Typical MRI Findings Research Articles

Hepatic focal nodular hyperplasia during follow-up of patients after cyclophosphamide- or oxaliplatin-based chemotherapy: differentiation from liver metastasis

ObjectivesNewly detected hepatic nodules during follow-up of cancer survivors receiving chemotherapy may pose a diagnostic dilemma. We investigated a series of hepatic focal nodular hyperplasia (FNH) diagnosed by either typical MRI features and follow-up or pathology in cancer survivors.MethodsThis retrospective study evaluated 38 patients with tumours who developed new hepatic FNH after cyclophosphamide-based (n = 19) and oxaliplatin-based (n = 19) chemotherapies. The main tumour types were breast cancer (n = 18) and colorectal cancer (n = 17). MRI findings, clinical features, and temporal evolution of all target hepatic lesions (n = 63) were reported. In addition, the two chemotherapy drug groups were compared.ResultsThe median interval between chemotherapy completion and FNH detection was 30.4 months (12.9, 49.4). Six patients underwent biopsy or surgery, while the remaining patients were diagnosed based on typical MRI features and long-term follow-up. Among the patients, 60.5% (23/38) presented with multiple nodules and 63 target lesions were detected. The median size of target lesions was 11.5 mm (8.4, 15.1). The median follow-up time was 32.5 months (21.2, 48.6), and 15 patients experienced changes in their lesions during the follow-up period (11 increased and 4 decreased). The cyclophosphamide-based treatment group had a younger population, a greater proportion of females, and a shorter time to discovery than the oxaliplatin-based chemotherapy group (all p ≤ 0.016).ConclusionsFNH may occur in cancer survivors after cyclophosphamide- or oxaliplatin-based chemotherapy. Considering a patient’s treatment history and typical MRI findings can help avoid misdiagnosis and unnecessary invasive treatment.Clinical relevance statementWhen cancer survivors develop new hepatic nodules during follow-up, clinicians should think of the possibility of focal nodular hyperplasia in addition to liver metastasis, especially if the cancer survivors were previously treated with cyclophosphamide or oxaliplatin.Key PointsCancer survivors, after chemotherapy, can develop hepatic focal nodular hyperplasia.Cyclophosphamide and oxaliplatin are two chemotherapeutic agents that predispose to focal nodular hyperplasia development.Focal nodular hyperplasia occurs at shorter intervals in patients treated with cyclophosphamide.Graphical

NFS-19. ATYPICAL PRESENTATION OF GLIOMAS IN ADOLESCENTS WITH NEUROFIBROMATOSIS TYPE 1 (NF1): A CASE SERIES

Abstract BACKGROUND Patients with NF1 are at risk for developing gliomas, usually low-grade in childhood but may be high-grade in adults. In children, the most common sites of disease are the optic pathway and brainstem; tumors in these regions often arise in young children and display histological features characteristic of pilocytic astrocytoma (PA) when biopsied. Typical MRI findings include T2 hyperintense, T1 hypointense lesions with minimal contrast enhancement and no diffusion restriction. Due to the well-established pattern of low-grade tumor formation in children with NF1, as well as the surgically challenging areas in which these tumors develop, low-grade glioma (LGG) therapy is often initiated without histologic confirmation of the diagnosis in classic cases. In cases with atypical disease location, older age at presentation or imaging appearance, a biopsy may be considered to exclude higher-grade lesions. METHODS Retrospective chart review, case series RESULTS Four adolescent patients with NF1 presented with atypical suspected gliomas. All four patients underwent surgical biopsy/resection. Case 1 was a left temporal lesion in the previous radiation field for optic pathway glioma; biopsy confirmed LGG with MAP2K1 mutation and increased focal proliferation index (28%), but methylation did not match with any established classification. The patient progressed through multiple rounds of therapy and succumbed to her tumor. Case 2 was a left occipital lesion; biopsy confirmed PA with CDKN2A deletion. The tumor displayed rapid regrowth, but subsequently stabilized. Case 3 was a right frontal lesion; confirmed PA. The tumor demonstrated some regrowth but then stabilized. Case 4 was a basal ganglia lesion; confirmed PA. The patient has demonstrated stable MRI findings and has not required further intervention. CONCLUSIONS Biopsy yielded helpful prognostic information (additional mutations, proliferation rate) in half of these atypical cases. Biopsy should be carefully considered for NF1 patients with atypical presentation or a history of radiation.

The Role of MRI in Groin Pain Syndrome in Athletes.

Groin pain syndrome (GPS) is one of the most frequent injuries in competitive sports. Stresses generated in the lower limbs by quick turns and accelerations, such as in soccer, basketball or hockey, can produce localized regions of increased forces, resulting in anatomical lesions. The differential diagnoses are numerous and comprise articular, extra-articular, muscular, tendinous and visceral clinical conditions and a correct diagnosis is crucial if treatment is to be efficient. MRI is the gold standard of diagnostic techniques, especially when an alternative pathology needs to be excluded and/or other imaging techniques such as ultrasound or radiography do not lead to a diagnosis. This paper, based on the current literature, gives a comprehensive review of the anatomy of the pubic region and of the typical MRI findings in those affected by GPS. Many clinical conditions causing GPS can be investigated by MRI within appropriate protocols. However, MRI shows limits in reliability in the investigation of inguinal and femoral hernias and therefore is not the imaging technique of choice for studying these clinical conditions.

Hashimoto's encephalitis - A case report

A 50 year-old woman with a background of focal epilepsy presented to Emergency Department (ED) in convulsive status epilepticus.After 1 year seizure-free on levetiracetam,she initially presented with headache, tremor, fatigue and general malaise. She was discharged, then re-presented to ED several days later in status epilepticus. Two doses of diazepam administered pre-hospital failed to terminate the seizure. She was loaded with phenytoin,intubated and ventilated and commenced on a midazolam infusion. She spent 7 days in neuro-intensive care and was discharged home on levetiracetam 1.5 g twice daily and phyentoin 250 mg twice daily.One month later, she re-presented to ED with 4 days of worsening tremors and reduced mobility. Physical examination revealed multifocal myoclonus. She had experienced significant cognitive decline and neuropsychiatric symptoms including severe anxiety, delusions and paranoia.InvestigationsImagingInitial MRI head with gadolinium showed marked symmetric abnormality within the white matter of both hemispheres extending into subcorticol regions, most predominant at the vertex and involving U fibres. The neuro-radiologist commented that the differential for these changes was broad, including an encephalitis, PML, meningitis or a leukoencephalopathy.Repeat MRI head 1 month later showed complete resolution of the white matter changes leaving no sequelae.Blood testsHer past medical history included subclinical hypothyroidism. Thyroid function tests showed an elevated TSH of 21.33 and thyroid peroxidase(TPO) antibody level of 188.0 IU/mL, with FT4 levels within normal range.Extensive relevant blood screen, including the following was all negative• NMDA, glycine receptor and anti-cardiolipin antibody• Connective tissue screen, anti-MPO and anti-PR3• Serum electrophoresis• Paraneoplastic antibody screen including Cerebellum IIF, MA2, MA1, amphiphysin, CV2(CRMP5), Anti-Ri (ANNA 2) Ab, Anti Yo Ab and Anti Hu Ab• HIV and syphilis serology• JC virus• Plasma amino acid, urine organic acid and ammoniaLumbar punctureCSF WCC 1/mm3CSF protein- 816 mg/LCSF viral PCR (including JC virus) and oligoclonal bands negativeEEG- normal background activity with no clear focal or diagnostic epileptiform abnormalities.Treatment and follow-upThe clinical picture, elevated TPO antibodies and absence of other relevant investigation abnormality raised Hashimoto's encephalitis as a potential unifying diagnosis. She had a good response to inpatient treatment with steroids, her neuropsychiatric features resolved and she has remained seizure-free since discharge. She remains under neurology outpatient follow-up.Discussion:It can be challenging to make a diagnosis of Hashimoto encephalitis, and other potential causes such as infection, metabolic or paraneoplastic processes must be rigorously ruled out (1). In this case, high titres of TPO alongside the clinical presentation with recurrent seizures and cognitive decline were key in making the diagnosis (2,3). Due to an overlap of features, including myoclonus and rapid cognitive decline, it was important to consider Creutzfeldt-Jakob disease (CJD) in the differential. We ruled out CJD due to the rapid response to steroid therapy and lack of typical EEG and MRI findings (4). Overall, due to low prevalence and non-specific MRI and EEG features, this diagnosis can be difficult to make and requires thorough systemic clinical assessment.

Classification of Uterine Adenomyosis: A Pictorial Essay

MRI is a crucial tool for diagnosing adenomyosis and identifying its related pathologies. To accurately diagnose adenomyosis, it is necessary to recognize both the typical MRI findings and atypical features of the condition. Recently, a standardized classification system has been developed to facilitate precise presurgical diagnosis of adenomyosis and to determine the appropriate treatment method. Differentiating between various subtypes based on MRI-based classification and identifying different MRI phenotypes can aid in categorizing patients with adenomyosis into specific treatment groups and monitoring their response to therapy.

Acute disseminated encephalomyelitis following the COVID-19 Vaccine Sinopharm in low- and middle-income country: a case report

Introduction and importance: Coronavirus disease 2019 (COVID-19) is a disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and various vaccines against it have been developed. Acute disseminated encephalomyelitis (ADEM) is a disease of the central nervous system that cause inflammation and demyelination and manifests as a multi-symptom acute neurological condition. Although infections are usually the cause of ADEM, vaccines may cause 5–10% of cases. Case presentation: A 40-year-old woman had received a second dose of the Sinopharm COVID-19 vaccine 4 months before her visit and experienced sudden gait imbalance and vertigo a day after her vaccination, which lasted for more than a month. On examination, no signs of skin bruising or bleeding were observed, and her vital signs were within the normal range. On neurological assessment, the patient had a Glasgow Coma Scale score of 14/15 (E4V5M5), had normal pupil size and light reaction, normal fundus, normal deep tendon reflexes and bilateral extensor plantar response. Meningeal symptoms were absent, and SARS-CoV-2 RNA tests using NAAT (Nucleic Acid Amplification Test) were negative. Development of central nervous system (CNS) manifestations during the recovery phase of fever, along with typical MRI findings; the diagnosis of para-infectious ADEM with COVID-19 vaccination was made. After the treatment with methylprednisolone sodium succinate injection, the patient showed improvement. Clinical discussion: ADEM associated with post-vaccinations is a rare condition. There has been growing evidence that shared epitopes between neuronal proteins and SARS-CoV-2 antigens may trigger autoimmune reactions against the CNS through molecular mimicry as its pathogenesis. Conclusion: We suggest the need for a strict vaccine safety monitoring system and post-vaccine monitoring and surveillance.

Neurodevelopmental delay, corneal clouding, hypomyelinating leukoencephalopathy: think mucolipidosis IV

Mucolipidosis type IV (MLIV) is an ultra-rare autosomal recessive lysosomal disorder characterized by typical neurological (early-onset developmental delay, spasticity), ocular (corneal clouding, retinopathy), and characteristic MRI findings (hypomyelinating leukoencephalopathy, thin corpus callosum, cerebellar atrophy). Although MLIV is predominantly reported in patients in the Ashkenazi Jewish community, it is a pan-ethnic disorder. The authors report on two siblings of Armenian origin with global neurodevelopmental delay, ophthalmological abnormalities and characteristic MRI features suggesting MLIV. Whole-Exome Sequencing confirmed two pathogenic variants in the MCOLN1 gene. This constellation of clinical and neuroimaging findings has been confirmed to provide a basis for the diagnosis of MLIV, and it is suggested that a focused diagnostic work-up should be considered for unexplained neurodevelopmental disorders.

Clinical Presentation, MRI findings and Molecular insights in Diffuse Intrinsic Pontine Gliomas (DIPGs): A Comprehensive Review.

Diffuse intrinsic pontine glioma (DIPG) is a highly aggressive and the most common brainstem tumor affecting pediatric patients, with a poor prognosis and limited treatment options. Despite extensive research, the median overall survival remains low, and current treatment mainly relies on radiotherapy. Recent discoveries of recurrent somatic mutations, particularly in histone 3 variants, have led to a reclassification of pediatric diffuse gliomas. However, the relationship between genetic alterations, imaging features, and prognosis is not yet fully understood. This review provides an overview of DIPG, including its clinical presentation, typical imaging findings (with a focus on MRI techniques), diagnostic challenges, treatment modalities, and recent advancements in molecular understanding. DIPG presents with characteristic neurological symptoms and often manifests as an expansile intra-axial mass in the pons, usually exhibiting typical MRI findings. Diffusion-weighted imaging and magnetic resonance spectroscopy can provide additional insights. Pathologically, most DIPGs are pediatric type of diffuse high-grade gliomas, with specific histological features and occasional leptomeningeal spread. Radiotherapy remains the mainstay treatment. However, clinical trials with new agents are ongoing, trying to improve outcomes for DIPG patients.

Susac syndrome: neurological update (clinical features, long-term observational follow-up and management of sixteen patients)

Susac syndrome is a likely autoimmune microangiopathy affecting the brain, retina and inner ear. Due to the rarity of this condition, diagnosis and treatment can be challenging. Diagnosis is based on the presence of the clinical triad of central nervous system dysfunction, branch retinal artery occlusions and sensorineural hearing loss. Typical MRI findings of callosal and peri-callosal lesions may assist in diagnosis. Clinical course can be monophasic, polycyclic or chronic continuous. It is important to look out for red flags to attain an accurate diagnosis and follow a therapeutic algorithm based on severity of the disease and response to treatment. Patients are treated with steroids and immunosuppressive agents with a variable response. Early aggressive treatment especially in severe cases, may help in preventing relapses and morbidity/disability. This study highlights important diagnostic features and proposes a treatment algorithm based on clinical experience from management of 16 patients from 2 neuroscience centres in the UK since 2007, who were followed up over a long period of 3–15 years.

Absence of Oligoclonal Bands in Multiple Sclerosis: A Call for Differential Diagnosis.

Immunoglobulin gamma (IgG) oligoclonal bands (OCB) in the cerebrospinal fluid (CSF) are absent in a small group of multiple sclerosis (MS) patients. According to previous research, OCB-negative MS patients differ genetically but not clinically from OCB-positive MS patients. However, whether OCB-negative MS is a unique immunological and clinical entity remains unclear. The absence of OCB poses a significant challenge in diagnosing MS. (1) Objective: The objective of this study was twofold: (1) to determine the prevalence of OCB-negative MS patients in the Uppsala region, and (2) to assess the frequency of misdiagnosis in this patient group. (2) Methods: We conducted a retrospective study using data from the Swedish MS registry (SMSreg) covering 83% of prevalent MS cases up to 20 June 2020 to identify all MS patients in the Uppsala region. Subsequently, we collected relevant information from the medical records of all OCB-negative MS cases, including age of onset, gender, presenting symptoms, MRI features, phenotype, Expanded Disability Status Scale (EDSS) scores, and disease-modifying therapies (DMTs). (3) Results: Out of 759 MS patients identified, 69 had an OCB-negative MS diagnosis. Upon re-evaluation, 46 patients had a typical history and MRI findings of MS, while 23 had unusual clinical and/or radiologic features. An alternative diagnosis was established for the latter group, confirming the incorrectness of the initial MS diagnosis. The average EDSS score was 2.0 points higher in the MS group than in the non-MS group (p = 0.001). The overall misdiagnosis rate in the cohort was 33%, with 22% of misdiagnosed patients having received DMTs. (4) Conclusions: Our results confirm that the absence of OCB in the CSF should raise suspicion of possible misdiagnosis in MS patients and prompt a diagnostic reassessment.

Determining the Accuracy of MRI in Evaluation of Infective Vertebral Lesions

Introduction:MRI is highly accurate in identifying vertebral anomalies by detecting even the smallest changes in water and fat components, making it the preferred method for assessing infectious lesions in the vertebral column. Clinical observations and different imaging properties can help with early diagnosis and treatment. Vertebral endplate destruction, changes in the signal intensity of intervertebral disc and bone marrow, and involvement of the soft tissues surrounding the vertebrae are typical MRI findings of infectious vertebral lesions.Methods:To determine the diagnostic accuracy of MRI in patients suspected of having infective vertebral lesions, a cross-sectional study was conducted involving 52 individuals. The study compared the validity of MRI diagnosis with the diagnosis obtained through CT-guided fine needle aspiration cytology for infective vertebral lesions.Results:By comparing the MRI diagnoses with those of fine needle aspiration cytological diagnosis of vertebral lesions, the sensitivity, specificity, positive and negative predictive values (PPVs and NPVs), and ultimately diagnostic accuracy of MRI, were computed. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of MRI diagnosis for infective vertebral lesions were 95.6%, 71.4%,95.6%, and 71.4%, respectively and 92.3% of diagnoses were made correctly overall.Conclusions:The finding of this study suggested that MRI should be considered to be the imaging modality of choice for patients with suspected infective vertebral lesions.

Van der Knaap Syndrome: Rare Case with an Atypical Presentation: A Case Report

Megalencephalic leukoencephalopathy with subcortical cysts, Van der Knaap Disease, is an autosomal recessive disorder seen in populations where consanguinity is common. It is a slowly progressive neurodegenerative disorder with infantile megalencephaly, neurological symptoms like ataxia and seizures and leukoencephalopathy. Prevalence is less than 1 in 1,000,000. Predisposed populations are the Libyan Turks, Egyptians, Jews and the Agrawal community of India. Here we present a case of a macrocephalic 4 month old female with infantile seizures with follow up at 8 months of age, having typical MRI findings of Van der Knaap disease and symptomatic worsening after meningitis. The case presented being of a non Agrawal family in India and born of a non consanguineous marriage is an atypical and rare presentation, indicating that the syndrome may be seen in other communities as well. Keywords: Megalencephalic leucoencephalopathy, vanishing white matter, Van der Knaap, neuroradiology, subcortical cysts, macrocephaly, developmental delay, ataxia, myelination, autosomal recessive, genetics, seizure, magnetic resonance imaging, magnetic resonance spectroscopy, brain

Magnetic resonance imaging characteristics of pediatric pilocytic astrocytoma.

MRI has an important role in diagnosing pilocytic astrocytoma and post-surgical follow-up since the surgical approach has a leading role in its treatment. The purpose of our study is to provide an overview of the typical and atypical MRI findings in a series of pediatric patients with isolated-not NF1-related-pilocytic astrocytomas and to correlate specific MRI patterns with clinical variables. This is a cross-sectional retrospective study providing the analysis of several clinical and neuroradiological findings from a cohort of pediatric pilocytic astrocytoma, starting from the data collected in the Fondazione IRCCS Istituto Neurologico Carlo Besta (FINCB) internal Cancer Registry during an 11-year time period (January 2008-January 2019). Fifty-six patients were included in the study. Median age at diagnosis was 9.4 years; a slight female prevalence was noticed (m/f ratio 44.6%/55.4%). The majority of pPAs had well-defined contours: 51 (91.1%), 47 (88.7%) were hypointense on T1-wi, all of them were hyperintense on T2-wi, 46 (90.2%) were hyperintense on FLAIR, and 48 (85.7%) were heterogeneous on T1-wi and T2-wi sequences. We found positive correlation between pPAs location and age (r = 0.017), and small degree of connection between pPAs location and gender (Cramer's V = 0.268). We presented typical and atypical pPAs MRI findings. Age and tumor location were positevely correlated, while degree of connection between gender and pPAs location was small. All of this may aid clinicians, most of all neuroradiologists, neurosurgeons, and neurologists in proper diagnoses and follow-up of these specific patient population.

The epidemiological and clinical characteristics of patients with young-onset genetic Creutzfeldt-Jakob disease

ABSTRACT Objectives The onset of Creutzfeldt-Jakob disease (CJD) is usually around the age of 60, but younger patients have been described as well. Our study characterizes the demographic and clinical features of young-onset CJD patients. Methods The CJD Israeli National Database was reviewed, and the patients were divided into groups of young (<40-year-old) (Y|) and older disease onset (>40-year-old) (O). Each group was further divided into sporadic (sCJD) and genetic (gCJD) patients. Clinical and demographic parameters were compared between the groups Results The study included 731 patients (Y- 18 patients, O- 713 patients). MRI showed classical features more often in the older population (O-76.9%, Y-36%, p = 0.006). Rapidly progressive dementia as a presenting feature was more common in the older group (O = 58%, Y = 27.7%, p = 0.019) whereas cerebellar onset (gait instability, dysarthria) was more common in the younger group (O = 6.7%, Y = 27.7%, p = 0.036)). Among gCJD patients, rapidly progressive dementia was commonly seen in older patients (O = 54%, Y = 21% p = 0.008) whereas cerebellar symptoms were seen in young patients (O = 7%, Y = 30% p = 0.01) Typical MRI findings were seen in 37% of young people compared to 87% of older patients (p = 0.002). No significant differences were between young and older patients in the sCJD group. Conclusion Young-onset gCJD patients have unique disease features including less typical brain MRI changes, a lower prevalence of dementia, and a higher prevalence of cerebellar signs at disease onset.

Overview of Spontaneous Intracranial Hypotension and Differential Diagnosis with Chiari I Malformation.

Spontaneous intracranial hypotension (SIH) occurs due to a leakage of the cerebrospinal fluid (CSF) lowering the pressure of subarachnoid space, mostly caused by a dural breach or discogenic microspur. As a result of less support provided by CSF pressure, intracranial structures are stretched downward, leading to a constellation of more or less typical MRI findings, including venous congestion, subdural effusions, brainstem sagging and low-lying cerebellar tonsils. Clinic examination and an MRI are usually enough to allow for the diagnosis; however, finding the location of the dural tear is challenging. SIH shares some MRI features with Chiari malformation type I (CM1), especially low-lying cerebellar tonsils. Since SIH is likely underdiagnosed, these findings could be interpreted as signs of CM1, leading to a misdiagnosis and an incorrect treatment pathway. Medical treatment, including steroids, bed rest, hydration caffeine, and a blind epidural blood patch, have been used in this condition with variable success rates. For some years, CSF venous fistulas have been described as the cause of SIH, and a specific diagnostic and therapeutic pathway have been proposed. The current literature on SIH with a focus on diagnosis, treatment, and differential diagnosis with CM1, is reviewed and discussed.

A novel variant in the tropomyosin 3 gene presenting as an adult-onset distal myopathy - a case report

BackgroundWe report a patient with a novel c.737 C > T variant (p.Ser246Leu) of the TPM3 gene presenting with adult-onset distal myopathy.Case presentationA 35-year-old Chinese male patient presentedwith a history of progressive finger weakness. Physical examination revealeddifferential finger extension weakness, together with predominant fingerabduction, elbow flexion, ankle dorsiflexion and toe extension weakness. MuscleMRI showed disproportionate fatty infiltration of the glutei, sartorius andextensor digitorum longus muscles without significant wasting. Muscle biopsy andultrastructural examination showed a non-specific myopathic pattern withoutnemaline or cap inclusions. Genetic sequencing revealed a novel heterozygousp.Ser246Leu variant (c.737C>T) of the TPM3 gene which is predicted tobe pathogenic. This variant is located in the area of the TPM3 genewhere the protein product interacts with actin at position Asp25 of actin.Mutations of TPM3 in these loci have been shown to alter the sensitivityof thin filaments to the influx of calcium ions.ConclusionThis report further expands the phenotypicspectrum of myopathies associated with TPM3 mutations, as mutations in TPM3had not previously been reported with adult-onset distal myopathy. We also discuss the interpretation of variantsof unknown significance in patients with TPM3 mutations and summarisethe typical muscle MRI findings of patients with TPM3 mutations.

Atypical Clinical Presentations and Neuroimaging Findings of Wernicke Encephalopathy (P4-4.004)

<h3>Objective:</h3> Wernicke encephalopathy is an acute neurological disorder secondary to thiamine deficiency with a clinical triad of confusion, eye disorders, and ataxia. Typical MRI Findings show symmetric hyperintensities in T2-weighted sequences predominantly affecting medial thalami, periaqueductal area, mammillary body, and the tectal plate. We describe two atypical cases of Wernicke encephalopathy. <h3>Background:</h3> N/A <h3>Design/Methods:</h3> Retrospective chart review. <h3>Results:</h3> <h3>First Case:</h3> 50-year-old female with history of endometrial cancer presented with altered mental status (AMS), truncal ataxia, neck titubation, and incomplete external ophthalmoplegia, progressing rapidly to stupor. She had recently undergone chemoradiation, complicated by chronic radiation enteritis causing poor oral intake, recurrent emesis, and weight loss. After an extensive negative infectious workup, MRI Brain with contrast was performed, which revealed restricted diffusion and T2-FLAIR sequence hyperintensities of bilateral cerebella, bilateral dorsomedial thalami, fornix with contrast enhancement of mammillary bodies concerning for Wernicke Syndrome. Thiamine levels were confirmed to be 70 nmol/l. <h3>Second Case:</h3> 22-year-old female with history of Autism Spectrum Disorder presented with AMS and seizure-like activity after experiencing severe nausea and vomiting for one week. Infectious workup including CSF analysis was unremarkable. No seizures or epileptiform changes were captured on vEEG. MRI Brain showed T2 FLAIR hyperintensities with restricted diffusion throughout the posterior brainstem, bilateral thalami, caudate nuclei, left medial lentiform nucleus, bilateral periventricular basal ganglia, bilateral frontal and parietal lobes raising concerns for Wernicke encephalopathy. Serum thiamine level was less than 20, corroborating with the diagnosis. Both patients had significant clinical and radiographic improvement with high-dose thiamine supplementation. <h3>Conclusions:</h3> The classic triad of symptoms of Wernicke encephalopathy is usually present in only 16% of patients. Atypical MRI Brain findings include involvement of the cerebral cortex and cerebellum which are more commonly seen in non-alcoholic patients. Mortality rate ranges from 10–20% so prompt recognition of the condition and early treatment is vital especially in atypical cases. <b>Disclosure:</b> Dr. Biyani has nothing to disclose. Dr. Verma has nothing to disclose. Dr. Arulprakash has nothing to disclose. Dr. Shah has nothing to disclose. Dr. Patrice has nothing to disclose.

A Case of COVID-Related MERS (Clinically Mild Encephalitis/Encephalopathy with a Reversible Splenial Lesion) with a Typical Imaging Course and Hyponatremia in Adults—A Case Report and Literature Review

Clinically mild encephalitis/encephalopathy with reversible splenial lesions (MERS) is a mild form of encephalitis/encephalopathy that appears in association with various conditions, including infection. COVID-19 is also known to cause MERS. MERS more commonly occurs in children, and adult cases are relatively rare. Typical head MRI findings include a round lesion in the mid-layer of the corpus callosum with a high signal intensity on diffusion-weighted images. Most improve within a week. Although the exact mechanism by which the cerebral corpus callosum is affected is still unknown, several hypotheses have been proposed, including the involvement of electrolyte abnormalities (e.g., hyponatremia) and inflammatory cytokines (e.g., IL-6). In this report, we describe the first case of COVID-associated MERS with a typical imaging course and hyponatremia, with a review of the relevant literature. When psychiatric symptoms and the disturbance of consciousness appear in COVID patients, MERS should be considered in addition to delirium due to fever and hypoxia.

Spinal tuberculosis: MRI findings in a case series of 35 patients

Tuberculosis (TB) remains a major health burden worldwide. Ten million people were diagnosed with TB in 2020. With 1.5 million deaths in 2020, TB is the 13th cause of mortality and the second most common cause of infectious deaths, preceded only by COVID-19. The vast majority of cases are reported from low- and middle-income countries. MRI of the spine is a reliable tool for the diagnosis of TB spondylitis. Findings such as involvement of the endplates and vertebral body, thoracic spine, para-spinal collection and psoas abscesses and relative sparing of the intervertebral disc are highly suggestive of spinal TB rather than other diagnoses. Combined with Gene Xpert tests, MRI can render very high diagnostic accuracy. This is essential for early detection of tuberculous disease of the spine and timely initiation of medical treatmen. We present a series of 35 patients with typical MRI findings of spinal tuberculosis.

Spontaneous intracranial hypotension: Typical MRI findings and methods to improve detection

Spontaneous intracranial hypotension: Typical MRI findings and methods to improve detection