Characteristic brain magnetic resonance imaging (MRI) findings in neonates with tuberous sclerosis complex

Neuroimaging in tuberous sclerosis complex

INTRODUCTION

Tuberous sclerosis complex (TSC) is a rare autosomal dominant disorder affecting multiple systems, due to inactivating mutations of TSC1 or TSC2 mTOR pathway genes. Neurological manifestations are observed in about 95% cases, representing the most frequent cause of morbidity and one of the most common causes of mortality.

BACKGROUND

Neuroimaging is crucial for early diagnosis, monitoring, and management of these patients. While computed tomography is generally used as first-line investigation at emergency department, magnetic resonance imaging is the reference method to define central nervous system involvement and investigate subtle pathophysiological alterations in TSC patients.

PURPOSE

Here, we review the state-of-the-art knowledge in TSC brain imaging, describing conventional findings and depicting the role of advanced techniques in providing new insights on the disease, also offering an overview on future perspectives of neuroimaging applications for a better understanding of disease pathophysiology.

A brain phantom for motion-corrected PROPELLER showing image contrast and construction similar to those of in vivo MRI

PURPOSE

A fast spin-echo sequence based on the Periodically Rotated Overlapping Parallel Lines with Enhanced Reconstruction (PROPELLER) technique is a magnetic resonance (MR) imaging data acquisition and reconstruction method for correcting motion during scans. Previous studies attempted to verify the in vivo capabilities of motion-corrected PROPELLER in real clinical situations. However, such experiments are limited by repeated, stray head motion by research participants during the prescribed and precise head motion protocol of a PROPELLER acquisition. Therefore, our purpose was to develop a brain phantom set for motion-corrected PROPELLER.

MATERIALS AND METHODS

The profile curves of the signal intensities on the in vivo T₂-weighted image (T₂WI) and 3-D rapid prototyping technology were used to produce the phantom. In addition, we used a homemade driver system to achieve in-plane motion at the intended timing. We calculated the Pearson's correlation coefficient (R²) between the signal intensities of the in vivo T₂WI and the phantom T₂WI and clarified the rotation precision of the driver system. In addition, we used the phantom set to perform initial experiments to show the rotational angle and frequency dependences of PROPELLER.

RESULTS

The in vivo and phantom T₂WIs were visually congruent, with a significant correlation (R²) of 0.955 (p<.001). The rotational precision of the driver system was within 1 degree of tolerance. The experiment on the rotational angle dependency showed image discrepancies between the rotational angles. The experiment on the rotational frequency dependency showed that the reconstructed images became increasingly blurred by the corruption of the blades as the number of motions increased.

CONCLUSIONS

In this study, we developed a phantom that showed image contrasts and construction similar to the in vivo T₂WI. In addition, our homemade driver system achieved precise in-plane motion at the intended timing. Our proposed phantom set could perform systematic experiments with a real clinical MR image, which to date has not been possible in in vivo studies. Further investigation should focus on the improvement of the motion-correction algorithm in PROPELLER using our phantom set for what would traditionally be considered problematic patients (children, emergency patients, elderly, those with dementia, and so on).

Using the neurofibromatosis tumor predisposition syndromes to understand normal nervous system development

Development is a tightly regulated process that involves stem cell self-renewal, differentiation, cell-to-cell communication, apoptosis, and blood vessel formation. These coordinated processes ensure that tissues maintain a size and architecture that is appropriate for normal tissue function. As such, tumors arise when cells acquire genetic mutations that allow them to escape the normal growth constraints. In this regard, the study of tumor predisposition syndromes affords a unique platform to better understand normal development and the process by which normal cells transform into cancers. Herein, we review the processes governing normal brain development, discuss how brain cancer represents a disruption of these normal processes, and highlight insights into both normal development and cancer made possible by the study of tumor predisposition syndromes.

Recommendations for the radiological diagnosis and follow-up of neuropathological abnormalities associated with tuberous sclerosis complex

Tuberous sclerosis complex (TSC) is a genetic condition with multisystem involvement, characterized by the development of tumors and other abnormalities in organs such as the brain, retina, skin, heart, kidneys, and lungs. Most patients have neuropathological abnormalities such as cortical tubers, white matter radial migration lines, subependymal nodules, and subependymal giant cell astrocytomas (SEGAs). These lesions are associated with different neurological manifestations that are frequently associated with TSC. These manifestations consist of epilepsy, intellectual disability, and neurobehavioral and psychiatric problems, including autism spectrum disorder. Hydrocephalus may also develop in patients with SEGAs due to ventricular obstruction, when this usually slow-growing tumor reaches sufficient size. Surgery has been the classical approach to treat SEGAs, although this treatment is associated with substantial morbidity and does not completely prevent tumor recurrence. Recently, the mammalian target of rapamycin (mTOR) inhibitor, everolimus, has been approved by the Food and Drug Administration and the European Medicines Agency for the treatment of patients with SEGAs associated with TSC. However, the treatment of SEGAs with these agents requires the development of guidelines that establish a differential diagnosis between SENs and SEGAs, in which neuroradiological examinations play an essential role. With the aim of improving the neuroradiological diagnosis and follow-up of the neuropathological abnormalities associated with TSC, a group of experts in this field has reviewed different aspects related to these issues and put together, a series of statements and recommendations intended to provide guidance to specialists involved in the management of TSC.

Intraventricular lesions in tuberous sclerosis complex: a possible association with the caudate nucleus

OBJECT

Tuberous sclerosis complex (TSC) can manifest with 3 principal intracranial pathological entities: cortical tubers, subependymal nodules (SENs), and subependymal giant cell astrocytomas (SEGAs). The authors analyzed the location and growth of intraventricular lesions in a large cohort of patients with TSC.

METHODS

After institutional review board protocol approval, the authors retrospectively reviewed brain MRI scans of TSC patients for whom at least 1 electronically stored cranial MRI study was available. Collected data included location, size, and growth over time of all intraventricular lesions.

RESULTS

The authors reviewed 560 scans in 103 patients, who harbored 496 intraventricular lesions. Of the 496 lesions, 157 lesions were located along the caudate-thalamic groove (CTG) in 88 patients. Twenty SEGAs were operated on. The remaining 339 lesions were distributed along the lateral ventricle, always in contact with the course of the caudate nucleus, and were presumed to be SENs. Twenty-two patients with more than 4 years of follow-up had 34 lesions along the CTG, of which 23 were stable in size and 11 grew. All other intraventricular lesions were stable. Seven-Tesla MRI showed the intimate association of SENs and the caudate nucleus in 1 patient.

CONCLUSIONS

Intraventricular lesions in TSC patients are located throughout the lateral ventricular wall. Their location exclusively follows the course of the caudate nucleus. Only lesions along the CTG showed the potential to grow, and these were then identified as SEGAs. The remaining lesions were SENs. Understanding why these lesions develop in relation to the caudate nucleus may offer insights into therapy.

Neuroimaging in tuberous sclerosis complex

PURPOSE OF REVIEW

In this review we discuss recent advances in the neuroimaging of patients with tuberous sclerosis complex (TSC), highlighting its application in improving clinical management, particularly in the case of intractable epilepsy.

RECENT FINDINGS

Progress in structural and functional imaging has led to further characterization of the brain lesions in TSC. New magnetic resonance imaging techniques that can delineate the extent of structural brain abnormalities in TSC have been developed. Diffusion tensor imaging unveils the microstructural abnormalities of the brain lesions and of the morphologically normal appearing white matter in TSC. It can potentially identify the epileptogenic zone. Positron emission tomography scanning with 2-deoxy-2-[18F]fluoro-D-glucose can assess the full extent of functional brain abnormalities in TSC. The use of alpha [11C] methyl-L-tryptophan positron emission tomography scanning has proven to be a useful tool in the identification of epileptogenic tubers and has improved the outcome of surgery for epilepsy in TSC.

SUMMARY

Major advances of neuroimaging in TSC have shown evidence of widespread structural and functional brain abnormalities. In TSC patients with intractable epilepsy, new neuroimaging modalities can now provide an accurate assessment of the epileptogenic zone, thereby permitting improved identification of patients who can have good seizure outcome following surgery for epilepsy.