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Ludovichetti R, Nierobisch N, Achangwa NR, De Vere-Tyndall A, Fierstra J, Reimann R, Togni C, Terziev R, Galovic M, Kulcsar Z, Hainc N. The split apparent diffusion coefficient sign: A novel magnetic resonance imaging biomarker for cortical pathology with possible implications in autoimmune encephalitis. Neuroradiol J 2024; 37:206-213. [PMID: 38146643 DOI: 10.1177/19714009231224416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2023] Open
Abstract
INTRODUCTION MRI is the imaging modality of choice for assessing patients with encephalopathy. In this context, we discuss a novel biomarker, the "split ADC sign," where the cerebral cortex demonstrates restricted diffusion (high DWI signal and low ADC) and the underlying white matter demonstrates facilitated diffusion (high or low DWI signal and high ADC). We hypothesize that this sign can be used as a biomarker to suggest either acute encephalitis onset or to raise the possibility of an autoimmune etiology. MATERIALS AND METHODS A full-text radiological information system search of radiological reports was performed for all entities known to produce restricted diffusion in the cortex excluding stroke between January 2012 and June 2022. Initial MRI studies performed upon onset of clinical symptoms were screened for the split ADC sign. RESULTS 25 subjects were encountered with a positive split ADC sign (15 female; median age = 57 years, range 18-82). Diagnosis included six herpes simplex encephalitis, three peri-ictal MRI changes, eight PRES, two MELAS, and six autoimmune (3 anti-GABAAR, two seronegative, and one anti-Ma2/Ta). Subjects were imaged at a mean 1.8 days after the onset of symptoms (range 0-8). DISCUSSION We present a novel visual MRI biomarker, the split ADC sign, and highlight its potential usefulness in subjects with encephalopathy to suggest acute disease onset or to raise the possibility of an autoimmune etiology when location-based criteria are applied. When positive, the sign was present on the initial MRI and can therefore be used to help focus further clinical and laboratory workup.
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Affiliation(s)
- Riccardo Ludovichetti
- Department of Neuroradiology, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Switzerland
| | - Nathalie Nierobisch
- Department of Neuroradiology, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Switzerland
| | - Ngwe Rawlings Achangwa
- Department of Neuroradiology, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Switzerland
| | - Anthony De Vere-Tyndall
- Department of Neuroradiology, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Switzerland
| | - Jorn Fierstra
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Switzerland
| | - Regina Reimann
- Institute of Neuropathology, University Hospital of Zurich, University of Zurich, Switzerland
| | - Claudio Togni
- Department of Neurology, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Switzerland
| | - Robert Terziev
- Department of Neurology, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Switzerland
| | - Marian Galovic
- Department of Neurology, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Switzerland
| | - Zsolt Kulcsar
- Department of Neuroradiology, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Switzerland
| | - Nicolin Hainc
- Department of Neuroradiology, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Switzerland
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Ota Y, Liao E, Shah G, Srinivasan A, Capizzano AA. Comprehensive Update and Review of Clinical and Imaging Features of SMART Syndrome. AJNR Am J Neuroradiol 2023; 44:626-633. [PMID: 37142432 PMCID: PMC10249687 DOI: 10.3174/ajnr.a7859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 03/20/2023] [Indexed: 05/06/2023]
Abstract
Stroke-like migraine attacks after radiation therapy (SMART) syndrome is a delayed complication of cranial irradiation, with subacute onset of stroke-like symptoms including seizures, visual disturbance, speech impairment, unilateral hemianopsia, facial droop, and aphasia, often associated with migraine-type headache. The diagnostic criteria were initially proposed in 2006. However, the diagnosis of SMART syndrome is challenging because clinical symptoms and imaging features of SMART syndrome are indeterminate and overlap with tumor recurrence and other neurologic diseases, which may result in inappropriate clinical management and unnecessary invasive diagnostic procedures. Recently, various imaging features and treatment recommendations for SMART syndrome have been reported. Radiologists and clinicians should be familiar with updates on clinical and imaging features of this delayed radiation complication because recognition of this entity can facilitate proper clinical work-up and management. This review provides current updates and a comprehensive overview of the clinical and imaging features of SMART syndrome.
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Affiliation(s)
- Y Ota
- From The Division of Neuroradiology, Department of Radiology, University of Michigan, Ann Arbor, Michigan
| | - E Liao
- From The Division of Neuroradiology, Department of Radiology, University of Michigan, Ann Arbor, Michigan
| | - G Shah
- From The Division of Neuroradiology, Department of Radiology, University of Michigan, Ann Arbor, Michigan
| | - A Srinivasan
- From The Division of Neuroradiology, Department of Radiology, University of Michigan, Ann Arbor, Michigan
| | - A A Capizzano
- From The Division of Neuroradiology, Department of Radiology, University of Michigan, Ann Arbor, Michigan
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Abu-Abaa M, Jumaah O, Mousa A, Abdulsahib A. Cortical Ribbon and Crossed Cerebellar Diaschisis in Subclinical Status Epilepticus: A Case Report. Cureus 2023; 15:e36900. [PMID: 37128532 PMCID: PMC10148567 DOI: 10.7759/cureus.36900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/30/2023] [Indexed: 04/03/2023] Open
Abstract
Cortical ribbon is an uncommon finding that is characteristic of Creutzfeldt-Jakob disease but has a broad differential diagnosis. On the other hand, crossed cerebellar diaschisis is also an uncommon finding in brain magnetic resonance imaging (MRI). Herein, we are describing an 88-year-old male patient with dementia, ambulatory dysfunction, and frequent falls who presented with acute on chronic right-sided subdural hemorrhage that was discovered after an episode of seizure. Although the subdural hemorrhage was associated with mild midline shift and lateral ventricle compression, no surgical drainage was attempted, and only middle meningeal artery embolization was pursued. Lack of further evidence of seizure and clinical stability prompted discharge. However, he was soon re-admitted for left-sided focal seizure that failed multiple antiepileptic medications and evolved into status epilepticus. MRI brain showed evidence of both cortical ribbon as well as crossed cerebellar diaschisis. No evidence of infection or autoimmune inflammation was found with continuous mental status deterioration. Code status was changed by his family, and comfort care was pursued. This case is not only interesting because of the rarity of both cortical ribbon and crossed cerebellar diaschisis, but this case helps to remind clinicians of the relationship between these findings and seizure/status epilepticus.
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Kang C, Min JH, Park JS, You Y, Jeong W, Ahn HJ, In YN, Lee IH, Jeong HS, Lee BK, Jeong J. Association of ultra-early diffusion-weighted magnetic resonance imaging with neurological outcomes after out-of-hospital cardiac arrest. Crit Care 2023; 27:16. [PMID: 36639809 PMCID: PMC9837995 DOI: 10.1186/s13054-023-04305-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 01/06/2023] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND This study aimed to investigate the association between ultra-early (within 6 h after return of spontaneous circulation [ROSC]) brain diffusion-weighted magnetic resonance imaging (DW-MRI) and neurological outcomes in comatose survivors after out-of-hospital cardiac arrest. METHODS We conducted a registry-based observational study from May 2018 to February 2022 at a Chungnam national university hospital in Daejeon, Korea. Presence of high-signal intensity (HSI) (PHSI) was defined as a HSI on DW-MRI with corresponding hypoattenuation on the apparent diffusion coefficient map irrespective of volume after hypoxic ischemic brain injury; absence of HSI was defined as AHSI. The primary outcome was the dichotomized cerebral performance category (CPC) at 6 months, defined as good (CPC 1-2) or poor (CPC 3-5). RESULTS Of the 110 patients (30 women [27.3%]; median (interquartile range [IQR]) age, 58 [38-69] years), 48 (43.6%) had a good neurological outcome, time from ROSC to MRI scan was 2.8 h (IQR 2.0-4.0 h), and the PHSI on DW-MRI was observed in 46 (41.8%) patients. No patients in the PHSI group had a good neurological outcome compared with 48 (75%) patients in the AHSI group. In the AHSI group, cerebrospinal fluid (CSF) neuron-specific enolase (NSE) levels were significantly lower in the group with good neurological outcome compared to the group with poor neurological outcome (20.1 [14.4-30.7] ng/mL vs. 84.3 [32.4-167.0] ng/mL, P < 0.001). The area under the curve for PHSI on DW-MRI was 0.87 (95% confidence interval [CI] 0.80-0.93), and the specificity and sensitivity for predicting a poor neurological outcome were 100% (95% CI 91.2%-100%) and 74.2% (95% CI 62.0-83.5%), respectively. A higher sensitivity was observed when CSF NSE levels were combined (88.7% [95% CI 77.1-95.1%]; 100% specificity). CONCLUSIONS In this cohort study, PHSI findings on ultra-early DW-MRI were associated with poor neurological outcomes 6 months following the cardiac arrest. The combined CSF NSE levels showed higher sensitivity at 100% specificity than on DW-MRI alone. Prospective multicenter studies are required to confirm these results.
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Affiliation(s)
- Changshin Kang
- grid.411665.10000 0004 0647 2279Department of Emergency Medicine, Chungnam National University Hospital, Daejeon, Republic of Korea ,grid.254230.20000 0001 0722 6377Department of Emergency Medicine, College of Medicine, Chungnam National University, 266 Munwha-ro, Jung-gu, Daejeon, 35015 Republic of Korea
| | - Jin Hong Min
- grid.254230.20000 0001 0722 6377Department of Emergency Medicine, College of Medicine, Chungnam National University, 266 Munwha-ro, Jung-gu, Daejeon, 35015 Republic of Korea
| | - Jung Soo Park
- grid.411665.10000 0004 0647 2279Department of Emergency Medicine, Chungnam National University Hospital, Daejeon, Republic of Korea ,grid.254230.20000 0001 0722 6377Department of Emergency Medicine, College of Medicine, Chungnam National University, 266 Munwha-ro, Jung-gu, Daejeon, 35015 Republic of Korea
| | - Yeonho You
- grid.411665.10000 0004 0647 2279Department of Emergency Medicine, Chungnam National University Hospital, Daejeon, Republic of Korea
| | - Wonjoon Jeong
- grid.411665.10000 0004 0647 2279Department of Emergency Medicine, Chungnam National University Hospital, Daejeon, Republic of Korea ,grid.254230.20000 0001 0722 6377Department of Emergency Medicine, College of Medicine, Chungnam National University, 266 Munwha-ro, Jung-gu, Daejeon, 35015 Republic of Korea
| | - Hong Joon Ahn
- grid.411665.10000 0004 0647 2279Department of Emergency Medicine, Chungnam National University Hospital, Daejeon, Republic of Korea ,grid.254230.20000 0001 0722 6377Department of Emergency Medicine, College of Medicine, Chungnam National University, 266 Munwha-ro, Jung-gu, Daejeon, 35015 Republic of Korea
| | - Yong Nam In
- grid.254230.20000 0001 0722 6377Department of Emergency Medicine, College of Medicine, Chungnam National University, 266 Munwha-ro, Jung-gu, Daejeon, 35015 Republic of Korea
| | - In Ho Lee
- grid.254230.20000 0001 0722 6377Department of Radiology, College of Medicine, Chungnam National University, 266, Munhwa-ro, Jung-gu, Daejeon, Republic of Korea
| | - Hye Seon Jeong
- grid.411665.10000 0004 0647 2279Department of Neurology, Chungnam National University Hospital, Daejeon, Republic of Korea
| | - Byung Kook Lee
- grid.14005.300000 0001 0356 9399Department of Emergency Medicine, Chonnam National University Medical School, Gwangju, Republic of Korea
| | - Jinwoo Jeong
- grid.255166.30000 0001 2218 7142Department of Emergency Medicine, Dong-A University College of Medicine, Busan, Korea
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Park S, Yu IK, Kim H. MRI Findings of Acute Hippocampal Disorders: Pictorial Essay. JOURNAL OF THE KOREAN SOCIETY OF RADIOLOGY 2022; 83:1046-1058. [PMID: 36276220 PMCID: PMC9574276 DOI: 10.3348/jksr.2021.0101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 08/29/2021] [Accepted: 09/23/2021] [Indexed: 12/05/2022]
Abstract
The hippocampus is one of the most metabolically active regions of the brain; therefore, it may be affected by various acute disorders. This study aimed to introduce and categorize various acute conditions that can involve the hippocampus and explain the findings of MRI, especially diffusion-weighted imaging (DWI). Acute hippocampal disorders are divided into six categories: infection, inflammation, metabolic, ischemic, traumatic, and miscellaneous. In this study, patients were retrospectively reviewed based on clinical findings and MRI, especially DWI. All diseases had been confirmed clinically or pathologically. Many acute hippocampal disorders overlap with the clinical manifestations. Thus, it is necessary to categorize acute hippocampal lesions and understand their specific imaging findings for differential diagnosis.
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Oshikiri K, Ohta R, Sano C. Food Aspiration Induced Hypoxic Encephalopathy Leading to Status Epilepticus. Cureus 2022; 14:e26766. [PMID: 35967132 PMCID: PMC9366028 DOI: 10.7759/cureus.26766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/11/2022] [Indexed: 11/23/2022] Open
Abstract
Cardiopulmonary arrest (CPA) is an emergency that can easily lead to death without appropriate life support. Even if the return of spontaneous circulation (ROSC) is achieved, survivors of sudden cardiac arrest have sustained various degrees of hypoxic encephalopathy. In Japan, rural community hospitals tend to provide care to patients with status epilepticus caused by hypoxic encephalopathy after CPA without sufficient resources. These hospitals neither have enough staff or equipment nor can they perform all the tests required to accurately estimate the prognosis. However, simple methods can be used for better estimation, including reviewing information on arrival, physical examinations, and imaging tests. Herein, we report a case of status epilepticus caused by hypoxic encephalopathy due to food aspiration in a 72-year-old man. For the sake of patients and their families, hospitals without sufficient staff or equipment should try to estimate the prognosis of patients in a manner similar to that described in this report.
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Zeng WG, Liao WM, Hu J, Chen SF, Wang Z. Mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes (MELAS) syndrome mimicking herpes simplex encephalitis: A case report. Radiol Case Rep 2022; 17:2428-2431. [PMID: 35601382 PMCID: PMC9118100 DOI: 10.1016/j.radcr.2022.04.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 04/08/2022] [Accepted: 04/09/2022] [Indexed: 11/20/2022] Open
Abstract
Mitochondrial myopathy, encephalopathy, lactic acidosis, and stroke-like episodes (MELAS) syndrome presents with the features of herpes simplex encephalitis (HSE), which is rare and has been described in only a few case reports. Our case describes a 17-year-old female with no significant previous medical history presenting with an acute onset of fever, headache, and epilepsy, similar to HSE. Computed tomography of the brain showed bilateral basal ganglia calcification. Magnetic resonance imaging demonstrated gyriform restricted diffusion with T2-weighted images prolongation. Further investigation showed elevated blood lactate concentration at rest. Hence, MELAS was suspected and the diagnosis was confirmed by the presence of a nucleotide 3243 A→G mutation in the mitochondrial DNA. The clinical presentation and imaging studies of MELAS are variable and may mimic those of HSE. Infection may have also precipitated MELAS manifestation in this patient. Laboratory features, such as elevated lactate, basal ganglia calcification, and gyriform restricted diffusion may be helpful in identifying patients with MELAS.
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Key Words
- ADC, apparent diffusion coefficient
- Basal ganglia calcification
- CJD, Creutzfeldt-Jakob disease
- CSF, cerebrospinal fluid
- CT, computed tomography
- Case report
- CoQ10, coenzyme 10
- DNA, deoxyribonucleic acid
- DWI, diffusion weighted imaging
- FLAIR, fluid attenuated inversion recovery
- HS-CRP, high-sensitivity C-reactive protein
- HSE, herpes simplex encephalitis
- Herpes simplex encephalitis
- MELAS
- MELAS, mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes
- MRA, magnetic resonance angiography
- MRI, magnetic resonance imaging
- NGS, next-generation sequencing
- NMDA, N-methyl-D-aspartate
- Next-generation sequencing
- PCR, polymerase chain reaction
- T1WI, T1-weighted image
- T2WI, T2-weighted image
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Affiliation(s)
- Wen-Gao Zeng
- Department of Neurology, Changsha Central Hospital, Yuhua District, Changsha, China
| | - Wan-Min Liao
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030, China
| | - Jue Hu
- Department of Neurology, Changsha Central Hospital, Yuhua District, Changsha, China
| | - Su-Fen Chen
- Department of Neurology, Changsha Central Hospital, Yuhua District, Changsha, China
| | - Zhen Wang
- Department of Neurology, Changsha Central Hospital, Yuhua District, Changsha, China
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Davies J, Marino M, Smith APL, Crowder JM, Larsen M, Lowery L, Castle J, Hibberd MG, Evans PM. Repeat and single dose administration of gadodiamide to rats to investigate concentration and location of gadolinium and the cell ultrastructure. Sci Rep 2021; 11:13950. [PMID: 34230532 PMCID: PMC8260729 DOI: 10.1038/s41598-021-93147-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 06/21/2021] [Indexed: 01/20/2023] Open
Abstract
Gadolinium based contrast agents (GBCA) are used to image patients using magnetic resonance (MR) imaging. In recent years, there has been controversy around gadolinium retention after GBCA administration. We sought to evaluate the potential toxicity of gadolinium in the rat brain up to 1-year after repeated gadodiamide dosing and tissue retention kinetics after a single administration. Histopathological and ultrastructural transmission electron microscopy (TEM) analysis revealed no findings in rats administered a cumulative dose of 12 mmol/kg. TEM-energy dispersive X-ray spectroscopy (TEM-EDS) localization of gadolinium in the deep cerebellar nuclei showed ~ 100 nm electron-dense foci in the basal lamina of the vasculature. Laser ablation-ICP-MS (LA-ICP-MS) showed diffuse gadolinium throughout the brain but concentrated in perivascular foci of the DCN and globus pallidus with no observable tissue injury or ultrastructural changes. A single dose of gadodiamide (0.6 mmol/kg) resulted in rapid cerebrospinal fluid (CSF) and blood clearance. Twenty-weeks post administration gadolinium concentrations in brain regions was reduced by 16-72-fold and in the kidney (210-fold), testes (194-fold) skin (44-fold), liver (42-fold), femur (6-fold) and lung (64-fold). Our findings suggest that gadolinium does not lead to histopathological or ultrastructural changes in the brain and demonstrate in detail the kinetics of a human equivalent dose over time in a pre-clinical model.
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Affiliation(s)
- Julie Davies
- GE Healthcare, Pollards Wood, Nightingales lane, Chalfont St. Giles, UK.
| | - Michael Marino
- GE Global Research Centre, 1 Research Circle, Niskayuna, NY, USA
| | - Adrian P L Smith
- GE Healthcare, Pollards Wood, Nightingales lane, Chalfont St. Giles, UK
| | - Janell M Crowder
- GE Global Research Centre, 1 Research Circle, Niskayuna, NY, USA
| | - Michael Larsen
- GE Global Research Centre, 1 Research Circle, Niskayuna, NY, USA
| | - Lisa Lowery
- GE Global Research Centre, 1 Research Circle, Niskayuna, NY, USA
| | - Jason Castle
- GE Global Research Centre, 1 Research Circle, Niskayuna, NY, USA
| | | | - Paul M Evans
- GE Healthcare, Pollards Wood, Nightingales lane, Chalfont St. Giles, UK
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Meyers SP. Intracranial Abnormalities with Diffusion Restriction. Magn Reson Imaging Clin N Am 2021; 29:137-161. [PMID: 33902900 DOI: 10.1016/j.mric.2021.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Multiple pathologic conditions can cause changes in the random movement of water, which can be detected with diffusion-weighted imaging (DWI). DWI plays a powerful clinical role in detecting restricted diffusion associated with acute brain infarction. Other disorders can also result in restricted diffusion. This article focuses on showing examples of common and uncommon disorders that have restricted diffusion secondary to cytotoxic and/or intramyelinic edema. These disorders include ischemia, infection, noninfectious demyelinating diseases, genetic mutations affecting metabolism, acquired metabolic disorders, toxic or drug exposures, neoplasms and tumorlike lesions, radiation treatment, trauma, and denervation.
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Affiliation(s)
- Steven P Meyers
- Department of Radiology/Imaging Sciences, University of Rochester Medical Center, University Medical Imaging, 4901 Lac de Ville Boulevard, Building D - Suite 140, Rochester, NY 14618, USA.
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Khan IR, Pai V, Mundada P, Sitoh YY, Purohit B. Detecting the Uncommon Imaging Manifestations of Posterior Reversible Encephalopathy Syndrome (PRES) in Adults: a Comprehensive Illustrated Guide for the Trainee Radiologist. Curr Probl Diagn Radiol 2020; 51:98-111. [PMID: 33257096 DOI: 10.1067/j.cpradiol.2020.11.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 10/28/2020] [Accepted: 11/09/2020] [Indexed: 12/11/2022]
Abstract
Posterior reversible encephalopathy syndrome (PRES) has traditionally been described as a reversible leukoencephalopathy with a distinct pattern of posteriorly distributed vasogenic oedema involving the subcortical regions of parietal and occipital lobes. PRES commonly occurs in the setting of hypertensive emergencies, pre-eclampsia/eclampsia, impaired renal function, and immunosuppressive therapy. The various clinical presentations of PRES include encephalopathy, seizures, headache, visual, and focal neurological deficits. As knowledge of this entity grows, the range of clinical, and radiological features is seen to be much broader than originally described. The brain oedema may not always be posteriorly distributed and the syndrome may not be uniformly reversible. Of special note are some uncommon imaging features (unilateral cerebral involvement, and isolated posterior fossa involvement) and also some uncommon complications (haemorrhage, cytotoxic oedema, and vasoconstriction). These red herrings may lead to potential diagnostic challenges and pitfalls especially for trainee radiologists, who often read these scans in an emergency setting. Early and accurate diagnosis is crucial for prompt optimum management, thereby avoiding residual morbidity. This review article focusses on the atypical radiological features of PRES in adults with extensive case-based imaging examples. A brief description of the pathophysiology, clinical, and classic radiological features of PRES has also been included. A tabulated summary of potential mimics with diagnostic pearls is provided to highlight pertinent take home points and to serve as an easy guide for day-to-day clinical practice.
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Affiliation(s)
- Iram R Khan
- Department of Neuroradiology, National Neuroscience Institute, 11 Jalan Tan Tock Seng, Singapore
| | - Vivek Pai
- Department of Neuroradiology, National Neuroscience Institute, 11 Jalan Tan Tock Seng, Singapore
| | - Pravin Mundada
- Department of Diagnostic and Interventional Radiology, Raffles Hospital, 585 North Bridge Rd, Singapore
| | - Yih Yian Sitoh
- Department of Neuroradiology, National Neuroscience Institute, 11 Jalan Tan Tock Seng, Singapore
| | - Bela Purohit
- Department of Neuroradiology, National Neuroscience Institute, 11 Jalan Tan Tock Seng, Singapore.
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