, in 6 of the 12 subjects. CONCLUSION: fMRI of the human cervical spinal cord on an 1.5-T unit detects neuronal activity related to a complex motor task. The location of the neuronal activation (spinal cord segment C5 through T1 with a peak on C8) corresponds to the craniocaudal anatomical location of the neurons that activate the muscles in use.

[Structure and content of the radiological report: an audit of 94 reports from a university education center]. / Structuur en inhoud van het radiologieverslag: een audit van 94 verslagen uit een universitair opleidingscentrum.

Efficient communication between the radiologist and the referring clinician is an essential feature of high quality radiology practice. The written report, the only result of the radiological investigation most clinicians will see, should therefore comply with a number of quality criteria. As far as reporting in Dutch is concerned, these criteria have not been clearly defined. Articles on the radiology report are scarce and mostly focus on reporting in English. We have investigated the quality of radiology reporting in a university hospital in Flanders, the Dutch speaking part of Belgium. A weighed sample of 94 reports of 24 radiologists (staff members and radiologists-in-training) was blinded and evaluated by a qualified radiologist with ten years of experience as a writer and editor-in-chief medical magazines. A scoring system was applied, based on five criteria: comprehensible, problem-oriented, correct Dutch, concise, and direct. This article gives an overview of the results and takes a closer look at three of the 94 reports examined.

Spinal tumors.

Spinal tumors are uncommon lesions but may cause significant morbidity in terms of limb dysfunction. In establishing the differential diagnosis for a spinal lesion, location is the most important feature, but the clinical presentation and the patient's age and gender are also important. Magnetic resonance (MR) imaging plays a central role in the imaging of spinal tumors, easily allowing tumors to be classified as extradural, intradural-extramedullary or intramedullary, which is very useful in tumor characterization. In the evaluation of lesions of the osseous spine both computed tomography (CT) and MR are important. We describe the most common spinal tumors in detail. In general, extradural lesions are the most common with metastasis being the most frequent. Intradural tumors are rare, and the majority is extramedullary, with meningiomas and nerve sheath tumors being the most frequent. Intramedullary tumors are uncommon spinal tumors. Astrocytomas and ependymomas comprise the majority of the intramedullary tumors. The most important tumors are documented with appropriate high quality CT or MR images and the characteristics of these tumors are also summarized in a comprehensive table. Finally we illustrate the use of the new World Health Organization (WHO) classification of neoplasms affecting the central nervous system.

Cervical spine fractures and soft tissue injuries.

Spinal cord injury is the major cause of quadriplegia and disability. Plain radiographs have a low sensitivity for identifying traumatic cervical spine lesions. Therefore trauma victims with plain films negative for cervical injury but with a high clinical suspicion of injury, or positive for cervical injury should undergo CT or MR for a more definitive evaluation of the cervical spine. Besides the higher sensitivity than plain radiography in detecting fractures, CT is also able to show soft-tissue abnormalities. MR is the definitive modality in assessing cervical soft-tissue injuries, especially in the evaluation of the spinal cord, intervertebral discs, and ligaments. It also allows differentiate spinal cord hemorrhage and edema, which may have a prognostic value. The role of medical imaging in the evaluation of whiplash injuries remains to be determined.

Tuberculosis of the central nervous system: overview of neuroradiological findings.

This article presents the range of manifestations of tuberculosis (TB) of the craniospinal axis. Central nervous system (CNS) infection with Mycobacterium tuberculosis occurs either in a diffuse form as basal exudative leptomeningitis or in a localized form as tuberculoma, abscess, or cerebritis. In addition to an extensive review of computed tomography and magnetic resonance features, the pathogenesis and the relevant clinical setting are discussed. Modern imaging is a cornerstone in the early diagnosis of CNS tuberculosis and may prevent unnecessary morbidity and mortality. Contrast-enhanced MR imaging is generally considered as the modality of choice in the detection and assessment of CNS tuberculosis.

Phase-contrast magnetic resonance angiography.

Time of flight (TOF) and phase contrast (PC) magnetic resonance angiography (MRA) are two established magnetic resonance (MR) techniques that were described and developed in the 1980s. Both of these techniques usually do not involve the use of intravascular contrast, but rather exploit the intrinsic contrast provided by flowing blood to produce vascular signal. Bolus infused (gadolinium-enhanced) MR angiography was only introduced in 1993. PC-MRA uses the phase shifts introduced to nuclei with motion in the presence of a magnetic field gradient. A bipolar magnetic field gradient will induce a phase shift to nuclei moving along the gradient dependent on the velocity, as well as acceleration and higher order motion terms. More complex gradient waveforms enable sensitivity to specific motion terms such as velocity or acceleration. By constructing an image in which the intensity is proportional to the phase shift of the nuclei, it is possible to create an angiographic image related to the flow properties of blood (or other liquids such as cerebrospinal fluid). The PC-MRA is a powerful technique and allows for encoding of flow in one or many directions in such a way that the velocity sensitivity can be chosen depending on the vessel of interest. This technique also allows for quantification of flow velocity and flow rate, which is not generally available with other angiographic techniques.

Review article: MRI of the postoperative lumbar spine.

Imaging assessment of the lumbosacral spine following surgery is complex and depends upon several factors, including the anatomy of the patient, the surgical procedure and the disease process for which it was performed, the age of the patient, the biomechanical condition of the underlying cortical and cancellous bone, intervertebral disc and musculoligamentous tissues, the time since surgery procedure and the duration and nature of the postsurgical syndrome. Depending upon these factors, one or a combination of complementary imaging modalities may be required to demonstrate any clinically relevant abnormality, to assist the surgeon in deciding if repeat surgery is necessary, its nature and at which vertebral level(s) it should be directed. This review stresses the important role of MRI following lumbar discectomy, intervertebral fusion and/or instrumentation in achieving the most beneficial and timely outcome in the patient presenting with an acute, subacute or chronic failed back surgery syndrome.