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Ahluwalia MS, Reardon DA, Abad AP, Curry WT, Wong ET, Figel SA, Mechtler LL, Peereboom DM, Hutson AD, Withers HG, Liu S, Belal AN, Qiu J, Mogensen KM, Dharma SS, Dhawan A, Birkemeier MT, Casucci DM, Ciesielski MJ, Fenstermaker RA. Phase IIa Study of SurVaxM Plus Adjuvant Temozolomide for Newly Diagnosed Glioblastoma. J Clin Oncol 2023; 41:1453-1465. [PMID: 36521103 PMCID: PMC9995096 DOI: 10.1200/jco.22.00996] [Citation(s) in RCA: 25] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 09/16/2022] [Accepted: 11/02/2022] [Indexed: 12/23/2022] Open
Abstract
PURPOSE Despite intensive treatment with surgery, radiation therapy, temozolomide (TMZ) chemotherapy, and tumor-treating fields, mortality of newly diagnosed glioblastoma (nGBM) remains very high. SurVaxM is a peptide vaccine conjugate that has been shown to activate the immune system against its target molecule survivin, which is highly expressed by glioblastoma cells. We conducted a phase IIa, open-label, multicenter trial evaluating the safety, immunologic effects, and survival of patients with nGBM receiving SurVaxM plus adjuvant TMZ following surgery and chemoradiation (ClinicalTrials.gov identifier: NCT02455557). METHODS Sixty-four patients with resected nGBM were enrolled including 38 men and 26 women, in the age range of 20-82 years. Following craniotomy and fractionated radiation therapy with concurrent TMZ, patients received four doses of SurVaxM (500 μg once every 2 weeks) in Montanide ISA-51 plus sargramostim (granulocyte macrophage colony-stimulating factor) subcutaneously. Patients subsequently received adjuvant TMZ and maintenance SurVaxM concurrently until progression. Progression-free survival (PFS) and overall survival (OS) were reported. Immunologic responses to SurVaxM were assessed. RESULTS SurVaxM plus TMZ was well tolerated with no serious adverse events attributable to SurVaxM. Of the 63 patients who were evaluable for outcome, 60 (95.2%) remained progression-free 6 months after diagnosis (prespecified primary end point). Median PFS was 11.4 months and median OS was 25.9 months measured from first dose of SurVaxM. SurVaxM produced survivin-specific CD8+ T cells and antibody/immunoglobulin G titers. Apparent clinical benefit of SurVaxM was observed in both methylated and unmethylated patients. CONCLUSION SurVaxM appeared to be safe and well tolerated. The combination represents a promising therapy for nGBM. For patients with nGBM treated in this manner, PFS may be an acceptable surrogate for OS. A large randomized clinical trial of SurVaxM for nGBM is in progress.
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Affiliation(s)
| | - David A. Reardon
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Ajay P. Abad
- Department of Neuro-oncology, Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - William T. Curry
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA
| | - Eric T. Wong
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA
| | - Sheila A. Figel
- Department of Neurosurgery, Roswell Park Comprehensive Cancer Center, Buffalo, NY
- MimiVax LLC, Buffalo, NY
| | - Laszlo L. Mechtler
- Department of Neuro-oncology, Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | | | - Alan D. Hutson
- Biostatistics and Bioinformatics, Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - Henry G. Withers
- Biostatistics and Bioinformatics, Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - Song Liu
- Biostatistics and Bioinformatics, Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - Ahmed N. Belal
- Department of Radiology, Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - Jingxin Qiu
- Department of Pathology, Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - Kathleen M. Mogensen
- Department of Neuro-oncology, Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - Sanam S. Dharma
- Department of Neurosurgery, Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - Andrew Dhawan
- Neurological Institute, Cleveland Clinic, Cleveland, OH
| | | | - Danielle M. Casucci
- Department of Neurosurgery, Roswell Park Comprehensive Cancer Center, Buffalo, NY
- MimiVax LLC, Buffalo, NY
| | - Michael J. Ciesielski
- Department of Neurosurgery, Roswell Park Comprehensive Cancer Center, Buffalo, NY
- MimiVax LLC, Buffalo, NY
| | - Robert A. Fenstermaker
- Department of Neurosurgery, Roswell Park Comprehensive Cancer Center, Buffalo, NY
- MimiVax LLC, Buffalo, NY
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Shuford S, Lipinski L, Abad A, Smith AM, Rayner M, O'Donnell L, Stuart J, Mechtler LL, Fabiano AJ, Edenfield J, Kanos C, Gardner S, Hodge P, Lynn M, Butowski NA, Han SJ, Redjal N, Crosswell HE, Vibat CRT, Holmes L, Gevaert M, Fenstermaker RA, DesRochers TM. Prospective prediction of clinical drug response in high-grade gliomas using an ex vivo 3D cell culture assay. Neurooncol Adv 2021; 3:vdab065. [PMID: 34142085 PMCID: PMC8207705 DOI: 10.1093/noajnl/vdab065] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Background Clinical outcomes in high-grade glioma (HGG) have remained relatively unchanged over the last 3 decades with only modest increases in overall survival. Despite the validation of biomarkers to classify treatment response, most newly diagnosed (ND) patients receive the same treatment regimen. This study aimed to determine whether a prospective functional assay that provides a direct, live tumor cell-based drug response prediction specific for each patient could accurately predict clinical drug response prior to treatment. Methods A modified 3D cell culture assay was validated to establish baseline parameters including drug concentrations, timing, and reproducibility. Live tumor tissue from HGG patients were tested in the assay to establish response parameters. Clinical correlation was determined between prospective ex vivo response and clinical response in ND HGG patients enrolled in 3D-PREDICT (ClinicalTrials.gov Identifier: NCT03561207). Clinical case studies were examined for relapsed HGG patients enrolled on 3D-PREDICT, prospectively assayed for ex vivo drug response, and monitored for follow-up. Results Absent biomarker stratification, the test accurately predicted clinical response/nonresponse to temozolomide in 17/20 (85%, P = .007) ND patients within 7 days of their surgery, prior to treatment initiation. Test-predicted responders had a median overall survival post-surgery of 11.6 months compared to 5.9 months for test-predicted nonresponders (P = .0376). Case studies provided examples of the clinical utility of the assay predictions and their impact upon treatment decisions resulting in positive clinical outcomes. Conclusion This study both validates the developed assay analytically and clinically and provides case studies of its implementation in clinical practice.
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Affiliation(s)
| | - Lindsay Lipinski
- Department of Neuro-oncology, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
| | - Ajay Abad
- Department of Neuro-oncology, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
| | | | | | | | | | - Laszlo L Mechtler
- Department of Neuro-oncology, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
| | - Andrew J Fabiano
- Department of Neuro-oncology, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
| | - Jeff Edenfield
- Department of Medicine, Prisma Health Cancer Institute, Greenville, South Carolina, USA
| | - Charles Kanos
- Deparment of Surgery, Prisma Health Southeastern Neurosurgical and Spine Institute, Greenville, South Carolina, USA
| | - Stephen Gardner
- Deparment of Surgery, Prisma Health Southeastern Neurosurgical and Spine Institute, Greenville, South Carolina, USA
| | - Philip Hodge
- Deparment of Surgery, Prisma Health Southeastern Neurosurgical and Spine Institute, Greenville, South Carolina, USA
| | - Michael Lynn
- Deparment of Surgery, Prisma Health Southeastern Neurosurgical and Spine Institute, Greenville, South Carolina, USA
| | - Nicholas A Butowski
- Department of Neurological Surgery, University of California, San Francisco, California, USA
| | - Seunggu J Han
- Department of Neurological Surgery, Oregon Health Sciences University, Portland, Oregon, USA
| | - Navid Redjal
- Department of Neurosurgery, Capital Health Institute for Neurosciences, Pennington, New Jersey, USA
| | | | | | | | | | - Robert A Fenstermaker
- Department of Neuro-oncology, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
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Abstract
PURPOSE OF REVIEW The use of cannabis for the treatment of migraine has become an area of interest with the legalization of medical cannabis in the USA. Understanding the mechanisms of cannabinoids, available studies, and best clinical recommendations is crucial for headache providers to best serve patients. RECENT FINDINGS Patients utilizing medical cannabis for migraine have reported improvement in migraine profile and common comorbidities. Reduction in prescription medication is also common, especially opioids. Side effects exist, with the majority being mild. Not enough data is available for specific dose recommendations, but THC and CBD appear to mediate these observed effects. The purpose of this article is twofold: review the limited research surrounding cannabis for migraine disease and reflect on clinical management experiences to provide recommendations that best capture the potential use of cannabis for migraine.
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Affiliation(s)
- Laszlo L Mechtler
- Dent Neurologic Institute, 3980 Sheridan Drive, Suite 600, Amherst, NY, 14226, USA.
| | - Fran M Gengo
- Dent Neurologic Institute, 3980 Sheridan Drive, Suite 300, Amherst, NY, 14226, USA
| | - Vincent H Bargnes
- Dent Neurologic Institute, 3980 Sheridan Drive, Suite 600, Amherst, NY, 14226, USA
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Pillai B, Farooque U, Sapkota M, Hassan SA, Mechtler LL. Symptomatic Cavum Septum Pellucidum Cyst: A Rare Presentation. Cureus 2020; 12:e10395. [PMID: 33062515 PMCID: PMC7550031 DOI: 10.7759/cureus.10395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
A cavum septum pellucidum is a cerebrospinal fluid (CSF) filled cavity situated between the lateral ventricles and is considered as a normal anatomic variant sporadically seen on neuroimaging. While a cavum septum pellucidum is a relatively uncommon incidental neuroimaging finding, symptomatic cysts of the cavum septum pellucidum are very rare, with only a few cases reported in the literature so far. They are defined as fluid-filled structures with lateral bowing of the walls and membranes separated by at least 10 mm or more. We present the case of a 25-year-old male patient with a rapidly expanding cyst of the septum pellucidum with headaches refractory to conventional pharmacological therapy. A 3T magnetic resonance imaging (MRI) of the brain with contrast was performed, which confirmed the diagnosis. Due to the failure of non-interventional treatment, he was treated with therapeutic endoscopic fenestration of the cyst. Postoperatively, he reported a complete resolution of the presenting symptoms.
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Mechtler LL. Neuroimaging. Neurol Clin 2020; 38:xi-xii. [DOI: 10.1016/j.ncl.2019.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Evans RW, Burch RC, Frishberg BM, Marmura MJ, Mechtler LL, Silberstein SD, Turner DP. Neuroimaging for Migraine: The American Headache Society Systematic Review and Evidence-Based Guideline. Headache 2019; 60:318-336. [PMID: 31891197 DOI: 10.1111/head.13720] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/21/2019] [Indexed: 01/02/2023]
Abstract
OBJECTIVE To provide updated evidence-based recommendations about when to obtain neuroimaging in patients with migraine. METHODS Articles were included in the systematic review if they studied adults 18 and over who were seeking outpatient treatment for any type of migraine and who underwent neuroimaging (MRI or CT). Medline, Web of Science, and Cochrane Clinical Trials were searched from 1973 to August 31, 2018. Reviewers identified studies, extracted data, and assessed the quality of the evidence in duplicate. We assessed study quality using the Newcastle-Ottawa Scale. RESULTS The initial search yielded 2269 publications. Twenty three articles met inclusion criteria and were included in the final review. The majority of studies were retrospective cohort or cross-sectional studies. There were 4 prospective observational studies. Ten studies evaluated the utility of CT only, 9 MRI only, and 4 evaluated both. Common abnormalities included chronic ischemia or atrophy with CT and MRI scanning, and non-specific white matter lesions with MRI. Clinically meaningful abnormalities requiring intervention were relatively rare. Clinically significant neuroimaging abnormalities in patients with headaches consistent with migraine without atypical features or red flags appeared no more common than in the general population. RECOMMENDATIONS There is no necessity to do neuroimaging in patients with headaches consistent with migraine who have a normal neurologic examination, and there are no atypical features or red flags present. Grade A Neuroimaging may be considered for presumed migraine for the following reasons: unusual, prolonged, or persistent aura; increasing frequency, severity, or change in clinical features, first or worst migraine, migraine with brainstem aura, migraine with confusion, migraine with motor manifestations (hemiplegic migraine), late-life migraine accompaniments, aura without headache, side-locked headache, and posttraumatic headache. Most of these are consensus based with little or no literature support. Grade C.
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Affiliation(s)
- Randolph W Evans
- Department of Neurology, Baylor College of Medicine, Houston, TX, USA
| | - Rebecca C Burch
- John R. Graham Headache Center, Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Benjamin M Frishberg
- The Neurology Center, Carlsbad, CA, USA.,University of California at San Diego School of Medicine, San Diego, CA, USA
| | - Michael J Marmura
- Jefferson Headache Center, Thomas Jefferson University, Philadelphia, PA, USA
| | | | | | - Dana P Turner
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Goadsby PJ, Sahai-Srivastava S, Kezirian EJ, Calhoun AH, Matthews DC, McAllister PJ, Costantino PD, Friedman DI, Zuniga JR, Mechtler LL, Popat SR, Rezai AR, Dodick DW. Safety and efficacy of sphenopalatine ganglion stimulation for chronic cluster headache: a double-blind, randomised controlled trial. Lancet Neurol 2019; 18:1081-1090. [DOI: 10.1016/s1474-4422(19)30322-9] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Revised: 07/29/2019] [Accepted: 07/29/2019] [Indexed: 11/17/2022]
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Shetty VS, Reis MN, Aulino JM, Berger KL, Broder J, Choudhri AF, Kendi AT, Kessler MM, Kirsch CF, Luttrull MD, Mechtler LL, Prall JA, Raksin PB, Roth CJ, Sharma A, West OC, Wintermark M, Cornelius RS, Bykowski J. ACR Appropriateness Criteria Head Trauma. J Am Coll Radiol 2017; 13:668-79. [PMID: 27262056 DOI: 10.1016/j.jacr.2016.02.023] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Accepted: 02/23/2016] [Indexed: 10/21/2022]
Abstract
Neuroimaging plays an important role in the management of head trauma. Several guidelines have been published for identifying which patients can avoid neuroimaging. Noncontrast head CT is the most appropriate initial examination in patients with minor or mild acute closed head injury who require neuroimaging as well as patients with moderate to severe acute closed head injury. In short-term follow-up neuroimaging of acute traumatic brain injury, CT and MRI may have complementary roles. In subacute to chronic traumatic brain injury, MRI is the most appropriate initial examination, though CT may have a complementary role in select circumstances. Advanced neuroimaging techniques are areas of active research but are not considered routine clinical practice at this time. In suspected intracranial vascular injury, CT angiography or venography or MR angiography or venography is the most appropriate imaging study. In suspected posttraumatic cerebrospinal fluid leak, high-resolution noncontrast skull base CT is the most appropriate initial imaging study to identify the source, with cisternography reserved for problem solving. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every three years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.
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Affiliation(s)
| | - Martin N Reis
- St Louis University School of Medicine, St Louis, Missouri
| | | | | | - Joshua Broder
- Duke University Division of Emergency Medicine, Cary, North Carolina, American College of Emergency Physicians
| | - Asim F Choudhri
- Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, Tennessee
| | | | - Marcus M Kessler
- University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | | | | | - Laszlo L Mechtler
- Dent Neurologic Institute, Amherst, New York, American Academy of Neurology
| | | | | | | | - Aseem Sharma
- Mallinckrodt Institute of Radiology, St Louis, Missouri
| | | | | | | | - Julie Bykowski
- University of California, San Diego, Health Center, San Diego, California
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Silberstein SD, Mechtler LL, Kudrow DB, Calhoun AH, McClure C, Saper JR, Liebler EJ, Rubenstein Engel E, Tepper SJ. Non-Invasive Vagus Nerve Stimulation for the ACute Treatment of Cluster Headache: Findings From the Randomized, Double-Blind, Sham-Controlled ACT1 Study. Headache 2017; 56:1317-32. [PMID: 27593728 PMCID: PMC5113831 DOI: 10.1111/head.12896] [Citation(s) in RCA: 164] [Impact Index Per Article: 23.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Revised: 05/11/2016] [Accepted: 06/10/2016] [Indexed: 01/03/2023]
Abstract
Objective To evaluate non‐invasive vagus nerve stimulation (nVNS) as an acute cluster headache (CH) treatment. Background Many patients with CH experience excruciating attacks at a frequency that is not sufficiently addressed by current symptomatic treatments. Methods One hundred fifty subjects were enrolled and randomized (1:1) to receive nVNS or sham treatment for ≤1 month during a double‐blind phase; completers could enter a 3‐month nVNS open‐label phase. The primary end point was response rate, defined as the proportion of subjects who achieved pain relief (pain intensity of 0 or 1) at 15 minutes after treatment initiation for the first CH attack without rescue medication use through 60 minutes. Secondary end points included the sustained response rate (15‐60 minutes). Subanalyses of episodic cluster headache (eCH) and chronic cluster headache (cCH) cohorts were prespecified. Results The intent‐to‐treat population comprised 133 subjects: 60 nVNS‐treated (eCH, n = 38; cCH, n = 22) and 73 sham‐treated (eCH, n = 47; cCH, n = 26). A response was achieved in 26.7% of nVNS‐treated subjects and 15.1% of sham‐treated subjects (P = .1). Response rates were significantly higher with nVNS than with sham for the eCH cohort (nVNS, 34.2%; sham, 10.6%; P = .008) but not the cCH cohort (nVNS, 13.6%; sham, 23.1%; P = .48). Sustained response rates were significantly higher with nVNS for the eCH cohort (P = .008) and total population (P = .04). Adverse device effects (ADEs) were reported by 35/150 (nVNS, 11; sham, 24) subjects in the double‐blind phase and 18/128 subjects in the open‐label phase. No serious ADEs occurred. Conclusions In one of the largest randomized sham‐controlled studies for acute CH treatment, the response rate was not significantly different (vs sham) for the total population; nVNS provided significant, clinically meaningful, rapid, and sustained benefits for eCH but not for cCH, which affected results in the total population. This safe and well‐tolerated treatment represents a novel and promising option for eCH. ClinicalTrials.gov identifier: NCT01792817.
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Affiliation(s)
| | - Laszlo L Mechtler
- Department of Neurology and Neuro-Oncology, Dent Neurologic Headache Center, Amherst, NY, USA
| | - David B Kudrow
- California Medical Clinic for Headache, Santa Monica, CA, USA
| | | | | | - Joel R Saper
- Michigan Head Pain and Neurological Institute, Ann Arbor, MI, USA
| | - Eric J Liebler
- Department of Scientific, Medical and Governmental Affairs, electroCore, LLC, Basking Ridge, NJ, USA
| | | | - Stewart J Tepper
- Department of Neurology, Geisel School of Medicine at Dartmouth, Hanover, NH, USA.,Dr. Tepper was at Cleveland Clinic Headache Center, Cleveland, OH, at the time of study completion
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Abstract
PURPOSE OF REVIEW This article reviews recent research on gadolinium deposit formation in the brain linked to contrast-enhanced MRI studies. RECENT FINDINGS Human and animal studies have confirmed the presence of gadolinium in the brain following the serial administration of gadolinium-based contrast agents. This is a relatively new and growing field of research primarily driven by concerns regarding unknown and potentially harmful side effects of gadolinium-based contrast agents. Retrospective observational in vivo studies in humans demonstrated T1 shortening effects in the brain parenchyma resulting from gadolinium exposure. These studies were followed by postmortem human and animal studies. Evidence exists that gadolinium may cause deposits in the brain and that this may occur independently of impaired renal function and in the presence of an intact blood-brain barrier. Gadolinium deposition has been linked primarily with the use of linear, rather than macrocyclic, gadolinium-based contrast agents. SUMMARY The formation of gadolinium deposits and its implications have been the focus of only a small number of research groups. The currently available data must be verified, and the potential factors that may be linked to this phenomenon and the clinical significance must be explored. Depending on future findings, changes in the clinical application of gadolinium-based contrast agents may be expected.
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Roth CJ, Angevine PD, Aulino JM, Berger KL, Choudhri AF, Fries IB, Holly LT, Kendi ATK, Kessler MM, Kirsch CF, Luttrull MD, Mechtler LL, O'Toole JE, Sharma A, Shetty VS, West OC, Cornelius RS, Bykowski J. ACR Appropriateness Criteria Myelopathy. J Am Coll Radiol 2015; 13:38-44. [PMID: 26653797 DOI: 10.1016/j.jacr.2015.10.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Accepted: 10/04/2015] [Indexed: 12/11/2022]
Abstract
Patients presenting with myelopathic symptoms may have a number of causative intradural and extradural etiologies, including disc degenerative diseases, spinal masses, infectious or inflammatory processes, vascular compromise, and vertebral fracture. Patients may present acutely or insidiously and may progress toward long-term paralysis if not treated promptly and effectively. Noncontrast CT is the most appropriate first examination in acute trauma cases to diagnose vertebral fracture as the cause of acute myelopathy. In most nontraumatic cases, MRI is the modality of choice to evaluate the location, severity, and causative etiology of spinal cord myelopathy, and predicts which patients may benefit from surgery. Myelopathy from spinal stenosis and spinal osteoarthritis is best confirmed without MRI intravenous contrast. Many other myelopathic conditions are more easily visualized after contrast administration. Imaging performed should be limited to the appropriate spinal levels, based on history, physical examination, and clinical judgment. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every three years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals, and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.
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Affiliation(s)
| | - Peter D Angevine
- Columbia University Medical Center, New York, New York, American Association of Neurological Surgeons/Congress of Neurological Surgeons
| | | | | | - Asim F Choudhri
- Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Ian Blair Fries
- Bone, Spine and Hand Surgery, Chartered, Brick, New Jersey, American Academy of Orthopaedic Surgeons
| | - Langston T Holly
- University of California Los Angeles, Los Angeles, California, American Association of Neurological Surgeons/Congress of Neurological Surgeons
| | | | - Marcus M Kessler
- University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | | | | | - Laszlo L Mechtler
- Dent Neurologic Institute, Amherst, New York, American Academy of Neurology
| | - John E O'Toole
- Rush University, Chicago, Illinois, American Association of Neurological Surgeons/Congress of Neurological Surgeons
| | - Aseem Sharma
- Mallinckrodt Institute of Radiology, Saint Louis, Missouri
| | | | | | | | - Julie Bykowski
- University of California San Diego Health Center, San Diego, California
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Shakir HJ, Qiu J, Prasad D, Mechtler LL, Fenstermaker RA. Papillary tumor of the pineal region with extended clinical and radiologic follow-up. Surg Neurol Int 2015; 6:S451-4. [PMID: 26539320 PMCID: PMC4604644 DOI: 10.4103/2152-7806.166782] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Accepted: 08/03/2015] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Papillary tumor of the pineal region (PTPR) is a rare neoplasm with only anecdotal data to guide the treatment. Results of treatment with surgery, radiation therapy, and chemotherapy have been reported to have varying degrees of success. Here we report a patient with a PTPR, who underwent subtotal resection, gamma knife stereotactic radiosurgery, and adjuvant temozolomide chemotherapy. CASE DESCRIPTION During 9 years of clinical and radiographic follow-up, the patient has had regression of residual tumor and remains asymptomatic. CONCLUSION When gross total resection of a PTPR is not possible, treatment with gamma knife stereotactic radiosurgery and temozolomide chemotherapy may provide long-term tumor control.
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Affiliation(s)
- Hakeem J Shakir
- Department of Neurosurgery, Roswell Park Cancer Institute, University at Buffalo, State University of New York, Buffalo, NY, USA ; Department of Neurosurgery, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY, USA
| | - Jingxin Qiu
- Department of Pathology, Roswell Park Cancer Institute, University at Buffalo, State University of New York, Buffalo, NY, USA
| | - Dheerendra Prasad
- Department of Neurosurgery, Roswell Park Cancer Institute, University at Buffalo, State University of New York, Buffalo, NY, USA ; Department of Radiation Medicine, Roswell Park Cancer Institute, University at Buffalo, State University of New York, Buffalo, NY, USA
| | - Laszlo L Mechtler
- Department of Neuro oncology, Roswell Park Cancer Institute, University at Buffalo, State University of New York, Buffalo, NY ; Dent Neurologic Institute, Amherst, NY, USA
| | - Robert A Fenstermaker
- Department of Neurosurgery, Roswell Park Cancer Institute, University at Buffalo, State University of New York, Buffalo, NY, USA ; Department of Neurosurgery, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY, USA
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Abstract
This article focuses on advancements in neuroimaging techniques, compares the advantages of each of the modalities in the evaluation of mild traumatic brain injury, and discusses their contribution to our understanding of the pathophysiology as it relates to prognosis. Advanced neuroimaging techniques discussed include anatomic/structural imaging techniques, such as diffusion tensor imaging and susceptibility-weighted imaging, and functional imaging techniques, such as functional magnetic resonance imaging, perfusion-weighted imaging, magnetic resonance spectroscopy, and positron emission tomography.
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Affiliation(s)
- Laszlo L Mechtler
- Department of Neurology and Neuro-Oncology, State University of New York at Buffalo, 3435 Main Street, Buffalo, NY 14223, USA; Dent Neurologic Institute, 3980A Sheridan Drive, Suite 101, Amherst, NY 14226, USA.
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Douglas AC, Wippold FJ, Broderick DF, Aiken AH, Amin-Hanjani S, Brown DC, Corey AS, Germano IM, Hadley JA, Jagadeesan BD, Jurgens JS, Kennedy TA, Mechtler LL, Patel ND, Zipfel GJ. ACR Appropriateness Criteria Headache. J Am Coll Radiol 2014; 11:657-67. [PMID: 24933450 DOI: 10.1016/j.jacr.2014.03.024] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2014] [Accepted: 03/30/2014] [Indexed: 10/25/2022]
Abstract
Most patients presenting with uncomplicated, nontraumatic, primary headache do not require imaging. When history, physical, or neurologic examination elicits "red flags" or critical features of the headache, then further investigation with imaging may be warranted to exclude a secondary cause. Imaging procedures may be diagnostically useful for patients with headaches that are: associated with trauma; new, worse, or abrupt onset; thunderclap; radiating to the neck; due to trigeminal autonomic cephalgia; persistent and positional; and temporal in older individuals. Pregnant patients, immunocompromised individuals, cancer patients, and patients with papilledema or systemic illnesses, including hypercoagulable disorders may benefit from imaging. Unlike most headaches, those associated with cough, exertion, or sexual activity usually require neuroimaging with MRI of the brain with and without contrast to exclude potentially underlying pathology before a primary headache syndrome is diagnosed. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.
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Affiliation(s)
| | | | | | | | - Sepideh Amin-Hanjani
- University of Illinois College of Medicine, Chicago, Illinois; American Association of Neurological Surgeons, Rolling Meadows, Illinois/Congress of Neurological Surgeons, Schaumburg, Illinois
| | | | | | - Isabelle M Germano
- Mount Sinai School of Medicine, New York, New York; American Association of Neurological Surgeons, Rolling Meadows, Illinois/Congress of Neurological Surgeons, Schaumburg, Illinois
| | - James A Hadley
- Physicians Regional Medical Center, Naples, Florida; American Academy of Otolaryngology-Head and Neck Surgery, Alexandria, Virginia
| | | | - Jennifer S Jurgens
- Walter Reed National Military Medical Center, Bethesda, Maryland, Society of Nuclear Medicine and Molecular Imaging, Reston, Virginia
| | | | - Laszlo L Mechtler
- Dent Neurologic Institute, Amherst, New York; American Academy of Neurology, Minneapolis, Minnesota
| | | | - Gregory J Zipfel
- Washington University School of Medicine, St. Louis, Missouri, American Association of Neurological Surgeons, Rolling Meadows, Illinois/Congress of Neurological Surgeons, Schaumburg, Illinois
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Cornelius RS, Martin J, Wippold FJ, Aiken AH, Angtuaco EJ, Berger KL, Brown DC, Davis PC, McConnell CT, Mechtler LL, Nussenbaum B, Roth CJ, Seidenwurm DJ. ACR Appropriateness Criteria Sinonasal Disease. J Am Coll Radiol 2013; 10:241-6. [DOI: 10.1016/j.jacr.2013.01.001] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2013] [Accepted: 01/02/2013] [Indexed: 10/27/2022]
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Recht L, Mechtler LL, Wong ET, O'Connor PC, Rodda BE. Steroid-sparing effect of corticorelin acetate in peritumoral cerebral edema is associated with improvement in steroid-induced myopathy. J Clin Oncol 2013; 31:1182-7. [PMID: 23382470 DOI: 10.1200/jco.2012.43.9455] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To compare the safety and efficacy of corticorelin acetate (CrA) and placebo in patients with malignant brain tumors requiring chronic administration of dexamethasone (DEX) to control the signs and symptoms of peritumoral brain edema (PBE). PATIENTS AND METHODS Prospective, randomized, double-blind study of 200 patients with PBE on a stable dose of DEX. Initially, DEX dose was decreased by 50% over a 2-week period and then held at this level for 3 weeks. The primary end point was the proportion of patients who responded to treatment-patients who achieved a ≥ 50% DEX reduction from baseline and achieved stable or improved neurologic examination score and Karnofsky performance score at week 2, and then continued to respond at week 5. RESULTS One hundred patients received subcutaneous injections of 1 mg twice per day of CrA and 100 patients received placebo for the duration of the study period. Although results did not attain statistical significance (at the P < .05 level), a clinically important difference in the proportion of responders between the CrA group (57.0%) and the placebo group (46.0%; P = .12) was observed. In addition, the maximum percent reduction in DEX dose achieved during the double-blind 12-week study was significantly greater in the CrA group (62.7%) than in placebo group (51.4%; P < .001). Patients receiving CrA demonstrated an improvement in myopathy and were less likely to develop signs of Cushing syndrome. CONCLUSION CrA enables a reduction in steroid requirement for patients with PBE and is associated with a reduction in the incidence and severity of common steroid adverse effects, including myopathy.
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Affiliation(s)
- Lawrence Recht
- Department of Neurology, Advanced Medicine Clinic, Stanford University School of Medicine, 875 Blake Wilbur Dr, Stanford, CA 94305, USA.
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Seidenwurm DJ, Wippold FJ, Cornelius RS, Angevine PD, Angtuaco EJ, Broderick DF, Brown DC, Davis PC, Garvin CF, Hartl R, Holly L, McConnell CT, Mechtler LL, Smirniotopoulos JG, Waxman AD. ACR Appropriateness Criteria® Myelopathy. J Am Coll Radiol 2012; 9:315-24. [DOI: 10.1016/j.jacr.2012.01.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2012] [Accepted: 01/17/2012] [Indexed: 11/26/2022]
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DeLaPaz RL, Wippold FJ, Cornelius RS, Amin-Hanjani S, Angtuaco EJ, Broderick DF, Brown DC, Creasy JL, Davis PC, Garvin CF, Hoh BL, McConnell CT, Mechtler LL, Seidenwurm DJ, Smirniotopoulos JG, Tobben PJ, Waxman AD, Zipfel GJ. ACR Appropriateness Criteria® on cerebrovascular disease. J Am Coll Radiol 2012; 8:532-8. [PMID: 21807345 DOI: 10.1016/j.jacr.2011.05.010] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2011] [Accepted: 05/26/2011] [Indexed: 11/17/2022]
Abstract
Stroke is the sudden onset of focal neurologic symptoms due to ischemia or hemorrhage in the brain. Current FDA-approved clinical treatment of acute ischemic stroke involves the use of the intravenous thrombolytic agent recombinant tissue plasminogen activator given <3 hours after symptom onset, following the exclusion of intracerebral hemorrhage by a noncontrast CT scan. Advanced MRI, CT, and other techniques may confirm the stroke diagnosis and subtype, demonstrate lesion location, identify vascular occlusion, and guide other management decisions but, within the first 3 hours after ictus, should not delay or be used to withhold recombinant tissue plasminogen activator therapy after the exclusion of acute hemorrhage on noncontrast CT scans. MR diffusion-weighted imaging is highly sensitive and specific for acute cerebral ischemia and, when combined with perfusion-weighted imaging, may be used to identify potentially salvageable ischemic tissue, especially in the period >3 hours after symptom onset. Advanced CT perfusion methods improve sensitivity to acute ischemia and are increasingly used with CT angiography to evaluate acute stroke as a supplement to noncontrast CT. The ACR Appropriateness Criteria(®) are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.
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Abstract
Chronic subdural hematomas (CSDHs) typically present with cognitive dysfunction and a history of trauma. Localized dural enhancement on postcontrast MRI scans associated with the surrounding membrane has been described in CSDH. We present an 83-year-old man with rapidly progressing cognitive dysfunction 4 weeks after head trauma related to a fall. MRI showed CSDHs, which in addition to localized dural gadolinium enhancement, showed a marked diffuse, symmetric, contiguous pachymeningeal enhancement of the supratentorial and infratentorial intracranial dural mater. Meningeal biopsy failed to disclose an infectious or neoplastic cause of the enhancement and instead showed fibrocollagenous change. We conclude that diffuse dural enhancement on MRI scans associated with CSDH cause does not necessarily indicate a superimposed process such as infection or malignancy. CSDH should be considered in the differential diagnosis of diffuse dural enhancement, especially when supported by appropriate clinical findings.
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Affiliation(s)
- Svetlana Blitshteyn
- Department of Neurology, Mayo Clinic Jacksonville, Mayo College of Medicine, Jacksonville, FL, USA
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Abstract
A 45-year-old man developed seizures and myelopathy. MRI showed bitemporal and cervical spinal cord hyperintense lesions on T2-weighted and FLAIR images that contrast-enhanced. Initial evaluation for sarcoidosis was negative, including serum angiotensin converting enzyme (ACE) and chest X-ray. Whole body fluorodeoxyglucose positron emission tomography (FDG-PET) revealed multiple hypermetabolic hilar and mediastinal foci and spinal cord hypermetabolism at the site of MRI abnormality. Temporal lobe MRI lesions were hypometabolic. Mediastinal lymph node biopsy was consistent with sarcoidosis. The brain, spinal cord, and chest metabolic abnormalities together with the clinical presentation were interpreted as being most consistent with sarcoidosis. FDG-PET helped target the site of biopsy that subsequently confirmed the diagnosis histologically. In patients with perplexing neurologic presentations, whole body FDG-PET can help secure a timely and minimally invasive diagnosis of neurosarcoidosis.
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Bakshi R, Kamran S, Kinkel PR, Bates VE, Mechtler LL, Belani SL, Kinkel WR. MRI in cerebral intraventricular hemorrhage: analysis of 50 consecutive cases. Neuroradiology 1999; 41:401-9. [PMID: 10426214 DOI: 10.1007/s002340050773] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
MRI of intraventricular haemorrhage (IVH) has not been studied formally. We aimed to describe the degradation rate and patterns shown on 1.5 T MRI in IVH, comparing them to other coexisting brain hemorrhage. We studied 50 consecutive cases using T1-, proton-density, and T2-weighted images. IVH was seen in two forms: layered (free-flowing in ventricles) (37 cases) and/or clotted (31). Both were best shown by proton-density image. Layered IVH was seen in the dependent portions of the lateral ventricles with fluid ("blood-CSF") levels, degrading more slowly than both clotted IVH and intraparenchymal hemorrhages (IPH) (acute blood products persisting for several more days; P < 0.05). Clotted IVH degraded at a rate comparable to IPH. IVH cleared rapidly and did not form hemosiderin. Subarachnoid hemorrhage (SAH) cleared faster and was less conspicuous than IVH. Hypertensive (22), aneurysmal (11), traumatic (2), idiopathic (9), or vascular malformation-related (6) IVH were seen. IVH coexisted with IPH (30) or SAH (12), or both (12). The high rate of layering with blood-CSF levels in IVH is most likely due to different densities of blood components and CSF and the fibrinolytic capability of the latter. Delayed degradation of layered IVH probably reflects high intraventricular oxygen and glucose content. Further study is necessary to determine if MRI characteristics of IVH are helpful in excluding other intraventricular diseases such as neoplasia and pyocephalus.
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Affiliation(s)
- R Bakshi
- Dent Neurologic Institute, Lucy Dent Imaging Center, Kaleida Health, State University of NY at Buffalo, 14203, USA.
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Bakshi R, Wright PD, Kinkel PR, Bates VE, Mechtler LL, Kamran S, Pullicino PM, Sirotkin I, Kinkel WR. Cranial magnetic resonance imaging findings in bacterial endocarditis: the neuroimaging spectrum of septic brain embolization demonstrated in twelve patients. J Neuroimaging 1999; 9:78-84. [PMID: 10208104 DOI: 10.1111/jon19999278] [Citation(s) in RCA: 46] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Infective endocarditis (IE) is an elusive systemic disorder that is often associated with neurologic complications. The contribution of brain magnetic resonance imaging (MRI) to the diagnosis of IE and the spectrum of such findings has been only sparsely described previously. The authors report cranial MRI findings in 12 patients with IE. Each of the patients had MRI evidence of cerebral embolization, with multiple brain lesions noted in most patients (n = 10). Cortical branch infarction was the most common lesion (n = 8), which usually involved the distal middle cerebral artery tree. The next most common finding (n = 7) was numerous small embolic lesions which typically lodged in the supratentorial gray-white junction, some of which were clinically silent and many of which enhanced (probable microabscesses). Brain hemorrhages were noted in four patients, most commonly subarachnoid hemorrhage (n = 3). Two patients developed multiple frank parenchymal macroabscesses/cerebritis lesions. A previously unreported finding in septic embolization, a stroke that became infected with abscess formation ("septic infarction"), was noted in two patients. MRI showed orbital cellulitis in two patients. Most patients studied with gadolinium showed enhancement of lesions (n = 5/8). The authors conclude that cranial MRI may be a valuable tool in the evaluation of patients with IE. The presence of characteristic cranial MRI lesions, especially of multiple types, may prompt early diagnosis and treatment.
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Affiliation(s)
- R Bakshi
- Lucy Dent Imaging Center, Millard Fillmore Health System, Buffalo, NY 14209, USA
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Bakshi R, Kamran S, Kinkel PR, Bates VE, Mechtler LL, Janardhan V, Belani SL, Kinkel WR. Fluid-attenuated inversion-recovery MR imaging in acute and subacute cerebral intraventricular hemorrhage. AJNR Am J Neuroradiol 1999; 20:629-36. [PMID: 10319974 PMCID: PMC7056041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/1998] [Indexed: 02/12/2023]
Abstract
BACKGROUND AND PURPOSE Fluid-attenuated inversion-recovery (FLAIR) MR imaging may show subarachnoid hemorrhage (SAH) with high sensitivity. We hypothesized that the FLAIR technique is effective and reliable in the diagnosis of cerebral intraventricular hemorrhage (IVH). METHODS Two observers evaluated the 1.5-T MR fast spin-echo FLAIR images, T1- and T2-weighted MR images, and CT scans of 13 patients with IVH and the FLAIR images of 40 control subjects. RESULTS IVH appeared bright on the FLAIR images obtained during the first 48 hours and was of variable appearance at later stages. FLAIR MR imaging detected 12 of 13 cases of IVH; no control subjects were falsely thought to have IVH (92% sensitivity, 100% specificity). However, IVH could not be fully excluded in the third ventricle (20%, n = 8) or in the fourth ventricle (28%, n = 11) on some control images because of CSF pulsation artifacts. Two cases had CT-negative IVH seen on FLAIR images. One case had FLAIR-negative IVH seen by CT. Although the sensitivities of conventional MR imaging (92%) and CT (85%) were also high, FLAIR imaging showed IVH more conspicuously than did standard MR imaging and CT in 62% of the cases (n = 8). FLAIR was as good as or better than CT in showing IVH in 10 cases (77%). FLAIR images showed all coexisting SAH. CONCLUSION FLAIR MR imaging identifies acute and subacute IVH in the lateral ventricles with high sensitivity and specificity. In cases of subacute IVH, conventional MR imaging complements FLAIR in detecting IVH. The usefulness of the FLAIR technique for detecting third and fourth ventricular IVH may be compromised by artifacts. Blood hemoglobin degradation most likely causes the variable FLAIR appearance of IVH after the first 48 hours.
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Affiliation(s)
- R Bakshi
- Dent Neurologic Institute, Lucy Dent Imaging Center, Kaleida Health System, Millard Fillmore Hospital, State University of NY, Buffalo 14209, USA
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Bakshi R, Mechtler LL, Kamran S, Gosy E, Bates VE, Kinkel PR, Kinkel WR. MRI findings in lumbar puncture headache syndrome: abnormal dural-meningeal and dural venous sinus enhancement. Clin Imaging 1999; 23:73-6. [PMID: 10416079 DOI: 10.1016/s0899-7071(99)00109-6] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Intracranial hypotension (IH) is a treatable cause of persistent headaches. Persistent cerebrospinal fluid (CSF) leak at a lumbar puncture (LP) site may cause IH. We present postcontrast MRI of a patient with post-lumbar-puncture headache (LPHA) showing abnormal, intense, diffuse, symmetric, contiguous dural-meningeal (pachymeningeal) enhancement of the supratentorial and infratentorial intracranial dura, including convexities, interhemispheric fissure, tentorium, and falx. MRI also showed abnormal dural venous sinus enhancement, a new finding in LPHA, suggesting compensatory venous expansion. Thus, IH and venodilatation may play a role in the development of LPHA.
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Affiliation(s)
- R Bakshi
- University at Buffalo (SUNY) School of Medicine and Biomedical Sciences, USA.
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Bakshi R, Kinkel WR, Bates VE, Mechtler LL, Kinkel PR. The cerebral intravascular enhancement sign is not specific: a contrast-enhanced MRI study. Neuroradiology 1999; 41:80-5. [PMID: 10090599 DOI: 10.1007/s002340050710] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The intravascular enhancement (IVE) sign, also known as the "arterial enhancement sign", is an abnormal finding in the brain on contrast-enhanced MRI studies. IVE has been described in arterial cerebrovascular disorders, most commonly in acute or subacute arterial ischemic infarcts. However, the specificity of this sign has not been established. We describe four patients with disorders other than arterial strokes in whom gadolinium-enhanced high-field (1.5 T) MRI suggested IVE. The conditions were herpes simplex viral encephalitis, idiopathic cerebellitis, pneumococcal meningitis, and superior sagittal sinus thrombosis with venous infarction. IVE in these cases may be due to multiple factors, including arterial, venous, perivascular, and leptomeningeal or sulcal contrast medium accumulation. Our observations suggest that arterial ischemia, previously described as the cardinal cause of IVE, probably does not explain all instances, and urge caution in interpreting this sign as a specific MRI manifestation of acute arterial infarction or ischemia.
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Affiliation(s)
- R Bakshi
- Millard Fillmore Health System, Department of Neurology, University at Buffalo, State University of New York, School of Medicine and Biomedical Sciences, Buffalo, NY 14209, USA.
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Bakshi R, Lindsay BD, Bates VE, Kinkel PR, Mechtler LL, Kinkel WR. Cerebral venous infarctions presenting as enhancing space-occupying lesions: MRI findings. J Neuroimaging 1998; 8:210-5. [PMID: 9780852 DOI: 10.1111/jon199884210] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Cerebral venous thrombosis is an unusual form of cerebrovascular disease that may cause cerebral venous infarction (CVI). Magnetic resonance imaging (MRI) of the brain may improve the often elusive diagnosis of CVI. However, the sensitivity, specificity, and full spectrum of such MRI findings are poorly understood. The authors present the cases of three patients with CVI whose MRI scans showed abnormally enhancing tumor-like brain lesions. Two of the CVIs were hemorrhagic and exerted mass effect. One patient showed increasingly nodular and heterogeneous ring-like enhancement progressing from the single-dose to the triple-dose gadolinium contrast images. The CVI of a second patient also showed ring-like enhancement. Biopsy was performed on one of these patients and was strongly considered for the other two patients to exclude neoplastic disease. Careful examination of the MRI appearance of venous structures and the use of specialized MRI techniques improved the recognition of CVI for two patients and prevented biopsy. This represents the first description of abnormal triple-dose MRI contrast enhancement in CVI. Consideration of CVI in the care of patients with enhancing tumor-like masses may lead to earlier diagnosis and treatment, preventing unnecessary invasive diagnostic procedures. CVI should be added to the differential diagnosis of supratentorial ring-enhancing masses.
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Affiliation(s)
- R Bakshi
- Department of Neurology, University at Buffalo, State University of New York, School of Medicine and Biomedical Sciences, NY, USA
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Bakshi R, Bates VE, Mechtler LL, Kinkel PR, Kinkel WR. Occipital lobe seizures as the major clinical manifestation of reversible posterior leukoencephalopathy syndrome: magnetic resonance imaging findings. Epilepsia 1998; 39:295-9. [PMID: 9578048 DOI: 10.1111/j.1528-1157.1998.tb01376.x] [Citation(s) in RCA: 76] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
PURPOSE Reversible posterior leukoencephalopathy syndrome (RPLS) is an increasingly recognized brain disorder most commonly associated with malignant hypertension, toxemia of pregnancy, or the use of immunosuppressive agents. When associated with acute hypertension, RPLS typically occurs concurrently with the fulminant clinical syndrome of hypertensive encephalopathy. We describe occipital lobe seizures, in the setting of only moderate elevations of blood pressure, as the major clinical manifestation of RPLS. METHODS Two patients from the Dent Neurologic Institute are presented with clinical and magnetic resonance imaging (MRI) correlation. RESULTS New onset secondarily generalized occipital seizures were noted, with MRI findings consistent with RPLS. Both of the patients had chronic renal failure and a moderate acute exacerbation of chronic hypertension. Other features of hypertensive encephalopathy were lacking, such as headache, nausea, papilledema, and an altered sensorium. Magnetic resonance imaging (MRI) showed edematous lesions primarily involving the posterior supratentorial white matter and corticomedullary junction, consistent with RPLS. With lowered blood pressure, the MRI lesions resolved and the patients became seizure-free without requiring chronic anticonvulsant therapy. CONCLUSIONS Occipital seizures may represent the only major neurologic manifestation of RPLS due to acute hypertension, especially in patients with renal failure. Other evidence of hypertensive encephalopathy, such as cerebral signs and symptoms, need not be present. Blood pressure elevations may be only moderate. Early recognition of this readily treatable cause of occipital seizures may obviate the need for extensive, invasive investigations. Despite the impressive lesions on MRI, prompt treatment of this disorder carries a favorable prognosis.
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Affiliation(s)
- R Bakshi
- Dent Neurologic Institute, Department of Neurology, University at Buffalo, State University of New York School of Medicine and Biomedical Sciences, USA
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Abstract
Cerebellitis, also known as acute cerebellar ataxia, is an inflammatory syndrome of cerebellar dysfunction that may reflect an infectious, post-infectious, or post-vaccination disorder. We present serial magnetic resonance imaging (MRI) findings in a partially reversible, idiopathic cerebellitis. Bilateral cerebellar parenchymal abnormalities were noted, including hyperintensities on T2-weighted images and cerebellar swelling. After contrast administration, the cerebellum showed abnormal bilateral enhancement. The authors state this represents the first report of abnormal contrast enhancement in this condition. The MRI lesions most likely reflect the reversible, inflammatory nature of the syndrome.
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Affiliation(s)
- R Bakshi
- Dent Neurologic Institute, Millard Filmore Health System, Department of Neurology, University at Buffalo, State University of New York School of Medicine and Biomedical Sciences, USA
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Bakshi R, Kinkel PR, Mechtler LL, Bates VE, Lindsay BD, Esposito SE, Kinkel WR. Magnetic resonance imaging findings in 22 cases of myelitis: comparison between patients with and without multiple sclerosis. Eur J Neurol 1998; 5:35-48. [PMID: 10210810 DOI: 10.1046/j.1468-1331.1998.510035.x] [Citation(s) in RCA: 45] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
We reviewed the magnetic resonance imaging (MRI) database of the Dent Neurologic Institute to study the abnormal findings in myelitis. We identified 22 patients, and compared non-MS-related acute transverse myelitis (ATM, n = 9), to myelitis associated with multiple sclerosis (MS-myelitis, n = 13). The ATM patients were significantly older than MS patients at the time of the myelitis diagnosis (mean age 46 vs 35, p < 0.05). ATM appeared as a "longitudinal myelitis", with fusiform cord expansion on T1-weighted images and intramedullary increased signal on T2-weighted images, each involving multiple spinal levels (mean = 7-8). However, MS-myelitis lesions appeared focal, involving significantly fewer spinal levels (mean = 1-2, p < 0.001), although the lesions were equally likely to expand the cord. Four (42%) of the ATM lesions showed abnormal, variable enhancement, whereas none of the MS myelitis lesions enhanced. Cranial MRI was more likely to be normal in ATM (78%) than in MS-myelitis patients (15%, p < 0.001). Although readily distinguishable from lesions due to MS, the various etiologies for ATM, including post-infectious (n = 2), post-vaccination (n = 3), and idiopathic (n = 4) were indistinguishable on MRI. The MRI findings of an extensively lesioned, swollen cord, suspicious for an intramedullary tumor and providing a temptation for a biopsy, may reflect a non-neoplastic inflammatory disorder.
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Affiliation(s)
- R Bakshi
- Dent Neurologic Institute, University at Buffalo, State University of New York, School of Medicine and Biomedical Sciences, Buffalo, NY, USA
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Bakshi R, Kinkel PR, Mechtler LL, Bates VE. Cerebral ventricular empyema associated with severe adult pyogenic meningitis: computed tomography findings. Clin Neurol Neurosurg 1997; 99:252-5. [PMID: 9491299 DOI: 10.1016/s0303-8467(97)00087-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Cerebral ventricular empyema (CVE), also known as pyocephalus, is a rare form of pyogenic ventriculitis. We present cranial computed tomography (CT) in an adult who developed a bilateral CVE associated with acute pyogenic meningitis. CT showed an obstructive ventriculomegaly and fluid-fluid levels layering in the lateral ventricles and the third ventricle. Frank neutrophilic pus was taken from the subarachnoid space. After antibiotic treatment, the pyocephalus resolved. CVE may be visualized on CT with pus layering in the ventricular CSF, creating a fluid level of intermediate hypodensity.
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Affiliation(s)
- R Bakshi
- Millard Fillmore Health System, Dent Neurologic Institute, Department of Neurology, State University of New York at Buffalo School of Medicine and Biomedical Sciences, USA.
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Bakshi R, Mechtler LL, Patel MJ, Lindsay BD, Messinger S, Gibbons KJ. Spinal leptomeningeal hemangioblastomatosis in von Hippel-Lindau disease: magnetic resonance and pathological findings. J Neuroimaging 1997; 7:242-4. [PMID: 9344008 DOI: 10.1111/jon199774242] [Citation(s) in RCA: 25] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
A 55-year-old man with von Hippel-Lindau disease presented with quadriparesis. Multiple enhancing cervical and thoracic spinal masses were seen on magnetic resonance imaging (MRI). A rim of diffuse, nodular enhancement linking all of the discrete masses was apparent on the surface of the cervical and thoracic regions of the cord. Surgical exploration revealed multiple extramedullary-intradural and intramedullary masses, extending to and infiltrating the cord; the leptomeninges contained numerous small tumor seeds at several levels. The excised spinal masses were diagnosed as capillary hemangioblastomas, which infiltrated the pia mater. Diffuse, intense, spinal leptomeningeal enhancement on MRI associated with multiple hemangioblastomas has not been previously reported and may be referred to as spinal "leptomeningeal hemangioblastomatosis."
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Affiliation(s)
- R Bakshi
- Dent Neurologic Institute, Millard Fillmore Health System, Department of Neurology, University of Buffalo, State University of New York Medicine and Biomedical Sciences, USA
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Capone PM, Mechtler LL, Bates VE, Kanna A, Kinkel PR. Multiple giant intracranial aneurysms associated with lymphomatoid granulomatosis. A magnetic resonance imaging and angiographic study. J Neuroimaging 1994; 4:109-11. [PMID: 8186526 DOI: 10.1111/jon199442109] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Lymphomatoid granulomatosis is an uncommon lymphoproliferative disorder that frequently has central nervous system manifestations. Lymphomatoid granulomatosis has clinical features similar to both vasculitis and lymphoma. The pathological hallmarks of this disease include necrotic angiocentric and angiodestructive infiltrations of premalignant or malignant lymphoid cells. There are, to the authors' knowledge, only a few magnetic resonance imaging reports and no magnetic resonance angiographic reports of this disorder. Presented here is a case of lymphomatoid granulomatosis producing multiple giant fusiform and saccular aneurysms throughout the major intracerebral arteries, along with patterns of vascular beading typically seen with vasculitis demonstrated by magnetic resonance angiography.
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Affiliation(s)
- P M Capone
- Lucy Dent Neuroimaging Center, State University of New York at Buffalo Millard Fillmore Hospital
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Abstract
A mere 5 to 7 years ago, the majority of literature on demyelinating, infectious, metabolic, and congenital diseases of the brain focused on comparison between computed tomography and magnetic resonance imaging (MRI). MRI has become not only the foremost diagnostic tool in imaging of the central nervous system, but also a key research instrument. This is displayed by the recent increase in papers concerning magnetic resonance spectroscopy. It is perhaps no better illustrated than in the study of multiple sclerosis. A review of neuroimaging in infectious diseases places a heavy emphasis on AIDS-related infections. The ongoing development of new scan sequences, contrast agents, and fast scanning techniques are broadening our image of the brain and, indeed, our understanding of pathophysiologic mechanisms of disease states. Excellent examples of this are the metabolic and congenital diseases where, based on the knowledge of metabolic pathways and embryology, MRI has become the modality of choice.
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Affiliation(s)
- L L Mechtler
- Division of Neuroimaging Research, Millard Fillmore Hospitals, Lucy Dent Imaging Center, Buffalo, NY 14209
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