Admission Magnetic Resonance Imaging Research Articles

Oxygen Extraction Fraction Mapping on Admission Magnetic Resonance Imaging May Predict Recovery of Hyperacute Ischemic Brain Lesions After Successful Thrombectomy: A Retrospective Observational Study.

In acute stroke, diffusion-weighted imaging (DWI) is used to assess the ischemic core. Dynamic-susceptibility contrast perfusion magnetic resonance imaging allows an estimation of the oxygen extraction fraction (OEF), but the outcome of DWI lesions with increased OEF postrecanalization is unclear. This study investigated the impact of OEF on the fate of DWI lesions in patients achieving recanalization after thrombectomy. This was a retrospective analysis of the HIBISCUS-STROKE cohort (Cohort of Patients to Identify Biological and Imaging Markers of Cardiovascular Outcomes in Stroke; NCT: 03149705), a single-center observational study that prospectively enrolled patients who underwent magnetic resonance imaging triage for thrombectomy and a day-6 T2-fluid-attenuated inversion recovery (FLAIR) magnetic resonance imaging. Automated postprocessing of admission dynamic-susceptibility contrast perfusion magnetic resonance imaging generated OEF maps. At visual analysis, the OEF status within DWI lesions was assessed in comparison to the contralateral side and correlated with volume changes (difference of ischemic lesion between admission DWI and registered day-6 T2-FLAIR). At voxel-based analysis, recovered DWI regions (lesions present on the admission DWI but absent on the registered day-6 T2-FLAIR) and nonrecovered regions were segmented to extract semiquantitative OEF values. Of the participants enrolled from 2016 to 2022, 134 of 321 (41.7%) were included (median age, 71.0 years; 58.2% male; median baseline National Institutes of Health Scale score, 15.0). At visual analysis, 46 of 134 (34.3%) patients had increased OEF within DWI lesions. These patients were more likely to show a reduction in ischemic lesion volumes compared with those without increased OEF (median change, -4.0 versus 4.8 mL; P<0.0001). Multivariable analysis indicated that increased OEF within DWI lesions was associated with a reduction in ischemic lesion volumes from admission DWI to day-6 T2-FLAIR (odds ratio, 0.68 [95% CI, 0.49-0.87]; P=0.008). At voxel-based analysis, recovered DWI regions had increased OEF, while nonrecovered regions had decreased OEF (median, 126.9% versus -27.0%; P<0.0001). Increased OEF within hyperacute DWI lesions was associated with ischemic lesion recovery between admission DWI and day-6 T2-FLAIR in patients achieving recanalization after thrombectomy. URL: https://www.clinicaltrials.gov; Unique identifier: NCT03149705.

Optic nerve sheath diameter and its association with brain swelling in pediatric cerebral malaria: a retrospective study.

Mortality in pediatric cerebral malaria (CM) in low- and middle-income countries (LMICs) is associated with brain swelling on magnetic resonance imaging (MRI); however, MRI is unavailable in most LMICs. Optic nerve sheath diameter (ONSD) measurement is an inexpensive method of detecting increased intracranial pressure compared with the invasive opening pressure (OP). Our primary objective was to determine if increased ONSD correlated with brain swelling on MRI in pediatric CM. Our secondary objective was to determine if increased ONSD correlated with increased OP and/or poor neurological outcome in pediatric CM. We hypothesized that increased ONSD would correlate with brain swelling on MRI and increased OP and that ONSD would be higher in survivors with sequelae and non-survivors. We performed a retrospective chart review of children aged 0-12 years in Blantyre, Malawi, from 2013 to 2022 with CM as defined by the World Health Organization. Brain swelling on admission MRI was characterized by brain volume scores (BVS); severe swelling was scored as 7-8, mild-to-moderate as 4-6, normal as 3. The admission ONSD was measured via ultrasound; it was defined as abnormal if it was >4.5 mm in children >1 year and >4 mm in children <1 year. Favorable outcome was defined as a normal neurological exam on discharge in survivors. The primary and secondary objectives were evaluated using Spearman's correlation; and the demographics were compared using chi-square and the Kruskal-Wallis test (Stata, College Station, TX, USA). Median age of the 207-patients cohort was 50 months [interquartile range (IQR) 35-75]; 49% (n = 102) were female. Of those, 73% (n = 152) had a favorable outcome, and 14% (n = 30) died. Twenty-nine (14%) had a normal BVS, 134 (65%) had mild-to-moderate swelling, and 44 (21%) had severe swelling. ONSD was elevated in 86% (n = 178) of patients, while 12% of patients had increased OP. There was a weakly positive correlation between BVS and ONSD (r = 0.14, p = 0.05). The median ONSD was not significantly different compared by discharge outcome (p = 0.11) or by BVS (p = 0.18). ONSD was not a reliable tool to correlate with BVS, neurological outcome, or OP in children with CM. Future studies to identify alternative methods of early identification of CM patients at highest risk for morbidity and mortality are urgently needed.

Diagnostic utility of brain MRI in spontaneous intracerebral hemorrhage: A retrospective cohort study and meta-analysis.

The diagnostic yield of brain Magnetic Resonance Imaging (MRI) in spontaneous intracerebral hemorrhage (ICH) is unclear. We performed both an independent single-center retrospective cohort study and a meta-analysis to assess the detection rate of secondary lesions on MRI in patients with spontaneous ICH. In the retrospective cohort study, we examined 856 consecutive patients with spontaneous ICH. Brain MRI scans on admission and follow-up were assessed for secondary lesions. We also examined clinical and CT radiographic variables associated with secondary lesions in univariable analysis. In the meta-analysis we searched PubMed and EMBASE for articles investigating the secondary lesion detection rate on brain MRI in spontaneous ICH. Of the 856 patients with ICH, 481 (56%) had at least one brain BRI performed [70 ± 14 years, 270 (56% male)]. 462 (54%) had an admission MRI and 138 (16%) had both admission and follow-up MRIs. The detection rate of secondary lesions on admission MRIs was 24/462 (5.2%). 4/127 (3.1%) patients with a negative admission MRI had a lesion identified on follow-up MRI. No clinical or radiographic variables were associated with a secondary lesion on MRI using univariable analysis. The meta-analysis included five studies total (four identified in the PubMed and EMBASE searches and our cohort study) comprising 1147 patients with spontaneous ICH who underwent brain MRI. The pooled detection rate of secondary lesions was 11% (95% CI: 7-16). No predictors of secondary lesion detection were identified in our cohort study. Prospective studies are required to better understand the diagnostic utility of MRI in spontaneous ICH.

545: OPTIC NERVE SHEATH DIAMETER AS A PREDICTOR OF BRAIN SWELLING IN PEDIATRIC CEREBRAL MALARIA

Introduction: Cerebral malaria (CM) is an important cause of death in children in low-and-middle income countries (LMICs) with a case fatality rate of >15%. Brain swelling on magnetic resonance imaging (MRI) is associated with morbidity and mortality in CM; however, this modality is expensive and unavailable in many LMICs. Optic nerve sheath diameter (ONSD) measurement is an inexpensive, non-invasive method of detecting increased ICP in other neurocritical illnesses. We hypothesized that increased ONSD would correlate with brain swelling on MRI and would be higher in survivors with neurological sequelae and non-survivors. Methods: We performed a retrospective chart review of 207 children aged 0-12 years in Blantyre, Malawi from 2013-22 with CM as defined by the World Health Organization. Brain swelling on admission MRI was characterized by brain volume scores (BVS) assigned by two blinded pediatric neuroradiologists; severe swelling was defined as 7-8, mild-to-moderate as 4-6, normal as 3. Admission ONSD measurement was taken via portable ultrasound (GE Logiq e); normal was defined as < 4.5 mm. Favorable outcome in survivors was defined as a grossly normal neurological exam on discharge. Data were compared using Kruskall-Wallis and Pearson’s correlation tests utilizing Stata (College Station, TX). Results: Median age of the cohort was 50 months (IQR 40); 49% (n=102) were female. 73% (n=152) had a favorable outcome, 12% (n=25) an unfavorable outcome, and 14% (n=30) died. Twenty-nine (14%) had a normal BVS, 134 (65%) had mild-to-moderate swelling, and 44 (21%) had severe swelling. ONSD was elevated in 86% (n=178) of patients overall; when compared by BVS group, it was elevated in 79% (n=23) of normal, 87% (n=117) of mild-to-moderate, and 86% (n=38) of severe. There was a weakly positive correlation between BVS and ONSD (r=0.14, p=0.05). Median ONSD was not significantly different when compared by discharge outcome (p=0.11) or when compared by BVS (p=0.18). Conclusions: ONSD was not a reliable tool to identify increased brain swelling as detected on MRI in children with CM. This may be due to heterogenous mechanisms leading to abnormal MRI findings. Future studies to identify an alternative method of early identification of children with CM that are high risk for morbidity and mortality are urgently needed.

Magnetic Resonance Imaging or Computed Tomography for Suspected Acute Stroke: Association of Admission Image Modality with Acute Recanalization Therapies, Workflow Metrics, and Outcomes.

ObjectiveTo examine rates of intravenous thrombolysis (IVT), mechanical thrombectomy (MT), door‐to‐needle (DTN) time, door‐to‐puncture (DTP) time, and functional outcome between patients with admission magnetic resonance imaging (MRI) versus computed tomography (CT).MethodsAn observational cohort study of consecutive patients using a target trial design within the nationwide Swiss‐Stroke‐Registry from January 2014 to August 2020 was carried out. Exclusion criteria included MRI contraindications, transferred patients, and unstable or frail patients. Multilevel mixed‐effects logistic regression with multiple imputation was used to calculate adjusted odds ratios with 95% confidence intervals for IVT, MT, DTN, DTP, and good functional outcome (mRS 0–2) at 90 days.ResultsOf the 11,049 patients included (mean [SD] age, 71 [15] years; 4,811 [44%] women; 69% ischemic stroke, 16% transient ischemic attack, 8% stroke mimics, 6% intracranial hemorrhage), 3,741 (34%) received MRI and 7,308 (66%) CT. Patients undergoing MRI had lower National Institutes of Health Stroke Scale (median [interquartile range] 2 [0–6] vs 4 [1–11]), and presented later after symptom onset (150 vs 123 min, p < 0.001). Admission MRI was associated with: lower adjusted odds of IVT (aOR 0.83, 0.73–0.96), but not with MT (aOR 1.11, 0.93–1.34); longer adjusted DTN (+22 min [13–30]), but not with longer DTP times; and higher adjusted odds of favorable outcome (aOR 1.54, 1.30–1.81).InterpretationWe found an association of MRI with lower rates of IVT and a significant delay in DTN, but not in DTP and rates of MT. Given the delays in workflow metrics, prospective trials are required to show that tissue‐based benefits of baseline MRI compensate for the temporal benefits of CT. ANN NEUROL 2022;92:184–194

Quantitative electrophysiological assessments as predictive markers of lower limb motor recovery after spinal cord injury: a pilot study with an adaptive trial design

Study designObservational, cohort study.Objectives(1) Determine the feasibility and relevance of assessing corticospinal, sensory, and spinal pathways early after traumatic spinal cord injury (SCI) in a rehabilitation setting. (2) Validate whether electrophysiological and magnetic resonance imaging (MRI) measures taken early after SCI could identify preserved neural pathways, which could then guide therapy.SettingIntensive functional rehabilitation hospital (IFR).MethodsFive individuals with traumatic SCI and eight controls were recruited. The lower extremity motor score (LEMS), electrical perceptual threshold (EPT) at the S2 dermatome, soleus (SOL) H-reflex, and motor evoked potentials (MEPs) in the tibialis anterior (TA) muscle were assessed during the stay in IFR and in the chronic stage (>6 months post-SCI). Control participants were only assessed once. Feasibility criteria included the absence of adverse events, adequate experimental session duration, and complete dataset gathering. The relationship between electrophysiological data collected in IFR and LEMS in the chronic phase was studied. The admission MRI was used to calculate the maximal spinal cord compression (MSCC).ResultsNo adverse events occurred, but a complete dataset could not be collected for all subjects due to set-up configuration limitations and time constraints. EPT measured at IFR correlated with LEMS in the chronic phases (r = −0.67), whereas SOL H/M ratio, H latency, MEPs and MSCC did not.ConclusionsAdjustments are necessary to implement electrophysiological assessments in an IFR setting. Combining MRI and electrophysiological measures may lead to better assessment of neuronal deficits early after SCI.

Large vessel cardioembolic stroke and embolic stroke of undetermined source share a common profile of matrix metalloproteinase‐9 level and susceptibility vessel sign length

Embolic stroke of undetermined source (ESUS) accounts for up to 25% of ischemic strokes. Identification of biomarkers that could improve the prediction of stroke subtype and subsequently of stroke prevention still remains a major issue. The HIBISCUS-STROKE cohort includes ischemic stroke patients with large vessel occlusion treated with mechanical thrombectomy following admission magnetic resonance imaging. Presence and length of susceptibility vessel sign (SVS) were assessed by gradient-recalled echo T2*-weighted imaging. Matrix metalloproteinase-9 (MMP-9) was measured on sera collected at admission. A multiple logistic regression model was performed to detect independent markers distinguishing cardioembolic (CE) from large-artery atherosclerosis (LAA) subtype. A total of 147 patients were included, of them the etiology was distributed as follows: 86 (58.5%) CE, 26 (17.7%) LAA, and 35 (23.8%) ESUS. The optimal cutoff for differentiating CE from LAA subtype was 14.5mm for SVS length (sensitivity, 79.7%; specificity, 72.7%) and 1110ng/ml for admission MMP-9 level (sensitivity, 85.3%; specificity, 52.2%). Multivariate analysis revealed that current smoking (odds ratio [OR] 0.07, 95% confidence interval [CI] 0.01-0.93), tandem occlusion (OR 0.01, 95% CI 0.01-0.21), SVS length (OR 0.78, 95% CI 0.63-0.97), and admission MMP-9 level (OR 0.99, 95% CI 0.99-1.00) were inversely associated with CE subtype. SVS length and MMP-9 level did not differ between ESUS and CE subtypes. SVS length and admission MMP-9 level may improve the prediction of CE subtype whose profile is close to ESUS, thus suggesting a common cardiac embolic source.

Matrix Metalloproteinase-9 and Monocyte Chemoattractant Protein-1 Are Associated With Collateral Status in Acute Ischemic Stroke With Large Vessel Occlusion.

In ischemic stroke, inflammatory status may condition the development of collateral circulation. Here we assessed the relationship between systemic inflammatory biomarkers and collateral status in large vessel occlusion before mechanical thrombectomy. HIBISCUS-STROKE is a cohort study including acute ischemic stroke patients with large vessel occlusion treated with mechanical thrombectomy following admission magnetic resonance imaging. MMP-9 (matrix metalloproteinase-9) and MCP-1 (monocyte chemoattractant protein-1) were measured on blood sampling collected at admission. Collateral status was assessed on pretreatment Digital subtraction angiography and categorized into poor (Higashida score, 0-2) and good (Higashida score, 3-4). A multiple logistic regression model was performed to detect independent markers of good collateral status. One hundred and twenty-two patients were included, of them 71 patients (58.2%) had a good collateral status. In univariate analysis, low MMP-9 levels (P=0.01), high MCP-1 levels (P<0.01), a low National Institute of Health Stroke Score (P=0.046), a high diastolic blood pressure (P=0.049), the absence of tandem occlusion (P=0.046), a high Alberta Stroke Program Early CT Score (P<0.01) and a low volume on the diffusion-weighted imaging (P<0.01) were associated with good collateral status. Following multivariate analysis, low MMP-9 levels (P=0.02) and high MCP-1 levels (P<0.01) remained associated with good collateral status. Low MMP-9 and high MCP-1 levels were associated with good pretreatment collateral status in patients with acute ischemic stroke with large vessel occlusion. These results might suggest a relationship between collateral status and inflammation.

Matrix Metalloproteinase-9 Relationship With Infarct Growth and Hemorrhagic Transformation in the Era of Thrombectomy.

Objective: To assess the relationship between matrix metalloproteinase 9 (MMP-9), a proteolytic enzyme involved in the breakdown of the blood-brain barrier, and infarct growth and hemorrhagic transformation in acute ischemic stroke (AIS) with large vessel occlusion (LVO) in the era of mechanical thrombectomy (MT) using the kinetics of MMP-9 and sequential magnetic resonance imaging (MRI).Methods: HIBISCUS-STROKE is a cohort study including AIS patients with LVO treated with MT following admission MRI. Patients underwent sequential assessment of MMP-9, follow-up CT at day 1, and MRI at day 6. The CT scan at day 1 classified any hemorrhagic transformation according to the European Co-operative Acute Stroke Study-II (ECASS II) classification. Infarct growth was defined as the difference between final Fluid-Attenuated Inversion Recovery volume and baseline diffusion-weighted imaging volume. Conditional logistic regression analyses were adjusted for main confounding variables including reperfusion status.Results: One hundred and forty-eight patients represent the study population. A high MMP-9 level at 6 h from admission (H6) (p = 0.02), a high glucose level (p = 0.01), a high temperature (p = 0.04), and lack of reperfusion (p = 0.02) were associated with infarct growth. A high MMP-9 level at H6 (p = 0.03), a high glucose level (p = 0.03) and a long delay from symptom onset to groin puncture (p = 0.01) were associated with hemorrhagic transformation.Conclusions: In this MT cohort study, MMP-9 level at H6 predicts infarct growth and hemorrhagic transformation.

Resection of a Posterior Fossa Endodermal Cyst With Exoscopic Assistance: 2-Dimensional Operative Video.

Neurenteric cysts are rare benign congenital tumors of endodermal origin that most commonly occur in the cervical and upper thoracic spine, with only about 10% to 18% of the reported cases occurring intracranially.1 A definitive preoperative diagnosis is complicated by the variable appearance of neurenteric cysts on magnetic resonance (MR) imaging.2 The recommended treatment of neurenteric cysts is complete surgical resection when possible.3,4 We present a case of a posterior fossa neurenteric cyst. A 33-yr-old man without medical history presented with left-sided headache and mild left-sided facial numbness and weakness. Admission MR imaging revealed a nonenhancing mass, which was hyperintense on T1-weighted MR images, compressing the brainstem anteriorly. The lesion was isointense on T2 FLAIR images and hypointense on diffusion-weighted imaging, initially read as possible epidermoid cyst. The patient underwent a left-sided retrosigmoid craniotomy via far lateral transcondylar approach. The tumor was adjacent to both vertebral arteries, the left PICA, and cranial nerves (CN) VII-XII with superior extension to CN V. The cyst was encased in a thin capsule, and its contents were yellowish in color and ranged from thick liquid to colloidal and caseous consistency. The cyst also contained heavily calcified portions, which were excised using sharp dissection. Images of the cyst wall show that it is focally lined with ciliated columnar epithelium with intracellular mucin confirming an endodermal or neurenteric cyst. After the operation, the patient's symptoms resolved, and he was discharged on postoperative day 4. Postoperative MR images confirmed gross total resection. The patient consented to video production.

Biopsy During Minimally Invasive Intracerebral Hemorrhage Clot Evacuation

The safety and efficacy of brain parenchyma biopsy during minimally invasive (MIS) intracerebral hemorrhage (ICH) clot evacuation has not been previously reported. The objective of this study was to establish the safety and diagnostic efficacy of brain biopsy during MIS ICH clot evacuation and to validate the modified Boston criteria as a predictor of cerebral amyloid angiopathy (CAA) in this cohort. From October 2016 to March 2018, superficial and perihematomal biopsies were collected for 40 patients undergoing MIS ICH clot evacuation and analyzed by the pathology department to assess for various ICH etiologies. Additionally, the admission magnetic resonance imaging or computed tomography scan of each patient was analyzed and evaluated for the likelihood of a CAA etiology based on the modified Boston criteria. Student t test was used to analyze intergroup differences in continuous variables, anda 2-tailed Fisher exact test was used to determine intergroup differences of categorical variables, with significance set at P < 0.05. Two of the 40 patients (5%) experienced postoperative rebleed. Four of the 40 patients (10%) had evidence of CAA on biopsy. Patients with CAA on biopsy were older (P= 0.005) and had a higher prevalence of parietal lobe (P= 0.02) and occipital lobe (P= 0.001) hemorrhage. The modified Boston criteria had a sensitivity of 100% (95% confidence interval [CI], 39.6%-100%) and a specificity of 72.2% (95% CI, 54.6%-84.2%) for predicting CAA on biopsy. Brain biopsy in MIS ICH clot evacuation is safe and allows for the diagnosis of various ICH etiologies.

Recrudescence of Deficits After Stroke

Reemergence of previous stroke-related deficits (or poststroke recrudescence [PSR]) is an underrecognized and inadequately characterized phenomenon. To investigate the clinical features, triggers, and risk factors for PSR. This retrospective study incorporated a crossover cohort study to identify triggers and a case-control study to identify risk factors. The study used the Massachusetts General Hospital Research Patient Data Repository to identify patients for the period January 1, 2000, to November 30, 2015, who had a primary or secondary diagnosis of cerebrovascular disease, who underwent magnetic resonance imaging of the brain at least once, and whose inpatient or outpatient clinician note or discharge summary stated the term recrudescence. In all, 153 patients met the preliminary diagnostic criteria for PSR: transient worsening of residual poststroke focal neurologic deficits or transient recurrence of prior stroke-related focal deficits, admission magnetic resonance imaging showing a chronic stroke but no acute infarct or hemorrhage, no evidence of transient ischemic attack or seizure, no acute lesion on diffusion-weighted imaging, and no clinical or electroencephalographic evidence of seizure around the time of the event. Clinical and imaging features of PSR; triggers (identified by comparing PSR admissions with adjacent admissions without PSR); and risk factors (identified by comparing PSR cases with control cases from the Massachusetts General Hospital Stroke Registry). Of the 153 patients, 145 had prior infarct, 8 had hypertensive brain hemorrhage, and 164 admissions for PSR were identified. The patients' mean (SD) age was 67 (16) years, and 92 (60%) were women. Recrudescence occurred a mean (SD) of 3.9 (0.6) years after the stroke, lasted 18.4 (20.4) hours, and was resolved on day 1 for 91 of the 131 episodes with documented resolution time (69%). Deficits were typically abrupt and mild and affected motor-sensory or language function. No patient had isolated gaze paresis, hemianopia, or neglect. During PSR, the National Institutes of Health Stroke Scale (NIHSS) score worsened by a mean (SD) 2.5 (1.9) points, and deficits were limited to a single NIHSS item in 62 episodes (38%). The underlying chronic strokes were variably sized, predominantly affected white matter tracts, and involved the middle cerebral artery territory for 112 patients (73%). Infection, hypotension, hyponatremia, insomnia or stress, and benzodiazepine use were higher during PSR admissions. Compared with the control group (patients who did not experience recrudescence), the PSR group (patients who were hospitalized for recrudescence) had more women, African American individuals, and those who self-identified as being from "other" race. The PSR group also had more diabetes, dyslipidemia, smoking, infarcts from small-vessel disease, and "other definite" causes and worse onset NIHSS scores. Six patients (4%) received intravenous tissue plasminogen activator without complications. The PSR features identified in the study should enable prompt diagnosis and distinguish recrudescence from mimics, such as transient ischemic attacks, migraine, Todd paralysis, and Uhthoff phenomenon. Prospective studies are required to validate the proposed diagnostic criteria and to decipher underlying mechanisms.

White Matter Hyperintensity Volume Correlates with Matrix Metalloproteinase-2 in Acute Ischemic Stroke

White matter hyperintensity (WMH), a common radiographic finding associated with stroke risk and outcome, has been linked to matrix metalloproteinase (MMP) activity and increased levels of oxidative stress in nonstroke populations. We sought to determine whether WMH severity is associated with plasma levels of MMPs and oxidative stress (F2-isoprostane) in subjects with acute ischemic stroke (AIS). We measured plasma biomarker levels at baseline and 48 hours in consecutive AIS subjects. White matter hyperintensity volume (WMHv) was quantified on admission magnetic resonance imaging using a validated semiautomated protocol, and Spearman correlation coefficients were derived for all measured biomarkers. We enrolled 405 AIS subjects (mean age 70±15 years; 58% male; median WMHv 3.4 cm3, interquartile range 1.4-9.5). WMHv and age were strongly correlated (ρ=.57, P<.0001). WMHv and MMP-2 levels were correlated at baseline (ρ=.23, P<.0001) and at 48 hours poststroke (ρ=.19, P=.002). In multivariate analysis, 48-hour MMP-2 levels were independently associated with WMHv (β=.12, P=.04). MMP-9 and F2-isioprostane levels did not correlate with WMHv. In AIS patients, MMP-2 levels are associated with the pre-existing burden of WMH. If validated, these findings may further elucidate the role of MMP-2 in pathophysiology of chronic cerebrovascular injury, such as WMH, and in brain susceptibility to acute ischemia.

′Wine Glass′ sign in recurrent postpartum hypernatremic osmotic cerebral demyelination

Osmotic demyelination syndrome resulting from postpartum hypernatremia is a recently described entity wherein young women present with hypernatremic encephalopathy and white matter hyperintensities along with quadriparesis from rhabdomyolysis. It is an acute monophasic condition with acute hypernatremia occurring during puerperium with good recovery in majority of the patients with treatment. To the best of our knowledge, recurrent postpartum hypernatremia with encephalopathy, osmotic demyelination, and rhabdomyolysis has not been described. We present a young lady who had two episodes of reversible postpartum hypernatremic encephalopathy with rhabdomyolysis. Cerebral magnetic resonance imaging (MRI) before treatment revealed osmotic demyelination on both occasions. During first admission MRI revealed hyperintensities in internal capsule and corpus callosum, and at second admission revealed more extensive white matter hyperintensity, which simulated the ‘wine glass’ appearance.

Pituitary apoplexy in the magnetic resonance imaging era: clinical significance of sphenoid sinus mucosal thickening

The authors report their experience with pituitary apoplexy and evaluate the clinical significance of sphenoid sinus mucosal thickening found on magnetic resonance (MR) imaging. The cases of 28 patients (19 males and nine females) with pituitary apoplexy were reviewed retrospectively. The mean age of the patients was 50 years (range 16-83 years), and the mean follow-up duration was 32 months (range 1-104 months). Admission MR imaging demonstrated hemorrhage or infarction in a pituitary tumor in each patient. A clinical grading scale for apoplexy was devised as follows: Grade I, presence of acute headache and/or endocrine abnormality (12 patients); Grade II, presence of the foregoing symptoms as well as cranial nerve deficit (visual and/or oculomotor; 15 patients); and Grade III, presence of all of these symptoms and a decreased level of consciousness (one patient). Twenty-five patients (89%) underwent early transsphenoidal resection within 9 days (80% within 72 hours) of diagnosis. Headaches and oculomotor paresis resolved completely in 100%, visual function resolved completely in 44% and partially in 56%, and hypopituitarism was reversed in 25%. Twelve patients (43%) required long-term hormone replacement therapy. Two of the three patients who were treated conservatively had prolactin-secreting adenomas, which were treated with dopamine agonist therapy. Thickening of sphenoid sinus mucosa was present in 22 patients (79%). Fifty percent of patients in Grade I and 100% of those in Grades II and III, including all those with persistent hypopituitarism and residual visual deficits, had thickened sphenoid sinus mucosa on MR imaging. Patients with thickened sphenoid sinus mucosa had larger tumors that compressed the optic chiasm or cavernous sinus, and these individuals also had a higher rate of cranial nerve deficits at presentation than those without mucosal thickening (73% compared with 0%). Patients with thickened mucosa had a higher rate of hypopituitarism and subsequent long-term hormone replacement therapy than those without thickened mucosa (55% compared with 17%). Thickened sphenoid sinus mucosa may correlate with higher grades of pituitary apoplexy and worse neurological and endocrinological outcomes.