Initial Magnetic Resonance Imaging Research Articles

Robot-Assisted Radical Prostatectomy in PIRADS 5 Lesions Without Prior Biopsy: Is Biopsy Really Necessary in This Cohort?

Introduction: Conventionally, confirmation of clinically significant prostate cancer (csPCa) (Gleason grade group ≥ 2) involves an initial multiparametric magnetic resonance imaging (mpMRI) followed by biopsy. Prostate biopsy incurs inherent risks of infection, bleeding, patient discomfort, and a 6-week delay before robot-assisted laparoscopic radical prostatectomy (RALP). We explored the feasibility of immediate RALP in men with PIRADS 5 lesions without preceding biopsy. Methodology: After obtaining institutional review board approval, a prospective analysis was conducted on 235 patients with PIRADS 5 lesions on mpMRI from December 2018 to February 2023. Patients were divided into 2 groups as follows: Group NoBiopsy (biopsy not done before RALP, cases, n = 118) and Group YesBiopsy (biopsy done before RALP, controls, n = 117). Baseline preoperative, intraoperative, and postoperative parameters were analyzed. Functional outcomes were monitored at 1, 3-, 6-, 9-, and 12-months follow-up post-RALP. Statistical analysis was performed using SPSS and STATA. Results: Ninety-five percent of cases and 87.17% controls had csPCa on final pathology post-RALP. Multivariable analysis did not find significant association between biopsy status and csPCa. Abnormal digital rectal examination (DRE), family history, preoperative PSA, and MRI lesion volume predicted csPCa. Significant differences were observed in console time (NoBiopsy vs. YesBiopsy, 60 ± 10 vs. 70 ± 9 minutes, p < 0.001) and estimated blood loss (80 ± 20 vs. 100 ± 30 mL, p < 0.01) between groups. At 6 months post-RALP, 96% of men in Group NoBiopsy were continent, compared with 88% of men in Group YesBiopsy (p < 0.04). All men in the study cohort were continent (0 pads) at 12 months post-RALP. Ninety-eight percent of cases and 92% of controls at 9 months and 12 months, respectively, were able to have penetrative sex with or without PDE-5 inhibitors post-RALP. Conclusion: RALP without antecedent prostate biopsy in men with PIRADS 5 lesions demonstrated substantial csPCa detection rates and superior functional outcomes, warranting further validation.

Axial Spondyloarthritis: Does Magnetic Resonance Imaging Classification Improve Report Interpretation.

The interpretation of magnetic resonance imaging (MRI) reports is crucial for the diagnosis of axial spondyloarthritis, but the subjective nature of narrative reports can lead to varying interpretations. This study presents a validation of a novel MRI reporting system for the sacroiliac joint in clinical practice. A historical review was conducted on 130 consecutive patients referred by 2 rheumatologists for initial MRI assessment of possible axial spondyloarthritis. The original MRI reports were interpreted by the rheumatologists and the radiologist who originally read the images and then categorized according to the novel system. Two musculoskeletal radiologists then reinterpreted the original MRI scans using the new system, and the resulting reports were interpreted and categorized by the same rheumatologists. The quality of the new framework was assessed by comparing the interpretations of both reports. Ninety-two patients met the study criteria. The rheumatologists disagreed on the categorization of the original MRI reports in 12% of cases. The rheumatologists and original radiologists disagreed on the categorization of the initial report in 23.4% of cases. In contrast, there was 100% agreement between the rheumatologists and radiologists on the categorization of the new MRI report. The new MRI categorization system significantly improved the agreement between the clinician and radiologist in report interpretation. The system provided a standard vocabulary for reporting, reduced variability in report interpretation, and may therefore improve clinical decision-making.

248 Isolated Traumatic Subarachnoid Hemorrhage on Head Computed Tomography Scan May Not Be Isolated

INTRODUCTION: Isolated traumatic subarachnoid hemorrhage (tSAH) after traumatic brain injury (TBI) on head computed tomography (CT) is often regarded as a “mild” injury, with reduced need for additional workup. However, tSAH is also a predictor of unfavorable outcomes. Magnetic resonance imaging (MRI) and blood-based biomarkers may improve the diagnosis of concurrent intracranial injury. METHODS: The prospective, 18-center Transforming Research and Clinical Knowledge in Traumatic Brain Injury study enrolled patients presenting to ED within 24 hours (h) of TBI who received a clinically-indicated head CT. A subset underwent venipuncture within 24h for plasma glial fibrillary acidic protein (GFAP) analysis, and 2-week research MRI. Participants aged = 17-years with GCS 13-15, isolated tSAH on initial CT, GFAP, and MRI data were analyzed. RESULTS: In 57 patients, median age was 46.0-years [quartile 1 to 3 (Q1-Q3): 34-57] and 53% were male. At ED disposition, 12.3% were discharged home, 61.4% admitted to hospital ward, and 26.3% to intensive care.MRI identified additional traumatic intracranial lesions in 45.6% of patients (1 type: 31.6%; 2 types: 14.0%); of these, 65.4% had axonal injury, 42.3% subdural hematoma, and 23.1% contusion. GFAP levels were higher in patients with additional MRI lesions (median: 630.6-pg/ml, Q1-Q3: [172.4-941.2] vs. 226.4 [105.8-436.1], p = 0.049), and correlated with axonal injury severity (none: median 226.7 [109.6-435.1], traumatic axonal injury: 716.3 [304.0-892.3], diffuse axonal injury: 873.2 [407.2-1321.4], p = 0.034). CONCLUSIONS: Isolated tSAH on head CT is insufficient to rule out additional traumatic injuries in GCS 13-15 TBI. Forty-six percent of patients had additional traumatic lesions on MRI. Plasma GFAP may be an important biomarker for the identification of additional injuries, including axonal injury. Patients with isolated tSAH on CT may require close clinical surveillance and follow-up.

Acute leukoencephalopathy with restricted diffusion – Case Series

Acute leukoencephalopathy with restricted diffusion (ALERD) is a clinicopathological diagnosis that is characterized by severe encephalopathy and seizures with extensive areas of restricted diffusion in cerebral parenchyma. Case 1: Apparently healthy 13-month-old male child presented with acute febrile encephalopathy with a flurry of seizures with raised intracranial pressure. Investigations were consistent with multiorgan dysfunction along with severe metabolic acidosis, ketosis, and hyperammonemia. Initial magnetic resonance imaging (MRI) Brain was normal. However subsequent MRI brain suggested features of diffuse ALERD. With immunotherapy and supportive management, he improved and was discharged without sequelae. Case 2: A 9-month-old male child who was premorbidly normal presented with fever, status epilepticus, and encephalopathy. MRI Brain was suggestive of central sparing ALERD. He was discharged with sequelae with the advice of rehabilitation. Unfortunately, he got succumbed due to aspiration. Case 3: A 10-day-old neonate presented with the refusal of feeds, multiple seizures, and encephalopathy. MRI Brain revealed central sparing ALERD. Improved with immunotherapy and was developmentally normal at five months of age. ALERD is a clinic-radiological syndrome characterized by acute encephalopathy with restricted areas of diffusion in subcortical white matter on MRI. Reported two categories are Diffuse and Central sparing ALERD. Diffuse ALERD has severe manifestations. However, Case 1 had a good outcome, suggesting a variable prognosis. Central sparing ALERD is a milder form, but when basal ganglia are involved, it may have a worsened outcome, as seen in Case 2. Case 3 had central sparing ALERD, and had a good prognosis as described in literature. This study highlights the varied signs and symptoms of ALERD, including neonatal age of onset. Diagnosis is based on the restricted diffusion in white matter on diffusion-weighted imaging and the apparent diffusion coefficient in MRI of the brain. MRI may be normal in the initial course; hence, it’s important to repeat if strongly suspected. Prompt immunotherapy and supportive care are emphasised.

Clinical Utility of Repeat Magnetic Resonance Imaging Studies Among Children With Acute Hematogenous Osteomyelitis.

There is limited guidance for whether repeat magnetic resonance imaging (MRI) studies are clinically impactful among children with acute hematogenous osteomyelitis (AHO) who fail to improve as expected. This study aimed to determine whether repeat MRIs changed management among children with AHO and identify clinical characteristics predictive of which patients benefit from repeat MRIs. Children admitted to a quaternary care pediatric hospital with AHO were identified during a 9-year period. Patients with chronic symptoms, non-hematogenous infections, or significant contributing comorbidities were excluded. Medical records were retrospectively reviewed for all MRIs performed 3 weeks before admission to 24 months after discharge. An MRI was considered clinically impactful if it identified a new infectious process (eg, abscess not seen on the initial MRI) or if it resulted in surgical intervention within 24 hours. Bivariable comparisons of categorical variables were performed, and multivariable logistic regression was used to assess the clinical factors of impactful repeat MRIs. Among the 239 included patients, 41 (17%) had more than 1 MRI performed during their clinical course, the majority of whom (53.7%) had a repeat MRI that impacted care. Patients who underwent repeat MRIs had longer hospitalizations (7 vs. 5 d, P <0.01), were more likely to have C-reactive protein (CRP) levels >20mg/dL (41% vs. 10%, P <0.01), and were more likely to have a delayed transition to oral antimicrobials (8.4 vs. 3.3d, P <0.01). Peak CRP >20mg/dL and prolonged bacteremia were found to be associated with increased odds of having an impactful repeat MRI, with adjusted odds ratios of 3.9 ( P =0.007) and 3.4 ( P =0.03), respectively. When used judiciously among ill children with complicated AHO, repeat MRI can be clinically impactful. Prospective studies are needed to better define which children with AHO benefit from repeat MRI. Level II evidence-this is a retrospective cohort study interested in determining the clinical utility of repeat magnetic resonance imaging studies for children with osteomyelitis.

Natural History of Quantitative Fatty Infiltration and 3D Muscle Volume After Nonoperative Treatment of Symptomatic Rotator Cuff Tears: A Prospective MRI Study of 79 Patients.

The severity of fatty infiltration (FI) predicts the treatment outcome of rotator cuff tears. The purpose of this investigation was to quantitatively analyze supraspinatus (SSP) muscle FI and volume at the initial presentation and after a 3-month minimum of conservative management. We hypothesized that progression of FI could be predicted with initial tear size, FI, and muscle volume. Seventy-nine shoulders with rotator cuff tears were prospectively enrolled, and 2 magnetic resonance imaging (MRI) scans with 6-point Dixon sequences were acquired. The fat fraction within the SSP muscle was measured on 3 sagittal slices, and the arithmetic mean was calculated (FI SSP ). Advanced FI SSP was defined as ≥8%, pathological FI SSP was defined as ≥13.5%, and relevant progression was defined as a ≥4.5% increase in FI SSP . Furthermore, muscle volume, tear location, size, and Goutallier grade were evaluated. Fifty-seven shoulders (72.2%) had normal FI SSP , 13 (16.5%) had advanced FI SSP , and 9 (11.4%) had pathological FI SSP at the initial MRI scan. Eleven shoulders (13.9%) showed a ≥4.5% increase in FI SSP at 19.5 ± 14.7 months, and 17 shoulders (21.5%) showed a ≥5-mm 3 loss of volume at 17.8 ± 15.3 months. Five tears (7.1%) with initially normal or advanced FI SSP turned pathological. These tears, compared with tears that were not pathological, had significantly higher initial mediolateral tear size (24.8 compared with 14.3 mm; p = 0.05), less volume (23.5 compared with 34.2 mm 3 ; p = 0.024), more FI SSP (9.6% compared with 5.6%; p = 0.026), and increased progression of FI SSP (8.6% compared with 0.5%; p < 0.001). An initial mediolateral tear size of ≥20 mm yielded a relevant FI SSP progression rate of 81.8% (odds ratio [OR], 19.0; p < 0.001). Progression rates of 72.7% were found for both initial FI SSP of ≥9.9% (OR, 17.5; p < 0.001) and an initial anteroposterior tear size of ≥17 mm (OR, 8.0; p = 0.003). Combining these parameters in a logistic regression analysis led to an area under the receiver operating characteristic curve (AUC) of 0.913. The correlation between FI SSP progression and the time between MRI scans was weak positive (ρ = 0.31). Three risk factors for relevant FI progression, quantifiable on the initial MRI, were identified: ≥20-mm mediolateral tear size, ≥9.9% FI SSP , and ≥17-mm anteroposterior tear size. These thresholds were associated with a higher risk of tear progression: 19 times higher for ≥20-mm mediolateral tear size, 17.5 times higher for ≥9.9% FI SSP , and 8 times higher for ≥17-mm anteroposterior tear size. The presence of all 3 yielded a 91% chance of ≥4.5% progression of FI SSP within a mean of 19.5 months. Diagnostic Level II . See Instructions for Authors for a complete description of levels of evidence.

Diffuse-Type Tenosynovial Giant Cell Tumor: What Are the Important Findings on the Initial and Follow-Up MRI?

Tenosynovial giant cell tumor (TSGCT) is a rare soft tissue tumor that involves the synovial lining of joints, bursae, and tendon sheaths, primarily affecting young patients (usually in the fourth decade of life). The tumor comprises two subtypes: the localized type (L-TSGCT) and the diffuse type (D-TSGCT). Although these subtypes share histological and genetic similarities, they present a different prognosis. D-TSGCT tends to exhibit local aggressiveness and a higher recurrence rate compared to L-TSGCT. Magnetic resonance imaging (MRI) is the preferred diagnostic tool for both the initial diagnosis and for treatment planning. When interpreting the initial MRI of a suspected TSGCT, it is essential to consider: (i) the characteristic findings of TSGCT-evident as low to intermediate signal intensity on both T1- and T2-weighted images, with a blooming artifact on gradient-echo sequences due to hemosiderin deposition; (ii) the possibility of D-TSGCT-extensive involvement of the synovial membrane with infiltrative margin; and (iii) the resectability and extent-if resectable, synovectomy is performed; if not, a novel systemic therapy involving colony-stimulating factor 1 receptor inhibitors is administered. In the interpretation of follow-up MRIs of D-TSGCTs after treatment, it is crucial to consider both tumor recurrence and potential complications such as osteoarthritis after surgery as well as the treatment response after systemic treatment. Given its prevalence in young adult patents and significant impact on patients' quality of life, clinical trials exploring new agents targeting D-TSGCT are currently underway. Consequently, understanding the characteristic MRI findings of D-TSGCT before and after treatment is imperative.

Osmotic Demyelination Syndrome in a Patient with Diabetic Ketoacidosis Despite No Rapid Sodium Correction.

Osmotic demyelination syndrome (ODS) occurs in patients with diabetes and hyponatremia. We herein report a case of ODS with chorea detected on serial magnetic resonance imaging (MRI), despite no prompt hyponatremia correction. A 74-year-old man with cirrhosis and uncontrolled type 2 diabetes developed an altered mental status and chorea during treatment for diabetic ketoacidosis (DKA). Despite no rapid sodium correction and normal initial brain MRI findings, serial MRI revealed ODS-related abnormalities. Clinicians should consider ODS in patients with DKA and a hyperosmolar hyperglycemic state displaying unconsciousness and neurological manifestations, including chorea, even without substantial changes in serum sodium levels. An MRI re-examination can help capture missing ODS complications.

Brain magnetic resonance imaging as predictors in pediatric anti-N-methyl-D-aspartate receptor encephalitis

ObjectiveTo investigate the associations between brain magnetic resonance imaging (MRI) changes and clinical profiles in children with anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis. MethodsClinical data and brain MRI results of children diagnosed with anti-NMDAR encephalitis in Guangzhou Women and Children's Medical Center from October 2014 to June 2022 were retrospectively studied. ResultsA total of 143 children (Male: female 54:89) were enrolled, with a mean onset age of 6.8 years (6.8 ± 3.1). 40.6 % (58/143) of patients had abnormal initial brain MRI. Lesions in temporal lobe (34.5 %, 20/58) and frontal lobe (25.9 %, 15/58) were relatively common. Children with abnormal initial brain MRI were prone to have fever (P = 0.023), dystonia (P = 0.037), positive MOG antibodies (P = 0.015), higher cerebrospinal fluid (CSF) white blood cell count (WBC) (P = 0.019) and to receive rituximab treatment (P = 0.037). There were no significant differences in modified Rankin Scale (mRS) scores before immunotherapy, after immunotherapy and at last follow-up between the normal initial brain MRI group and abnormal group. No initial brain MRI changes were found to be associated with relapses. Brain MRI was reviewed in 72 patients at last follow-up with a median follow-up time of 25.5 months and 48.6 % (35/72) of patients had abnormal brain MRI. The mRS score of the group with normal brain MRI at last follow-up was significantly lower than that of the abnormal group. ConclusionsAbout 40.0 % of children with anti-NMDAR encephalitis had abnormal initial brain MRI. Initial brain MRI was associated with certain clinical profiles, but not with relapse and prognosis. Around half of patients had abnormal brain MRI at last follow-up and were prone to have higher mRS score.

Methotrexate Induced Central Nervous System Manifestations in Children Receiving Treatment for Acute Lymphoid Malignancies

Methotrexate (MTX) is an essential part of most chemotherapy regimens for acute lymphoblastic leukemia (ALL). It is administered intrathecally (IT), intravenously, and orally during ALL therapy. We performed a retrospective chart review to assess the central nervous system (CNS) manifestations induced by MTX in all children who received ALL therapy at our institution between July 2013 and June 2023. A list of patients with the ICD-9/10 codes for ALL or ALLy was obtained from the Electronic Medical Records for the study time period. Data collected included demographics, cytogenetics, laboratory test results, MTX pharmacological data if available, and details of the treatment of CNS manifestations attributable to MTX. Lastly, we had a single neuroradiologist re-review all the brain Magnetic Resonance Imaging (MRI) obtained in patients with MTX induced CNS manifestations. Sixty-five children were treated for ALL during the study decade. The average age at diagnosis was 4.7 ± 4 years. Our cohort consisted of 38 males and 27 females. Twelve of 65 patients (19%) developed MTX-induced CNS manifestations. The average age at the onset of symptoms was 5.3 ± 2 years. Ten patients had received a dose of IT MTX within 2 weeks of experiencing symptoms. Symptoms included raised intracranial pressure (ICP) (64%), headache (36%), confusion (36%), altered mental status (29%), and altered level of consciousness (29%). Treatment of MTX-induced CNS manifestations consisted of therapeutic drainage of cerebrospinal fluid (CSF) with their scheduled IT chemotherapy administration (65%), acetazolamide (57%), theophylline + leucovorin + dextromethorphan (64%), and addition of hydrocortisone with IT medications (36%). In 3 (25%) patients the subsequent doses of MTX were delayed. The symptoms of CNS manifestations resolved in 100% of cases and MTX was able to be readministered in all the patients. Only one patient had recurrence of CNS manifestations twice after rechallenging with MTX; however, with specific symptomatic treatment, was able to tolerate the remainder of the IT therapy inclusive of MTX. Brain MRIs were obtained in all patients. Initial imaging studies yielded normal results in 6 (50%) patients. Abnormal findings included subcortical white matter changes, vividly observed on T2/FLAIR MRI. These changes were represented by regions of acute hyperintensity seen in diffuse bilateral cerebral hemispheres (33%), parietal regions (33%), frontoparietal regions (17%), occipital regions (17%) and the left parietooccipital region (17%). A follow up MRI was performed 3 to 8 months after the initial MRI and was repeated up to 6 times over a course of 6 years in a patient. The earliest MRI improvement was evident after 3 months of initial imaging. About 20% of patients developed MTX induced CNS manifestations in our cohort. IT MTX was the most common culprit. Raised ICP, on opening pressure measured during IT procedures happened to be the most common finding. This has not widely been reported previously under MTX induced CNS complications in published data. One of the suspected etiologies is the inflammation of arachnoid villi impairing CSF drainage. These patients responded well to acetazolamide and therapeutic drainage of CSF. Finally subcortical while matter changes on T2/FLAIR MRI was a common CNS manifestation.

Glial Fibrillary Acidic Protein (GFAP) Astrocytopathy: An Emerging Cause of Meningoencephalomyelitis in Children and Adolescents.

Introduction: We describe 5 children with GFAP astrocytopathy with the goal of further characterizing this rare form of meningoencephalomyelitis. Methods: Retrospective chart review of patients diagnosed with GFAP astrocytopathy between 2019 and 2021. Results: Patients were 8-17 years old, and all were male. Fever, headache, and vomiting were common presenting symptoms, and weakness, tremor, and ataxia were common initial examination findings. Initial magnetic resonance imaging (MRI) showed spinal cord abnormalities in 2 patients and leptomeningeal enhancement in 1. Most patients had cerebral spinal fluid pleocytosis, and all screened negative for malignancy. Three patients progressed to coma, and all were treated with immunosuppressant therapy. By discharge, all patients had improved over their clinical nadir, although none had returned to baseline. Discussion: GFAP astrocytopathy is a recently recognized cause of meningoencephalomyelitis in children. Here, we expand our understanding of this entity with the goal of aiding those treating children with GFAP astrocytopathy.

Central positional nystagmus due to acute medial medullary infarction

A 70-year-old male with risk factors for vascular disease presented with dizziness and instability. The patient showed horizontal geotropic nystagmus when turning his head while lying down, with larger slow phase velocity observed when turning to the left. There were no other neurological deficits. Video head impulse tests and vestibular evoked myogenic potentials were normal. The initial magnetic resonance imaging (MRI) findings were negative; however, the patient experienced subsequent right-side weakness, right tilting, and recurrent episodes of vertigo. A follow-up MRI revealed an acute left medial medullary infarction, which seems to have caused the paroxysmal geotropic central positional nystagmus in this patient.

NCOG-13. OUTCOMES OF CNS WHO GRADE 2 OLIGODENDROGLIOMA IN ADULT PATIENTS ; IMPACT OF ADJUVANT TREATMENT ON OVERALL RESULTS

Abstract OBJECTIVE Patients with oligodendroglioma (ODG), isocitrate dehydrogenase (IDH)-mutant, 1p19q codeleted, CNS WHO grade 2 have a median overall survival of longer than 10 years. Patients with ODG who are high-risk by RTOG criteria are offered radiation in combination with procarbazine, lomustine, and vincristine (PCV). The study aims to analyze the patient’s outcomes and assess the efficacy of postoperative treatment. METHODS A total of 138 adult patients who underwent resection for newly diagnosed grade 2 ODG between 1994 and 2021 were enrolled. Sixty-three (45.7%) were observed after gross total resection (GTR) or near total resection (NTR), 5 (0.4%) received adjuvant treatment after GTR or NTR, 37 (26.8%) were observed after subtotal resection (STR) or biopsy, and 33 (24.0%) received adjuvant treatment after STR or biopsy. The study analyzed progression-free survival (PFS), overall survival (OS), and risk variables. RESULTS Out of the 138 patients, 38 (27%) patients received adjuvant treatment, with 30 of them (78.9%) underwent radiotherapy only, 6 (15.8%) underwent radiochemotherapy, and 2 (5.3%) received chemotherapy alone. The median PFS was 6.8 years. Multivariate analysis revealed STR or biopsy (p=0.04), initial MR imaging enhancement (p=0.002), and postoperative observation(p=0.006) were associated with poorer PFS outcomes. The 5-year overall survival rate was 95.5% and the 10-year overall survival was 76.1%. Poor OS prognosis was associated with STR or biopsy (p=0.03), preoperative seizure (p=0.002), and initial MR imaging enhancement (p&amp;lt; 0.001). CONCLUSIONS : GTR and NTR is essential for achieving prolonged PFS and OS in ODG patients. Postoperative treatment is associated with favorable PFS outcomes but does not significantly affect OS. For an accurate diagnosis and appropriate treatment, the utmost care should be taken to avoid underestimating the results of the biopsy.

Abstract 16260: Children With Increased Native T1, Extracellular Volume and T2 Values on Initial Cardiac Magnetic Resonance Imaging for Acute Myocarditis Have Less Improvement in Late Gadolinium Enhancement on Follow Up Imaging: Risk Factor for Adverse Events?

Introduction: Late gadolinium enhancement (LGE) in pediatric patients with acute myocarditis has been shown to be a risk factor for adverse events. On follow up cardiac magnetic resonance imaging (CMR), some patients show improvement and/or resolution of LGE but others do not. Factors associated with residual LGE have not been described. Hypothesis: Measurements on initial CMR would be associated with degree of improvement of LGE on follow up CMR. Methods: We conducted a retrospective cohort study of patients &lt;21 years with acute myocarditis who underwent initial CMR within 14 days of presentation and returned for follow up CMR. Those who suffered cardiac arrest or with autoimmune disease, known cardiomyopathy or congenital heart disease were excluded. LGE was defined as tissue with signal intensity 5 standard deviations above mean signal intensity of unaffected myocardium on viability imaging; this mass was measured and indexed to total left ventricular mass. Strain was measured using CMR feature tracking. Spearman’s correlation was used to determine associations between change in indexed LGE mass on follow up CMR to values from initial CMR. Results: We enrolled 36 patients aged 16.4 years (IQR 14.9-17.2 years) with median time to follow up CMR 229 days (IQR 171, 407). Native T1 (Figure 1), T2, peak T2 relaxation times and ECV on initial CMR inversely correlated with change in indexed LGE mass on follow up CMR while indexed right ventricular end diastolic volume (RVEDVi) on initial CMR positively correlated. (Table 1) Strain and ventricular function did not correlate with change in LGE mass on follow up CMR. Conclusions: Elevated T1 and T2 values and ECV on initial CMR in patients with acute myocarditis are associated with less improvement of LGE on follow up CMR; increased RVEDVi was associated with greater improvement. Further work is needed to determine which are the most useful predictors of residual LGE following myocarditis in children.

Functional to structural plasticity in unilateral sudden sensorineural hearing loss: neuroimaging evidence

A cortical plasticity after long-duration single side deafness (SSD) is advocated with neuroimaging evidence while little is known about the short-duration SSDs. In this case-cohort study, we recruited unilateral sudden sensorineural hearing loss (SSNHL) patients and age-, gender-matched health controls (HC), followed by comprehensive neuroimaging analyses. The primary outcome measures were temporal alterations of varied dynamic functional network connectivity (dFNC) states, neurovascular coupling (NVC) and brain region volume at different stages of SSNHL. The secondary outcome measures were pure-tone audiograms of SSNHL patients before and after treatment. A total of 38 SSNHL patients (21 [55%] male; mean [standard deviation] age, 45.05 [15.83] years) and 44 HC (28 [64%] male; mean [standard deviation] age, 43.55 [12.80] years) were enrolled. SSNHL patients were categorized into subgroups based on the time from disease onset to the initial magnetic resonance imaging scan: early- (n = 16; 1-6 days), intermediate- (n = 9; 7-13 days), and late- stage (n = 13; 14-30 days) groups. We first identified slow state transitions between varied dFNC states at early-stage SSNHL, then revealed the decreased NVC restricted to the auditory cortex at the intermediate- and late-stage SSNHL. Finally, a significantly decreased volume of the left medial superior frontal gyrus (SFGmed) was observed only in the late-stage SSNHL cohort. Furthermore, the volume of the left SFGmed is robustly correlated with both disease duration and patient prognosis. Our study offered neuroimaging evidence for the evolvement from functional to structural brain alterations of SSNHL patients with disease duration less than 1 month, which may explain, from a neuroimaging perspective, why early-stage SSNHL patients have better therapeutic responses and hearing recovery.

What an adult multiple sclerosis registry can tell us about pediatric onset multiple sclerosis?

Multiple Sclerosis (MS) is an immune-mediated, chronic disease of the central nervous system that affects mainly adults. However, it is increasingly recognized that MS may start in childhood resulting in a relentlessly progressive disability and cognitive impairment. Registries across the globe are reporting inconstant data about their Pediatric-Onset Multiple Sclerosis (POMS) patients. Moreover, newer lines of treatments are emerging and showing efficacy in controlling the MS disease regardless of the onset. Therefore, there is a requirement for more research into the clinical profile of POMS in different populations and ethnicities. This study was a cross-sectional study that included MS patients who visited the MS unit at Alexandria University from January 2019 to January 2021. We analyzed their epidemiological, clinical, radiological data, and cerebrospinal fluid (CSF) results from their updated records as well as follow-up interviews. Annual Relapse Rate (ARR) was marginally less in POMS than AOMS (0.72 ± 0.57 vs 1.04 ± 0.78 relapse/year, P =.008). POMS patients had a bigger gap to their first relapse (40.0 ± 47.35 vs 22.71 ± 34.33 months, p= .066). The difference in relapse rate between the two groups was abolished after the exclusion of patients who had a gap of more than 5 years to their first relapse. AOMS patients were significantly more likely to start with a second-line disease-modifying treatment (DMT) than POMS patients (11.5% vs 31%, p= .04), whereas POMS patients were more likely to be escalated to the second line (34.6% vs 19.3%, p= .07). ARR had a positive and significant correlation with expanded disability status scale (EDSS) progression per year (rs(24)= .57 p=.003). A Mann-Whitney test indicated that POMS patients who had infratentorial involvement in the initial MRI brain had higher EDSS (3.08 ± 1.99) than POMS who did not (1.07 ± 0.79) U=24 P =.013. IgG index had a significant and positive correlation with annual EDSS progression rate rs (8)=0.8 p=.001. Early disease onset does not mean a higher relapse rate when including the full spectrum of POMS and longer follow-up duration. POMS patients relapsed more on the first-line DMT and escalation should be considered early. Infratentorial involvement in the initial magnetic resonance imaging (MRI) brain and high IgG index are potential predictors for aggressive disease course in POMS.

Evaluating the Etiology of Osteochondritis Dissecans of the Knee: The Role of the Articular-Epiphyseal Cartilage Complex

Introduction: In pathologic form, osteochondritis dissecans (OCD) is a focal end-stage disease of articular cartilage. Comparative anatomy studies have demonstrated that injury to epiphyseal anlage cartilage leads to development of OCD in many species, whereas in humans, the exact etiology is suspected but remains unknown. A potential candidate is the articular-epiphyseal cartilage complex, and our hypothesis is that injury at the junction between the epiphyseal anlage cartilage and the articular cartilage results in childhood OCD.Methods: A retrospective, two-institution assessment of children with magnetic resonance imaging (MRI) of the affected knee before the onset of an OCD lesion was performed. Demographics were recorded, including the history of why each initial pre-OCD MRI (Index-MRI) was obtained. MRI measurements were made on the Index-MRI as well as the subsequent OCD-MRI of the epiphyseal ossification length (Growth), marrow edema, the distance of lesion from physis (Lesion Position), and the distance from articular surface (OCD Depth). Comparisons over time were then calculated.Results: Six children (seven knees) were identified with an Index-MRI (Pre-OCD development) obtained at median age 11.6 years and OCD-MRI obtained at a median of 1.9 years later. ‘Growth' occurred in at least one dimension for all children (sagittal MRI, p=0.018). As a group, the ‘Lesion Position' did not change significantly in any plane but two demonstrated continued ossification of the epiphysis and one demonstrated bone necrosis. As a group, the ‘OCD Depth' was significantly different (coronal plane, p=0.029 and sagittal plane, p=0.026) over time, with all lesions increasing their depth (since none existed on the Index-MRI).Discussion: Even though the articular-epiphyseal cartilage complex appeared to be involved with the etiology of knee OCD in this limited series, we found significant variation in the response to a presumed injury with either halted progression, continued ossification, or even regression of ossification adjacent to the OCD. This variation either indicates that there is a multimodal etiology, or that the articular-epiphyseal cartilage complex inconsistently responds to injury. This may explain the inconsistent response to management and calls for further basic science studies to ascertain the exact location of injury in the human articular-epiphyseal cartilage complex.Level of Evidence: III, Retrospective Cohort StudyKey Concepts•Osteochondritis dissecans may have more than one etiology that leads to a similar pathology pattern at the time of presentation.•Future study will be important to identify when certain patterns of progression are present that may indicate one management modality over another one.•Understanding the variation in OCD etiology may have repercussions regarding animal model development.

Aortic Steal Correlates with Acute Organ Dysfunction and Short-Term Outcomes in Neonates with Vein of Galen Malformation

Plain Language SummaryVein of Galen malformation is a rare, congenital intracerebral arteriovenous malformation with high morbidity and mortality in neonatal manifestation despite modern interdisciplinary strategies. Currently, there is no valid, noninvasive parameter for early prediction of clinical progression at the bedside. A typical finding of hemodynamically relevant vein of Galen malformation is flow reversal in the descending aorta (aortic steal). Therefore, we developed a new ultrasound method to quantify the percentage of reflux in the preductal aortic isthmus and integrated the measurement method into routine clinical practice. In this study, we retrospectively investigated the association between percentage of aortic steal, organ dysfunction parameters, mortality, and brain injury on magnetic resonance imaging (MRI) at baseline and follow-up in 12 neonates with vein of Galen malformation admitted between January 2021 and June 2022. Statistical analyses showed that the severity of organ dysfunction, mortality, and brain damage on MRI increased with increasing percentage of aortic steal. These correlations and associations showed a linear relationship between percentage reflux in the aortic isthmus and all outcome parameters. The potential of sonographically determined aortic steal to predict clinical progression and short- and long-term outcomes needs to be investigated in larger, prospective cohorts. If this marker proves as promising as the data from this study suggest, it could become an important diagnostic component for management and decision-making in critically ill neonates with vein of Galen malformation.

Drug-resistant temporal lobe epilepsy with temporal encephaloceles: How far to resect

PurposeThis study sought to evaluate the impact of surgical extent on seizure outcome in drug-resistant temporal lobe epilepsy (DR-TLE) with temporal encephaloceles (TE). MethodsThis was a single-institution retrospective study of patients who underwent surgery for DR-TLE with TE between January 2008 and December 2020. The impact of surgical extent on seizure outcome was evaluated. In a subset with dominant DR-TLE, the impact of surgical extent on neuropsychometric outcome was evaluated. ResultsThirty-four patients were identified (female, 56%; median age at surgery, 43 years). TE were frequently overlooked on initial magnetic resonance imaging (MRI), with encephaloceles only detected after repeat or expert re-review of MRI, additional multi-modal imaging, or intra-operatively in 31 (91%). Sixteen (47%) underwent limited resections, including encephalocele resection only (n = 5) and encephalocele resection with more extensive temporal corticectomy sparing the amygdala and hippocampus (n = 11). The remainder (n = 18, 53%) underwent standard anterior temporal lobectomy and amygdalohippocampectomy (ATLAH). Limited resection was performed more frequently on the left (12/17 vs. 4/17, p = 0.015). Twenty-seven patients (79%) had a favourable outcome (Engel I/II), and 17 (50%) were seizure-free at the last follow-up (median seizure-free survival of 27.3 months). There was no statistically significant difference in seizure-free outcomes between limited resection and ATLAH. In dominant DR-TLE, verbal memory decline was more likely after ATLAH than limited resection (3/4 vs. 0/9, p = 0.014). ConclusionExpert re-review of imaging and multi-modal advanced imaging improved TE identification. There was no statistical difference in seizure-free outcomes based on surgical extent. Preservation of verbal memory supports limited resection in dominant temporal cases.

MRI Tumor Regression Grade Combined with T2-Weighted Volumetry May Predict Histopathological Response in Locally Advanced Rectal Cancer following Neoadjuvant Chemoradiotherapy-A New Scoring System Proposal.

Modern studies focus on the discovery of innovative methods to improve the value of post-treatment magnetic resonance imaging (MRI) in the prediction of pathological responses to preoperative neoadjuvant chemoradiotherapy (nCRT) in locally advanced rectal cancer (LARC). The aim of this study was to assess the potential benefits of combining magnetic resonance tumor regression grade (mrTRG) with T2-weighted volumetry in the prediction of pathological responses to nCRT in LARC. This was a cohort study conducted on patients with histopathologically confirmed LARC in a period from 2020 to 2022. After histopathological verification, all patients underwent initial MRI studies, while the follow-up MRI was performed after nCRT. Tumor characteristics, MRI estimated tumor regression grade (mrTRG) and tumor volumetry were evaluated both initially and at follow-up. All patients were classified into responders and non-responders according to pathological tumor regression grade (pTRG) and mrTRG. A total of 71 patients, mostly male (66.2%) were included in the study. The median tumor volume reduction rate was significantly higher in nCRT-responders compared to non-responders (79.9% vs. 63.3%) (p = 0.003). Based on ROC analysis, optimal cut-off value for tumor volume reduction rate was determined with an area under the curve (AUC) value of 0.724 (p = 0.003). Using the tumor volume reduction rate ≥75% with the addition of response to nCRT according to mrTRG, a new scoring system for prediction of pTRG to preoperative nCRT in LARC was developed. Diagnostic performance of prediction score was tested and the sensitivity, PPV, specificity, and NPV were 81.8%, 56.3%, 71.4%, and 89.7%, respectively. The combination of mrTRG and T2-weighted volumetry increases the MRI-based prediction of pTRG to preoperative nCRT in LARC. The proposed scoring system could aid in distinguishing responders to nCRT, as these patients could benefit from organ-preserving treatment and a "watch and wait" strategy.