Non-enhancing Lesions Research Articles

AARS2-related Leukodystrophy Without Ovarian Failure Mimicking Multiple Sclerosis in a Female: A Case Report With a Novel Pathogenic Variant (P4-12.010)

<h3>Objective:</h3> N/A <h3>Background:</h3> <i>AARS2</i> mutations affect mitochondrial alanyl-transfer RNA (tRNA) synthetase. This enzyme is responsible of charging alanine to its cognate tRNA for protein translation within mitochondria. Individuals with <i>AARS2</i> mutations were reported to present either severe infantile cardiomyopathy or progressive leukoencephalopathy as the main clinical presentation. <i>AARS2</i>-related leukoencephalopathy is an ultra-rare white matter disorder, characterized by spasticity, ataxia, and impaired cognition. Further disease progression manifests as psychiatric illness and executive dysfunction. Ovarian failure is reported in almost all females with <i>AARS2</i>-related leukoencephalopathy. <h3>Design/Methods:</h3> N/A <h3>Results:</h3> A 32-year-old female was referred to the clinic due to the development of progressive neurological symptoms since 2011. Ascending numbness of the lower limbs was the first clinical symptom that further extended to her abdomen. Patient, then, developed visual impairment in both eyes. Other symptoms included cognitive decline and language impairment that began abruptly with fast progression. She has one child and her menstrual cycles have been always regular. Multiple sclerosis was initially diagnosed and she was treated with corticosteroid, natalizumab, and rituximab without achieving improvements. The brain magnetic resonance imaging (MRI) of a patient performed in our institute showed multiple focal and confluent areas of diffusion restriction in bilateral periventricular and deep white matter, involving bilateral centrum semiovale/ corona radiate. Diffuse brain volume loss and bilateral thinning of optic nerves were observed. The MRI of thoracic spinal cord showed non-enhancing short segment T2 hyperintense lesions within the right ventral cord at T8-T9 and T12-L1. Molecular study reported a novel homozygous variant of c.929G&gt;T (p.Gly310Val) in <i>AARS2</i>. <h3>Conclusions:</h3> <i>AARS2</i>-related leukoencephalopathy in females can present without ovarian failure. The overlapping clinical and imaging features of white matter disorders may lead to misdiagnosis of the disease. Detailed review of clinical characteristics, MRI patterns, and molecular study can be helpful to reach to an accurate diagnosis. <b>Disclosure:</b> Mr. Amanat has nothing to disclose. Julie Cohen, 377 has received personal compensation in the range of $500-$4,999 for serving as a Consultant for PTC Therapeutics. Julie Cohen, 377 has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Illumina. The institution of Julie Cohen, 377 has received research support from A Cure for Ellie. Dr. Fatemi has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Bluebirdbio. Dr. Fatemi has received personal compensation in the range of $10,000-$49,999 for serving as an Expert Witness for RCO law. The institution of Dr. Fatemi has received research support from Minoryx. The institution of Dr. Fatemi has received research support from Viking Therapeutics. The institution of Dr. Fatemi has received research support from Swanbio Therapeutics . The institution of Dr. Fatemi has received research support from Autobahn Therapeutics. The institution of Dr. Fatemi has received research support from Nuvelution. The institution of Dr. Fatemi has received research support from NIH. The institution of Dr. Fatemi has received research support from A Cure for Ellie Foundation. The institution of Dr. Fatemi has received research support from Brian’s Hope Foundation . Dr. Fatemi has received intellectual property interests from a discovery or technology relating to health care. Dr. Fatemi has a non-compensated relationship as a Director (Board member) with ALDConnect that is relevant to AAN interests or activities. The institution of Dr. Fine has received research support from NIH.

Balo’s Concentric Sclerosis presenting as Sensorineural Hearing Loss (P14-3.007)

<h3>Objective:</h3> Multiple sclerosis (MS) can affect other cranial nerves apart from optic nerve. We report an interesting case of Balo’s concentric sclerosis (BCS) that presented with sensorineural hearing loss (SNHL). <h3>Background:</h3> BCS is a rare variant of MS. It derives its name from the concentric pattern of demyelination alternating with preserved myelin seen on magnetic resonance imaging (MRI). It typically has a fulminant monophasic clinical course with a fatal outcome although there has been an increasing number of cases reported with a benign clinical course. <h3>Design/Methods:</h3> NA <h3>Results:</h3> 48-year-old presented to our neuro-immunology clinic for evaluation of abnormal MRI which revealed non-enhancing T2 hyperintensities in juxta-cortical, peri-ventricular and infratentorial cerebellar lesions concerning for demyelination. He had tinnitus and SNHL of right ear ongoing for 3–4 months prior to presentation. Extensive workup was pursued to rule out MS mimics including nutritional, autoimmune, and infectious etiologies. LP revealed no evidence of oligoclonal bands. He was originally diagnosed with radiologically isolated syndrome with plans to monitor with MRI brain annually for surveillance. Repeat MRI brain a year later revealed new non-enhancing concentric juxta-cortical lesion along the right frontal operculum exhibiting a laminated appearance with surrounding perilesional edema consistent with BCS. He had no new neurological symptoms in the interim. On re-evaluation, his auditory symptoms were deemed as a clinical event, and he was diagnosed with MS with subsequent initiation of disease modifying therapy. <h3>Conclusions:</h3> BCS may occur simultaneously with MS like lesions or may herald the onset of MS. SNHL is a rare manifestation of MS with demyelinating lesion along the course of vestibulocochlear nerve or nucleus in brain stem. MRI brain can fail to reveal signs of demyelination either due to timing of MRI brain from symptom onset or sub-optimal diagnostic accuracy as vestibular evoked myogenic potentials have detected demyelinating lesions which are invisible on MRI brain. <b>Disclosure:</b> Dr. Potluri has nothing to disclose. Dr. Samaniego has nothing to disclose. Dr. Lannen has received personal compensation in the range of $5,000-$9,999 for serving as an Editor, Associate Editor, or Editorial Advisory Board Member for Genentech. Dr. Lannen has received personal compensation in the range of $500-$4,999 for serving as an Editor, Associate Editor, or Editorial Advisory Board Member for TG Therapeutics.

Neurocysticercosis in Non-Endemic Areas: The Experience in Qatar (P3-10.007)

<h3>Objective:</h3> To characterize Neurocysticercosis (NCC) in Qatar with a large database of a multiethnic population. <h3>Background:</h3> Qatar is a nation in the Gulf region of the Middle East with a predominantly immigrant population, making it a unique area of study for the epidemiology of NCC. Historically, NCC is not endemic in the region. <h3>Design/Methods:</h3> We retrospectively studied instances of NCC (n=420) recorded in Qatar from 2013–2018 through the national healthcare system. We analyzed the data and stratified it based on several variables such as symptoms, treatment, and outcome, as well as radiological features. <h3>Results:</h3> Out of the 420 patients, 93.6% were men, and 98.3% were immigrants from NCC endemic countries such as Nepal (63.8%) and India (29.5%). Eighty percent of patients presented with seizures, with the majority (69%) experiencing generalized tonic-clonic seizures. Five percent presented with status epilepticus. Headaches, the second most common complaint, were reported in 18% of subjects. On imaging, 50% had a single lesion while 63% were at the calcified stage. The lesions were parenchymal in 99.5% of cases, predominantly in the frontal lobe (59%). Thirteen percent were diagnosed incidentally on imaging, mainly in the form of isolated calcified non-enhancing lesions. Phenytoin was the most prescribed anti-seizure drug (57%), and albendazole was received by 55% of patients. When follow up information was available, clinical improvement was noted in 81% of patients. <h3>Conclusions:</h3> NCC is prevalent in Qatar and remains confined to the large proportion of Southeast Asian immigrants within the population. Given this, dissemination most likely occurred in their countries of origin where NCC is endemic. NCC is a significant contributor to the epilepsy burden in Qatar, often with a good outcome regarding seizure control. NCC with an intraparenchymal single lesion seems to be over represented in our cohort. <b>Disclosure:</b> Miss Nauman has nothing to disclose. Ms. Wahbeh has nothing to disclose. Dr. Shaheen has nothing to disclose. Dr. Abunaib has nothing to disclose. Dr. Melikyan has nothing to disclose. Dr. Mesraoua has nothing to disclose. Dr. Deleu has nothing to disclose. Dr. Al Hail has nothing to disclose. Ahmed El Sotouhy has nothing to disclose. Ziyad Mahfoud, 5273 has nothing to disclose. Dr. Haddad has nothing to disclose.

Approach to Balancing Risk in Multiple Sclerosis Management: a Worldwide Practice Survey (P14-3.013)

Approach to Balancing Risk in Multiple Sclerosis Management: a Worldwide Practice Survey (P14-3.013)

Teaching NeuroImages: Prosopagnosia heralding anti-NMDA receptor encephalitis

A 23-year-old right-hand-dominant woman presented with 3 weeks of progressive difficulty recognizing faces, including her own, subsequently developing psychosis. Noncontrast CT head and MRI brain with contrast revealed a nonenhancing lesion of the right posterior temporal lobe and fusiform gyrus, with corresponding hypermetabolism on FDG-PET/CT brain (figure). EEG demonstrated right posterior temporal slowing. CSF and serum anti–NMDA receptor (NMDAR) antibodies were positive, with CT abdomen/pelvis revealing ovarian teratoma. Teratoma removal, plasmapheresis, and 1 cycle of rituximab yielded symptom resolution over 1 month. Anti-NMDAR encephalitis rarely presents with prosopagnosia,1 and in this case, is likely secondary to right fusiform gyrus dysfunction.2

Endoscopic fenestration of an enlarging giant occipital arachnoid cyst

This case demonstrates an endoscopic fenestration of an enlarging giant occipital arachnoid cyst. The patient is a 42-year-old woman presenting with headache, progressive vision loss, and nausea and vomiting. MRI demonstrates a large, nonenhancing cystic lesion in the right occipital lobe measuring up to 8.3 cm, consistent with an arachnoid cyst. This surgical video illustrates the technique for an endoscopic fenestration into the native ventricular system utilizing stereotactic MRI-guided stealth navigation. Postoperatively, the patient had full recovery with improvement of headaches and vision and was discharged on postoperative day 1 without complications. The video can be found here: https://stream.cadmore.media/r10.3171/2023.1.FOCVID22129.

Letter: Chordoma and Ecchordosis Physaliphora: 2 Sides of the Same Coin.

To the Editor: Chordoma and ecchordosis physaliphora (EP) are tumors arising from the notochord's remains along the axial skeleton from the dorsum sella to the sacrococcygeal region. Each year, 1 person in a million is diagnosed with chordoma, but only 45 cases of EP have been reported.1-12 In 1857, Virchow invented the acronym EP for the newly discovered dorsum sella lesion, believing it was cartilage related. A year later, Muller discovered notochord rests in the synchondrosis sphenooccipitalis and hypothesized that these were the source of the EP dorsum sella masses. Ribbert then endorsed this theory.13 Over a century later, Congdon and Wolfe coined the terms benign chordoma and intradural chordoma.14,15 Cha et al justified distinguishing EP from chordoma because they are treated differently and have a different prognosis because one is more aggressive than the other. So far, approximately 45 cases of EP have been diagnosed, with 10 patients displaying symptoms. In 1 of these cases, the patient died as a result.13 Two chief aspects spring to mind when pondering this subject. The first is the manner in which these instances were diagnosed and distinguished from chordoma cases. The second issue stems from the first, namely how to determine the ideal modality of treatment when there is no objective way to distinguish between those pathologies. The articles concur that it is impossible to distinguish between them based on histology or immunohistochemistry staining results because they are derived from the same embryonic notochord. Although certain histopathologic characteristics such as hypocellularity, sparse pleomorphism, and the lack of mitosis may aid in the differentiation of EP from chordoma, they are not considered diagnostic criteria.5,6,16 In addition, it has been stated that an intradural location favors EP over chordoma, yet there are instances of chordoma being an intradural.17 From an imaging point of view, chordoma frequently presents a contrast-enhanced lesion. However, it may occasionally exhibit a mild or nonenhanced lesion similar to EP.18 A study of 28 patients found that 65% of magnetic resonance images of chordoma showed mild or no enhancement.19 Moreover, all reported spinal EPs demonstrated enhanced extradural mass, similar to chordoma lesions.3-6,13 In conclusion, differentiation based on histology, immunohistochemistry staining, radiologic results, or the presence of symptoms is inaccurate. Based on the foregoing, it is impossible, or at least impractical, to distinguish between the 2 terms because they refer to the same ailment. Additional environmental or genetic factors may influence the severity and progression of the disease.20 It would be prudent to consolidate these 2 disorders as part of the spectrum of the same disease, chordoma, and classify it based on severity according to the radiologic findings for size, location, and bone involvement. We hope this paradigm shift will lay the groundwork for novel approaches to chordoma management.

Characterization of Incidental Liver Lesions: Comparison of Multidetector CT versus Ultrasonography

Background: Due to recent advancements in imaging techniques, as well as the widespread use of routine medical exams and screenings, incidental LL are now more frequently discovered by US. Physicians must decide whether to simply follow up when incidental LL are discovered in the US or to order additional imaging tests for lesion classification. The goal of our study was to identify LL using MDCT and US. Methods and Results: A total of 50 participants were selected from a variety of male and female patients with abdominal pain and suspected liver diseases, and received a CT triphasic scan and US at the Royal Care International Hospital, Ibn Alhaitham Diagnostic Center, Alfaisal Specialized Hospital, and the Department of Diagnostic Radiology in the CT department of Sudan from April 2018 to May 2020. The results of the ultrasound scanning (liver lesions and related findings) performed on patients before the CT scanning indicated that ascites+ liver lesions was predominant (48.6%). The incidental liver lesions that take peripheral nodular enhancement by MDCT when contrast media is injected, were liver metastases (30%), hemangioma (14%), and HCC (10%). Liver cysts represent 10(20%) of the total cases of lesions that were non-enhanced by CT, with a few cases of liver cirrhosis (2%), hepatosplenomegaly (2%), and cyst + hepatitis (2%). We found a significant relationship between peripheral nodular enhancement for liver lesions by MDCT and non-enhancing liver lesions (P=0.001). Conclusion: The US and CT scan findings have a statistically significant relationship (P≤0.017). Contrast-enhanced CT performs better at diagnosing liver lesions than does standard US.

Transverse myelitis following bivalent COVID‐19 booster vaccine and quadrivalent seasonal influenza vaccine

Transverse myelitis following bivalent <scp>COVID</scp>‐19 booster vaccine and quadrivalent seasonal influenza vaccine

Combining in vivo proton exchange rate (k ex) MRI with quantitative susceptibility mapping to further stratify the gadolinium-negative multiple sclerosis lesions.

Conventional gadolinium (Gd)-enhanced MRI is currently used for stratifying the lesion activity of multiple sclerosis (MS) despite limited correlation with disability and disease activity. The stratification of MS lesion activity needs further improvement to better support clinics. To investigate if the novel proton exchange rate (k ex ) MRI combined with quantitative susceptibility mapping (QSM) may help to further stratify non-enhanced (Gd-negative) MS lesions. From December 2017 to December 2020, clinically diagnosed relapsing-remitting MS patients who underwent MRI were consecutively enrolled in this IRB-approved retrospective study. The customized MRI protocol covered conventional T2-weighted, T2-fluid-attenuated-inversion-recovery, pre- and post-contrast T1-weighted imaging, and quantitative sequences, including k ex MRI based on direct-saturation removed omega plots and QSM. Each MS lesion was evaluated based on its Gd-enhancement as well as its susceptibility and k ex elevation compared to the normal appearing white matter. The difference and correlation concerning lesion characteristics and imaging contrasts were analyzed using the Mann-Whitney U test or Kruskal-Wallis test, and Spearman rank analysis with p < 0.05 considered significant. A total of 322 MS lesions from 30 patients were identified with 153 Gd-enhanced and 169 non-enhanced lesions. We found that the k ex elevation of all lesions significantly correlated with their susceptibility elevation (r = 0.30, p < 0.001). Within the 153 MS lesions with Gd-enhancement, ring-enhanced lesions showed higher k ex elevation than the nodular-enhanced ones' (p < 0.001). Similarly, lesions with ring-hyperintensity in QSM also had higher k ex elevation than the lesions with nodular-QSM-hyperintensity (p < 0.001). Of the 169 Gd-negative lesions, three radiological patterns were recognized according to lesion manifestations on the k ex map and QSM images: Pattern I (k ex + and QSM+, n = 114, 67.5%), Pattern II (only k ex + or QSM+, n = 47, 27.8%) and Pattern III (k ex - and QSM-, n = 8, 4.7%). Compared to Pattern II and III, Pattern I had higher k ex (p < 0.001) and susceptibility (p < 0.05) elevation. The percentage of Pattern I of each subject was negatively correlated with the disease duration (r = -0.45, p = 0.015). As a potential imaging biomarker for inflammation due to oxidative stress, in vivo k ex MRI combined with QSM is promising in extending the clinical classification of MS lesions beyond conventional Gd-enhanced MRI.

Diagnostic Contrast-Enhanced Mammography Performed Immediately Prior to Same-Day Biopsy: An Analysis of Index Lesion Enhancement Compared to Histopathology and Follow-up in Patients With Suspicious Ultrasound Findings.

To measure the diagnostic performance of contrast-enhanced mammography (CEM) for the index lesion when it is performed the same day prior to biopsy in patients with suspicious findings at US. This IRB-approved retrospective study compared radiologist original reports of the presence or absence of index lesion enhancement on CEM to biopsy results and follow-up. The most suspicious lesion or the larger of equally suspicious lesions recommended for biopsy by US after a diagnostic workup including mammography was considered the index lesion. CEM exams were performed the same day, immediately prior to the scheduled biopsy, as requested by the radiologist recommending the biopsy. Numeric variables were summarized with means and standard deviations, or medians and the minimum and maximum, where appropriate. Biopsy demonstrated cancer in 64.7% (200/309) of index lesions. Of these, 197/200 demonstrated enhancement for a sensitivity of 98.5% (95% CI: 95.7%-99.7%) (197/200) and the negative predictive value of CEM for non-enhancing index lesions was 95.1% (58/61; 95% CI: 86.1%-98.4%). The three false negative exams were two grade 1 ER+ HER2- invasive ductal cancers that were 6 mm and 7 mm in size, and a 3-mm grade 2 ductal carcinoma in situ in a complex cystic and solid mass. False positive exams made up 20.6% (51/248) of the positive exams. Diagnostic CEM showed high sensitivity and specificity for cancer in lesions with suspicious US findings. CEM may reduce the need for some biopsies, and negative CEM may support a true negative biopsy result.

Quantitative T1 mapping detects blood–brain barrier breakdown in apparently non-enhancing multiple sclerosis lesions

ObjectivesThe disruption of the blood–brain barrier (BBB) is a key and early feature in the pathogenesis of demyelinating multiple sclerosis (MS) lesions and has been neuropathologically demonstrated in both active and chronic plaques. The local overt BBB disruption in acute demyelinating lesions is captured as signal hyperintensity in post-contrast T1-weighted images because of the contrast-related shortening of the T1 relaxation time. On the contrary, the subtle BBB disruption in chronic lesions is not visible at conventional radiological evaluation but it might be of clinical relevance. Indeed, persistent, subtle BBB leakage might be linked to low-grade inflammation and plaque evolution. Here we hypothesised that 3D Quantitative Transient-state Imaging (QTI) was able to reveal and measure T1 shortening (ΔT1) reflecting small amounts of contrast media leakage in apparently non-enhancing lesions (ANELs). Materials and methodsThirty-four patients with relapsing remitting MS were included in the study. All patients underwent a 3 T MRI exam of the brain including conventional sequences and QTI acquisitions (1.1 mm isotropic voxel) performed both before and after contrast media administration. For each patient, a ΔT1 map was obtained via voxel-wise subtraction of pre- and post- contrast QTI-derived T1 maps. ΔT1 values measured in ANELs were compared with those recorded in enhancing lesions and in the normal appearing white matter. A reference distribution of ΔT1 in the white matter was obtained from datasets acquired in 10 non-MS patients with unrevealing MR imaging. ResultsMean ΔT1 in ANELs (57.45 ± 48.27 ms) was significantly lower than in enhancing lesions (297.71 ± 177.52 ms; p < 0. 0001) and higher than in the normal appearing white matter (36.57 ± 10.53 ms; p < 0.005). Fifty-two percent of ANELs exhibited ΔT1 higher than those observed in the white matter of non-MS patients. ConclusionsQTI-derived quantitative ΔT1 mapping enabled to measure contrast-related T1 shortening in ANELs. ANELs exhibiting ΔT1 values that deviate from the reference distribution in non-MS patients may indicate persistent, subtle, BBB disruption. Access to this information may be proved useful to better characterise pathology and objectively monitor disease activity and response to therapy.

Ependymal lined paraventricular neuroglial cyst: an outcome of endoscopic cystoventriculostomy concomitant ventriculoperitoneal shunt procedures: a case report

Neuroglial cysts are one of the problems that might develop in the neuroaxis region. We present the case of a 79-year-old male with an acute decrease in consciousness, dysphagia, and seizure with a past medical history of a cystic mass in the frontal lobe since 5 years ago. A cystic lesion with a calcification component was found in the regio left frontal after the patient received a head CT without contrast. The periventricular white matter is where the lesion is found. Subsequent brain MRI with and without contrast showed hypointense T1 weighted image (T1W1), hyperintense T2-weighted imaging (T2W1), hypointense fluid-attenuated inversion recovery (FLAIR), and non-restricted diffusion-weighted imaging (DW1). A non-enhancing intra-axial lesion measuring 5.1 cm (AP) x 3.1 cm (LL) x 3.6 cm (CC). Following a discussion of the benefits and risks with his family, the decision was eventually made to proceed with Endoscopic Cystoventriculotomy (Cyst Fenestratum) and concurrent ventriculoperitoneal (VP)-shunting. This method produced positive results. The preferred method is endoscopic fenestration since it carries fewer risks and consequences than open craniotomies and fenestration.

ORBIAL DERMOID CYST: CLINICAL SCENARIO

In this case report, we describe a case of superotemporal orbital dermoid that came to our tertiary care center. An 8-year-old female presented with swelling of the left superolateral orbital region, which gradually increased over the past 3 years. A CT scan was performed, which showed a welldened non-enhancing cystic lesion with thin internal septa in the extraconal space of the left orbit, in the superolateral compartment. Although the denitive diagnosis was not clear, it appeared to be a dermoid cyst on CT ndings. Surgical excision of the mass was performed by the sub-brow approach and histopathological examination of the specimen was performed, which conrmed that it was a dermoid cyst. After the surgery, the swelling subsided

Aseptic pleocytosis eight days after the first dose of a vector-based SARS-CoV-2 vaccine.

Vaccination against SARS-CoV-2 is considered beneficial by the majority, but side effects occur in some cases. We report on a 28-year-old female who developed fever within 3 days of an initial dose with a vector-based SARS-CoV-2 vaccine. Eight days after vaccination, she developed paresthesias and dysesthesias of all four limbs. Cerebral imaging showed two non-specific and non-enhancing lesions in the left white matter. Cerebrospinal fluid (CSF) studies revealed pleocytosis of 82/3 cells. Examination for multiple sclerosis, neuromyelitis optica, acute, demyelinating encephalomyelitis, and Guillain-Barre syndrome was negative. She received steroids, which resulted in complete resolution of the neurological abnormalities. In summary, SARS-CoV-2 vaccination can occasionally be complicated by an inflammatory CSF syndrome, which resolves on administration of steroids.

Idiopathic acquired dacryocystocele in an adult: case report of a rare entity

BackgroundIdiopathic acquired dacryocystocele in adults is a rare disorder of the lacrimal drainage pathway. Only 20 cases have been reported in the literature. It presents with a triad of epiphora, medial canthal swelling, and recurrent dacryocystitis. Patients presenting without recurrent dacryocystitis is quite uncommon. This presentation can be confused with secondary nasolacrimal duct obstruction and other non-inflammatory pathologies. Dacryocystorhinostomy with stenting is the treatment employed in most reported cases.Case presentationA 24-year-old male presented with epiphora and medial canthal swelling for 3 years. Examination revealed features of left nasolacrimal duct obstruction. Imaging was suggestive of a cystic, homogenous, non-enhancing lesion in the left lacrimal sac region without bone destruction. Findings were suggestive of dacryocystocele. Patient underwent endoscopic dacryocystorhinostomy without stenting. Postoperatively, the swelling and epiphora resolved. Patient is symptom-free on follow-up.ConclusionIdiopathic dacryocystocele must be considered in evaluation of a medial canthal mass with epiphora without dacryocystitis. Conservative treatment is ineffective. Endoscopic dacryocystorhinostomy is safe and effective.

Endoscopic nasal surgery for mucocele and pyogenic mucocele of turbinate: Three case reports

Cases of turbinate mucocele or pyogenic mucocele are extremely rare. During nasal endoscopy, turbinate hypertrophy can be detected in patients with turbinate or pyogenic mucocele. However, in many instances, differentiating between turbinate hypertrophy and turbinate mucocele is difficult. Radiological examinations, such as computed tomography (CT) or magnetic resonance imaging (MRI), are essential for the accurate diagnosis of turbinate mucocele. Herein, we report three cases of mucocele or pyogenic mucocele of turbinate, including their clinical presentation, imaging findings, and treatments, to help rhinologists understand this condition better. Three cases of turbinate and pyogenic mucocele were encountered in our hospital. In all patients, nasal obstruction and headache were the most common symptoms, and physical examination revealed hypertrophic turbinates. On CT scan, mucocele appeared as non-enhancing, homogeneous, hypodense, well-defined, rounded, and expansile lesions. Meanwhile, MRI clearly illustrated the cystic nature of the lesion on T2 sequences. Two patients with inferior turbinate mucocele underwent mucocele lining removal, while the patient with pyogenic mucocele underwent endoscopic middle turbinate marsupialization. The patients were followed up on the first, third, sixth month, and 1 year after discharge, and no complaints of headache and nasal congestion were reported during this period. In conclusion, both CT and MRI are helpful in the diagnosis of turbinate or pyogenic mucocele. Additionally, endoscopic nasal surgery is considered to be the most effective treatment method.

Comparison of Apparent Diffusion Coefficient Value Measurement and Contrast-Enhanced T1-Weighted Imaging in Detecting Active Demyelinating Lesions in Multiple Sclerosis

Objective: To find a difference in apparent diffusion coefficient (ADC) values of non-enhancing and enhancing lesions in patients with multiple sclerosis (MS) and to find a cutoff ADC value to predict the enhancement of the MS lesion. Materials and Methods: A retrospective review of magnetic resonance imaging (MRI) of the brain in MS patients between January 2015 and December 2019 was done. The MS plaques in the images were mapped in fluid attenuation inversion recovery (FLAIR) and post-contrast T1- weighted imaging sequences (T1WI). The lesions were categorized into enhancing and non-enhancing lesions based on the presence of enhancement on post-contrast T1WI. The ADC value of each lesion was measured using circular regions of interest (ROI) placed in the enhancing portion. The difference in mean ADC values between the two groups was assessed. Results: There were 22 patients with 194 MS lesions. The mean ADC values of the enhancing lesions at 0.891±0.164×10⁻³ mm²/s were significantly lower than those of the non-enhancing lesions at 1.303±0.280×10⁻³ mm²/s (p&lt;0.001). A cutoff ADC value of 1.117×10⁻³ mm²/s was used to distinguish between the enhancing and the non-enhancing lesions. The best results were obtained with a sensitivity of 93.9%, specificity of 71.4%, positive predictive value (PPV) of 40.3%, negative predictive value (NPV) of 98.3%, and accuracy of 75.3%. Conclusion: ADC value measurement can be used to predict the enhancement of the MS plaque, which may be helpful as a screening tool for active demyelinating plaque in MS patients. Keywords: Multiple sclerosis; Active demyelinating lesion; Active MS; Contrast-enhanced T1-weighted imaging; ADC value

NIMG-65. IMPROVED SPATIAL MAPPING OF TUMOR AGGRESSIVENESS WITH 1H MAGNETIC RESONANCE SPECTROSCOPY AND DEEP LEARNING IN PATIENTS WITH NEWLY-DIAGNOSED GLIOMA

Abstract INTRODUCTION Noninvasive, radiopathomic mapping of tumor aggressiveness can benefit patients with glioma by guiding the selection of tissue samples for diagnosis, increasing extent of resection, and non-invasively characterizing residual tumor burden for subsequent treatment. Although prior studies have demonstrated the utility of metabolic metrics quantified from 1H-MR Spectroscopy (MRS) in probing tumor pathology, this study evaluated the benefit of using the entire 1D-spectrum and deep learning for radiopathomic mapping of intratumoral cellularity, proliferation (ki-67), and a new tumor aggressiveness index (TAI) defined as log((n(ki−67)+n(cellularity))*tumor-score). METHODS Multi-voxel 1H-MRS was acquired on 281 patients newly diagnosed with a glioma (47% IDH-wildtype) immediately before surgical resection. After reconstructing individual spectra at the locations where tissue samples were obtained during surgery and normalizing by NAA in contralateral normal-appearing-white-matter, 607 spectra with corresponding histopathology were deemed of sufficient quality for analysis. A 1D convolutional-neural-network with bidirectional long- and short-term memory deep-learning model using the entire spectrum (0.6-3.6ppm) was compared to mixed-effects regression (with choline-to-NAA index[CNI]) and Random Forest (with CNI+normalized peak heights) models for predicting ki-67, cellularity, and TAI. Results &amp; DISCUSSION Using deep-learning on the entire spectrum resulted in 10.3%-22.1% lower mean absolute error (MAE) and 0.32-0.37 higher R2 values compared to using CNI alone or a random forest model with multiple metabolic metrics. MAE values for all 3 deep-learning models were 26-44% &amp;lt; 1 standard deviation of the ground truth, demonstrating reasonable prediction accuracy within the test data set. Although the lowest MAE (0.16) and highest R2 (0.41) was attained when predicting TAI with deep-learning, the prediction of cellularity resulted in the lowest %MAE. Colormaps of predicted pathology identified regions of heightened aggressiveness surrounding tissue samples with most abnormal pathological features that sometimes extended beyond the non-enhancing lesion. Current work is evaluating the clinical utility of our deep-learning model and predicted maps of aggressiveness.

NIMG-46. TOWARDS PREDICTING TUMOR AGGRESSIVENESS WITH RADIOPATHOMIC ANALYSIS OF MULTI-PARAMETRIC ANATOMICAL, DIFFUSION-WEIGHTED, AND METABOLIC MRI IN PATIENTS WITH NEWLY-DIAGNOSED GLIOMAS

Abstract INTRODUCTION Pathologically aggressive tumor biology can extend beyond the contrast-enhancing or non-enhancing anatomical lesions in patients with glioma. Identification of malignant regions can help guide diagnosis and subsequent treatment planning. This study leverages a unique multi-parametric MRI dataset with tissue samples of known spatial coordinates to noninvasively predict cellular proliferation (KI-67) and a novel index of tumor aggressiveness (TAI), that combines proliferation, cellularity, and tumor-score. METHODS 420 tissue samples were collected from 162 patients with newly-diagnosed glioma (47% IDH-wildtype). Clinical imaging consisted of T2-weighted, T2-FLAIR, T1-weighted pre- and post-contrast images, and apparent diffusion coefficient (ADC) and fractional anisotropy (FA) from diffusion-weighted imaging. Mean normalized imaging metrics were quantified from 5mm spheres centered at the location of the tissue sample. A single spectrum was reconstructed at the location of each tissue sample from 3D 1H-MR Spectroscopic Imaging (MRSI) before quantifying normalized metabolite peak-heights for choline, creatine, NAA, lactate/lipid, and relative indices. Univariate mixed-effects linear regression models were employed and features with p&amp;lt; 0.2 were selected for subsequent model building. Support vector machine (SVM), random forest, and gradient boosting machine-learning algorithms were trained and tested on a ⅔-⅓ train-test split with 4-fold cross-validation in training to predict a high/low KI-67 and TAI. RESULTS Although none of the individual imaging metrics were significantly associated with KI-67 in the univariate analysis, all diffusion and several MRSI metrics (ncholine, nNAA, CNI, excess choline and creatine) were significantly associated with cellularity. Preliminary multivariate analyses to date suggest that the best radiopathomic model performance is achieved when an SVM was used along with T1-precontrast, nADC, and all metabolite levels (mean cross-validation AUC=0.73 and accuracy=.77). CONCLUSION Our results suggest that multi-parametric physiologic and metabolic MRI are useful for radiopathomic-mapping of tumor aggressiveness and are currently being optimized in a larger cohort.