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Sandweiss AJ, Kannan V, Desai NK, Kralik SF, Muscal E, Fisher KS. Arterial Spin Labeling Changes Parallel Asymmetric Perisylvian and Perirolandic Symptoms in 3 Pediatric Cases of Anti-NMDAR Encephalitis. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2023; 10:10/4/e200119. [PMID: 37094999 PMCID: PMC10136681 DOI: 10.1212/nxi.0000000000200119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 02/24/2023] [Indexed: 04/26/2023]
Abstract
BACKGROUND AND OBJECTIVES Anti-NMDA receptor autoimmune encephalitis (NMDAR AE) is an autoantibody-mediated disorder characterized by seizures, neuropsychiatric symptoms, movement disorder, and focal neurologic deficits. Conventionally defined broadly as an inflammatory brain disease, the heterotopic localization is rarely discussed in children. Imaging findings are often nonspecific, and there are no early biomarkers of disease other than the presence of anti-NMDAR antibodies. METHODS We conducted a retrospective analysis of our pediatric NMDAR AE cases (as determined by either positive serum or CSF antibodies or both) at Texas Children's Hospital between 2020-2021 and extracted medical record data of those patients who had arterial spin labeling (ASL) as part of their imaging workup for encephalitis. The ASL findings were described in the context of their symptoms and disease courses. RESULTS We identified 3 children on our inpatient floor, intensive care unit (ICU), and emergency department (ED) settings who were diagnosed with NMDAR AE and had ASL performed as part of their focal neurologic symptom workup. All 3 patients presented with focal neurologic deficits, expressive aphasia, and focal seizures before the onset of other well-characterized NMDAR AE symptoms. Their initial MRI revealed no diffusion abnormalities but uncovered asymmetric and predominantly unilateral multifocal hyperperfusion of perisylvian/perirolandic regions on ASL that correlated with focal EEG abnormalities and their focal examination findings. All 3 patients were treated with first-line and second-line therapies, and their symptoms improved. DISCUSSION We found that ASL may be a suitable early imaging biomarker to highlight perfusion changes corresponding to the functional localization of NMDAR AE in pediatric patients. We briefly highlight the neuroanatomic parallels between working models of schizophrenia, chronic NMDAR antagonist administration (ketamine abuse), and NMDAR AE affecting primarily language centers. The regional specificity seen in NMDAR hypofunction may make ASL a reasonable early and specific biomarker of NMDAR AE disease activity. Future studies are necessary to evaluate regional changes in those patients who present with primarily psychiatric phenotypes rather than classical focal neurologic deficits.
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Affiliation(s)
- Alexander J Sandweiss
- From the Division of Pediatric Neurology and Developmental Neuroscience (A.J.S., V.K., K.S.F.), Department of Pediatrics; Department of Radiology (N.K.D., S.F.K.); and Department of Pediatrics (E.M.), Section of Rheumatology, Baylor College of Medicine and Texas Children's Hospital
| | - Varun Kannan
- From the Division of Pediatric Neurology and Developmental Neuroscience (A.J.S., V.K., K.S.F.), Department of Pediatrics; Department of Radiology (N.K.D., S.F.K.); and Department of Pediatrics (E.M.), Section of Rheumatology, Baylor College of Medicine and Texas Children's Hospital
| | - Nilesh K Desai
- From the Division of Pediatric Neurology and Developmental Neuroscience (A.J.S., V.K., K.S.F.), Department of Pediatrics; Department of Radiology (N.K.D., S.F.K.); and Department of Pediatrics (E.M.), Section of Rheumatology, Baylor College of Medicine and Texas Children's Hospital
| | - Stephen F Kralik
- From the Division of Pediatric Neurology and Developmental Neuroscience (A.J.S., V.K., K.S.F.), Department of Pediatrics; Department of Radiology (N.K.D., S.F.K.); and Department of Pediatrics (E.M.), Section of Rheumatology, Baylor College of Medicine and Texas Children's Hospital
| | - Eyal Muscal
- From the Division of Pediatric Neurology and Developmental Neuroscience (A.J.S., V.K., K.S.F.), Department of Pediatrics; Department of Radiology (N.K.D., S.F.K.); and Department of Pediatrics (E.M.), Section of Rheumatology, Baylor College of Medicine and Texas Children's Hospital
| | - Kristen S Fisher
- From the Division of Pediatric Neurology and Developmental Neuroscience (A.J.S., V.K., K.S.F.), Department of Pediatrics; Department of Radiology (N.K.D., S.F.K.); and Department of Pediatrics (E.M.), Section of Rheumatology, Baylor College of Medicine and Texas Children's Hospital.
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Zhang X, Zheng D, Huang Q. Regarding "Brain Perfusion Alterations on 3D Pseudocontinuous Arterial Spin-Labeling MR Imaging in Patients with Autoimmune Encephalitis: A Case Series and Literature Review". AJNR Am J Neuroradiol 2022; 43:E36-E37. [PMID: 36007948 PMCID: PMC9451636 DOI: 10.3174/ajnr.a7563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Affiliation(s)
- X Zhang
- Department of RadiologyNanjing Brain Hospital, Nanjing Medical UniversityJiangning District, Nanjing, China
| | - D Zheng
- Department of RadiologyNanjing Brain Hospital, Nanjing Medical UniversityJiangning District, Nanjing, China
| | - Q Huang
- Department of RadiologyNanjing Brain Hospital, Nanjing Medical UniversityJiangning District, Nanjing, China
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Buch K, Hakimelahi R, Locascio JJ, Bolar DS, Gonzalez RG, Schaefer PW. Clinical utility of arterial spin labeling perfusion images in the emergency department for the work-up of stroke-like symptoms. Neuroradiology 2021; 64:925-934. [PMID: 34664110 DOI: 10.1007/s00234-021-02835-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 10/11/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE To assess the utility of ASL in evaluating patients presenting to the ED with stroke-like symptoms. METHODS ASL and DWI images from 526 consecutive patients presenting to the ED with acute stroke symptoms were retrospectively reviewed. DWI images were evaluated for volume of restricted diffusion using ABC/2. ASL maps were evaluated for decreased, normal, or increased signal. The volume of decreased ASL signal was calculated using the same ABC/2 technique. The volume of decreased ASL signal was correlated with the volume of DWI signal abnormality to identify cases of mismatch (DWI:ASL ratio > 1.8) and to correlate this mismatch with infarct growth on imaging follow-up. NIHSS, length of hospital stay, mRS, and future admission for acute stroke-like symptoms were recorded. Correlations between ASL abnormalities and clinical parameters were evaluated using a two-tailed t-test. RESULTS Of the 526 patients presenting with acute stroke symptoms, 136 patients had an abnormal ASL scan and 388 patients had a normal ASL scan. Of the 136 patients with abnormal ASL, 84 patients had low ASL signal with 79 of these being related to acute infarcts. Elevated ASL signal was seen in 52 patients, of which 30 of these patients had reperfusion hyperemia related to acute infarctions. ASL had a negative predictive value of 94% for evaluating patients with acute ischemic stroke. A subset of patients with abnormal ASL scans with a discharge diagnosis of acute infarction were found to have an ASL:DWI mismatch (ratio > 1.8) and demonstrated significant lesion growth on follow-up imaging (57%). This included some patients who exhibited low ASL signal before development of diffusion restriction (infarction). CONCLUSION In patients presenting to the ED with acute stroke symptoms, ASL provides information not available with DWI alone. The NPV of ASL for evaluating patients with acute ischemia was 94%.
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Affiliation(s)
- Karen Buch
- Department of Radiology, Massachusetts General Hospital, 55 Fruit Street, Gray 241 G, Boston, MA, 02114, USA.
| | - Reza Hakimelahi
- Department of Radiology, Massachusetts General Hospital, 55 Fruit Street, Gray 241 G, Boston, MA, 02114, USA
| | - Joseph J Locascio
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Divya S Bolar
- Department of Radiology, University of California San Diego School of Medicine, La Jolla, CA, USA
| | - R Giliberto Gonzalez
- Department of Radiology, Massachusetts General Hospital, 55 Fruit Street, Gray 241 G, Boston, MA, 02114, USA
| | - Pamela W Schaefer
- Department of Radiology, Massachusetts General Hospital, 55 Fruit Street, Gray 241 G, Boston, MA, 02114, USA
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Sekar S, Vinayagamani S, Thomas B, Kesavadas C. Arterial spin labeling hyperperfusion in seizures associated with non-ketotic hyperglycaemia: is it merely a post-ictal phenomenon? Neurol Sci 2020; 42:739-744. [PMID: 33047197 DOI: 10.1007/s10072-020-04815-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 10/08/2020] [Indexed: 11/28/2022]
Abstract
A 53-year-old chronic uncontrolled diabetic patient presented with one episode of generalized seizures followed by drowsiness and post-ictal confusion. MR imaging at admission revealed left temporal subcortical T2/FLAIR hypointensities with overlying cortical T2/FLAIR hyperintensities and increased perfusion on arterial spin labeling (ASL). Follow-up imaging at 4- and 8-week interval revealed persistent ASL hyperperfusion with significant resolution of conventional MR imaging findings. Delayed persistent ASL hyperperfusion suggests that hyperglycemia-induced increased blood-brain barrier permeability rather than a mere post-ictal phenomenon in non-ketotic hyperglycemia (NKH) and may result in long-term cognitive disturbances.
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Affiliation(s)
- Sabarish Sekar
- Department of Imaging Sciences and Interventional Radiology, Sree chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, 695011, India.
| | - Selvadasan Vinayagamani
- Department of Imaging Sciences and Interventional Radiology, Sree chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, 695011, India
| | - Bejoy Thomas
- Department of Imaging Sciences and Interventional Radiology, Sree chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, 695011, India
| | - Chandrasekharan Kesavadas
- Department of Imaging Sciences and Interventional Radiology, Sree chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, 695011, India
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Polyanskaya MV, Demushkina AA, Vasiliev IG, Gazdieva HS, Kholin AA, Zavadenko NN, Alikhanov AA. Role of contrast-free MR-perfusion in the diagnosis of potential epileptogenic foci in children with focal epilepsia. ACTA ACUST UNITED AC 2018. [DOI: 10.17749/2077-8333.2018.10.2.006-018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
ASL (Arterial Spin Labeling) – a novel modality of MR angiography – is based on radio-frequency labeling of aqueous protons in the arterial blood; the method is used to monitor blood supply to organs, including the brain. So far there has been little information on the use of ASL in children with focal epilepsy, especially in the pre-surgery period.Aim:to evaluate the perfusion patterns in seizure-free children with drug resistant focal epilepsy (FE) using the ASL mode of MRI.Materials and methods.We studied the ASL data of 54 (23-boys/31 girls) patients with FE treated in the Dpt. of Neurology at the Russian State Children Hospital from 2015 to 2018. The patients’ age varied from 4 months to 17 years. All images were produced with a 3T GE Discovery 750W system.Results. We found several brain perfusion patterns in children with FE; among other factors, those patterns depended on the clinical status of the patient, i. e. the interictal period or the early post- seizure period. The main pattern of the interictal period was characterized by a focal decrease in perfusion located around a structural focus identified on MRI scans. In the early post-seizure period, there was an increase in the arterial perfusion in the area of a structural epileptogenic lesion.Conclusion.ASL-MRI is an effective diagnostic method providing more information on children with FE during their pre-surgery phase. The ASL modality needs further research to rationalize its wider use as a preferred diagnostic tool or as a combination with the more complex PET and SPECT.
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Nagesh C, Kumar S, Menon R, Thomas B, Radhakrishnan A, Kesavadas C. The Imaging of Localization Related Symptomatic Epilepsies: The Value of Arterial Spin Labelling Based Magnetic Resonance Perfusion. Korean J Radiol 2018; 19:965-977. [PMID: 30174487 PMCID: PMC6082755 DOI: 10.3348/kjr.2018.19.5.965] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Accepted: 03/19/2018] [Indexed: 11/15/2022] Open
Abstract
Accurate identification of the epileptogenic zone is an important prerequisite in presurgical evaluation of refractory epilepsy since it affects seizure-free outcomes. Apart from structural magnetic resonance imaging (sMRI), delineation has been traditionally done with electroencephalography and nuclear imaging modalities. Arterial spin labelling (ASL) sequence is a non-contrast magnetic resonance perfusion technique capable of providing similar information. Similar to single-photon emission computed tomography, its utility in epilepsy is based on alterations in perfusion linked to seizure activity by neurovascular coupling. In this article, we discuss complementary value that ASL can provide in the evaluation and characterization of some basic substrates underlying epilepsy. We also discuss the role that ASL may play in sMRI negative epilepsy and acute scenarios such as status epilepticus.
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Affiliation(s)
- Chinmay Nagesh
- Department of Imaging Sciences & Interventional Radiology, Sree Chitra Tirunal Institute for Medical Sciences & Technology (SCTIMST), Trivandrum 695011, India
| | - Savith Kumar
- Department of Imaging Sciences & Interventional Radiology, Sree Chitra Tirunal Institute for Medical Sciences & Technology (SCTIMST), Trivandrum 695011, India
| | - Ramshekhar Menon
- Comprehensive Epilepsy Centre, Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences & Technology (SCTIMST), Trivandrum 695011, India
| | - Bejoy Thomas
- Department of Imaging Sciences & Interventional Radiology, Sree Chitra Tirunal Institute for Medical Sciences & Technology (SCTIMST), Trivandrum 695011, India
| | - Ashalatha Radhakrishnan
- Comprehensive Epilepsy Centre, Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences & Technology (SCTIMST), Trivandrum 695011, India
| | - Chandrasekharan Kesavadas
- Department of Imaging Sciences & Interventional Radiology, Sree Chitra Tirunal Institute for Medical Sciences & Technology (SCTIMST), Trivandrum 695011, India
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Wong AMC, Yeh CH, Lin JJ, Liu HL, Chou IJ, Lin KL, Wang HS. Arterial spin-labeling perfusion imaging of childhood encephalitis: correlation with seizure and clinical outcome. Neuroradiology 2018; 60:961-970. [PMID: 30046856 DOI: 10.1007/s00234-018-2062-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Accepted: 07/17/2018] [Indexed: 11/30/2022]
Abstract
PURPOSE In childhood encephalitis, perfusion abnormalities have been infrequently reported to associate with clinical status. We investigated whether perfusion abnormalities correlated with seizure and clinical outcome in encephalitis. METHODS We retrospectively analyzed the MR studies of 77 pediatric patients with encephalitis. Pseudo-continuous arterial spin-labeling (ASL) imaging was performed on a 3-T scanner. The patients were divided into five groups according to ASL perfusion imaging pattern: normal perfusion (NP), focal hypoperfusion (Lf), extreme global hypoperfusion (LE), focal hyperperfusion (Hf), and extreme global hyperperfusion (HE). Clinical outcome at 3 weeks was dichotomized to unfavorable or favorable outcome according to the Glasgow outcome scale. Multivariate logistic regression was conducted to predict unfavorable outcome and presence of seizure separately, based on explanatory variables including age, sex, and ASL pattern. RESULTS Twenty-seven (35%) patients were designated as in group Hf, five (7%) in group Lf, 11 (14%) in group LE, none in group HE, and 34 (44%) in group NP. Multivariate logistic regression analysis showed that ASL pattern was significantly associated with unfavorable outcome (P = 0.005) and with presence of seizure (P = 0.005). For ASL pattern, group LE was 17.31 times as likely to have an unfavorable outcome as group NP (odds ratio confidence interval [CI] 3.084, 97.105; P = 0.001). Group Hf was 6.383 times as likely to have seizure as group NP (CI 1.765, 23.083; P = 0.005). CONCLUSIONS In childhood encephalitis, patients with extreme global hypoperfusion had poor neurological outcome and those with focal hypoperfusion were more likely to have seizure.
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Affiliation(s)
- Alex Mun-Ching Wong
- Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, Keelung/Linkou, and Chang Gung University, 5 Fu-Hsing Street, Taoyuan, 333, Taiwan.
| | - Chih-Hua Yeh
- Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, Keelung/Linkou, and Chang Gung University, 5 Fu-Hsing Street, Taoyuan, 333, Taiwan
| | - Jainn-Jim Lin
- Division of Pediatric Critical Care Medicine, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Ho-Ling Liu
- Department of Imaging Physics, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - I-Jun Chou
- Division of Pediatric Neurology, Department of Pediatrics, Chang Gung Children's Hospital and Chang Gung University, Linkou, Taiwan
| | - Kuang-Lin Lin
- Division of Pediatric Neurology, Department of Pediatrics, Chang Gung Children's Hospital and Chang Gung University, Linkou, Taiwan
| | - Huei-Shyong Wang
- Division of Pediatric Neurology, Department of Pediatrics, Chang Gung Children's Hospital and Chang Gung University, Linkou, Taiwan
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Effect of blood T1 estimation strategy on arterial spin labeled cerebral blood flow quantification in children and young adults with kidney disease. J Neuroradiol 2018; 46:29-35. [PMID: 29604324 DOI: 10.1016/j.neurad.2018.03.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Revised: 02/10/2018] [Accepted: 03/10/2018] [Indexed: 02/07/2023]
Abstract
PURPOSE To compare blood T1 estimation approaches used for quantifying cerebral blood flow (CBF) with arterial spin labeled (ASL) perfusion MRI in a developmental cohort of chronic kidney disease (CKD) patients with anemia and a control group. METHODS 61 patients with CKD and 47 age-matched control subjects were studied. Blood T1 approaches included: (1) a fixed value, (2) estimation based on measured hematocrit (Hct), and (3) estimation based on Age+Sex using a published formula. Resulting T1 and CBF values were compared along with group, age and sex effects. RESULTS Highly significant group differences in CBF using fixed blood T1 were reduced when Hct-corrected blood T1 was used, and were eliminated entirely when using the Age+Sex estimated approach. In the control cohort, fixed T1 method showed the strongest correlations of CBF with age and sex. Hct-corrected T1 preserved a significant correlation between CBF and age and sex, while Age+Sex estimated T1 produced a poor fit of CBF with age and sex. CONCLUSIONS Blood T1 estimation method can confound the interpretation of CBF changes measured using ASL MRI in patients with CKD. Blood T1 should ideally be corrected for hematocrit effects in clinical populations with anemia.
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