Repeat MRI Scan Research Articles

THE EffiCACY OF GAMMA KNIFE RADIOSURGERY FOR CYSTIC METASTASIS COMPARED WITH NON-CYSTIC METASTASIS

Abstract AIMS Between 20-40% of patients with cancer develop brain metastases (BMets), with metastasis representing the most common type of brain tumour. Cystic metastasis describes a rarer type of BMet characterised by oedematous collections. Stereotactic radiosurgery (SRS) is an effective and minimally invasive method for treating non-cystic BMets but controversy exists regarding its use in cystic BMets. The traditional view that cystic lesions are less responsive to SRS however is not fully evidenced. This investigation aims to elucidate the effectiveness of Gamma Knife (GK) radiosurgery in achieving local control of cystic BMets and enhancing survival versus GK radiosurgery for non-cystic BMets. METHOD Patients who had undergone fractionated GK for either a non-cystic or cystic BMet between 2018 and 2021 were identified. BMet volume on pre-GK MRI was calculated. Information was additionally collected on BMet location, maximum cyst diameter, if present, the patient’s primary tumour and its control and their performance status at the time of GK. The follow-up of patients is ongoing with survival being calculated using the Kaplan- Meier method and local progression through volumetric analysis of repeat MRI scans. RESULTS 57 patients with 79 cystic BMets were identified and 67 patients with non-cystic BMets. The most common primary tumour in both the non-cystic and the cystic BMets group was lung, comprising 30% and 23% respectively. The second most common tumour amongst non-cystic BMets was renal (12%) however in the cystic cohort it was breast (9%). The median tumour volume before treatment was 6.2cm3 in the non-cystic group and 12.5cm3 amongst cystic BMets. Median cyst size was 17.4 mm. Karnofsky Performance Status (KFS) was similar across both groups. CONCLUSION By comparing outcomes following GK for cystic and non-cystic metastasis, with the same primary tumours, this study can uncover the efficacy of fractionated GK for cystic lesions and aid the selection of treatments for these patients.

P079 Denosumab treatment for bone marrow oedema - a case series

Abstract Background/Aims This is a case series of patients treated with a single dose of denosumab to improve bone marrow oedema. Bone marrow oedema can cause significant pain and functional limitations. On MRI imaging, bone marrow oedema is identified as T1 hypointensities and T2 hyperintensities. Denosumab is a human monoclonal antibody that inhibits osteoclast bone absorption via binding to the cytokine RANKL [receptor activator of nuclear factor kappa-B ligand]. The exact aetiology of bone marrow oedema is unknown. It typically occurs in those aged between 40 to 60 years old. Studies have described therapeutic improvement with antiresorptive medications. Bone marrow oedema will generally resolve if left untreated. However, pharmacological treatments can curtail the clinical course. Methods This case series has emerged from Chelsea and Westminster hospital. Data was collected over a five year period for seven patients with bone marrow oedema [demonstrated on MRI] that were treated with denosumab. Six of the seven patients had a spontaneous insufficiency fracture associated with the bone marrow oedema on imaging. In our case series, two of the patients had bone marrow oedema in their hips and five in their knees. Denosumab was administered as a single 60mg subcutaneous injection. Response to treatment was ascertained by repeat MRI scan 2-4 months after denosumab treatment as well as patient reported outcomes. Results The average age of the patients was 56.4 years [age range 48-68 years]. Five of the patients [71%] reported improved symptoms at the affected site. Four patients [57%] had complete resolution of their bone marrow oedema on imaging with a further patient [14%] having an improved radiological appearance. Visual analogue scale [VAS] scores improved by 50%, although this data was only collected for some of the patients. No side-effects or complications were noted from the treatment. One of the patients who did not improve with denosumab treatment went on to have a total hip replacement due to complete loss of joint space. It is noteworthy that following further investigations, five of the seven patients were diagnosed with osteopenia on dual-energy x-ray absorptiometry [DEXA] scan, one had osteoporosis [and was subsequently commenced on alendronic acid] and one did not attend for their DEXA scan. Conclusion This series demonstrates that denosumab is an effective treatment for bone marrow oedema. Denosumab given as a single dose can be considered a safe treatment; there is not the risk of rebound worsening of bone density on treatment cessation that can be seen with prolonged treatment. Denosumab should be offered to patients who are symptomatic from bone marrow oedema to allow for quicker symptom relief and radiological improvement. Our findings are similar to that of a slightly larger case series of fourteen patients by Rolvien et al. published in 2017. Disclosure M. Galloway: None. A. Jacobs: None. M. Ismajli: None.

SHARED AND DISTINCT ASSOCIATIONS OF MANUAL DEXTERITY AND GROSS MOTOR FUNCTION WITH BRAIN ATROPHY

Abstract Poor motor function is associated with brain volume and cognitive impairment. Less is known about the associations among motor domains and brain atrophy and whether associations are affected by cerebrovascular burden and/or physical activity. We analyzed data from 726 Baltimore Longitudinal Study of Aging participants (mean age 70.6±10.1 years, 56%women, 27%Black), 525 of whom had repeat MRI scans over 5.0±2.1 years. Two motor domains were operationalized as latent variables. Manual dexterity using the Purdue Pegboard and gross motor function using grip strength and comprehensive physical performance testing. Associations between the latent variables and cortical and subcortical brain volumes of interest were examined using latent growth curve modeling, adjusted for demographics, white matter hyperintensities, and physical activity. Both higher manual dexterity and gross motor function were cross-sectionally associated with smaller ventricular volume and greater white matter volumes in the frontal, parietal, and temporal lobes (all p<.05). Higher manual dexterity was also cross-sectionally associated with greater parietal gray matter ( =0.14;95%CI:0.05,0.23), hippocampal ( =0.10;95%CI:0.01,0.20), postcentral gyrus ( =0.11;95%CI:0.01,0.20), and occipital white matter ( =0.10;95%CI:0.01,0.21) volumes, and better gross motor function with greater temporal gray matter volume ( =0.16;95%CI:0.05,0.26). Longitudinally, higher manual dexterity and gross motor function were associated with lower temporal white matter and occipital gray matter atrophy (all p<0.05). Greater manual dexterity was also associated with a slower rate of ventricular enlargement ( =-0.17;95%CI:-0.29,-0.05) and less atrophy of occipital white matter ( =0.39;95%CI:0.04,0.71). Among cognitively normal middle- and older-aged adults, manual dexterity and gross motor function exhibited shared as well as distinct associations with brain atrophy over time.

Shared and Distinct Associations of Manual Dexterity and Gross Motor Function With Brain Atrophy.

Poor motor function is associated with brain atrophy and cognitive impairment. Less is known about the relationship between motor domains and brain atrophy and whether associations are affected by cerebrovascular burden and/or physical activity. We analyzed data from 726 Baltimore Longitudinal Study of Aging participants (mean age 70.6 ± 10.1 years, 56% women, 27% Black), 525 of whom had repeat MRI scans over an average of 5.0 ± 2.1 years. Two motor domains, manual dexterity and gross motor, were operationalized as latent variables. Associations between the latent variables and cortical and subcortical brain volumes of interest were examined using latent growth curve modeling, adjusted for demographics, white matter hyperintensities, and physical activity. Both higher manual dexterity and gross motor function were cross-sectionally associated with smaller ventricular volume and greater white matter volumes in the frontal, parietal, and temporal lobes (all p < .05). Manual dexterity was also cross-sectionally associated with parietal gray matter (B = 0.14; 95% CI: 0.05, 0.23), hippocampus (B = 0.10; 95% CI: 0.01, 0.20), postcentral gyrus (B = 0.11; 95% CI: 0.01, 0.20), and occipital white matter (B = 0.10; 95% CI: 0.01, 0.21) volumes, and gross motor function with temporal gray matter volume (B = 0.16; 95% CI: 0.05, 0.26). Longitudinally, both higher manual dexterity and gross motor function were associated with less temporal white matter and occipital gray matter atrophy (all p < .05). Manual dexterity was also associated with a slower rate of ventricular enlargement (B = -0.17; 95% CI: -0.29, -0.05) and less atrophy of occipital white matter (B = 0.39; 95% CI: 0.04, 0.71). Among cognitively normal middle- and older-aged adults, manual dexterity and gross motor function exhibited shared as well as distinct associations with brain atrophy over time.

Marchiafava–Bignami disease after the white matter lesions: A case report

AbstractMarchiafava–Bignami disease (MBD) is an uncommon alcoholism‐related neuropsychiatric disorder, featured with symmetrical demyelination of part or whole corpus callosum (CC). Previous studies reported follow‐up neuroimaging changes with necrosis, cystic degeneration, and atrophy of the CC after the diagnosis of MBD, but it is unclear whether the white matter is damaged before MBD. We report a case of alcoholic MBD whose magnetic resonance imaging revealed structural lesions in the white matter before the typical demyelination of CC during MBD, which support the prior hypothesis that chronic hazardous drinking may initially lead to microstructure abnormalities of the white matter and CC through some possible mechanisms, then microstructure lesions in the CC, and white matter deterioration into extensive demyelination, that is MBD. In future clinical practice, when patients with chronic alcoholism seek treatment for neuropsychiatric disorders, they may need to undergo repeated MRI scans to reveal progressive neuroimaging features before and after MBD.

Assessing the Appropriateness of Repeat MRI Scan Requests Within a Foot and Ankle Department

Category: Other Introduction/Purpose: With diagnostic resources often in great demand, it is important to ensure clinicians request investigations appropriately. Unnecessary radiological investigations are costly and delay patient care. This study aimed to assess the incidence and appropriateness of repeat MRI scans being requested in a single foot and ankle unit, to identify areas which can be improved. Methods: This was a retrospective analysis of 1322 scans between October-2019 to October-2022. We included all patients who had a diagnostic MRI scan requested after being assessed in our foot-and-ankle clinics. Assessments were made on the proportion of repeat scans, the seniority of requester, the indications put forward for the repeat scan, the modality of patient assessment (telephone vs face-to-face appointment), and the impact on patient management. A scan was considered a repeat, if the same anatomical location was scanned within a 3-year period. Scans were deemed appropriate if they were: part of a clinical trial, for tumour/infection/stress-fracture monitoring, for new trauma, pre-operative planning, following agreement in MDT discussions, or following significant changes in clinical symptoms. We expected that scans should ideally only be requested where the result is expected to influence management and that a scan should not be repeated without evidence of change in clinical symptoms (unless for monitoring). Results: Over the 3-year period, 6.5% of MRI scans performed were considered repeat scans. The average time between initial and repeat scans was 13.1±8.6months (range 1-33 months). 88% of patients had only one repeat scan. The majority(58%) of repeat scans were requested by non-senior clinicians. In total, 47/85(55%) scans were deemed appropriate. 75% of the patients in this cohort had been assessed face-to-face. Twenty of these scans were repeated for significant change in clinical symptoms and 50% meaningfully influenced management plans. Conversely, 38/85(45%) repeat scans did not have strong clinical indications. The majority(80%) of these were requested by non- senior clinicians and 50% were requested after a telephone review. From the scans requested by the non-senior clinicians, none(0%) had a meaningfully influence on patients’ management plans. Conclusion: This study highlights that although repeat MRI scans were not common, they seldom influenced patient management unless there was a meaningful change in patient symptoms. MRI scans were more likely to influence management when initiated by senior clinicians and following a face-to-face assessment. In order to streamline patient care and reduce unnecessary investigations we propose a protocol to guide the requesting of repeat scans. This protocol includes identifying significant symptomatic change, in-person review, and senior clinician or multi-disciplinary input when a repeat scan is being considered.

Routine MRI Among Patients With a Suspected Scaphoid Fracture Risks Overdiagnosis.

In the setting of a suspected scaphoid fracture, MRI may result in overdiagnosis and potential overtreatment. This is in part because of the low prevalence of true fractures among suspected fractures, but also because of potentially misleading variations in signal that may be more common than fracture-related signal changes. To better understand the risk of overdiagnosis, we first need insight into the relative prevalence of useful and potentially distracting signal changes among patients with a suspected scaphoid fracture. What is the proportion of signal changes representing definite and possible scaphoid fractures relative to other types of signal changes on MRI among patients with a suspected scaphoid fracture? In a retrospective study in an orthopaedic trauma clinic associated with a Level I trauma center, we evaluated MR images of patients 16 years and older with a clinically suspected scaphoid fracture. At our institution, patients with symptoms and signs of a possible scaphoid fracture and negative radiographs undergo MRI scanning. Between January 1, 2012, and September 1, 2019, a total of 310 patients 16 years or older had an MRI to evaluate a suspected scaphoid fracture. Exclusion criteria included a scaphoid fracture that was visible on radiographs before MRI as reported by the radiologist (four patients), no available radiographs before MRI (two), MRI more than 3 weeks after injury (28), unknown date of injury (nine), and repeat or bilateral MRI scans (11), leaving 256 MR images for analysis. Sixty percent (153) of patients were women, and the median age was 34 years (IQR 21 to 50 years). The images were taken a median of 8 days (IQR 2 to 12 days) after injury. MR images were screened for the presence of scaphoid signal changes. We identified the following patterns of signal change with a reliability of kappa 0.62: definite scaphoid fracture, possible scaphoid fracture, signal in the waist area other than possible or definite fractures, and other signal changes. A definite scaphoid fracture was defined as a linear, focal, and bicortical signal abnormality, with adjacent edema and a relatively transverse orientation relative to the scaphoid long axis. The transverse linear signal was visible on more than one cut in multiple planes. A possible scaphoid fracture had a transverse linear signal on more than one cut on sagittal or coronal planes, with or without adjacent edema. Six percent (16 of 256) of MR images were categorized as revealing definite (2% [four of 256]) or possible (5% [12 of 256]) scaphoid fractures, whereas 29% (74 of 256) were categorized as revealing nonspecific signal changes at the waist (14% [35 of 256]) and other areas (15% [39 of 256]). Of the 51 patients with scaphoid waist signal changes, 69% (35) were categorized as having distracting and potentially misleading MRI findings. The high prevalence of signal changes that are distracting and potentially misleading, the low prevalence of signal changes that clearly represent a scaphoid fracture, and the low pretest odds of a true fracture among patients with a suspected scaphoid fracture illustrate that routine MRI of suspected scaphoid fractures carries a notable risk of overdiagnosis and potential overtreatment. Two alternative strategies are supported by preliminary evidence and merit additional attention: more-selective use of MRI in people deemed at higher risk according to a clinical prediction rule and strategies for involving the patient in decisions regarding how to manage the notably small risk of future symptomatic nonunion. Level IV, diagnostic study.

EPS5.03 Elexacaftor/Tezacaftor/Ivacaftor for 76 weeks is associated with a reduced orocaecal transit time: the GIFT-CF3 extension study

Background and objectives: The effect of elexacaftor/tezacaftor/ivacaftor (ETI) on the gut in cystic fibrosis (CF) is currently unknown. The GIFT-CF3 study (NCT04618185), a prospective cohort study, has used MRI to compare gastrointestinal (GI) function before, 12 weeks and 24 weeks after starting ETI. The primary outcome is orocaecal transit time (OCTT), or the time for food to pass from mouth to caecum. We previously found that OCTT at 24 weeks post ETI (median 360 minutes) did not change significantly vs baseline. In the GIFT-CF3 extension study, we invited participants for repeat MRI scans to evaluate whether the use of ETI lead to a reduction in OCTT after 76 weeks of ETI.

Real-World Effectiveness of Ocrelizumab in a Multi-Centre Pediatric-Onset Multiple Sclerosis (POMS) Cohort in the United Kingdom (S31.007)

<h3>Objective:</h3> The aim of this study was to evaluate the efficacy and safety of ocrelizumab treatment for pediatric-onset Multiple Sclerosis (POMS) in a real-world clinical setting. <h3>Background:</h3> There is a growing consensus favouring earlier use of highly effective disease modifying therapies (DMTs) in POMS. <h3>Design/Methods:</h3> We conducted a prospective study including consecutive POMS (&lt;18 years) from three UK tertiary paediatric neurosciences centers who received ocrelizumab. <h3>Results:</h3> We included a total of 60 POMS patients; 49 female (81.7%), 41 non-white (68.3%), median age 14.6 yrs (IQR 13.3, 15.5). Median follow-up period was 1.0 yr (range, 0.1–2.6). Forty-three patients (71.7%) had ocrelizumab as their first DMT. The median number of relapses per patient pre-treatment was 2 (range 1–5). Two patients relapsed within one month of starting ocrelizumab and 1 patient had an optic neuritis 6-months post ocrelizumab initiation. During the follow-up period, a median of 2 (range 1–5) repeated MRI scans were performed (total scans, n=140). Forty out of 43 (93.0%) patients achieved no evidence of disease activity (NEDA-3) at 12-months follow-up; two patients had one new brain lesion each at 6-months and a different patient had a relapse (optic neuritis) without new brain lesions at 6-months post treatment. Median EDSS score remained stable during follow-up; 1.0 at baseline and follow-up (p=0.21). In addition, there was no change in cognitive measures at follow-up; baseline SDMT mean score 46 vs follow-up SDMT mean score 48 (p=0.39). The most common adverse events reported were infusion-related-reactions (33/60, 55%), all of which were grade 1 or 2. Serious adverse events were recorded in one patient with enterovirus meningitis, who made a full recovery. <h3>Conclusions:</h3> This study confirms that ocrelizumab, which is proven efficacious for adults with MS, is also effective in POMS with a comparable safety profile. Assessment for long-term efficacy and safety is ongoing. <b>Disclosure:</b> Dr. Abdel-Mannan has nothing to disclose. Arman Eshaghi has nothing to disclose. Dr. Champsas has nothing to disclose. Kshitij Mankad has nothing to disclose. Dr. Brownlee has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Roche. Dr. Brownlee has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Biogen. Dr. Brownlee has received personal compensation in the range of $500-$4,999 for serving as a Consultant for EMD Serono. Dr. Brownlee has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Sanofi. Dr. Brownlee has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Novartis. Dr. Brownlee has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Janssen. Dr. Brownlee has received personal compensation in the range of $500-$4,999 for serving as an Editor, Associate Editor, or Editorial Advisory Board Member for Sage. Dr. Rossor has nothing to disclose. Sukhvir Wright has nothing to disclose. Dr. Wassmer has received personal compensation in the range of $500-$4,999 for serving on a Speakers Bureau for Biogen. The institution of Dr. Wassmer has received research support from Birmingham Children’s Hospital Charity Research Foundation. The institution of Cheryl Hemingway has received personal compensation in the range of $0-$499 for serving as a Consultant for Biogen. The institution of Cheryl Hemingway has received personal compensation in the range of $0-$499 for serving as a Consultant for Novartis. The institution of Cheryl Hemingway has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for UCB. The institution of Cheryl Hemingway has received personal compensation in the range of $500-$4,999 for serving on a Speakers Bureau for Sanofi. The institution of Cheryl Hemingway has received research support from Medical research Committee. Ming Lim has nothing to disclose. Prof. Ciccarelli has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Novartis. Prof. Ciccarelli has received personal compensation in the range of $0-$499 for serving on a Speakers Bureau for Merck. Prof. Ciccarelli has received personal compensation in the range of $10,000-$49,999 for serving as an Editor, Associate Editor, or Editorial Advisory Board Member for NEUROLOGY Journal. Dr. Hacohen has nothing to disclose.

Absence of cortical lesions after the first seizure in a patient with anti-myelin oligodendrocyte glycoprotein-associated cortical encephalitis

A 31-year-old man developed headache and generalized convulsions. At the time of the first seizure, there was no distinct MRI abnormality. He was admitted to the hospital with repeated seizures, left-sided hemiparesis, and left-sided neglect. He had a slight fever, elevated cerebrospinal fluid (CSF) pressure, and increased CSF cell count with predominance of mononuclear cells. A repeat MRI scan on day 8 after the recurrent seizure showed cortical edema in the right cerebral hemisphere on fluid-attenuated inversion recovery (FLAIR), abnormal high signal on DWI, and decreased apparent diffusion coefficient. The patient was diagnosed with aseptic meningoencephalitis and treated with antiviral drugs and methylprednisolone pulse therapy. Serum anti-myelin oligodendrocyte glycoprotein (MOG) antibody was subsequently detected, and prednisolone was added to treat the FLAIR-hyperintense lesions in anti-MOG antibody associated encephalitis with seizures (FLAMES). It is important to identify the clinical picture and typical images of FLAMES to allow early treatment.

Prostatic Abscess Due to Idiopathic Granulomatous Disease: A Rare Complication of a Chameleon Disorder &amp;lt;br/&amp;gt;—Prostatic Abscess Due to Idiopathic Granulomatous Disease

Background: Prostatic abscesses are usually diagnosed in the setting of bacterial prostatitis. Rarely, they reveal or complicate granulomatous prostatitis (GP). Four cases of idiopathic xanthogranulomatous GP have been described previously and the present case report is the first of typical idiopathic variety. The case: A 60-year-old man presented with urine retention that was associated with pyuria and massively enlarged prostate. Cystoscopy revealed prostatic abscess (PA) that was opened. Urine and prostatic culture were negative for bacteria. Prostatic biopsy revealed multiple non-caseating granulomata surrounded by lymphocytes, plasma cells yet without foamy histiocytes, parasites and vasculitis. Special stains were negative for vasculitis, fungiand acid-fast organisms. The patient was treated with Solumedrol 1 g intravenously daily for 3 days followed by Prednisone 1 mg/kg/day for 1 month followed by gradual tapering till discontinuation by 3rd month. Moreover, he had received Mycophenolate mofetil (MMF) 1 g twice/daily. By the end of 2nd month; he was asymptomatic and without pyuria. Repeat cystourethroscopy and MRI scan of the prostate showed near normal prostate. In Conclusion: Idiopathic GP can present with PA that requires proper drainage and since it is a locally hyperimmune disease with genetic predisposition; MMF therapy will be maintained for a total of 2 years to prevent future disease-relapse.

Amyloidoma Presenting as Compressive Myelopathy.

Spinal cord compression is a common problem in clinical practice. Sometimes puzzling symptoms may mislead the clinician in the initial days. We present a 59 year old lady who presented with progressive numbness of both feet and abdomen, walking difficulties for which the initial evaluation did not yield any result. The work up at our facility showed collapsed D3 vertebra, prevertebral collection and cord compression. She was tentatively started on antituberculous treatment, based on the radiologist opinion. Two months later, the patient had further progression of symptoms and had to undergo D3 laminectomy and surgical decompression. She also developed hypertension and diabetes in the meantime. Histopathology did not favour tuberculous process, but showed amyloid deposition. Antituberculous treatment was halted and she was evaluated for plasma cell dyscrasias. The serum protein electrophoresis with immunofixation was in favour of IgG Kappa light chain monoclonal gammopathy. She was further subjected to bone marrow aspiration and biopsy at a Cancer institute. The result was negative for plasma cell malignancy, and was suggestive of only reactive lymphocytosis. On the advice of oncologist, antituberculous treatment was started again and continued as RH- two drug regimen for 9 months along with supportive care. She improved symptomatically, able to walk independently and attended regular follow up. Three years later, a repeat MRI scan showed enlargement of the lesion to involve the posterior mediastinum. The oncology service decided to irradiate the lesion, only if she develops new symptoms. This outcome suggests the unusual presentation of the disease, and the so litary amyloidoma is probably a primary disease in itself or secondary to a neoplastic process.

464 Local Extension of a Solitary Extra Medullary Nasal Plasmacytoma into the Orbit

AimExtramedullary plasmacytoma are rare neoplasms, which mainly occur in the head and neck, the most common site being the nasal cavity or septum. Patients may present with epistaxis, nasal obstruction, or rhinorrhoea. Extension into the orbit is rare but can lead to visual disturbances.MethodThis case report pertains to a 69-year-old female patient who initially presented with a 6-week history of recurrent sinusitis, with left sided cheek pain and diplopia.ResultsA CT and MRI scan was performed, which showed opacification of the left maxillary, ethmoid and sphenoid sinuses with bony destruction of the medial and anterior maxillary walls and into the anterior soft tissues. The mass was completely obstructing the left nasal cavity extending into the inferomedial orbit. Staging CT scans also showed nodal disease in the neck.Biopsy with histology was positive for CD138, with diffuse proliferation of plasma cells of varying maturity and atypia. Additionally, mono IgG kappa was also positive as was CD45 suggestive of a lymphoid neoplasm. Bone marrow biopsy and PET scan confirmed there was no systemic involvement.Radiotherapy was initiated after the patient recovered from COVID -19. A repeat MRI scan 6 weeks post radiotherapy showed a partial response with reduction in the size of the tumour, resolution of the intra-orbital extension and disappearance of paraprotein.ConclusionsThis case report illustrates need for earlier consideration of EMP diagnostically to reduce the risk of conversion of the plasmacytoma to multiple myeloma, which is a known possibility and to ensure minimal delay in the commencement of treatment.

1.5 versus 3 Tesla structural MRI in patients with focal epilepsy.

Structural MRI is a critical component in the pre-surgical investigation of epilepsy, as identifying an epileptogenic lesion increases the chance of post-surgical seizure freedom. In general practice, 1.5T and 3T MRI scans are still the mainstream in most epilepsy centres, particularly in resource-poor countries. When 1.5T MRI is non-lesional, a repeat scan is often performed as a higher-field structural scan, usually 3T. However, it is not known whether scanning at 3T increases diagnostic yield in patients with focal epilepsy. We sought to compare lesion detection and other features of 1.5T and 3T MRI acquired in the same patients with epilepsy. MRI scans (1.5T and 3T) from 100 patients were presented in a blinded, randomized order to two neuroradiologists. The presence, location, and number of potentially epileptogenic lesions were compared. In addition, tissue contrast and the presence of motion/technical artifacts were compared using a 4-point subjective scale. Both the qualitative tissue contrast and motion/technical artifacts were improved at 3T. However, this did not result in statistically significant improvement in lesion detection. Qualitatively, five patients had subtle lesions seen only at 3T. However, minor differences in image acquisition parameters between 1.5T and 3T scans in these cases may have resulted in greater lesion visibility at 3T in four patients. Based on a general linear model analysis, the presence of a focal abnormality on EEG was predictive of the presence of a lesion at 1.5T and 3T. Repeat MRI scanning of patients with focal epilepsy at 3T using similar scan protocols does not significantly increase diagnostic yield over scanning at 1.5T; the increased signal-to-noise ratio can potentially be better allocated for novel scan sequences in order to provide more clinical value.

The effects of repeated brain MRI on chromosomal damage

BackgroundMagnetic resonance imaging (MRI) is currently considered a safe imaging technique because, unlike computed tomography, MRI does not expose patients to ionising radiation. However, conflicting literature reports possible genotoxic effects of MRI. We herein examine the chromosomal effects of repeated MRI scans by performing a longitudinal follow-up of chromosomal integrity in volunteers.MethodsThis ethically approved study was performed on 13 healthy volunteers (mean age 33 years) exposed to up to 26 3-T MRI sessions. The characterisation of chromosome damage in peripheral blood lymphocytes was performed using the gold-standard biodosimetry technique augmented with telomere and centromere staining.ResultsCytogenetic analysis showed no detectable effect after a single MRI scan. However, repeated MRI sessions (from 10 to 20 scans) were associated with a small but significant increase in chromosomal breaks with the accumulation of cells with chromosomal terminal deletions with a coefficient of 9.5% (95% confidence interval 6.5–12.5%) per MRI (p < 0.001). Additional exposure did not result in any further increase. This plateauing of damage suggests lymphocyte turnover. Additionally, there was no significant induction of dicentric chromosomes, in contrast to what is observed following exposure to ionising radiation.ConclusionsOur study showed that MRI can affect chromosomal integrity. However, the amount of damage per cell might be so low that no chromosomal rearrangement by fusion of two deoxyribonucleic breaks is induced, unlike that seen after exposure to computed tomography. This study confirms that MRI is a safe imaging technique.

Spontaneous Regression of Disc Prolapse – An Underlooked Phenomena: A Case Report and Literature Review

Introduction: Intervertebral disc prolapse is a very common abnormality found in the population, that can manifest in a variety of complaints like back pain, radiculopathy, and even to the extent that it might lead to more adverse neurological deficits. Symptoms improve in majority of patients only with conservative treatment. However, some patients may require surgical intervention. In some cases, spontaneous regression of herniated disc can be seen. Thus, the interest in the phenomenon of spontaneous resorption of the herniated discs has increased, which raised the controversy regarding managing such patients. Here, we report a case of a huge lumbosacral spontaneous disc resolution at the level of L5-S1 in which clinical improvement was associated with a significant decrease in the size of a huge, herniated disc. In addition, we performed a comprehensive review of literature of all reported cases of spontaneous disc resolution to provide an updated discussion of such an underlooked phenomena.&#x0D; Case Report: A 53-year-old female not known to have any medical illness presented at the Neurosurgery Clinic with complaints of chronic back pain for six years which was progressing and radiating to both of her lower extremities (right more than left) and had become more intense in the last year. It was slightly relieved by simple analgesics and aggravated by sitting or lying down. There was no history of trauma, weaknesses, or sphincteric disturbances. Upon evaluation in our clinic, local exam revealed lower back midline tenderness at the level of L5-S1 vertebrae. No tenderness was observed in the paravertebral area or facets. Straight leg raising test was positive at 70º in the right side and 90º in the left, normal power, intact sensation, normal tone, and reflexes. Negative Babinski and clonus was noted in both limbs. MRI lumbar spine showed significant right paracentral L5-S1 disk prolapse indenting the thecal sac compressing the root. A full-course and effective medical treatment was initiated as the patient was never treated properly before for her back pain, along with physical therapy and regular OPD follow-ups. A follow-up MRI a year later revealed significant reduction in the size of the disk prolapse as compared to the initial imaging study. Overall, patient’s symptoms significantly improved, and she was kept on conservative management.&#x0D; Conclusion: To conclude, the case presented here shows the efficacy and validity of conservative management for patients who are diagnosed with a herniated disc in the absence of neurological deficits. This shows the importance of not pushing surgical treatment for patient with lumbar disc herniation without neurological deficits, each patient should receive a trial of conservative therapy and close OPD follow-ups and repeated MRI scans for further assessment of any advancement or improvement, because herniated discs can regress spontaneously. Radiological changes alone should not be the main target for assessing improvement, what matters more is clinical and symptomatic improvement. Surgical management remains an important therapeutic option for patients who failed conservative management and patients who have severe neurological deficits.

O29 Keeping a watchful eye: IgG4-positive lymphoma masquerading as IgG4-related ocular disease

Case report - IntroductionIgG4-related disease (IgG4-RD) is increasingly recognised in rheumatology practice. We describe a case of orbital swelling initially diagnosed as IgG4-RD. It was exquisitely steroid responsive and she was treated with 6 years of immunosuppression but her symptoms later deteriorated. She developed worsening left eye swelling that required debulking surgery; histopathology demonstrated IgG4-positive lymphoma. She had an excellent response to localised radiotherapy and remains in remission. Although her initial presentation was typical of IgG4-RD, her subsequent lack of response to steroids prompted reconsideration of the initial diagnosis and re-examination of her previous biopsy specimen, confirming IgG4-positive Iymphoma at both timepoints.Case report - Case descriptionA 25-year-old lady presented in 2008 with a swollen left eye. She had a history of childhood eczema, asthma and sinusitis. Diagnostic excision was undertaken; histology was considered to show chronic inflammation, scattered eosinophils, dense fibrosis and no granulomas. She was diagnosed with a ‘granulomatosis with polyangiitis-like’ orbital pseudotumour. It was exquisitely steroid responsive; mycophenolate mofetil was added from an early stage of treatment.The patient was referred to rheumatology 3 years after diagnosis as she was unable to reduce her prednisolone below 5mg daily. Her immunology screen was negative. Although her plasma IgG4 levels were normal at 0.14g/L, the original histology was reviewed and immunostained for IgG4. This demonstrated more than 80% of plasma cells to be IgG4 positive, with the previously noted dense fibrosis and chronic inflammatory infiltrate. Her diagnosis was revised to orbital IgG4-RD. She commenced azathioprine as she was planning a pregnancy.Following an uncomplicated pregnancy in 2014, her symptoms significantly deteriorated, with worsening pain, discharge and swelling in her left eye. A repeat MRI scan showed a new cuff of abnormal tissue within the lateral aspect of the left orbit. She was referred to ophthalmology and underwent left anterior orbitotomy with debulking. Histopathology at this time was consistent with extranodal marginal zone lymphoma (EMZL) of MALT (mucosa-associated lymphoid tissue) type, IgG4 positive. An extraordinary feature was an abundance of crystal-storing histiocytes, presumed to contain ingested IgG4.To investigate whether she had an IgG4-secreting lymphoma from the beginning or whether there had been malignant transformation of her orbital IgG4-RD, the histology from 2009 was reviewed. This was considered to indicate a MALT-type EMZL.The patient was referred to haematology and she was treated with localised radiotherapy with an excellent response. She remains in remission following this and she has subsequently been discharged from haematology follow-up.Case report - DiscussionIgG4-RD is a condition involving fibroinflammatory lesions that can affect any organ in the body. As a newly recognised condition, the role of IgG4 in IgG4-RD is still not fully understood. Questions that remain unanswered include whether or not IgG4 is directly pathogenic and whether there is an increased risk of malignancy in patients with IgG4-RD.Our patient’s case demonstrates how IgG4-positive lymphoma can mimic IgG4-RD. It is important to keep a broad differential diagnosis in complex cases, and to support the eventual diagnosis with blood results, imaging studies and histology. It is essential to involve colleagues in radiology and histopathology so that a multidisciplinary decision can be made with regards to management. IgG4-RD is a steroid-responsive condition. When there is poor response to conventional treatment, this should raise doubts regarding the diagnosis, and it would be prudent to consider a repeat biopsy as well as obtaining previous pathology specimens so that they can be re-reviewed.Ocular adnexal lymphomas form 1—2% of non-Hodgkin lymphomas and 8% of extranodal lymphomas. Over recent decades the incidence has increased, partly reflecting better diagnostic techniques. The most common subtype of ocular adnexal lymphomas are EMZL of MALT type, as in our patient.There are several case reports of lymphoma arising in patients with established IgG4-RD, raising the question of potential lymphomagenesis in IgG4-RD. The earliest reports come from Asia and most have been reported in patients with ocular IgG4-RD. However, the link between malignancy and IgG4-RD is still being investigated. It is important to consider a potential malignancy when managing patients with IgG4-RD, especially if there is a lack of response to steroids.Case report - Key learning pointsThere is no single diagnostic test for IgG4-RD. Diagnosis should be based on the overall clinical picture, supported by blood results, imaging and histopathology.IgG4-RD is a steroid-responsive disease. If there is a poor response to treatment, the diagnosis should be re-considered.Re-examination of previous biopsy specimens can be invaluable, especially in patients refractory to standard treatment.The link between IgG4-RD and malignancy has not been established and it is important to remain vigilant. As ocular adnexal lymphomas are not uncommon, it is important to keep this differential diagnosis in mind when reviewing patients with eye swelling thought to be secondary to IgG4-related ocular disease.

Cerebrovascular Infarcts in the Setting of Disseminated Intravasulcar Coagulation As Presenting Symptom in Acute Promyelocytic Leukemia

Introduction:Patients with newly diagnosed Acute Promyelocytic Leukemia (APL) commonly present with disseminated intravascular coagulation (DIC) that can lead to hemorrhagic insult. Hematologists caring for APL patients understand that aggressive transfusion support with platelets, cryoprecipitate, and fresh frozen plasma must be initiated to correct the underlying DIC. Rarely, a patient with APL will present with arterial thrombosis in the setting of DIC and little is known about how to best manage these patients.On review of the literature, five cases were described where patients with newly diagnosed APL presented with CNS arterial thrombosis; 3 patients are alive with neurologic deficit and 2 are dead. (Table 1).We have experience with three patients diagnosed with APL who presented with cerebrovascular infarct. We report our experience to heighten awareness of this unusual presentation of this rare type of leukemia.Methods:Chart review was conducted with IRB approval on three patients with known diagnosis of APL who presented to Emory University with signs and symptoms of stroke who were found to have ischemic cranial events. Demographics, past medical history, and treatment regimen for both infarction and APL were collected.Case Series:Patient 1- 21-year-old male who presented to an outlying hospital with expressive aphasia. MRI scan showed large right temporoparietal infarction. Labs showed WBC 21.6, platelets 9,000, low fibrinogen, elevated PT and elevated d-dimer. High-risk APL was confirmed and ATRA and IV dexamethasone were started. Heparin drip was initiated to decrease risk of further ischemic insult. Worsening neurologic symptoms 4 days later led to a repeat MRI scan, which showed progressive right sided infarct and a new infarct in the left distal territory of the middle cerebral territory and expired shortly thereafter. Images 1 and 2 show infarcts on day 2 and 6 of admission.Patient 2- 55-year-old female with presented with dysarthria and altered mental status. CT head showed left middle cerebral infarction and was immediately given tPA. Her admission labs showed WBC 37.6, platelets 48,000, PT 19, aPTT 35.3, Fibrinogen 67 and a diagnosis of high risk APL was established. She was induced with ATRA, Idarubicin and ATO and discharged in hematologic remission with no neurologic deficit.Patient 3- 59 year old female, Jehovah's Witness, with multiple comorbidities presented with shortness of breath. Influenza A and PE were diagnosed and oseltamivir and warfarin was initiated. New left arm tingling prompted a brain MRI scan that showed multifocal bilateral acute infarcts. She was discharged with anticoagulation but readmitted 5 days later with a WBC of 38.4 and platelets 19,000. CT head showed progression of all the infarcts. APL was diagnosed and ATRA and ATO was started but she refused transfusions and died of neurologic deterioration.Conclusions:Our case series review is consistent with the previous literature. The mortality in patients with APL presenting with CNS arterial thrombosis is extremely high. Since it is a rare occurrence in a rare malignancy, not enough is known on the best management strategy. More dedicated observation and research is warranted on this topic to improve outcomes in this otherwise very curable malignancy. [Display omitted] DisclosuresArellano:Cephalon Oncology: Research Funding. Kota:Takeda Pharmaceuticals: Consultancy; Xcenda: Consultancy; Leukemia Lymphoma Society: Research Funding; Incyte: Consultancy; Novartis: Consultancy; Pfizer: Consultancy.

Evaluation of Cerebral Blood Flow Measured by 3D PCASL as Biomarker of Vascular Cognitive Impairment and Dementia (VCID) in a Cohort of Elderly Latinx Subjects at Risk of Small Vessel Disease.

Cerebral small vessel disease (cSVD) affects arterioles, capillaries, and venules and can lead to cognitive impairments and clinical symptomatology of vascular cognitive impairment and dementia (VCID). VCID symptoms are similar to Alzheimer’s disease (AD) but the neurophysiologic alterations are less well studied, resulting in no established biomarkers. The purpose of this study was to evaluate cerebral blood flow (CBF) measured by 3D pseudo-continuous arterial spin labeling (pCASL) as a potential biomarker of VCID in a cohort of elderly Latinx subjects at risk of cSVD. Forty-five elderly Latinx subjects (12 males, 69 ± 7 years) underwent repeated MRI scans ∼6 weeks apart. CBF was measured using 3D pCASL in the whole brain, white matter and 4 main vascular territories (leptomeningeal anterior, middle, and posterior cerebral artery (leptoACA, leptoMCA, leptoPCA), as well as MCA perforator). The test-retest repeatability of CBF was assessed by intra-class correlation coefficient (ICC) and within-subject coefficient of variation (wsCV). Absolute and relative CBF was correlated with gross cognitive measures and domain specific assessment of executive and memory function, vascular risks, and Fazekas scores and volumes of white matter hyperintensity (WMH). Neurocognitive evaluations were performed using Montreal Cognitive Assessment (MoCA) and neuropsychological test battery in the Uniform Data Set v3 (UDS3). Good to excellent test-retest repeatability was achieved (ICC = 0.77–0.85, wsCV 3–9%) for CBF measurements in the whole brain, white matter, and 4 vascular territories. Relative CBF normalized by global mean CBF in the leptoMCA territory was positively correlated with the executive function composite score, while relative CBF in the leptoMCA and MCA perforator territory was positively correlated with MoCA scores, controlling for age, gender, years of education, and testing language. Relative CBF in WM was negatively correlated with WMH volume and MoCA scores, while relative leptoMCA CBF was positively correlated with WMH volume. Reliable 3D pCASL CBF measurements were achieved in the cohort of elderly Latinx subjects. Relative CBF in the leptomeningeal and perforator MCA territories were the most likely candidate biomarker of VCID. These findings need to be replicated in larger cohorts with greater variability of stages of cSVD.

Corrigendum to: An analysis of short-term repeat MRI scans of vertebral corner lesions in suspected early axSpA: defining the prevalence and evolution of clinically significant spinal lesions without concurrent SIJ changes on imaging.

Corrigendum to: An analysis of short-term repeat MRI scans of vertebral corner lesions in suspected early axSpA: defining the prevalence and evolution of clinically significant spinal lesions without concurrent SIJ changes on imaging.