Diffuse Large B-Cell Epstein-Barr Virus-Positive Primary CNS Lymphoma in Non-AIDS Patients: High Diagnostic Accuracy of DSC Perfusion Metrics

BACKGROUND AND PURPOSE

Immunodeficiency-associated CNS lymphoma may occur in different clinical scenarios beyond AIDS. This subtype of CNS lymphoma is diffuse large B-cell and Epstein-Barr virus-positive. Its accurate presurgical diagnosis is often unfeasible because it appears as ring-enhancing lesions mimicking glioblastoma or metastasis. In this article, we describe clinicoradiologic features and test the performance of DSC-PWI metrics for presurgical identification.

MATERIALS AND METHODS

Patients without AIDS with histologically confirmed diffuse large B-cell Epstein-Barr virus-positive primary CNS lymphoma (December 2010 to January 2022) and diagnostic MR imaging without onco-specific treatment were retrospectively studied. Clinical, demographic, and conventional imaging data were reviewed. Previously published DSC-PWI time-intensity curve analysis methodology, to presurgically identify primary CNS lymphoma, was used in this particular lymphoma subtype and compared with a prior cohort of 33 patients with Epstein-Barr virus-negative CNS lymphoma, 35 with glioblastoma, and 36 with metastasis data. Normalized curves were analyzed and compared on a point-by-point basis, and previously published classifiers were tested. The standard percentage of signal recovery and CBV values were also evaluated.

RESULTS

Seven patients with Epstein-Barr virus-positive primary CNS lymphoma were included in the study. DSC-PWI normalized time-intensity curve analysis performed the best for presurgical identification of Epstein-Barr virus-positive CNS lymphoma (area under the receiver operating characteristic curve of 0.984 for glioblastoma and 0.898 for metastasis), followed by the percentage of signal recovery (0.833 and 0.873) and CBV (0.855 and 0.687).

CONCLUSIONS

When a necrotic tumor is found in a potentially immunocompromised host, neuroradiologists should consider Epstein-Barr virus-positive CNS lymphoma. DSC-PWI could be very useful for presurgical characterization, with especially strong performance of normalized time-intensity curves.

Hemodynamic profiling: cardiac phenotypes and multiorgan organ failure in acute myocardial infarction with cardiogenic shock

Introduction

Cardiogenic shock (CS) is a spectrum of phenotypes and multiorgan failure (MOF). Recent works [1] approach the typification, but no continuous hemodynamic patterns has been associated with these phenotypes nor MOF.

Methods

295 AMI-CS patients (SBP ≤90 mmHg, vasopressor use, cardiac index ≤2.2 L/min/m2, or lactate ≥2 mmol/L) and pulmonary artery (PA) catheter. Cut-off values were used to divide in 3 phenotypes cardiac [C0] (no organ involvement), cardiorenal [CR] (eGFR <45 ml/min/1.73 m2), and cardiometabolic [CM] (renal+hepatic [AST or ALT >3 ULN]) [2] SCAI definitions were used [3]. MODS score defines MOF as ≥2 organs [4]; AKI (rise Cr >0.3 mg/dL) and electric instability (VT/VF). Repeated measures ANOVA was used to compare 24 h hemodynamic data. 30-day mortality hazard ratios were obtained (Fig. 1E).

Results

C0 represent 64.41% (190), CR 14.91% (44) and CM 20.68% (61). SCAI C was more in C0 (24.74 vs 0, 0%), E in the CM (23.16, 38.64 vs 63.93%); SCAI D had differences in CR and CM (61.36 vs 36.07%). C0 were younger (59, vs CR 66, CM 62; p<0.001); diabetes was more common in CM (60.66) vs CR (56.82) or C0 (42.63%) (p=0.024). Hypertension predominates in CR (72.73 vs CM 57.38, C0 44.21%). GRACE score was lower in C0 (180.64, 157–206) against CR (211.07, 186.5–237), CM (218, 195–247) (p<0.001). AKI was higher in CR, CM (79.55, 86.89 vs 65.79%, p<0.001), as hemodialysis (18.18 and 34.43 vs 6.32, p<0.001) compared to C0. In CM: leukocytes, BUN, Cr, AST, ALT, and CRP were higher with lower levels of eGFR and platelets. C0 had fewer vasoactive requirements (p<0.001). IABP (p=0.741) and VT/FV (p=0.687) had no differences. MOF prevalence was C0 62.6% vs CR 86.4% and CM 96.7% (p<0.001). MODS ≥4 was C0 39.5, CR 65.9, CM 85.2% and SOFA ≥7 was C0 32.6, CR 63.6, CM 83.6%. Mortality was higher in CR (56.82%) and CM (54.1%) compared to C0 (39.47%, p=0.032) (p=0.001, Fig. 1A). RAP (p<0.001, Fig. 2A), PCWP (0.007, Fig. 2C), cardiac output (<0.001, Fig. 2B), index (0.001), power (0.001), perfusion pressure (PP = MAP-RAP, 0.028) and PAPi (0.043) discriminate the C0 phenotype.

AKI had lower survival (p<0.001, Fig. 1B) related to lower SBP (<0.001), DBP (0.003), MAP (<0.001, Fig. 2F) cardiac output (0.002), index (<0.001), power (<0.001, Fig. 2E), and PP (<0.001, Fig. 2D) and higher RAP (0.003), PADP (0.024), PAMP (0.011), PCWP (0.001). Electrical instability had lower survival (p<0.001, Fig. 1C), lower SBP (0.004), DBP (0.011), MAP (0.001, Fig. 2G), cardiac outpu t(0.036), index (0.019), power (0.003, Fig. 2I), PP (0.002, Fig. 2H) and higher PAMP (0.04). Finally, multiorgan failure had a decreased survival (p=0.016, Fig. 1D), higher heart rates (p=0.018), RAP (0.001, Fig. 2K), PCWP (<0.001), PADP (0.02) and lower SBP (0.017), DBP (0.002), MAP (<0.001) cardiac output (<0.001), index (0.004), power (<0.001), PP (<0.001, Fig. 2J), PAPi (<0.001, Fig. 2L).

Conclusions

We demonstrated associations with hemodynamic trajectories across time, which has not been reported before, could reveal AMI-CS phenotypes and related organ dysfunction patterns.

Funding Acknowledgement

Type of funding sources: None.

Effect of selective dopamine D3 and D4 receptor agonists on trunk pulmonary artery vascular reactivity from control and monocrotaline-treated rats

Dopamine D1-like and D2-like receptors are expressed in the pulmonary arteries, however there is a little information about their effect on vascular tone in pulmonary circulation, even the vascular effect of activation of the dopamine D₃ and D₄ subtypes in physiological and pathological conditions such as pulmonary hypertension is unknown. The objective of this study was to evaluate the vascular response of trunk pulmonary artery rings from saline and monocrotaline-treated rats in the presence of selective dopamine receptor agonists. In trunk pulmonary artery rings with intact and denuded endothelium, cumulative concentration-response curves were performed for phenylephrine, acetylcholine, and dopamine receptor agonists (apomorphine-D2-like, SKF38393-D₁, quinpirole-D₂/D₃, 7-OH-DPATD₃, and PD168077-D₄) alone and in the presence of corresponding selective dopamine receptor antagonists (SCH23390-D₁, raclopride-D₂/D₃, U99194 maleate-D₃, and L-745,870-D₄). Contractile and relaxant effects generated during the activation with phenylephrine and acetylcholine, respectively, were significantly reduced in intact and denuded endothelium trunk pulmonary artery rings from monocrotaline rats in comparison with control rats. All dopamine receptor agonists, except the 7-OH-DPAT, produced significant vascular relaxation in intact trunk pulmonary artery rings precontracted with phenylephrine in both experimental groups. Also, the vascular relaxation of SKF38393, and particularly apomorphine and PD168077 was significant in denuded endothelium trunk pulmonary artery rings from control and monocrotaline groups. Furthermore, the vasorelaxation induced by these dopamine agonists was significantly reduced in pulmonary preparations from monocrotaline-treated rats in comparison to that recorded in preparations from control rats. The effect of dopamine receptor agonists decreased significantly in the presence of the corresponding antagonist in both experimental groups. The results support that dopamine D₄ receptor agonist induces significant vascular relaxation, whereas dopamine D₃ receptor agonist induces vasoconstriction in intact and denuded endothelium trunk pulmonary artery rings in control and monocrotaline-induced pulmonary arterial hypertension rats.

Presurgical Identification of Primary Central Nervous System Lymphoma with Normalized Time-Intensity Curve: A Pilot Study of a New Method to Analyze DSC-PWI

BACKGROUND AND PURPOSE

DSC-PWI has demonstrated promising results in the presurgical diagnosis of brain tumors. While most studies analyze specific parameters derived from time-intensity curves, very few have directly analyzed the whole curves. The aims of this study were the following: 1) to design a new method of postprocessing time-intensity curves, which renders normalized curves, and 2) to test its feasibility and performance on the diagnosis of primary central nervous system lymphoma.

MATERIALS AND METHODS

Diagnostic MR imaging of patients with histologically confirmed primary central nervous system lymphoma were retrospectively reviewed. Correlative cases of glioblastoma, anaplastic astrocytoma, metastasis, and meningioma, matched by date and number, were retrieved for comparison. Time-intensity curves of enhancing tumor and normal-appearing white matter were obtained for each case. Enhancing tumor curves were normalized relative to normal-appearing white matter. We performed pair-wise comparisons for primary central nervous system lymphoma against the other tumor type. The best discriminatory time points of the curves were obtained through a stepwise selection. Logistic binary regression was applied to obtain prediction models. The generated algorithms were applied in a test subset.

RESULTS

A total of 233 patients were included in the study: 47 primary central nervous system lymphomas, 48 glioblastomas, 39 anaplastic astrocytomas, 49 metastases, and 50 meningiomas. The classifiers satisfactorily performed all bilateral comparisons in the test subset (primary central nervous system lymphoma versus glioblastoma, area under the curve = 0.96 and accuracy = 93%; versus anaplastic astrocytoma, 0.83 and 71%; versus metastases, 0.95 and 93%; versus meningioma, 0.93 and 96%).

CONCLUSIONS

The proposed method for DSC-PWI time-intensity curve normalization renders comparable curves beyond technical and patient variability. Normalized time-intensity curves performed satisfactorily for the presurgical identification of primary central nervous system lymphoma.

Lorazepam and diazepam in the treatment of neurotic anxiety: a double-blind trial

Fifty-eight neurotic patients with intense anxiety were treated with either lorazepam or diazepam in a double blind between-patients trial. Statistical analysis indicated that the two groups were homogeneous before treatment and that the results of treatment were similar for both drugs. According to the global rating of illness week after week, after four weeks of treatment more patients on lorazepam than on diazepam were normal or had mild illness (82.1% vs. 70.8%). In the investigators' judgment, 71.9% of the patients treated with lorazepam had an excellent or good response compared with 56.7+ of those treated with diazepam. The mean reduction in score on the Hamilton Anxiety Scale was 17.7 for lorazepam and 16.5 for diazepam. However, none of the above differences in results were statistically significant. The largest dose of lorazepam required in treatment was 6 mg, compared with 30 mg of diazepam. Two patients treated with lorazepam had side effects, against six with diazepam. Six patients in the diazepam group did not complete the trial, including three who discontinued because of side effects (rash, tremors, agitation); no patients in the lorazepam group dropped out.