Morphologic Features on MR Imaging Classify Multifocal Glioblastomas in Different Prognostic Groups

BACKGROUND AND PURPOSE

Multifocal glioblastomas (ie, glioblastomas with multiple foci, unconnected in postcontrast pretreatment T1-weighted images) represent a challenge in clinical practice due to their poor prognosis. We wished to obtain imaging biomarkers with prognostic value that have not been found previously.

MATERIALS AND METHODS

A retrospective review of 1155 patients with glioblastomas from 10 local institutions during 2006-2017 provided 97 patients satisfying the inclusion criteria of the study and classified as having multifocal glioblastomas. Tumors were segmented and morphologic features were computed using different methodologies: 1) measured on the largest focus, 2) aggregating the different foci as a whole, and 3) recording the extreme value obtained for each focus. Kaplan-Meier, Cox proportional hazards, correlations, and Harrell concordance indices (c-indices) were used for the statistical analysis.

RESULTS

Age (P < .001, hazard ratio = 2.11, c-index = 0.705), surgery (P < .001, hazard ratio = 2.04, c-index = 0.712), contrast-enhancing rim width (P < .001, hazard ratio = 2.15, c-index = 0.704), and surface regularity (P = .021, hazard ratio = 1.66, c-index = 0.639) measured on the largest focus were significant independent predictors of survival. Maximum contrast-enhancing rim width (P = .002, hazard ratio = 2.05, c-index = 0.668) and minimal surface regularity (P = .036, hazard ratio = 1.64, c-index = 0.600) were also significant. A multivariate model using age, surgery, and contrast-enhancing rim width measured on the largest foci classified multifocal glioblastomas into groups with different outcomes (P < .001, hazard ratio = 3.00, c-index = 0.853, median survival difference = 10.55 months). Moreover, quartiles with the highest and lowest individual prognostic scores based on the focus with the largest volume and surgery were identified as extreme groups in terms of survival (P < .001, hazard ratio = 18.67, c-index = 0.967).

CONCLUSIONS

A prognostic model incorporating imaging findings on pretreatment postcontrast T1-weighted MRI classified patients with glioblastoma into different prognostic groups.

[Lymphomatosis cerebri as the cause of leukoencephalopathy]

INTRODUCTION

Lymphomatosis cerebri (LC) is an infrequent type of primary lymphoma of the central nervous system that is characterised by diffuse, infiltrating involvement of the white matter of the brain without the formation of a mass.

AIM

To report the case of a patient with LC in order to draw attention to this disease, which is rarely diagnosed, and to its initial presentation in magnetic resonance imaging (MRI) as leukoencephalopathy.

CASE REPORT

Our patient was a 56-year-old female who had clinical signs and symptoms of sub-acute dementia. Computerised axial tomography and MRI of the head revealed extensive, diffuse and bilateral involvement of the white matter, basal nuclei, mesencephalon and pons, with no mass effect or contrast enhancement. A stereotactic biopsy of the white matter (which was not conclusive) showed a perivascular mixed mononuclear-cell inflammatory infiltrate of B and T cells. No cytologic atypia was observed. Treatment was established with corticoids, which produced a clinical and radiological improvement in the first two months. During the next month the patient underwent rapid clinical deterioration with sleepiness and a worsening of the ability to walk. In an MRI scan the lesion had a more heterogeneous appearance with mass effect on adjacent structures and patchy contrast enhancement. A wedge biopsy of brain tissue led to a diagnosis of high-grade B-cell lymphoma.

CONCLUSIONS

The imaging and histological appearance of LC may not be the one typically found in primary lymphomas of the central nervous system, and its clinical presentation may be similar to that of other diffuse processes involving compromise of the white matter (cerebral gliomatosis, inflammatory diseases of the white matter, such as Behçet's disease, Sjögren's disease or systemic lupus erythematosus).

[Acalculia. Neurological bases, evaluation and disorders]

OBJECTIVE

To make a review of the literature on alterations in mathematical ability secondary to structural cerebral lesions.

DEVELOPMENT AND CONCLUSIONS

We refer to the initial classification of acalculia of Berger (secondary acalculia when this is due to broader neuropsychological deficits and primary acalculia when it occurs alone) to the classical division of Hecaen (alexia and numerical agraphia with or without alterations in reading and writing of letters and words, visuo-spatial acalculia due to alterations in the spatial organization of multi-digit figures and the partial results of arithmetical operations, anarithmetia or primary failure in mathematical ability) and the most recent classifications based on neurocognitive models, which subdivide the acalculias into those secondary to changes in the system for processing numbers and those due to changes in the cognitive system for mathematics (McCloskey and Caramazza). Similarly, we review the correlations between the clinical changes in mathematics and the cerebral localization of the causative lesions (left parieto-temporal, right and including frontal and subcortical associative areas) together with the association of acalculia and other neuropsychological deficits. Finally we review the neuropsychological instruments available for the evaluation of acalculias, with particular reference to the tools validated and scaled for our language and sociocultural setting.

[Treatment of refractory infantile epilepsy with vigabatrin in a series of 55 patients]

We present the results of treatment with vigabatrin in the polytherapy of resistant infantile epilepsy. A retrospective review of 55 children with resistant epilepsy aged between 2 months and 15 years was carried out between January 1992 and January 1995. Semiologically, the crises treated were simple partial crises (CPS), complex partial crises (CPC), West's syndrome, the Lennox-Gastaut syndrome and polymorphic crises. The efficacy of the drug (defined as a 50% or more reduction in crises), secondary effects and the reduction in the number of drugs necessary were evaluated. 60% of the children studied improved. 20% became completely free of crises. 34% remained unchanged and 3% became worse. In West's syndrome 100% responded satisfactorily, as did 80% of the cases of partial crises, but only 40% of those with Lennox's syndrome responded. Generalized tonic-clonic crises did not respond, and myoclonic crises became worse. Aetiologically, there was greater improvement in the symptomic cases than in the essential cases, the improvement being 70% while 5 patients with tuberose sclerosis responded particularly well. Medication was stopped in one case because of side-effects, due to a psychiatric disturbance, and in another case vigabatrin caused transitory side-effects. In 10% of the subjects the initial efficacy wore off around 6 months later. We have shown the usefulness of vigabatrin in the polytherapy of infantile epilepsy, which is resistant to conventional epileptic drugs, mainly in simple and complex partial crises and in West's syndrome. Its minimal side-effects and the favourable response in over 50% of cases make it an extremely useful drug.

[Atypical internuclear ophthalmoplegia in a patient with subacute lymphocytic meningitis]

The local expression of tuberculous meningitis has an high incidence. They respond to a Koch bacillus direct lesion or vasculitis disease. The clinic implication of ocular movement is frequent and usually answers to a nervous trunk direct injury. Exceptionally the clinic expression of the oculomotor disturbance is due to a conjugate ocular tract or nucleus damage. The posterior internuclear ophthalmoplegia is a well-known manifestation and correspond with a dwindle of the medial longitudinal fasciculus electrical transmission and lies in falling of the medial rectus to move synchronously with the contralateral rectus on attempted lateral gaze to either side. In such a case the medial longitudinal fasciculus is damaged between the sith nerve nucleous below and the opposite third nerve nucleus above. A patient with AIDS B3 category who presents right internuclear ophthalmoplegia and right eye vertical conjugate gaze impairment with left vertical nystagmus due to a paramedial mesencephalic stroke as debut of a linfocitary subacute meningitis is present.