Fluid-attenuated Inversion Recovery Abnormalities Research Articles

MADR-Net: multi-level attention dilated residual neural network for segmentation of medical images

Medical image segmentation has made a significant contribution towards delivering affordable healthcare by facilitating the automatic identification of anatomical structures and other regions of interest. Although convolution neural networks have become prominent in the field of medical image segmentation, they suffer from certain limitations. In this study, we present a reliable framework for producing performant outcomes for the segmentation of pathological structures of 2D medical images. Our framework consists of a novel deep learning architecture, called deep multi-level attention dilated residual neural network (MADR-Net), designed to improve the performance of medical image segmentation. MADR-Net uses a U-Net encoder/decoder backbone in combination with multi-level residual blocks and atrous pyramid scene parsing pooling. To improve the segmentation results, channel-spatial attention blocks were added in the skip connection to capture both the global and local features and superseded the bottleneck layer with an ASPP block. Furthermore, we introduce a hybrid loss function that has an excellent convergence property and enhances the performance of the medical image segmentation task. We extensively validated the proposed MADR-Net on four typical yet challenging medical image segmentation tasks: (1) Left ventricle, left atrium, and myocardial wall segmentation from Echocardiogram images in the CAMUS dataset, (2) Skin cancer segmentation from dermoscopy images in ISIC 2017 dataset, (3) Electron microscopy in FIB-SEM dataset, and (4) Fluid attenuated inversion recovery abnormality from MR images in LGG segmentation dataset. The proposed algorithm yielded significant results when compared to state-of-the-art architectures such as U-Net, Residual U-Net, and Attention U-Net. The proposed MADR-Net consistently outperformed the classical U-Net by 5.43%, 3.43%, and 3.92% relative improvement in terms of dice coefficient, respectively, for electron microscopy, dermoscopy, and MRI. The experimental results demonstrate superior performance on single and multi-class datasets and that the proposed MADR-Net can be utilized as a baseline for the assessment of cross-dataset and segmentation tasks.

Advanced magnetic resonance imaging for glioblastoma: Oncology-radiology integration.

Aggressive brain tumors like glioblastoma multiforme (GBM) pose a poor prognosis. While magnetic resonance imaging (MRI) is crucial for GBM management, distinguishing it from other lesions using conventional methods can be difficult. This study explores advanced MRI techniques better to understand GBM properties and their link to patient outcomes. We studied MRI scans of 157 GBM surgery patients from January 2020 to March 2024 to extract radiomic features and analyze the impact of fluid-attenuated inversion recovery (FLAIR) resection on survival using statistical methods, proportional hazards regression, and Kaplan-Meier survival analysis. Predictive models achieved high accuracy (area under the curve of 0.902) for glioma-grade prediction. FLAIR abnormality resection significantly improved survival, while diffusion-weighted image best-depicted tumor infiltration. Glioblastoma infiltration was best seen with advanced MRI compared to metastasis. Glioblastomas showed distinct features, including irregular shape, margins, and enhancement compared to metastases, which were oval or round, with clear edges and even contrast, and extensive peritumoral changes. Advanced radiomic and machine learning analysis of MRI can provide noninvasive glioma grading and characterization of tumor properties with clinical relevance. Combining advanced neuroimaging with histopathology may better integrate oncology and radiology for optimized glioblastoma management. However, further studies are needed to validate these findings with larger datasets and assess additional MRI sequences and radiomic features.

Exploring the Spectrum of RHOBTB2 Variants Associated with Developmental Encephalopathy 64: A Case Series and Literature Review.

Rho-related BTB domain-containing protein 2 (RHOBTB2) is a protein that interacts with cullin-3, a crucial E3 ubiquitin ligase for mitotic cell division. RHOBTB2 has been linked to early infantile epileptic encephalopathy, autosomal dominant type 64 (OMIM618004), in 34 reported patients. We present a case series of seven patients with RHOBTB2-related disorders (RHOBTB2-RD), including a description of a novel heterozygous variant. We also reviewed previously published cases of RHOBTB2-RD. The seven patients had ages ranging from 2 years and 8 months to 26 years, and all had experienced seizures before the age of one (onset, 4-12 months, median, 4 months), including various types of seizures. All patients in this cohort also had a movement disorder (onset, 0.3-14 years, median, 1.5 years). Six of seven had a baseline movement disorder, and one of seven only had paroxysmal dystonia. Stereotypies were noted in four of six, choreodystonia in three of six, and ataxia in one case with multiple movement phenotypes at baseline. Paroxysmal movement disorders were observed in six of seven patients for whom carbamazepine or oxcarbazepine treatment was effective in controlling acute or paroxysmal movement disorders. Four patients had acute encephalopathic episodes at ages 4 (one patient) and 6 (three patients), which improved following treatment with methylprednisolone. Magnetic resonance imaging scans revealed transient fluid-attenuated inversion recovery abnormalities during these episodes, as well as myelination delay, thin corpus callosum, and brain atrophy. One patient had a novel RHOBTB2 variant (c.359G>A/p.Gly120Glu). RHOBTB2-RD is characterized by developmental delay or intellectual disability, early-onset seizures, baseline movement disorders, acute or paroxysmal motor phenomena, acquired microcephaly, and episodes of acute encephalopathy. Early onsets of focal dystonia, acute encephalopathic episodes, episodes of tongue protrusion, or peripheral vasomotor disturbances are important diagnostic clues. Treatment with carbamazepine or oxcarbazepine was found to be effective in controlling acute or paroxysmal movement disorders. Our study highlights the clinical features and treatment response of RHOBTB2-RD.

Glioblastoma: A Retrospective Analysis of the Role of the Maximal Surgical Resection on Overall Survival and Progression Free Survival

Glioblastoma (GBM) is the most common and aggressive primary brain tumor in adults; despite advances in the understanding of GBM pathogenesis, significant achievements in treating this disease are still lacking. The aim of this study was to evaluate the prognostic significance of the extent of surgical resection (EOR), beyond the neoplastic mass, on the overall survival (OS). A retrospective review of a single-institution glioblastoma patient database (January 2012-September 2021) was undertaken. The series is composed of 64 patients who underwent surgery at the University Department of Neurosurgery of Ancona; the series was divided into four groups based on the amount of tumor mass excision with the fluid-attenuated inversion recovery (FLAIR) abnormalities (SUPr-supratotal resection, GTR-gross total resection, STR-subtotal resection, BIOPSY). The hypothesis was that the maximal resection of FLAIR abnormalities may improve the overall survival compared to the resection of the visible T1 contrast-enhanced neoplastic area only. In the univariate analysis, SUPr and GTR are correlated with the overall survival (p = 0.001); the percentage of total neoplastic removal threshold conditioning outcome was 90% (p = 0.027). These results were confirmed by the multivariate analysis. Maximal surgical resection, when feasible, involving areas of FLAIR abnormalities represents an advantageous approach for the OS in GBM patients.

Imaging of status epilepticus: Making the invisible visible. A prospective study on 206 patients

BackgroundPeri-ictal MRI abnormalities (PMA) frequently affect the cerebral cortex, hippocampus, pulvinar of the thalamus, corpus callosum, and cerebellum. In this prospective study, we aimed to characterize the spectrum of PMA in a large cohort of patients with status epilepticus. MethodsWe prospectively recruited 206 patients with SE and an acute MRI. The MRI protocol included diffusion weighted imaging (DWI), fluid-attenuated inversion recovery (FLAIR), arterial spin labeling (ASL), and T1-weighted imaging pre-and post-contrast application. Peri-ictal MRI abnormalities were stratified as either neocortical or non-neocortical. Amygdala, hippocampus, cerebellum, and corpus callosum were regarded as non-neocortical structures. ResultsPeri-ictal MRI abnormalities were observed in 93/206 (45%) of patients in at least one MRI sequence. Diffusion restriction was observed in 56/206 (27%) of patients, which was mainly unilateral in 42/56 (75%) affecting neocortical structures in 25/56 (45%), non-neocortical structures in 20/56 (36%) and both areas in 11/56 (19%) of patients. Cortical DWI lesions were located mostly in frontal lobes 15/25 (60%); non-neocortical diffusion restriction affected either the pulvinar of the thalamus or hippocampus 29/31 (95%).Alterations in FLAIR were observed in 37/203 (18%) of patients. They were mainly unilateral 24/37 (65%); neocortical 18/37 (49%), non-neocortical 16/37 (43%), or affecting both neocortical and non-neocortical structures 3/37 (8%).In ASL, 51/140 (37%) of patients had ictal hyperperfusion. Hyperperfused areas were located mainly in the neocortex 45/51 (88%) and were unilateral 43/51 (84%).In 39/66 (59%) of patients, PMA were reversible in one week. In 27/66 (41%), the PMA persisted and a second follow-up MRI was performed three weeks later in 24/27 (89%) patients. In 19/24 (79%) PMA were resolved. ConclusionsAlmost half of the patients with SE had peri-ictal MRI abnormalities. The most prevalent PMA was ictal hyperperfusion followed by diffusion restriction and FLAIR abnormalities. Neocortex was most frequently affected especially the frontal lobes. The majority of PMAs were unilateral. This paper was presented at the 8th London-Innsbruck Colloquium on Status Epilepticus and Acute Seizures held in September 2022.

Cerebral Amyloid Angiopathy-Related Inflammation in Down Syndrome-Related Alzheimer Disease.

A 59-year-old woman with Down syndrome (DS) and prodromal Alzheimer disease (AD) presenting progressive cognitive impairment in the previous year, with no focal symptoms, headache, seizures, or accelerated cognitive decline, underwent 3T brain MRI showing cortico-subcortical tumefactive fluid-attenuated inversion recovery (FLAIR) hyperintensities, associated with microbleeds and superficial siderosis (Figure 1). These FLAIR abnormalities have moved spatially compared with a previous MRI, suggesting an inflammatory process (Figure 2). The diagnosis of cerebral amyloid angiopathy (CAA)–related inflammation (CAA-ri) was made.1 DS is a genetic form of AD and has increased CAA prevalence.2 As future anti-amyloid trials will likely include individuals with DS, neurologists must be aware of CAA-ri in this population.

Idiopathic Moyamoya Disease Presenting as Isolated Hemichorea

AbstractThe study aimed to describe a case of a 7-year-old Caucasian girl who developed isolated chorea in her right upper and lower extremities progressively increasing over 2 years. This study is a case report and conducted at tertiary care center. A 7-year-old Caucasian girl who gradually developed worsening choreiform movements in her right upper and lower extremities over the course of 2 years until medical attention was sought. Literature review of children presenting with chorea as the only manifestation in moyamoya disease. A 7-year-old right-handed Caucasian girl presented with progressively worsening choreiform movements in her right upper and lower extremities affecting her fine motor skills and gait impairment There was no weakness, hyperreflexia, or spasticity on her neurological exam. Neuroimaging studies showed “ivy sign,” asymmetric prominence of vessels within the subarachnoid spaces overlying the left cerebral hemisphere with corresponding serpiginous T2 fluid-attenuated inversion recovery abnormality, but no parenchymal volume loss or diffusion restriction. Magnetic resonance angiography showed focal moderate-to-severe stenosis at the junction of the paraophthalmic and supraclinoid segments of the left internal carotid artery, with poststenotic dilatation. Angiography demonstrated focal stenosis involving the ophthalmic segment of the left internal carotid artery with 50% stenosis. There was compensation through a medium sized left posterior communicating artery as well as posterior cerebral artery to middle cerebral artery and anterior cerebral artery collateralization. Brain single-photon emission computerized tomography scan showed no evidence of perfusion defects in the cerebral hemispheres, basal ganglia, or thalami. She underwent successful revascularization procedure (left pial synangiosis) with resolution of her choreiform movements and normalization of her gait. Our case demonstrates that moyamoya disease should be suspected when evaluating a child with hemichorea and describes resolution of symptoms after revascularization surgery. Neuroimaging and vascular studies should be obtained in children with unilateral movement disorder.

Teaching NeuroImage: Nonalcoholic Wernicke Encephalopathy.

A 40-year-old woman with chronic gastritis who did not have alcoholism had lost 50 pounds in the past 45 days and presented with dyscoordination and diplopia. Examination showed confabulation, ophthalmoplegia, nystagmus, and appendicular ataxia. Brain MRI (Figure) showed diffusion-weighted imaging and fluid-attenuated inversion recovery abnormalities suggestive of Wernicke encephalopathy (WE). With classic triad of WE and MRI findings, IV thiamine 500 mg TID was administered for 3 days, followed by maintenance oral thiamine. The patient showed substantial improvement. Thiamine replacement therapy should be considered in patients with malnutrition or malabsorption as it is important in maintaining cellular osmotic gradients. Thiamine deficiency may lead to cytotoxic edema, especially in high metabolic demand regions such as thalami and mammillary bodies.1

Prognostic Value of a Structural Brain MRI Score in the Acute Phase of Aneurysmal Subarachnoid Hemorrhage: A Pilot Study

Aneurysmal subarachnoid hemorrhage (aSAH) is associated with high morbidity and mortality despite advances in management. We evaluated the prognostic significance of a qualitative score using brain magnetic resonance imaging (MRI) features obtained early after aSAH. Patients with aSAH were enrolled in a prospective observational cohort and underwent brain MRI during their acute hospitalization. MRIs were rated using a scoring system that considers the anatomical location of signal intensity changes on diffusion-weighted imaging (DWI) and fluid-attenuated inversion recovery (FLAIR) sequences. The relationship between MRI scores and functional outcome defined by modified Rankin scale (mRS) at 6months was evaluated in uni- and multivariable models. The cohort included 45 aSAH patients (median World Federation of Neurologic Surgeons (IQR) 2 (1-4)) who underwent brain MRI a mean (SD) of 9.0 ± 8.0days after aSAH. At 6months after aSAH, 26 patients had achieved a favorable outcome (mRS ≤ 2) while 15 had an unfavorable outcome (mRS > 2). Deep gray nuclei (DGN) score (p = 0.016), cortex + DGN score (p = 0.015), FLAIR score (p = 0.016), DWI score (p = 0.0045), and overall score (p = 0.0081) were significantly lower in patients with favorable outcome compared to those with unfavorable outcome. However, MRI scores were not independent predictors of outcome in multivariable models adjusting for admission Hunt and Hess, Glasgow Coma Scale, or World Federation of Neurologic Surgeons scales. In this pilot study, a qualitative scoring system using anatomically defined MRI FLAIR and DWI signal abnormalities identified in the acute phase of aSAH was linked to 6-month functional outcome. However, these scores did not add prognostic value to established indices of neurological severity.

Urea Cycle Disorders: A Neuroimaging Pattern Approach Using Diffusion and FLAIR MRI.

This study aimed to assess characteristic regions of MRI involvement utilizing diffusion weighted imaging (DWI) and fluid-attenuated inversion recovery (FLAIR) at urea cycle disorder (UCD) diagnosis to determine the possible association between initial MRI patterns within 10days of the first hyperammonemia episode, serum ammonia levels, and severity of neurological outcome based on clinical follow-up of >30 days. Ten patients with UCDs (4 females; median age: 5.4 years, age range: 6 days-54 years) were included who underwent MRI during a first episode of hyperammonemia. The topographical distribution of the DWI and FLAIR abnormalities in the cerebral cortex, deep gray matter, white matter, posterior limb of internal capsule, cerebral peduncle, and cerebellum was evaluated. Possible correlations between the brain injury patterns on DWI/FLAIR images, serum ammonia levels, and severity of neurological outcome were investigated by a trend correlation. The UCD cohort (n = 10) involved four ornithine transcarbamoylase deficiencies, four argininosuccinic aciduria, one carbomoylphosphate synthetase deficiency, and one citrullinemia type-1. The observed trend in the distribution of DWI abnormalities as the severity of neurological sequela outcome increased was with diffuse cerebral cortex or corpus striatum involvement. Patients with initial peak serum ammonia ≥450 µmol/L had a grade 2 to 4 outcome, and those with peak ammonia <450 µmol/L had a grade 0 or 1 outcome. The presence of more severe neurological outcome could be associated with diffuse cerebral cortex or corpus striatum involvement on DWI and high serum ammonia levels in patients with UCD.

Inner ear fluid-attenuated inversion recovery MRI signal intensity in dogs with vestibular disease.

The inner ear contains endolymph and perilymph. The second is comparable and in continuity with the cerebrospinal fluid (CSF) so it is expected to suppress in fluid-attenuated inversion recovery (FLAIR) magnetic resonance imaging (MRI) if normal. Even though inner ear FLAIR abnormalities have been extensively described in humans with inner ear disease, its diagnostic value in dogs is yet to be proven. The goal of this retrospective cohort study was to investigate the diagnostic utility of FLAIR MRI in dogs with vestibular disease. A review of medical records identified 101 dogs that had brain MRI performed because of vestibular signs. Based on the final diagnosis, patients were allocated to three groups: otitis media/interna, idiopathic vestibular disease, and central vestibular disease. Additionally, a control group (n=73) included dogs with normal MRI and without vestibular signs. Inner ears were delineated using a region of interest, and signal intensity was measured in FLAIR and T2-weighted images. The percentages of suppression in FLAIR were calculated and compared between affected and unaffected sides of each individual and between groups using a general linear mixed model. Correlation between suppression and CSF cell count and protein concentration was assessed. Affected inner ears in dogs with otitis media/interna had decreased suppression in FLAIR compared to the unaffected side (P<.001), and all other groups (P<.01). No significant correlation was detected between CSF results and suppression. These results show the diagnostic value of FLAIR in otitis media/interna due to lack of suppression in the affected inner ear.

Randomized prospective trial of fractionated stereotactic radiosurgery with chemotherapy versus chemotherapy alone for bevacizumab-resistant high-grade glioma.

Outcomes for patients with recurrent high-grade glioma (HGG) progressing on bevacizumab (BEV) are dismal. Fractionated stereotactic radiosurgery (FSRS) has been shown to be feasible and safe when delivered in this setting, but prospective evidence is lacking. This single-institution randomized trial compared FSRS plus BEV-based chemotherapy versus BEV-based chemotherapy alone for BEV-resistant recurrent malignant glioma. HGG patients on BEV with tumor progression after 2 previous treatments were randomized to 1) FSRS plus BEV-based chemotherapy or 2) BEV-based chemotherapy with irinotecan, etoposide, temozolomide, or carboplatin. FSRS was delivered as 32Gy (8Gy × 4 fractions within 2weeks) to the gross target volume and 24Gy (6Gy × 4 fractions) to the clinical target volume (fluid-attenuated inversion recovery abnormality). The primary endpoints were local control (LC) at 2months and progression-free survival (PFS). Of the 35 patients enrolled, 29 had glioblastoma (WHO IV) and 6 had anaplastic glioma (WHO III). The median number of prior recurrences was 3. Patients treated with FSRS had significantly improved PFS (5.1 vs 1.8months, P < .001) and improved LC at 2months (82% [14/17] vs 27% [4/15], P = .002). The overall median survival was 6.6months (7.2months with FSRS vs 4.8months with chemotherapy alone, P = .11). FSRS combined with BEV-based chemotherapy in recurrent HGG patients progressing on BEV is feasible and improves LC and PFS when compared to treatment with BEV-based chemotherapy alone.

T2 Fluid-Attenuated Inversion Recovery Resection for Glioblastoma Involving Eloquent Brain Areas Facilitated Through Awake Craniotomy and Clinical Outcome

Despite evidence that a greater extent of resection (EOR) improves survival, the role of extended resection based on magnetic resonance imaging (MRI) fluid-attenuated inversion recovery (FLAIR) in the prognosis of glioblastoma (GBM) remains controversial. This study aims to investigate the role of additional resection of FLAIR-detected abnormalities and its influence on clinical outcomes of patients with GBM. Forty-six patients with newly diagnosed GBM involving eloquent brain areas were included. Surgeries were performed using awake craniotomy (AC) or AC combined with sodium fluorescein (SF) guidance. Following total removal of the contrast-enhancing tumor area, the EOR of FLAIR abnormalities was dichotomized to identify the best separation threshold for progression-free survival (PFS), overall survival (OS), and 30-day postoperative neurologic function of patients with GBM. The threshold for removal of FLAIR abnormalities affecting survival was determined to be 25%. The median OS and PFS were shorter in the group with FLAIR resection <25% compared with the group with FLAIR resection ≥25% (12 months vs. 26 months; P= 0.001 and 6months vs. 15 months; P= 0.016, respectively). Univariate and multivariate analyses identified tumor location within or near the eloquent brain areas and the 25%threshold for FLAIR EOR as independent factors affecting OS and PFS. Identifying a feasible threshold for the resection of FLAIR abnormalities is valuable in improving the survival of patients with GBM. Extended resection of GBM involving eloquent brain areas was safe when using a combination of AC and SF-guided surgery.

Automatic assessment of glioma burden: a deep learning algorithm for fully automated volumetric and bidimensional measurement.

BackgroundLongitudinal measurement of glioma burden with MRI is the basis for treatment response assessment. In this study, we developed a deep learning algorithm that automatically segments abnormal fluid attenuated inversion recovery (FLAIR) hyperintensity and contrast-enhancing tumor, quantitating tumor volumes as well as the product of maximum bidimensional diameters according to the Response Assessment in Neuro-Oncology (RANO) criteria (AutoRANO).MethodsTwo cohorts of patients were used for this study. One consisted of 843 preoperative MRIs from 843 patients with low- or high-grade gliomas from 4 institutions and the second consisted of 713 longitudinal postoperative MRI visits from 54 patients with newly diagnosed glioblastomas (each with 2 pretreatment “baseline” MRIs) from 1 institution.ResultsThe automatically generated FLAIR hyperintensity volume, contrast-enhancing tumor volume, and AutoRANO were highly repeatable for the double-baseline visits, with an intraclass correlation coefficient (ICC) of 0.986, 0.991, and 0.977, respectively, on the cohort of postoperative GBM patients. Furthermore, there was high agreement between manually and automatically measured tumor volumes, with ICC values of 0.915, 0.924, and 0.965 for preoperative FLAIR hyperintensity, postoperative FLAIR hyperintensity, and postoperative contrast-enhancing tumor volumes, respectively. Lastly, the ICCs for comparing manually and automatically derived longitudinal changes in tumor burden were 0.917, 0.966, and 0.850 for FLAIR hyperintensity volume, contrast-enhancing tumor volume, and RANO measures, respectively.ConclusionsOur automated algorithm demonstrates potential utility for evaluating tumor burden in complex posttreatment settings, although further validation in multicenter clinical trials will be needed prior to widespread implementation.

Proliferation-dominant high-grade astrocytoma: survival benefit associated with extensive resection of FLAIR abnormality region.

The aim of this study was to investigate the relationship between extent of resection (EOR) and survival in terms of clinical, molecular, and radiological factors in high-grade astrocytoma (HGA). Clinical and radiological data from 585 cases of molecularly defined HGA were reviewed. In each case, the EOR was evaluated twice: once according to contrast-enhanced T1-weighted images (CE-T1WI) and once according to fluid attenuated inversion recovery (FLAIR) images. The ratio of the volume of the region of abnormality in CE-T1WI to that in FLAIR images (VFLAIR/VCE-T1WI) was calculated and a receiver operating characteristic curve was used to determine the optimal cutoff value for that ratio. Univariate and multivariate analyses were performed to identify the prognostic value of each factor. Both the EOR evaluated from CE-T1WI and the EOR evaluated from FLAIR could divide the whole cohort into 4 subgroups with different survival outcomes (p < 0.001). Cases were stratified into 2 subtypes based on VFLAIR/VCE-T1WI with a cutoff of 10: a proliferation-dominant subtype and a diffusion-dominant subtype. Kaplan-Meier analysis showed a significant survival advantage for the proliferation-dominant subtype (p < 0.0001). The prognostic implication has been further confirmed in the Cox proportional hazards model (HR 1.105, 95% CI 1.078-1.134, p < 0.0001). The survival of patients with proliferation-dominant HGA was significantly prolonged in association with extensive resection of the FLAIR abnormality region beyond contrast-enhancing tumor (p = 0.03), while no survival benefit was observed in association with the extensive resection in the diffusion-dominant subtype (p = 0.86). VFLAIR/VCE-T1WI is an important classifier that could divide the HGA into 2 subtypes with distinct invasive features. Patients with proliferation-dominant HGA can benefit from extensive resection of the FLAIR abnormality region, which provides the theoretical basis for a personalized resection strategy.

Cochlear FLAIR Signal Changes in Hearing Preservation Vestibular Schwannoma Surgery.

Cochlear fluid-attenuated inversion recovery (FLAIR) magnetic resonance imaging (MRI) signal intensity has been shown to be elevated in patients with vestibular schwannomas (VS). This study evaluated the preoperative and postoperative cochlear signal on FLAIR sequences in patients undergoing hearing preservation surgery. Retrospective chart review. Tertiary referral center. All patients undergoing middle cranial fossa or retrosigmoid craniotomy for VS at a single institution from September 2013 to January 2017 were screened.Hearing was graded according to the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) hearing classification. Inclusion criteria included preoperative AAO-HNS class A or B hearing and available preoperative and postoperative FLAIR sequences. Signal intensity of cochlear FLAIR signal was measured in the affected cochlea and normalized to the contralateral cochlea. Hearing preservation was defined as AAO-HNS class A or B postoperatively. Eighteen patients met all inclusion criteria, and 12/18 experienced hearing preservation. There was no difference in preoperative FLAIR ratio between hearing preserved and nonpreserved groups (2.02 vs 2.32, p = 0.52). Postoperatively, FLAIR ratio was lower in the hearing preserved group compared to the nonpreserved group (1.19 vs 1.87, p = 0.033). The current study is the first to examine postoperative cochlear FLAIR changes in VS patients undergoing hearing preservation surgery. In our study population, abnormal hyperintense FLAIR signal normalized in patients experiencing successful hearing preservation, while those who lost hearing maintained abnormal signal. Future studies may investigate the role of FLAIR in guiding optimal timing of operative intervention in VS patients.

Nonmeasurable Speckled Contrast-Enhancing Lesions Appearing During Course of Disease Are Associated With IDH Mutation in High-Grade Astrocytoma Patients

Because treatment options at progression are limited for patients with glioma, accuracy in definition of progression is pivotal. Clinically asymptomatic, newly detected, nonmeasurable, speckled contrast-enhancing lesions (SCEs) without immediate relation to prior immune therapy or radiation therapy appear relatively frequently during the course of disease in patients with glioma and challenge the definition of progression based on Response Assessment in Neuro-oncology criteria. Therefore, data characterizing these SCEs are needed for recommendations of subsequent clinical management. Magnetic resonance imaging of 746 patients with glioma included in this study were retrospectively revised for appearance of newly detected SCEs during the course of disease. Associations with molecular and clinical baseline parameters and their prognostic impact were statistically analyzed, and frequency, natural course, and location of SCEs were described. SCEs occurred more frequently in World Health Organization grade 2 and 3 astrocytoma and oligodendroglial tumors and were significantly associated with isocitrate dehydrogenase mutation in World Health Organization grade 3 astrocytoma and glioblastoma. SCEs mostly remained stable or dissolved in follow-up magnetic resonance imaging, even if no new treatment was initiated. SCEs were frequently located within the tumor or tumor-associated fluid-attenuated inversion recovery abnormalities, but distant appearance also occurred. In patients with glioblastoma, SCEs were associated with a favorable prognosis, which was also observed in the subgroup of patients with glioblastoma with isocitrate dehydrogenase wildtype status. The data demonstrate a predominantly benign course of SCEs after their appearance and emphasize cautious definitions of progression and regular clinical and radiographic follow-up rather than premature initiation of new antitumor therapies until progression is confirmed.

Atypical Cerebral Manifestations of Disseminated Mycobacterium tuberculosis.

We investigated the patterns of cerebral manifestations in patients with underlying pulmonary or extrapulmonary tuberculosis or disseminated tuberculosis. From January 2010 to September 2016, brain magnetic resonance imaging (MRI) scans were obtained to evaluate cerebral manifestations in patients with underlying pulmonary or extrapulmonary tuberculosis. We also included patients with drug-resistant tuberculosis or disseminated tuberculosis. MRI findings of tuberculous meningitis and tuberculoma were classified as typical; other MRI findings were classified as atypical. Demographic data, risk factors, and drug regimens were collected and analyzed. Twenty-two patients were diagnosed with cerebral tuberculosis. Cerebral tuberculosis was due to hematogenous spread from pulmonary tuberculosis (10 patients), spinal tuberculosis (8 patients), disseminated tuberculosis (3 patients), and unknown causes (1 patient). There were six patients with typical MRI findings (three patients with typical meningitis involving the basal cistern and supratentorium, one patient with tuberculomas, and two patients with both) and seven patients with atypical MRI findings [five patients with evidence of early meningitis, such as high signal intensity on fluid-attenuated inversion recovery (FLAIR) along the cerebellar folia, and two patients with only hydrocephalus]. Besides the typical sites of meningeal involvement, overlooked findings such as FLAIR abnormalities along the cerebellar folia or hydrocephalus should be checked for early detection of cerebral tuberculosis and initiation of the appropriate treatment against disseminated tuberculosis.

Maximize surgical resection beyond contrast-enhancing boundaries in newly diagnosed glioblastoma multiforme: is it useful and safe? A single institution retrospective experience.

The extent of surgical resection (EOR) has been recorded as conditioning outcome in glioblastoma multiforme (GBM) patients but no significant improvements were recorded in survival. The study aimed to evaluate the impact of EOR on survival, investigating the role of fluid-attenuated inversion recovery (FLAIR) abnormalities removal. 282 newly diagnosed GBM patients were treated with surgery followed by concurrent and adjuvant chemo-radiotherapy. The EOR was defined as: SUPr, in case of resection amounting to 100% of enhanced and FLAIR areas; gross total (GTR) in case of resection between 90 and 100% of enhanced areas with variable amount of FLAIR abnormalities; sub-total (STR), between 10 and 89%; biopsy (B) <10%. FLAIR-RTV was dichotomized in percentage values to identify the best separation threshold for progression free survival (PFS) and overall survival (OS). SUPr was obtained in 21 patients (7.4%), GTR in 60 (21.3%), STR in 143 (50.7%) and biopsy only in 58 (20.6%). The median, 1, 2-year PFS were 10.4 ± 0.4 months, 39.0 ± 3.0, and 17.0 ± 2.0%; the median, 1, 2-year OS were 14.5 ± 0.5 months, 63.3 ± 3.0, and 23.1 ± 3.1%. EOR was significantly influencing survival (p < 0.001). The median, 1, 2-year OS were 28.6 ± 5.2 months, 90.0 ± 6.0, 71.0 ± 10.0% for patients underwent SUPr vs. 16.2 ± 1.2 months, 81.0 ± 5.0, 24.0 ± 6.0% for GTR. The FLAIR removal threshold conditioning survival was 45%. Minor complications were recorded in 14 (5%) patients and major in 8 (2.8%). surgical resection beyond contrast-enhancing boundaries could represent a promising strategy to improve outcome in GBM patients. The identification of a FLAIR-RTV threshold can be useful in clinical practice and it was recorded as factor influencing survival.

Patterns of response and relapse in primary CNS lymphomas after first-line chemotherapy: imaging analysis of the ANOCEF-GOELAMS prospective randomized trial

Our aim was to review MRI characteristics of patients with primary CNS lymphoma (PCNSL) enrolled in a randomized phase II trial and to evaluate their potential prognostic value and patterns of relapse, including T2 fluid attenuated inversion recovery (FLAIR) MRI abnormalities. Neuroimaging findings in 85 patients with PCNSL enrolled in a prospective trial were reviewed blinded to outcomes. MRI characteristics and responses according to International PCNSL Collaborative Group (IPCG) criteria were correlated with progression-free survival (PFS) and overall survival (OS). Multivariate analysis showed that objective response at 2 months (P < .001) and at end of treatment (P = .015) were predictors of prolonged OS. Infratentorial location (P = .008) and large (>11.4 cm3) enhancing tumor volume (P = .006) were associated with poor OS and PFS, respectively. Ratio of change in product of largest diameters at early MRI evaluation but not timing of complete response achievement (early vs delayed) was prognostic for OS. Sixty-nine patients relapsed. Relapse in the brain (n = 52) involved an initial enhancing site, a different site, or both in 46%, 40%, and 14% of patients, respectively. At baseline, non-enhancing T2-FLAIR hypersignal lesions distant from the enhancing tumor site were detected in 18 patients. These lesions markedly decreased (>50%) in 16 patients after chemotherapy, supporting their neoplastic nature. Of these patients, 10/18 relapsed, half (n = 5) in the initially non-enhancing T2-FLAIR lesions. Baseline tumor size and infratentorial localization are of prognostic value in PCNSL. Our findings provide evidence that non-enhancing FLAIR abnormalities may add to overall tumor burden, suggesting that response criteria should be refined to incorporate evaluation of T2-weighted/FLAIR sequences.