Magnetic resonance spectroscopy of the frontal region in patients with metabolic syndrome: correlation with anthropometric measurement

The added value of brain MR spectroscopy in children with Crigler-Najjar syndrome type-I: correlation with demographic, neurodevelopmental, and laboratory findings

OBJECTIVE

The aim of this study is to demonstrate the role of proton magnetic resonance spectroscopy (1H-MRS) in the detection of brain microstructural changes in patients with Crigler-Najjar syndrome type-I (CNs-I), and its correlation with demographic, neurodevelopmental and laboratory findings.

METHODS

Prospective study was conducted on 25 children with CNs-I and 25 age and sex-matched children, who served as control. They underwent multivoxel 1H-MRS of basal ganglion at echo time 135-144 ms. N-acetyl aspartate/Creatine (NAA/Cr) and Choline (Ch)/Cr were calculated and correlated with demographic, clinical, and laboratory findings of patients with CNs-I.

RESULTS

There was a significant difference in NAA/Cr and Ch/Cr between patients and controls. The cut-off value for NAA/Cr and Ch/Cr used to differentiate patients from controls were 1.8 and 1.2 with an area under the curve (AUC) of 0.91 and 0.84 respectively. There was a significant difference in MRS ratios between patients with neurodevelopmental delay (NDD) and patients without NDD. The cut-off values for NAA/Cr and Ch/Cr used to differentiate between patients with NDD and patients without NDD were 1.47 and 0.99, with AUC of 0.87 and 0.8 respectively. The NAA/Cr and Ch/Cr were well correlated with family history (p = 0.006 and p < 0.001) respectively, consanguinity (p < 0.001 and p = 0.001), neurodevelopmental delay (p = 0.001 and p = 0.004), serum bilirubin level (r = -0.77, p < 0.001), (r = -0.49, p = 0.014), phototherapy (p < 0.001 and p = 0.32), blood transfusion (p < 0.001 and p = 0.001) respectively.

CONCLUSION

1H-MRS can be a useful tool in the detection of neurological changes in patients with CNs-I; NAA/Cr and Ch/Cr parameters are well correlated with demographic, clinical, and laboratory findings.

ADVANCES IN KNOWLEDGE

Our study is the first report on using MRS in assessing neurological manifestations in CNs. 1H-MRS can be a useful tool in the detection of neurological changes in patients with CNs-I.

Diffusion tensor imaging of dorsal stream language areas in patients with post-stroke aphasia

Background

Aphasia complicating stroke occurs due to language deficits that decrease communication abilities and functional independence. Our study aims to assess fractional anisotropy (FA) and mean diffusivity (MD) parameters of diffusion tensor imaging (DTI) of the dorsal stream language areas in patients with post-stroke aphasia. It was conducted on 27 patients with post-stroke aphasia and 27 age- and sex-matched controls who underwent DTI of the brain. FA and MD values of Broca's area (BA), Wernick's area (WA), superior longitudinal fasciculus (SLF), and arcuate fasciculus (AF), and number of tract fibers (TF) of AF and SLF were calculated. Results were correlated with National Institutes of Health Stroke Scale (NIHSS), Arabic version of Comprehensive Aphasia Test (Arabic CAT), and Mansoura Arabic Screening Aphasia Test (MASAT).

Results

FA of AF and SLF in patients was significantly lower (P = 0.001) than controls. MD of AF and SLF in patients was significantly higher (P = 0.001) than controls. The mean volume TF of AF and SLF in patients was significantly (P = 0.001) lower than the mean volume in controls for AF and SLF. FA cutoff for AF was 0.34 and for SLF, it was 0.35 with sensitivity, specificity, and accuracy (85.2%, 62.1%, 73.2%) for AF, (74.1%, 69%, 71.4%) for SLF, respectively. MD cutoff value for AF was 0.87, and 0.84 for SLF with sensitivity, specificity, and accuracy (63%, 72.4%, 67.8%) for AF, (81.5%, 79.3%, 80.4%) for SLF, respectively. Cutoff TF of AF was 1728 and for SLF it was 601 with sensitivity, specificity, and accuracy (88.9%, 72.4%, 80.4%) for AF and (85.2%, 85.2%, 78.6%) for SLF, respectively.

Conclusions

DTI is a non-invasive promising method that can be used to assess language areas in patients with post-stroke aphasia.

Imaging of vascular cognitive impairment

Vascular cognitive impairment (VCI) is a major health challenge and represents the second most common cause of dementia. We review the updated imaging classification and imaging findings of different subtypes of VCI. We will focus on the magnetic resonance imaging (MRI) markers of each subtype and highlight the role of advanced MR imaging sequences in the evaluation of these patients. Small vessel dementia appears as white matter hyperintensity, lacunae, microinfarcts, and microbleeds. Large vessel dementia includes strategic infarction and multi-infarction dementias. Hypoperfusion dementia can be seen as watershed infarcts and cortical laminar necrosis. Hemorrhagic dementia results from cerebral amyloid angiopathy and cortical superficial siderosis. Hereditary forms of VCI, caused by gene mutations such as CADASIL, should be suspected when dementia presents in young patients. Mixed dementia is seen in patients with Alzheimer's disease and the coexistence of cerebrovascular disease.

Imaging of Neuronal and Mixed Glioneuronal Tumors

Neuronal and mixed glioneuronal tumors represent a group of neoplasms with varying degrees of neural and glial elements. Their age of presentation varies, but they are most commonly seen in children and young adults. With the exception of anaplastic ganglioglioma and other atypical variants, most lesions are low grade; however, they can have significant morbidity because of seizures, mass effect, or difficult to treat hydrocephalus. Although many tumors show overlapping clinical and imaging features, some have relatively distinctive imaging characteristics that may aid in narrowing the differential diagnosis. In this review, we discuss relevant clinical and pathologic characteristics of these tumors and provide an overview of conventional and advanced imaging features that provide clues as to the diagnosis.

Imaging of Fulminant Demyelinating Disorders of the Central Nervous System

We aim to review the imaging appearance of fulminant demyelinating disorders of central nervous system that have different pathological features, clinical course, clinical features, and imaging findings different from classic multiple sclerosis. Routine magnetic resonance imaging (MRI) can help in accurate localization of the lesions, detection of associated lesions, and monitoring of these patients. Advanced MRI combined with routine MRI can aid in differentiation fulminant demyelinating lesions from simulating malignancy. Tumefactive demyelination lesions are located in supratentorial white matter mainly frontal and parietal regions with incomplete rim enhancement. Baló concentric sclerosis shows characteristic concentric onion skin appearance. Schilder disease is subacute or acute demyelinating disorders with one or more lesions commonly involving the centrum semiovale. Marburg disease is the most severe demyelinating disorder with diffuse infiltrative lesions and massive edema involving both the cerebral hemisphere and brain stem.

Multi-parametric arterial spin labelling and diffusion-weighted magnetic resonance imaging in differentiation of grade II and grade III gliomas

Purpose

To assess arterial spin labelling (ASL) perfusion and diffusion MR imaging (DWI) in the differentiation of grade II from grade III gliomas.

Material and methods

A prospective cohort study was done on 36 patients (20 male and 16 female) with diffuse gliomas, who underwent ASL and DWI. Diffuse gliomas were classified into grade II and grade III. Calculation of tumoural blood flow (TBF) and apparent diffusion coefficient (ADC) of the tumoral and peritumoural regions was made. The ROC curve was drawn to differentiate grade II from grade III gliomas.

Results

There was a significant difference in TBF of tumoural and peritumoural regions of grade II and III gliomas (p = 0.02 and p =0.001, respectively). Selection of 26.1 and 14.8 ml/100 g/min as the cut-off for TBF of tumoural and peritumoural regions differentiated between both groups with area under curve (AUC) of 0.69 and 0.957, and accuracy of 77.8% and 88.9%, respectively. There was small but significant difference in the ADC of tumoural and peritumoural regions between grade II and III gliomas (p = 0.02 for both). The selection of 1.06 and 1.36 × 10^-3 mm²/s as the cut-off of ADC of tumoural and peritumoural regions was made, to differentiate grade II from III with AUC of 0.701 and 0.748, and accuracy of 80.6% and 80.6%, respectively. Combined TBF and ADC of tumoural regions revealed an AUC of 0.808 and accuracy of 72.7%. Combined TBF and ADC for peritumoural regions revealed an AUC of 0.96 and accuracy of 94.4%.

Conclusion

TBF and ADC of tumoural and peritumoural regions are accurate non-invasive methods of differentiation of grade II from grade III gliomas.

Neuroimaging endophenotypes of type 2 diabetes mellitus: a discordant sibling pair study

Background

Type 2 diabetes mellitus (T2DM) is characterized by notable familial aggregation involving common variants of many genes, and its heritability leads to a high prevalence in the siblings of affected individuals compared with the general population. Endophenotypes are objective, heritable, quantitative traits that appear to reflect the genetic risk for polygenic disorders at more biologically tractable levels. Based on a sibling pair design, we aimed to find the neuroimaging endophenotypes of T2DM and investigate the role of inherent neurological disorders in the pathogenesis and deterioration of T2DM.

Methods

Twenty-six pairs of diagnosed T2DM patients with unaffected siblings and 26 unrelated controls were included in this study. Both high-resolution structural MRI and three-dimensional pseudo-continuous arterial spin labelling (3D-pCASL) MRI data were acquired with a 3.0 T MRI system. Voxel-based morphometry (VBM) analysis was performed on the structural T1W images, and cerebral blood flow (CBF) maps were obtained. All data were processed with the SPM8 package under the MATLAB 7.6 operation environment.

Results

The T2DM patients and their unaffected siblings shared significant atrophy in the right inferior/middle temporal gyrus, and left insula, in addition to elevated CBF in the right prefrontal lobe. Several regions with abnormal CBF in siblings, including the right inferior/middle temporal gyrus, left insula, left operculum, right supramarginal gyrus, right prefrontal lobe, and bilateral anterior cingulate cortex, also presented significant atrophy in T2DM patients.

Conclusions

The shared brain regions with grey matter (GM) loss and CBF increases may serve as neuroimaging endophenotypes of T2DM, and the regions with abnormal CBF in siblings indicate an increased risk for T2DM.

Adult-onset mitochondrial encephalopathy in association with the MT-ND3 T10158C mutation exhibits unique characteristics: A case report

BACKGROUND

Mitochondrial diseases are a heterogenous group of multisystemic disorders caused by genetic mutations affecting mitochondrial oxidation function. Brain involvement is commonly found in most cases but rarely as the unique clinical manifestation. Since the knowledge of its clinical manifestation combined with genetic testing is important for preventing misdiagnosis and delay in treatment, we report here how we diagnosed and managed a very unusual case of mitochondrial encephalopathy.

CASE SUMMARY

We report a 52-year-old woman with recurrent stroke-like episodes carrying the m.10158T>C mutation in the MT-ND3 gene, which is also responsible for fatal infant-onset Leigh syndrome. Despite the common mutation, the present case featured a distinct clinical and neuroimaging manifestation from Leigh syndrome. This patient presented with sudden onset of right-sided hemiparesis and hemilateral sensory disturbance accompanied by a left temporal cluster-like headache and later developed epilepsy during hospitalization, with no other signs suggestive of myopathy, lactate acidosis, or other systemic symptoms. Brain magnetic resonance imaging revealed variable lesions involving multiple cortical and subcortical regions. Furthermore, a negative genetic test obtained from peripheral blood delayed the diagnosis of mitochondrial disease, which was eventually established through second-generation DNA sequencing using biopsied muscle.

CONCLUSION

Based on this report, we suggest that clinicians pursue proper genetic testing for patients when the clinical phenotype is suggestive of mitochondrial diseases.

Two cases of variant late infantile ceroid lipofuscinosis in Jordan

BACKGROUND

Late infantile ceroid lipofuscinosis is a rare neurodegenerative disorder that appears between the ages of 2 and 4 years and is difficult to diagnose. In this report we present two sisters with this condition, and the clinical course consisted of delayed developmental skills initially and later regression of previously acquired skills. The cases were initially considered as childhood disintegrative disorder (CDD); however, when whole exome sequencing (WES) genetic testing was done, they proved to be variant late infantile ceroid lipofuscinosis. This is the first report from Jordan.

CASE SUMMARY

Clinical presentation included developmental delay and initially speech delay, followed by lose of sphincter control. Motor development was normal until 4 years of age, then they developed ataxia (fear of going downstairs) and weakness while walking. Atonic and myoclonic seizures become intractable, and this was followed by inability to stand or sit and loss of expressive language. In addition to complete blood count test, liver function test, kidney function test, serum electrolyte test, and blood sugar test, serum amino acid profile, B12 level test, thyroid function test, and a brain computed tomography scan were also normal. An electroencephalogram showed a generalized spike and wave pattern, and magnetic resonance imaging showed little to no abnormalities. After dealing with the cases as CDD, WES testing proved a final diagnosis of variant late infantile ceroid lipofuscinosis. Current treatment is anti-epileptic drugs and supportive care at home, and they are now in vegetative state.

CONCLUSION

This report highlights the importance of WES for the identification of genetic diseases, especially neurodegenerative disorders.

Quality of life in patients with minimal hepatic encephalopathy

Minimal hepatic encephalopathy (MHE) represents the mildest type of hepatic encephalopathy (HE). This condition alters the performance of psychometric tests by impairing attention, working memory, psychomotor speed, and visuospatial ability, as well as electrophysiological and other functional brain measures. MHE is a frequent complication of liver disease, affecting up to 80% of tested patients, depending of the diagnostic tools used for the diagnosis. MHE is related to falls, to an impairment in fitness to drive and the development of overt HE, MHE severely affects the lives of patients and caregivers by altering their quality of life (QoL) and their socioeconomic status. MHE is detected in clinically asymptomatic patients through appropriate psychometric tests and neurophysiological methods which highlight neuropsychological alterations such as video-spatial orientation deficits, attention disorders, memory, reaction times, electroencephalogram slowing, prolongation of latency evoked cognitive potentials and reduction in the critical flicker frequency. Several treatments have been proposed for MHE treatment such as non-absorbable disaccharides, poorly absorbable antibiotics such rifaximin, probiotics and branched chain amino acids. However, because of the multiple diagnosis methods, the various endpoints of treatment trials and the variety of agents used in trials, to date the treatment of MHE is not routinely recommended apart from on a case-by-case basis. Aim of this review is analyze the burden of MHE on QoL of patients and provide a brief summary of therapeutic approaches.

The correlation between controlled attenuation parameter and metabolic syndrome and its components in middle-aged and elderly nonalcoholic fatty liver disease patients

This study aims to investigate the correlation between controlled attenuation parameter (CAP) and metabolic syndrome (MetS) and its components in middle-aged and elderly nonalcoholic fatty liver disease (NAFLD) patients.Middle-aged and elderly patients with NAFLD, who visited our hospital from June 2016 to May 2017, were enrolled as study subjects, whereas middle-aged and elderly patients without liver disease were enrolled as controls in the same period. The prevalence of MetS, MetS components, and the different numbers of MetS components were compared among patients with different CAP values.As the CAP value increased, the prevalence of MetS, MetS components, and the different numbers of MetS components significantly increased. The CAP value was positively correlated with the prevalence of MetS, obesity, hypertriglyceridemia, hypertension, hyperglycemia, hyperuricemia, and the number of MetS components, and was negatively correlated with the prevalence of hypo-high-density-lipoprotein cholesterolemia.CAP values are closely correlated to MetS and its components in middle-aged and elder NAFLD patients. CAP may be an indicator of risk of MetS and the severity of metabolic disorders in middle-aged and elderly NAFLD patients.