FLAIR Hyperintensity Research Articles

Survival after reoperation for recurrent glioblastoma

Determining which patients will benefit from reoperation for recurrent glioblastoma remains difficult and the impact of the volume of FLAIR signal hyperintensity is not well known. The primary purpose of this study is to analyze the impact of preoperative volume of FLAIR hyperintensity on prognosis. 37 patients who underwent a reoperation for recurrent glioblastoma after initial gross total resection followed by standard chemoradiation were retrospectively reviewed. Volumetric analysis of preoperative MR images from the initial and second surgery was performed and correlated with clinical data. Survival probabilities were estimated using the Kaplan-Meier method and Cox regression to assess the effect of risk factors on time to reoperation (TTR), progression-free survival (PFS) after reoperation, and overall survival (OS). The volumes of FLAIR signal hyperintensity prior to the initial surgery and reoperation were not associated with prognosis. TTR and OS were significantly affected by the preoperative enhancement volume at the initial surgery, with increasing volumes yielding poorer prognosis. Patients with tumor in critical/eloquent areas were found to have a worse prognosis. Median TTR was 11 months, median PFS after reoperation was 3 months, and OS in patients undergoing a reoperation was 21 months. The results suggest FLAIR signal change seen in patients with glioblastoma does not influence time to reoperation, progression-free survival, or overall survival. These findings suggest the amount of FLAIR signal change should not greatly influence a surgeon’s decision to perform a second surgical resection compare to other factors, and when appropriate, aggressive surgical intervention should be considered.

Leukoaraiosis in a 54 Year Old Nigerian Male: A Case Report

Background: Leukoaraiosis is a chronic atherosclerotic disease with an abnormal periventricular and cerebral white matter disease. Hypertension and old age were reported as the most-important risk factor for leukoaraiosis. Other risk factors like diabetes mellitus, abdominal obesity, hyperlipidaemia, tobacco use, alcohol abuse and chronic kidney disease has been reported. The aim of this case report is to highlight leukoaraiosis in a 54 year old Nigerian who presented with neurological manifestation. Case information: we report a case of a 54 year old male with long standing hypertension presenting with features of leukoaraiosis. Result: the diagnosis was confirmed with MRI which revealed scattered nodular white matter T2 and FLAIR hyperintensities in the cerebral cortices with fluid restriction on diffusion weighted imaging. Conclusion: detailed identification and control of risk factors are the main stay of treatment for leukoaraiosis. Hypertension was managed via proper education on dietary and life style modifications, medications and regular follow-up in clinics.

Super Refractory Status Epilepticus in a Case of Post Mumps Autoimmune Encephalitis: A Rare Case Report


 
 
 
 Seizure is a common problem in many paediatric patients. When seizures persist even after 24 hrs of anaesthetic treatment it is known as Super Refractory Status Epilepticus (SRSE). We report a 10 years old girl admitted with fever, altered sensorium and GTCS with a provisional diagnosis of viral encephalitis. In the line of SRSE infusion thiopental was also started after giving first line antiepileptic as per guidelines. Seizures persisted despite six anti-epileptic drugs, steroids and infusion anaesthetic. MRI brain was suggestive of T2W Flair hyperintensity in B/L hippocampal and Para-hippocampal gyrus and CSF and blood positive for Mumps IgM. This was suggestive of Mesial temporal sclerosis (MTS) which is the scarring and loss of neurons in the deepest portion of the temporal lobe due to oxygen starvation to the brain, head trauma, brain infection or without any apparent cause. Dramatic response was seen after 36-48 hours of IVIG administration.
 
 
 

MRI for prediction of hemorrhagic transformation in acute ischemic stroke: a systematic review and meta-analysis.

Hemorrhagic transformation increases mortality and morbidity in patients with acute ischemic stroke. The purpose of this study is to evaluate the diagnostic performance of magnetic resonance imaging (MRI) for prediction of hemorrhagic transformation in acute ischemic stroke. A systematic literature search of MEDLINE and EMBASE was performed up to 27 July 2018, including the search terms "acute ischemic stroke," "hemorrhagic transformation," and "MRI." Studies evaluating the diagnostic performance of MRI for prediction of hemorrhagic transformation in acute ischemic stroke were included. Diagnostic meta-analysis was conducted with a bivariate random-effects model to calculate the pooled sensitivity and specificity. Subgroup analysis was performed including studies using advanced MRI techniques including perfusion-weighted imaging, diffusion-weighted imaging, and susceptibility-weighted imaging. Nine original articles with 665 patients were included. Hemorrhagic transformation is associated with high permeability, hypoperfusion, low apparent diffusion coefficient (ADC), and FLAIR hyperintensity. The pooled sensitivity was 82% (95% confidence interval [CI] 61-93) and the pooled specificity was 79% (95% CI 71-85). The area under the hierarchical summary receiver operating characteristic curve was 0.85 (95% CI 0.82-0.88). Although study heterogeneity was present in both sensitivity (I2=67.96%) and specificity (I2=78.93%), a threshold effect was confirmed. Studies using advanced MRI showed sensitivity of 92% (95% CI 70-98) and specificity of 78% (95% CI 65-87) to conventional MRI. MRI may show moderate diagnostic performance for predicting hemorrhage in acute ischemic stroke although the clinical significance of this hemorrhage is somewhat uncertain.

Prognostic Predictions for Patients with Glioblastoma after Standard Treatment: Application of Contrast Leakage Information from DSC-MRI within Nonenhancing FLAIR High-Signal-Intensity Lesions.

Attempts have been made to quantify the microvascular leakiness of glioblastomas and use it as an imaging biomarker to predict the prognosis of the tumor. The purpose of our study was to evaluate whether the extraction fraction value from DSC-MR imaging within nonenhancing FLAIR hyperintense lesions was a better prognostic imaging biomarker than dynamic contrast-enhanced MR imaging parameters for patients with glioblastoma. A total of 102 patients with glioblastoma who received a preoperative dynamic contrast-enhanced MR imaging and DSC-MR imaging were included in this retrospective study. Patients were classified into the progression (n = 87) or nonprogression (n = 15) groups at 24 months after surgery. We extracted the means and 95th percentile values for the contrast leakage information parameters from both modalities within the nonenhancing FLAIR high-signal-intensity lesions. The extraction fraction 95th percentile value was higher in the progression-free survival group of >24 months than at ≤24 months. The median progression-free survival of the group with an extraction fraction 95th percentile value of >13.32 was 17 months, whereas that of the group of ≤13.32 was 12 months. In addition, it was an independent predictor variable for progression-free survival in the patients regardless of their ages and genetic information. The extraction fraction 95th percentile value was the only independent parameter for prognostic prediction in patients with glioblastoma among the contrast leakage information, which has no statistically significant correlations with the DCE-MR imaging parameters.

Progression of Central Nervous System Vasculopathy in Young Adults with Sickle Cell Anemia

Progression of Central Nervous System Vasculopathy in Young Adults with Sickle Cell Anemia

Subarachnoid haemorrhage due to intracranial vertebral artery dissection presenting with atypical cauda equina syndrome features: case report

BackgroundFailing to recognise the signs and symptoms of subarachnoid haemorrhage (SAH) causes diagnostic delay and may result in poorer outcomes. We report a rare case of SAH secondary to a vertebral artery dissection (VAD) that initially presented with cauda equina-like features, followed by symptoms more typical of SAH.Case presentationA 55-year-old man developed severe lower back pain after sudden movement. Over the next 5 days he developed paraesthesiaes in the feet, progressing to the torso gradually, and reported constipation and reduced sensation when passing urine. On day six he developed left facial palsy, and later gradual-onset headache and intermittent confusion.Magnetic resonance imaging of the brain showed diffuse subarachnoid FLAIR hyperintensity, concerning for blood, including a focus of cortical/subcortical high signal in the left superior parietal lobule, which was confirmed by computed tomography. Digital subtraction angiography demonstrated a left VAD with a fusiform aneurysm.ConclusionWe present a very rare case of intracranial VAD with SAH initially presenting with spinal symptoms. The majority of subsequent clinical features were consistent with a parietal focus of cortical subarachnoid blood, as observed on neuroimaging.

Progressive multifocal leukoencephalopathy (PML) presenting as focal seizures in a filipino male with aids a case report

A 38-year old male, health care worker presented one month PTA with myoclonic jerks of the left upper extremity lasting approximately one minute associated with left hemiparesis. He was initially managed as cerebrovascular disease (CVD) infarct at a local hospital. Brain plain CT scan and MRI were both unremarkable. Patient was discharged with noted improvement of his motor strength. A week after he developed intermittent fever and recurrence of myoclonic seizures. MRI of the brain plain and contrast showed a non-specific and non - enhancing T2W and FLAIR hyperintensities in the right and left parietal white matter due to small vessel ischemic change or foci of demyelination and temporal lobe volume loss (Fig. 1). His social history revealed MSM (male having sex with male). HIV ELISA was positive and CD4 T-cell count was of 22 cells/ul. Blood Cultures, serum electrolytes and Chest X-ray taken were all unremarkable. Patient was started on combination antiretroviral drug therapy, Azithromycin and Cotrimoxazole and Levetiracetam and discharged. He developed recurrent fever, headache, left sided hemiparesis, blurring of vision, focal seizures and progressive deterioration of sensorium and was readmitted. Empiric Ceftriaxone, IV Valproic Acid and Levetiracetam were started.CSF samples were sent for cultures and film array ®assay for meningitis and encephalitis, India ink and TB gene Expert were all negative (Table 1). CSF Polymerase Chain Reaction (PCR) for JC virus was positive. He deteriorated, became comatose and eventually succumbed on the 3rdweek of admission.

MR Imaging of Meningioangiomatosis in a Pediatric Population

Meningioangiomatosis (MA) is a rare intracranial hamartomatous lesion. We retrospectively reviewed the MRIs in 6 pediatric patients with a histopathologic diagnosis of MA. Patients with MA demonstrated a solitary lesion in the frontotemporal regions, with FLAIR hyperintensity and leptomeningeal enhancement. A solitary brain lesion in the frontotemporal lobes associated with leptomeningeal enhancement and T2/FLAIR hyperintensity should include the possibility of MA in a pediatric patient who presents with seizures or headaches.

Multiple sclerosis with adrenal insufficiency mimicking adrenoleucodystrophy

The diagnosis of multiple sclerosis (MS) is based on clinical, radiological and biological findings. A misinterpretation of non specific clinical and radiological findings may contribute to misdiagnosing MS mimickers such as inherited leucoencephalopathies. Mrs NS, a 28 year-old woman was referred to our unit for vertigos and gait disturbances evolving since 15 days. Neurological assessment showed central vestibular syndrome and deep sensory alterations. Brain and spinal cord MRI showed non enhancing T2 and Flair hyperintensities in the parieto-occipital periventricular white matter, cerebellar pedoncules and the cervical portion of the spinal cord. Lumbar puncture showed oligoclonal bands in cerebrospinal fluid. The visual evoked potentials showed bilateral optic demyelinating neuropathy. Biochemistry revealed adrenal insufficiency. The diagnosis of adrenoleucodystrophy in a carrier woman was plausible all the more we noted high Lactate-to-pyruvate ratio. However the dosage of Very-Long-Chain-Fatty-Acids was normal. Hence, the diagnosis of MS was made. The patient received five days pulsed-methylprednisolone and experienced rapid improvement. Many patients are misdiagnosed with multiple sclerosis, and might be given disease modifying therapies while they suffer from metabolic or systemic disorders mimicking inflammatory demyelinating diseases. There are many overlapping factors mainly: inflammation which is the underlying mechanism of X-linked adrenoleucodystrophy (X-ALD), demyelinating optic neuritis, the presence of oligoclonal bands in CSF which were reported in X-ALD patients. In our case we ruled out the diagnosis of X-ALD but this should be considered in patients with atypical MRI features or family history of adrenomyelopathy mainly in males.

1447 A Rare but Fatal Case of N-methyl-D-aspartate Receptor Antibody Encephalitis Associated With a Pancreatic Neuroendocrine Tumor

INTRODUCTION: N-methyl-D-aspartate receptor antibody (NMDAR-Ab) encephalitis is an autoimmune inflammatory condition of the brain thought to be paraneoplastic given its strong association with malignancy, but such related tumors are rarely detected in older males. To our knowledge, there is only a single case report of NMDAR-Ab encephalitis related to a pancreatic neuroendocrine tumor (NET). Here, we report a case of NMDAR-Ab encephalitis associated with pancreatic NET that was fatal despite early tumor resection. CASE DESCRIPTION/METHODS: A 79-year-old man with hypertension presented with acute onset of confusion, agitation, and urinary and bowel incontinence. He was living independently but had progressive short-term memory loss over the year prior. Electroencephalogram showed diffuse slowing without seizure activity. Magnetic resonance imaging of the brain noted trace sulcal FLAIR hyperintensity in perirolandic regions. Cerebrospinal fluid (CSF) analysis revealed elevated protein (96 mg/dL), low nucleated cell count, no oligoclonal bands, and negative infectious serology and cultures. CSF paraneoplastic panel was positive for anti-NR1 antibody, confirming the diagnosis of NMDAR-Ab encephalitis. Malignancy workup revealed a 1.2 cm mass in the pancreatic tail, and endoscopic ultrasound-guided fine-needle biopsy showed positive staining for synaptophysin and chromogranin A consistent with a well-differentiated NET. The patient rapidly declined from worsening encephalopathy and required percutaneous gastrostomy tube placement. He underwent laparoscopic distal pancreatectomy and splenectomy with intravenous immunoglobulin and glucocorticoids, but a repeat CT abdomen next month showed peritoneal metastases with diffuse uptake on somatostatin receptor scintigraphy and rising serum chromogranin A (603 ng/mL). He had no significant neurologic recovery and eventually died on comfort measures without further interventions. DISCUSSION: Though rare, prior cases of NMDAR-Ab encephalitis associated with NET described the importance of early surgical removal of the underlying tumor to provide the best chance of neurologic recovery. Metastatic disease portends a poor prognosis as it renders encephalitis impossible to resolve. Worldwide experience with NMDAR-Ab encephalitis is limited and further observations are needed to refine current treatment strategies.

WERNICKE ENCEPHALOPATHY AFTER GASTRIC BYPASS: A SURPRISING ETIOLOGY OF ALTERED MENTAL STATUS PROGRESSING TO CARDIAC ARREST

SESSION TITLE: Wednesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Wernicke’s Encephalopathy (WE) after bariatric surgery is more frequent than commonly understood. Doctors and patients must be aware of the risk and predisposing factors for WE to effectively prevent this potentially fatal condition. In this case, we present a patient with a late diagnosis of WE, with altered mental status resulting in eventual cardiac arrest and intubation. CASE PRESENTATION: A 63-year-old woman was brought to the ED after being found at home confused. She had no history of alcohol use. She exhibited disconjugate gaze and mental slowing, but was otherwise neurologically intact. CT brain demonstrated no acute changes and labs were normal. The patient had a sleeve gastrectomy 2 months prior, and a history of depression and anxiety. Family reported that following bariatric surgery she had poor oral intake and frequent vomiting. She was admitted for confusion and dehydration, and diagnosed with a UTI. She remained altered and on hospital day 9 the patient suffered a cardiac arrest of unclear etiology and CPR was started. She was intubated and transferred to the ICU, where she remained minimally responsive for several days. A brain MRI then demonstrated evidence of WE, specifically T2 FLAIR hyperintense signal abnormalities involving the mammillary bodies, medial thalami, periaqueductal area, and around the third ventricle. Intravenous thiamine was started immediately. Over the next few days, her mental status slowly began to recover. DISCUSSION: WE is primarily associated with malnutrition and chronic alcohol use, however hyperemesis gravidarum or bariatric surgery recovery can also produce the syndrome. Patients who undergo bariatric surgery are at risk of multiple vitamin deficiencies; B1 deficiency is common enough to have garnered the nickname “bariatric beriberi”. The classic triad for WE consists of ataxia, nystagmus, and confusion. The underlying pathophysiology is related to severe thiamine deficiency, and symptoms can be precipitated by glucose loading causing lactic acidosis in the medial thalamus resulting in neuronal damage. In a 2008 review of 84 existing cases, 94% occurred within the first 6 months post-surgery. As with our patient, MRI revealed lesions in 47% of patients. In 2007, another review found WE was most likely to occur between 4 and 12 weeks after surgery; our patient presented with symptoms at 8 weeks post-surgery. A case series from Southern Europe reported a preventive intervention after biliopancreatic diversion; no WE cases were observed after initiating administration of large doses of thiamine to patients reporting small food intakes during early postoperative weeks. CONCLUSIONS: Our patient’s altered mentation seems to have begun after diminishing PO intake for days at home. Given the risk for WE with progression to severe altered mental status, providers should consider thiamine deficiency in altered patients with recent bariatric surgeries. Reference #1: Aasheim ET. Wernicke Encephalopathy After Bariatric Surgery. Annals of Surgery. 2008;248(5):714-720. https://doi.org/10.1097/SLA.0b013e3181884308. Reference #2: Sonal S, Abhay K. Wernicke encephalopathy after obesity surgery Neurology Mar 2007, 68 (11) 807-811; https://doi.org/10.1212/01.wnl.0000256812.29648.86 DISCLOSURES: No relevant relationships by Mitchell Brown, source=Web Response No relevant relationships by Amy Wolfe, source=Web Response

Prognostic value of 11C-methionine PET/CT and MRI in diffuse intrinsic brain stem glioma patients

Objective To explore the prognostic value of 11C-methionine positron emission tomography/CT (MET-PET/CT) combined with MRI in patients with diffuse intrinsic pontine glioma (DIPG). Methods A total of 41 patients clinically suspicious of DIPG admitted to Department of Neurosurgery of Beijing Tiantan Hospital, Capital Medical University from March 2016 to June 2017 were prospectively included and underwent MET-PET/CT scan and brain MRI. The measurements on MET-PET/CT included tumor metabolic volume (MTV), maximum standardized uptake value (SUVmax) and mean standardized uptake value (SUVmean), while those on MRI enhancement volume (EV) and FLAIR displayed volume (FV). The EV/MTV values were also calculated for analysis. Within 2 weeks after imaging, 33 patients underwent tumor resection, and the remaining 8 underwent stereotactic biopsy. Postoperative radiotherapy and/or chemotherapy were performed in 27 patients. Cox regression analysis was used to analyze the effects of MET-PET/CT and MRI measurements on the overall survival (OS) of DIPG patients. Results Of the 41 patients, 24 (58.5%) FLAIR hyperintensity and 39 (95.1%) MRI enhancement presented and all (100.0%) MET-PET/CT uptake increased. The median follow-up time of 41 patients was 9 months (1-27months). The median survival time was 14.4 months (12.0-16.7 months). At the end of follow-up, 20 patients survived and 21 died. Univariate prognostic analysis discovered that age 18 or older and adjuvant therapy were prognostic protective factors, while EV, SUVmax, SUVmean and tumor grade were prognostic risk factors (all P<0.05). Multivariate analysis showed that EV (HR=2.983, 95%CI: 1.074-8.284, P=0.036), tumor grade (HR=7.568, 95% CI: 2.029-28.229, P=0.003) and adjuvant therapy (HR=0.212, 95%CI: 0.078-0.582, P=0.003) were independent prognostic factors. Conclusion MET-PET/CT combined with MR could predict the prognosis of DIPG patients in this prospective cohort study. Key words: Brain stem tumor; Glioma; Positron emission tomography; 11C- methionine

Intraoperative MRI and FLAIR Analysis: Implications for low-grade glioma surgery

PurposeIntraoperative MRI (iMRI) offers the possibility of acquiring intraoperatively real-time images that will guide neurosurgeons when removing brain tumors. The objective of this study was to report the existence of FLAIR abnormalities on iMRI that may occur on the margin of a brain resection and may lead to misdiagnosis of residual tumor. MethodsWe retrospectively analyzed intraoperative MRI (iMRI) in 21 consecutive patients who underwent surgery for a low-grade glioma. Two readers independently reviewed iMRI images to search for the presence of a FLAIR hyperintensity surrounding the surgical cavity. For each patient, they were instructed to characterize FLAIR abnormalities on the margins of the resected area as (1) no FLAIR abnormality; (2) “linear FLAIR hyperintensity (LFH)”, when a<5mm linear FLAIR hyperintensity was present; or (3) “nodular FLAIR hyperintensity (NFH)”, in the case of a thick and nodular FLAIR hyperintensity. ResultsLFH were present on at least one surgical margin of one third of the patients analyzed with iMRI, and vanished on follow-up MRI, confirming its transient condition; whereas NFH were linked to persistence of pre-surgical abnormalities, such as residual tumor as confirmed or by histopathological analysis of a second surgery or by its remnant on follow-up MRI. ConclusionLinear FLAIR hyperintensities can be present on surgical margins analyzed by iMRI and should not be mistaken for residual tumor.

P14.27 The significance of multicentric noncontrast-enhancing lesions distant from surgically resected glioblastoma: Case series of 3 patients

Abstract BACKGROUND Glioblastoma is the most malignant primary brain tumor. The tumor location and multiplicity plays an important role in surgical and further treatment. The incidence of multiple lesions at the time of diagnosis was known as 1–20%, which showed a poor prognostic factor. Most researches has focused on multiple contrast-enhancing lesions, however, multicentric non-enhancing lesions distant from glioblastoma has been rarely evaluated. The authors reported the case series of the patient who showed multicentric non contrast-enhancing lesions without connection to histologically-proven glioblastoma. MATERIAL AND METHODS Multicentric non contrast-enhancing lesions were defined as areas of FLAIR hyperintensity and mass effect without post-contrast enhancement, separated from the histologically-proven glioblastoma in a newly diagnosed disease. Three patients who showed distant non-enhancing lesions with appearance of a multicentric low-grade glioma were included in this study. The typical enhancing lesions were surgically resected and standard chemo-radiotherapy was followed in all patients. RESULTS All patients were male and their age was 38, 60 and 65 years old respectively. Multicentric tumor location was as follows: Case 1, left frontal lobe with non-enhancing lesion in left parahippocampal gyrus; Case 2, left parietal with non-enhancing lesion in left anteromedial temporal lobe; Case 3, left thalamus with non-enhancing lesions in both basal frontal and right temporal lobe. Pathologically, the resected enhancing tumor revealed glioblastoma in 2 patients and diffuse midline glioma in 1. All tumors were IDH-wild type. The resected enhanced lesion showed no progression but all non-enhancing lesions developed contrast-enhancing tumors at 3, 13 and 17 months after initial treatment, with high tracer uptake on 18FDG-PET or 18FDOPA-PET. Despite multidisciplinary treatment, two patients died from disease progression at 30 and 32 months after diagnosis and one patient is still alive with overall survival of 15 months. CONCLUSION The appearance of multicentric non-enhancing lesions distant from a typically enhancing tumor showed an uncommon finding in glioblastoma and poor prognostic features. These lesions progress faster than expected for a low-grade glioma. These lesions should be distinguished from typical low-grade glioma and should be considered more advanced lesions than their appearances suggest.

Posterior reversible encephalopathy syndrome with lumbar drainage and surgery: coincidence or correlation? A case report

BackgroundPosterior reversible encephalopathy syndrome (PRES) is a rare neurological disorder usually associated with specific medical conditions that cause a disturbance of the CNS homeostasis. It has seldom been reported to be a consequence of an iatrogenic intervention causing intracranial hypotension.Case presentationWe report the case of an individual 69-year-old male presenting with headache and blurred vision following cerebrospinal fluid (CSF) leak from resection of a sellar mass. The patient developed the condition following removal of the lumbar drain post-operatively. Magnetic Resonance Imaging showed bilateral occipital, parieto-occipital, and cerebellar T2 FLAIR hyper-intensities, suggesting a radiological diagnosis of posterior reversible encephalopathy syndrome (PRES). The patient’s symptoms started to improve shortly afterwards and had completely resolved at 3 months follow-up.ConclusionsThe absence of severe hypertension and presence of an intraoperative CSF leak requiring placement of the lumbar drain suggests that decreased CSF volume and associated reactive hyperemia could have a role in the pathophysiology of the disease.

Memory loss and confusion

•FLAIR hyperintensity affecting the limbic system has a range of differentials.•Small cell lung carcinoma is the most common cause of paraneoplastic limbic encephalitis.•Extrapulmonary neuroendocrine tumours can also cause limbic encephalitis.•Paraneoplastic limbic encephalitis is often associated with auto-antibodies. A 59 year old female with a metastatic neuroendocrine tumour of the gallbladder (mixed small cell and large cell morphology) presented with ongoing memory loss and confusion, in the context of an episode of reduced conscious state 4 days earlier. This was investigated with MRI (Fig. 1): What is the most likely diagnosis?:a)Herpes simplex encephalitisb)Limbic encephalitisc)Low grade gliomad)Subacute infarct Patient details and images have been anonymised. Answer on page 264. Memory loss and confusion: AnswerJournal of Clinical NeuroscienceVol. 70PreviewB. Limbic encephalitis (paraneoplastic) Full-Text PDF

Autoidentification of perivascular spaces in white matter using clinical field strength T1 and FLAIR MR imaging

Recent interest in enlarged perivascular spaces (ePVS) in the brain, which can be visualized on MRI and appear isointense to cerebrospinal fluid on all sequence weightings, has resulted in the necessity of reliable algorithms for automated segmentation to allow for whole brain assessment of ePVS burden. However, several publicly available datasets do not contain sequences required for recently published algorithms. This prospective study presents a method for identification of enlarged perivascular spaces (ePVS) in white matter using 3T T1 and FLAIR MR imaging (MAPS-T1), making the algorithm accessible to groups with valuable sets of limited data. The approach was applied identically to two datasets: 1) a repeated measurement in a dementia-free aged human population (N = 14), and 2) an aged sample of multisite ADNI datasets (N = 30). ePVS segmentation was accomplished by a stepwise local homogeneity search of white matter-masked T1-weighted data, constrained by FLAIR hyperintensity, and further constrained by width, volume, and linearity measurements. Pearson’s r was employed for statistical testing between visual (gold standard) assessment and repeated measures in cohort one. Visual ePVS counts were significantly correlated with MAPS-T1 (r = .72, P < .0001). Correlations between repeated measurements in cohort one were significant for both visual and automated methods in the single visually-rated slice (MAPS-T1: r = .87, P < .0001, visual: (r = .86, P < .0001) and for whole brain assessment (MAPS-T1: r = .77, P = .001). Results from each cohort were manually inspected and found to have positive predictive values of 77.5% and 87.5%, respectively. The approach described in this report is an important tool for detailed assessment of ePVS burden in white matter on routinely acquired MRI sequences.

Methotrexate-Induced Subacute Neurotoxicity Surrounding an Ommaya Reservoir in a Patient with Lymphoma.

Patient: Male, 21Final Diagnosis: Methotrexate induced neurotoxicitySymptoms: Dysarthria • hemiparesisMedication: MethotrexateClinical Procedure: —Specialty: HematologyObjective:Challenging differential diagnosisBackground:Intraventricular administration of methotrexate (MTX) using an Ommaya reservoir is a useful therapeutic maneuver for malignant CNS involvement in patients with hematological malignancies. MTX-induced subacute neurotoxicity is a rare complication that typically progresses with involvement of the basal ganglia. Local toxicity due to misplaced catheters has been described, although the impact of normally positioned catheters on toxicity is not clear.Case Report:We report the case of a 21-year-old man diagnosed with stage IV diffuse large B-cell lymphoma who experienced a central nervous system relapse. While receiving intraventricular MTX using an Ommaya reservoir and systemic MTX, he experienced sudden left-side hemiparesis. All diagnostic tests were negative except for altered MRI findings with FLAIR hyperintensity in the basal ganglia and restricted diffusion in the same location that followed the track of the Ommaya catheter. The syndrome resolved after administration of high-dose steroids, and the patient received subsequent MTX courses without recurrence.Conclusions:MTX-induced neurotoxicity is a rare adverse event related to systemic and intrathecal administration of the drug. Many cases of Ommaya-related CNS symptoms have been described, although most were related to misplaced or malfunctioning catheters. Here we present a case of subacute MTX toxicity affecting the area around a correctly positioned catheter, suggesting that the catheter track could be more susceptible to MTX-induced toxicity.

077 An unusual presentation of antibody negative autoimmune encephalitis: a case report

IntroductionImmune-mediated encephalitis can occur in the absence of measurable pathogenic antibodies in CSF or serum.Methods and resultsWe present the case of a 29-year-old Sudanese woman presented with four days history of meningism. She is three months post-partum with her fifth child and does not have significant past medical history. She is a current smoker with history of methamphetamine and heroin use until 5 years ago. There were no focal neurological deficits on examination. CT brain was normal and her CSF had 420×106/L leucocytes (Polymorphs 18, Mononuclears 402). Three days later, she deteriorated clinically with GCS 11 and developed left sided hemiplegia requiring intubation and ventilation in intensive care.The CSF culture along with autoimmune encephalitis panel, anti-neuronal antibodies, HSV, VZV, Enterovirus, cryptococcal antigen, TB quantiferon, HIV, Malaria were negative. Her immunology tests were unremarkable including rheumatoid factor, complements, anti-nuclear antibodies, dsDNA, PR3, MPO, RNP, Smith, Ro, La, Scleroderma 70 and Jo-1 antibodies. The MRI Brain showed persistent changes in right hemispheric cortical and subcortical gyriform FLAIR hyperintensities which were also present in DWI images. The EEG showed right temporo-occipital region 7–8 Hz rhythmic discharges with generalised diffuse slowing. She had right parietal lobe brain biopsy which shows perivascular and intramural inflammation by mononuclear cells almost comprised of CD3 T-cells consistent with encephalitis associated with secondary lymphocytic vasculitis. She was treated with intravenous pulsed methylprednisolone and IVIg followed by plasma exchange. Then given high dose oral corticosteroids with slow tapering and intravenous Cyclophosphamide four weekly. Significant neurological improvement noted over next 8 weeks with patient being alert and participating in ongoing multidisciplinary rehabilitation for hemiplegia.ConclusionA case of cerebral biopsy confirmed, CSF and serum antibody-negative encephalitis is presented.