Agreement between neuroimages and reports for natural language processing-based detection of silent brain infarcts and white matter disease.

BACKGROUND: There are numerous barriers to identifying patients with silent brain infarcts (SBIs) and white matter disease (WMD) in routine clinical care. A natural language processing (NLP) algorithm may identify patients from neuroimaging reports, but it is unclear if these reports contain reliable information on these findings. METHODS: Four radiology residents reviewed 1000 neuroimaging reports (RI) of patients age > 50 years without clinical histories of stroke, TIA, or dementia for the presence, acuity, and location of SBIs, and the presence and severity of WMD. Four neuroradiologists directly reviewed a subsample of 182 images (DR). An NLP algorithm was developed to identify findings in reports. We assessed interrater reliability for DR and RI, and agreement between these two and with NLP. RESULTS: For DR, interrater reliability was moderate for the presence of SBIs (k = 0.58, 95 % CI 0.46-0.69) and WMD (k = 0.49, 95 % CI 0.35-0.63), and moderate to substantial for characteristics of SBI and WMD. Agreement between DR and RI was substantial for the presence of SBIs and WMD, and fair to substantial for characteristics of SBIs and WMD. Agreement between NLP and DR was substantial for the presence of SBIs (k = 0.64, 95 % CI 0.53-0.76) and moderate (k = 0.52, 95 % CI 0.39-0.65) for the presence of WMD. CONCLUSIONS: Neuroimaging reports in routine care capture the presence of SBIs and WMD. An NLP can identify these findings (comparable to direct imaging review) and can likely be used for cohort identification.

Primary meningeal melanoma masquerading as neurofibromatosis type 2: illustrative case.

BACKGROUND: Primary meningeal melanocytic neoplasms are exceedingly rare tumors, representing only 0.06% to 0.1% of all primary brain tumors and ranging in spectrum from benign localized tumors to highly aggressive malignant lesions. The diagnosis of these tumors is often challenging from clinical, radiological, and pathologic standpoints. Equally challenging is the distinction between primary meningeal melanocytic neoplasm and metastatic melanoma. OBSERVATIONS: The authors reported the case of a 41-year-old man with imaging findings diagnostic of neurofibromatosis type 2: bilateral internal auditory canal lesions (most consistent with bilateral vestibular schwannomas), two dura-based lesions presumed to be meningiomas, multiple spinal lesions consistent with peripheral nerve sheath tumors, and one intramedullary spinal lesion consistent with an ependymoma. Biopsy of these lesions revealed melanocytic neoplasms with mild to moderate atypia and a mildly elevated proliferation index, which made the distinction between benign and malignant challenging. In addition, the disseminated nature of these tumors made it difficult to determinate whether they arose from the meninges or represented metastases from an occult primary melanoma. LESSONS: This case illustrated the challenges presented by the diagnosis of meningeal melanocytic neoplasms and highlighted the importance of integrating the clinical and radiographic findings with histologic appearance and molecular studies.

Patients' responses to incidentally discovered silent brain infarcts - a qualitative study.

BACKGROUND: Incidentally discovered silent brain infarcts (id-SBIs) are an understudied condition with probable clinical significance, but it is not known how patients respond to or prioritize this condition. We sought to assess reporting of id-SBIs and how patients approach their diagnosis. METHODS: Patients with id-SBIs were identified from sequential scans between 12/2015-5/2016, were referred by treating clinicians, or self-referred for the study. This study used qualitative semi-structured interviews. Purposeful sampling was used to achieve diversity in acuity, setting, and recruitment strategy. Interviews were audio-recorded and transcribed. A constant comparative method was used to develop a coding schema, find consensus, and iteratively explore emergent themes until thematic saturation was achieved. RESULTS: Only 10 of 102 patients prospectively identified by neuroimaging were informed of the imaging findings. Twelve participants in total were interviewed. Among the study participants, the primary themes were cognitive, emotional, and behavioral responses to diagnostic, prognostic, and therapeutic uncertainty regarding id-SBIs. Clinicians described id-SBIs to participants as an ambiguous condition. Participants feared potential consequences of id-SBIs, including symptomatic stroke, dementia, and disability. Participants attempted to reduce uncertainty with strategies including equating id-SBIs with symptomatic stroke, self-education about stroke, and seeking second opinions. CONCLUSION: Participants considered id-SBIs to be a serious medical condition. Ambiguous counseling by clinicians on id-SBIs provoked or failed to attenuate fear, leading to participants adopting strategies aimed at reducing uncertainty.

Correction: Clinicians' perspectives on incidentally discovered silent brain infarcts - A qualitative study.

[This corrects the article DOI: 10.1371/journal.pone.0194971.].

Clinicians' perspectives on incidentally discovered silent brain infarcts - A qualitative study.

BACKGROUND: While silent brain infarcts (SBIs) in screened cohorts are associated with risk of symptomatic stroke and dementia, the clinical significance of incidentally discovered SBIs (id-SBIs) is unknown. Detection may offer an opportunity to initiate prevention measures, but uncertainties about id-SBIs may impede clinicians from addressing them and complicate further study of this condition. METHODS AND RESULTS: This study used semi-structured interviews of practicing clinicians. Interviews were audio recorded, transcribed, and analyzed using a grounded theory approach. A constant comparative method was used to organize emergent themes and examine new themes. Purposeful sampling was employed to achieve participant diversity. Fifteen clinicians were interviewed. Emergent themes centered on uncertainty about id-SBIs, clinical decision making in response to uncertainty, and evidence needed to resolve uncertainty. All clinicians reported uncertainty about id-SBIs: diagnostic, prognostic, or therapeutic. Differential responses to uncertainties resulted in practice variation within and between specialties. Diagnostic and prognostic uncertainty discouraged disclosure of imaging findings to patients. Vascular neurologists viewed the prognostic significance of id-SBIs as similar to symptomatic stroke. Therapeutic uncertainty was common, but most participants endorsed using stroke secondary prevention strategies. Regarding future research, all internists indicated they would consider changing practices in response to observational studies, whereas half of the neurologists expressed reluctance to modify practices based on non-randomized data. Several expressed concerns about clinical trial feasibility and lack of equipoise. CONCLUSIONS: id-SBIs are a focus of uncertainty for clinicians, leading to practice variation. Future studies must address diagnostic and prognostic uncertainty to facilitate implementation of prevention strategies.

Spinal Intradural, Extramedullary Ependymoma with Astrocytoma Component: A Case Report and Review of the Literature.

Ependymomas are common spinal lesions, with the vast majority arising in an intramedullary location. Several cases have been described in the literature of ependymomas in an intradural, extramedullary location. The authors present a case of a 56-year-old female who presented with several weeks of lower back pain and weakness. MRI revealed an intradural, extramedullary enhancing mass at L1-L2. The mass was successfully resected surgically. Pathologic evaluation revealed a low grade glioma with components of both ependymoma and pilocytic astrocytoma with MUTYH G382D mutation. Extramedullary ependymomas are very rare tumors. To the authors' knowledge, this is the first case of ependymoma/astrocytoma collision tumors described in an extramedullary location.