Mild phenotype in a male with pyruvate dehydrogenase complex deficiency associated with novel hemizygous in-frame duplication of the E1α subunit gene (PDHA1)

Pyruvate dehydrogenase complex (PDHC) deficiency is an inborn error of metabolism that occurs most commonly due to mutations in the X-linked E1α subunit gene (PDHA1). We report a novel duplication of PDHA1 associated with a mild phenotype in a 15-year-old boy who was diagnosed with PDHC deficiency at 4 years of age following a history of seizures and lactic acidosis. The novel c.1087_1119 mutation in exon 11 resulted in an in-frame duplication of 11 amino acids. Measurements of PDHC activity in cultured skin fibroblasts were low, corresponding to 18.6 and 11.6% of the mean with respect to prior controls, whereas the E1 PDH component was absent. He has borderline intellectual functioning and maintains normal lactate levels on a ketogenic diet in between relapses due to illness. Review of the literature reveals wide variation of clinical phenotype in patients with mutations of the E1α subunit gene (PDHA1). There appears to be a higher incidence of normal or borderline intellectual ability in individuals who have insertions or deletions that are in-frame versus those that are out-of-frame. Furthermore, there is no correlation between mean residual PDH activity and phenotype in these patients.

Neuroimaging findings of the post-treatment effects of radiation and chemotherapy of malignant primary glial neoplasms

Post-treatment radiation and chemotherapy of malignant primary glial neoplasms present a wide spectrum of tumor appearances and treatment-related entities. Radiologic findings of these post-treatment effects overlap, making it difficult to distinguish treatment response and failure. The purposes of this article are to illustrate and contrast the imaging appearances of recurrent tumor from necrosis and to discuss other radiologic effects of cancer treatments. It is critical for radiologists to recognize these treatment-related effects to help direct clinical management.

Retrospective review of cerebral mycotic aneurysms in 26 patients: focus on treatment in strongly immunocompromised patients with a brief literature review

BACKGROUND AND PURPOSE

Cerebral mycotic aneurysms are a rare and deadly type of aneurysm that have no definitive treatment guidelines. Our purpose was to retrospectively review known or suspected cases of CMA in order to identify patient populations that may be associated with higher morbidity and mortality. We hope that the identification of patients with these risk factors will lead to early stratification upon presentation, and more urgent treatment of their CMAs. We also hoped to identify any benefit or complication that was specific to either the endovascular or neurosurgical repair of CMAs.

MATERIALS AND METHODS

A retrospective multi-institutional study was performed examining cases of CMA during a 15-year period. Patients were considered strongly immunocompromised if there were long-term severely immunocompromised states: AIDS, chemotherapy, or steroid immunosuppression. Patients were excluded if angiographic findings suggested an alternative diagnosis or if an infectious etiology was unknown. Antibiotics were considered "noninvasive treatment." Endovascular and neurosurgical repair were considered "invasive treatment." Data were recorded by reviewing electronic medical records and imaging reports.

RESULTS

Twenty-six patients with 40 CMAs were included. Three patients were considered strongly immunocompromised and presented with 4 CMAs, which demonstrated larger average size and more rapid growth; 3 of these patients' aneurysms were treated invasively in the acute period, with the one that was not ruptured causing death. Technical success (aneurysm occlusion without rupture or recanalization) and clinical success (no neurologic complication attributable to the intervention) were obtained equally endovascularly and neurosurgically. Clipping was aborted in favor of coiling for 1 patient. Anticoagulation needed reversal before 2 patients underwent craniotomy for clipping after valve replacement. For CMAs treated with antibiotics alone with angiographic follow-up (n=11), initial aneurysm size was unrelated to persistence and 64% completely regressed.

CONCLUSIONS

We recommend initial invasive treatment for CMAs in strongly immunocompromised patients. Testing for underlying immunocompromised states is warranted in patients with CMAs. Endovascular treatment is favored over neurosurgical treatment in patients requiring acute cardiac valve repair due to delays with anticoagulation reversal.

Cerebral thromboembolism: value of susceptibility-weighted imaging in the initial diagnosis of acute infarction

Susceptibility-weighted imaging (SWI) is commonly used to diagnose cerebral hemorrhage, calcification, and other T2* lesions. Its role in the detection of cerebral thromboemboli has been suggested for emboli of the anterior division of the middle cerebral artery (MCA). The purpose of our study was to determine SWI's accuracy and sensitivity in detection of all sites of cerebral thromboemboli, not just MCA emboli. Two neuroradiologists retrospectively reviewed consecutive MRI brain examinations with SWI for cerebral thromboemboli in 100 patients with clinical suspicion for stroke determined by the NIH Stroke Scale (NIHSS) score. FLAIR, MRA, CT, and catheter angiography were reviewed for thromboemboli in the same patients. Thromboembolic sites included: the internal carotid artery (ICA) terminus, anterior MCA, posterior MCA, any other cerebral artery, or if not present. The exclusion criteria included: no magnetic resonance angiogram (MRA) or catheter angiogram for comparison, lack of restricted diffusion, lacunar infarcts, and the presence of massive hemorrhage. The accuracy, sensitivity, and specificity of each imaging modality were determined. Twenty-four patients were excluded based on the aforementioned criteria. Cerebral thromboemboli were identified in 35 of the remaining 76 patients. Of the 35 patients with thromboemboli, 30 were identified on SWI. FLAIR detected 22/35 emboli, MRA 30/33, CT 18/35, and catheter angiography 12/12. The accuracies for SWI, FLAIR, and CT were 97%, 84%, and 74%, respectively. The sensitivities for SWI, FLAIR, and CT were 85%, 61%, and 52%, respectively. The specificities for SWI, FLAIR, and CT were 100%, 98%, and 93%, respectively. There is an adjunctive role of SWI to identify cerebral thromboemboli in patients with acute infarction. SWI is superior to FLAIR and CT, and complementary to MRA and catheter angiography in emboli detection. This study supports SWI detection of MCA emboli, but also emphasizes its utility in emboli detection of other arteries based on a high accuracy and sensitivity.

Assessment of the Correlation between Apparent Diffusion Coefficient and Intervertebral Disk Degeneration Using 3 Tesla MRI

The objective is to use DW-MR imaging using 3 Tesla MRI to assess the correlation between the mean ADC with degenerative disk disease (DDD). We recruited 34 subjects and used DWI-MR to image lumbar intervertebral disks. We acquired a T2W scan and DWIs. The disks were graded for DDD. Assessment of correlation between mean ADC was made. 170 disks were evaluated. The observed sample correlation between mean ADC and disk degeneration was r = 0.65 [0.55-0.73]. The observed sample correlation between mid-sagittal ADC and disk degeneration was r = 0.61 [0.51-0.70]. The differences between mean ADC of each grade were significant, except between grades 4 and 5. There is a correlation of 0.65 between the mean ADC and disk degeneration. This correlation is not strong enough to use the ADC to determine DDD in clinical settings. There was no evident difference in ADC between the studied anatomic lumbar levels.

Toward a uniform policy for handling incidental findings in neuroimaging research

A recent study carried out at the University of California, Irvine exemplifies a commonly overlooked ethical conundrum of neuroimaging research: incidental findings. Research study designs must address the potential of uncovering unexpected findings in subjects during the study and delineate a protocol for reporting and initiating treatment. We urge the community to petition their home institutional review board to mandate inclusion of an incidental findings protocol into all neuroimaging research applications.

Imaging of craniofacial and sinonasal anomalies

Whereas CT imaging techniques such as multiple detector spiral imaging with multi-planar reconstructions are desirable in the evaluation of congenital and developmental anomalies of the midface and skull base, there is an essential role for MRI whenever there are related intracranial anomalies. This presentation will focus on describing and classifying the known craniofacial anomalies that have common manifestations in the sinonasal regions, the orbits, and the skull base. Diagrams and clinical cases are utilized to demonstrate the key embryological events leading to the common dysplasias of the craniofacial and sinonasal regions.

Pituicytoma: diagnostic features on selective carotid angiography and MR imaging

We report a case of pituicytoma, a rare primary tumor of the neurohypophysis. A 64-year-old man presented with progressive visual complaints, bitemporal hemianopsia, and headache. Imaging studies revealed distinctive features of a mass lesion that thickened the pituitary stalk with a bilobed protrusion extending into the hypothalamus. Angiography demonstrated tumor vascular supply from the superior hypophyseal arteries representing the diencephalic branches of the internal carotid arteries. We discuss the imaging and pathology of this unusual tumor.

Magnetic resonance imaging of cranial nerve VII

Magnetic resonance imaging (MRI) is well suited for the evaluation of lesions of the seventh cranial (facial) nerve. The preferred MRI approach requires use of multiplanar thin sections of the full course of the nerve from the pons through to its terminal branches on the face. The use of paramagnetic contrast greatly increases the sensitivity of MRI and for the most part precludes the need to use computed tomography scans in conjunction with the MRI scans.

Basilar and distal vertebral artery occlusive disease: correlation of MR imaging and MR angiography

The purpose of this study is to evaluate the correlation of brain lesions seen on magnetic resonance imaging with vascular occlusive disease of the basilar and distal vertebral arteries as documented on MR angiography. The clinical findings are also correlated with the findings on MR imaging and MR angiography. The clinical records of twenty-one patients with proven occlusive disease of the distal vertebral and/or basilar arteries were retrospectively reviewed. All the patients were imaged utilizing either the Siemens Magnetom 1.5 T SP 4000 and the Siemens 1.0 T Impact systems. Dual MR angiographic techniques were employed including two-dimensional (2D) and three-dimensional time-of-flight. The 2D sequences utilized fast low angle shot gradient echo sequences. The 3D sequences utilized fast image steady-state precession gradient echo sequences. Gadolinium contrast was utilized for increased angiographic detail in one patient. Magnetization transfer contrast was used in three patients. The individual partitions as well as the maximum intensity pixel projection images were evaluated in each case. The most extensive brain lesions were seen in the group of patients with severe basilar and/or combined vertebrobasilar disease. One-half of these patients showed non-specific scattered foci of T2 lengthening similar to the findings found in a group of patients with noncritical stenosis. MR imaging invariably demonstrated more lesions than were clinically suspected. Even though the brain lesions tended to be more extensive in patients with severe vascular disease, the amount of brain tissue damage was not an adequate parameter to document the degree of vascular narrowing. The degree of vascular narrowing was useful in therapy planning. Such data was obtained by the MR angiograms, but not by MR imaging. MR angiography is a useful complementary examination when lesions in the basilar and distal vertebral vascular territories are diagnosed on MR imaging. MR angiography can differentiate critical from noncritical stenosis and can thus play a key role in the therapeutic decision making process.

Cerebral ischemia and infarction

Cerebral infarction is most commonly related to atherosclerotic disease in the carotid and vertebrobasilar circulations. TIAs are manifestations of this same disease process and may occur before a complete infarction. The transformation of pale to hemorrhagic infarction may result from reperfusion of an infarct or from migration of an embolus. CT is often the primary imaging study to exclude frank hemorrhage. The use of MR is increasing, in both the acute and the subacute phases of stroke. The combination of MR imaging and MR angiography is gradually replacing CT, particularly in patients with TIAs. In addition, the depiction of minute alterations in contrast and subtle mass effect is visualized with MR more often than with CT. The precise localization of brain stem and posterior fossa infarctions is improved by the ability of MR to view complex structures in two or more orthogonal planes. Vascular structures are readily identified both on the spin echo images and with MR angiography. Slow or obstructed flow in the venous channels may be recognized, which makes MR the ideal examination for the evaluation of cerebral ischemia and infarction.

Intracranial vascular malformations

Magnetic resonance imaging is a useful process in the evaluation and follow-up examination of intracranial vascular malformations. Magnetic resonance imaging as related to the four subtypes of these malformations, arteriovenous malformations, venous angiomas, cavernous malformations, and capillary telangiectasis, is discussed.

Intracranial vascular tumors

The study of intracranial vascular tumors is of significant importance because these tumors may stimulate vascular malformations, infarctions, or infections. This article describes vascular tumors and discusses their appearance on MR imaging studies. Choroid plexus neoplasms, primitive neuroectodermal tumors, hemangioblastoma and other disorders are discussed.

Efficacy evaluation of gadoteridol for MR angiography of intracranial vascular lesions

A phase III multicenter study was conducted in 89 patients with known intracranial vascular lesions to evaluate an extracellular gadolinium contrast agent, gadoteridol, for intracranial magnetic resonance (MR) angiography. The pre- and postcontrast MR angiograms of 82 patients were evaluated by the unblinded investigators and by two blinded readers (A and B) for visualization of lesions; arterial and venous anatomy; extent, size, and number of lesions; and disease classification. The unblinded readers indicated that lesions were visualized better on postcontrast images in the following categories: venous anatomy, 87 (81%) of 107 lesions; arterial anatomy, 43 lesions (40%); and extent or size of lesions, 38 lesions (36%). In 29 (35%) of 82 patients, the unblinded readers determined that enhanced MR angiography provided more diagnostic information than unenhanced MR angiography. The blinded readers determined that enhanced MR angiography provided more information for visualization of vascular anatomy in more than 60% of cases. The additional information provided with gadoteridol would have changed the diagnosis in nine (8%) of 107 lesions seen by the unblinded readers, 11 (12%) of 90 lesions seen by reader A, and three (3%) of 93 lesions seen by reader B. The results confirm that the use of gadoteridol improves the visualization of intracranial vascular lesions with MR angiography. The authors conclude that development of new postprocessing algorithms will improve the utility of contrast-enhanced MR angiography.

Magnetic resonance imaging of the paranasal sinuses and nasal cavities

Magnetic resonance imaging has proven to be a useful tool for imaging the paranasal sinuses and nasal cavities. Of particular interest in this region is the ability to distinguish between lesions that are highly cellular with little free water (neoplasms) and lesions that have significant amounts of serous and mucinous secretions and thus contain predominantly free water (infections).

Magnetic resonance imaging of soft tissues of the neck

Magnetic resonance imaging (MRI) has proven to be an ideal examination for evaluating a variety of soft tissue lesions in the extracranial head and neck. In this article we will describe the MRI characteristics of a variety of the soft tissue lesions found in the neck. Pathophysiology, clinical presentation, treatment, and prognosis are also discussed.

Hyperventilation-induced cerebral ischemia in patients with acute brain lesions: demonstration by xenon-enhanced CT

PURPOSE

To examine the possibility that hyperventilation, commonly used to prevent or treat increased intracranial pressure in patients with acute brain lesions, may induce significant cerebral ischemia.

METHODS

Local cerebral blood flow and vascular reactivity were measured before and after hyperventilation using xenon-enhanced CT in 12 patients with acute brain lesions.

RESULTS

Five patients showed "paradoxical" reactivity (increased cerebral blood flow during hyperventilation) within the lesions. In five patients, hyperventilation induced ischemia in apparently normal regions of brain. In three patients, areas of luxury perfusion became ischemic during hyperventilation, while in three patients, lesions with moderate ischemia became more ischemic. Most patients showed more than one type of reactivity.

CONCLUSIONS

These findings document hyperventilation-induced ischemia in acute brain lesions, and demonstrate that this phenomenon affects both injured and apparently intact areas of the brain. Further studies are required to determine the clinical significance of these pathophysiologic changes.

Cystic acoustic schwannomas: MR characteristics

PURPOSE

To evaluate the spectrum of MR characteristics of cystic acoustic schwannoma and to investigate its incidence.

METHODS

We retrospectively reviewed the MR findings and clinical records of 16 patients with cystic acoustic schwannomas. In addition, the MR examinations of 411 consecutive patients referred for clinical suspicion of acoustic schwannomas were reviewed retrospectively to assess the incidence of acoustic schwannomas with cystic lesions arising from the internal auditory canal.

RESULTS

Of the 16 acoustic schwannomas with MR evidence of intramural cysts, 11 tumors had single small cysts, and five had multiple intramural cysts of variable size. Intramural cysts in 11 of the 16 tumors exhibited higher signal intensity than that of cerebrospinal fluid; the remainder were isointense to cerebrospinal fluid on both T1- and T2-weighted images. All intramural cysts showed circumferential enhancement after contrast administration. Nine of the 16 cystic acoustic schwannomas also had MR evidence of extramural/arachnoid cysts. Six of the extramural/arachnoid cysts had epicenters away from the dural interface, and the other three cysts were broadly based against the dura. The incidence of cystic acoustic schwannomas was 11.3% and association with extramural/arachnoid cysts 7.5%.

CONCLUSION

Our series suggests that cystic changes in acoustic schwannomas and the association with extramural/arachnoid cysts are not as rare as previously reported by other diagnostic methods. The high signal intensity of intramural cysts is probably related to necrotic material, blood, or colloid-rich fluid. The difference in the MR characteristics of extramural/arachnoid cysts associated with acoustic schwannomas and those of typical arachnoid cysts not associated with neoplasia may be related to higher protein and/or colloid contents secreted by the tumor. Most extramural/arachnoid cysts had epicenters between the tumor and brain, suggesting that the most likely mechanism of formation is peritumoral adhesions. It creates a pseudo-duplication caused by the trapping of fluid between the leptomeninges and the mass, resulting in an acquired type of arachnoid cyst.

Adult extra-axial brain tumors

Magnetic resonance imaging is the preferred cross-sectional imaging study for the evaluation of nearly all extra-axial brain tumors in adults. This article outlines the neoplasms by their pathology. The discussion covers the neoplasms originating from central neuroglial cells, meninges, and cranial nerves. In addition, developmental tumors and cysts and secondary extra-axial tumors are discussed.

Effects of the interaction between ferric iron and L-dopa melanin on T1 and T2 relaxation times determined by magnetic resonance imaging

T1 and T2 relaxation times of agar phantoms containing L-dopa melanin and Fe3+ were measured under MRI conditions. Fe3+ shortened T1 and T2 relaxation times. Melanin influenced relaxation times only in the presence of Fe3+; thus, contrast in MR images of the basal ganglia may depend upon levels of both paramagnetic iron and neuromelanin.

Fetal kleeblattschädel cranium: morphologic, radiographic, and histologic analysis

The kleeblattschädel deformity is a rare craniofacial condition typified by its trilobed, cloverleaf skull. The pathophysiology of this process is controversial. The morphologic, radiographic, and histologic abnormalities identified in the cranial base of an 18-gestational-week fetus with kleeblattschädel skull have not been described previously. Recently, the intrauterine diagnosis of kleeblattschädel was established by serial ultrasonography and, based on this evidence, the fetus was aborted. The fetus was studied extensively. Standard radiographs and high-resolution CT scans were obtained. Three-dimensional, reformatted contour surface images were constructed from the CT scan data. The cranial base was examined grossly, radiographically, and histologically. Histologic microanatomic study concentrated on structures of the mid-sagittal cranial base from the occiput to the mid maxilla. The distorted cranial architecture in kleeblattschädel deformity has, in the past, been attributed largely to the cranial base deformity which secondarily distorts the developing brain. Our study, however, suggests that the calvarium itself may be the primary focus of abnormal events leading to synostosis. The findings in this study seem to be inconsistent with earlier theories about the abnormal development of craniodysostoses.

Pediatric choroid plexus neoplasms: MR, CT, and pathologic correlation

Choroid plexus papillomas are rare, constituting approximately 0.5% of all intracranial neoplasms. Four benign choroid plexus papillomas and one choroid plexus carcinoma were retrospectively reviewed in patients aged 4-20 months who had been examined with magnetic resonance (MR) imaging with a field strength of 0.5 T or 1.0 T and with computed tomography (CT) before and after the administration of contrast material. In general, the tumors were of intermediate signal intensity on T1-weighted images and of either intermediate or increased signal intensity (T2 lengthening) with T2 weighting. All demonstrated variable areas of internal signal void interpreted as signifying regional blood flow, calcification, or old hemorrhage. CT findings included relatively uniform contrast enhancement. Microscopic pathologic changes of the benign lesions mimicked the appearance of normal choroid plexus and confirmed the highly vascular nature of these tumors. MR imaging, with its high-resolution multiplanar techniques, offers direct visualization of these lesions in relation to normal anatomy and better discrimination and confirmation of their intraventricular location, facilitating surgery and postoperative follow-up.