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Simple Summary: Glioblastoma is the most common malignant primary tumor of the central nervous system, with a poor prognosis despite many available treatments, including surgery, radiotherapy, and chemotherapy. The evaluation of treatment response is essential to optimize patient outcomes. While structural MRI remains the cornerstone of imaging evaluation, advanced MRI modalities have increasingly become crucial in characterizing treatment effects more comprehensively. The purpose of this pictorial essay is to provide an overview on the role of advanced MRI modalities at the different clinical-therapeutic timepoints, thus helping radiologists and clinicians to be more confident in their applicability in clinical practice and at the proper timepoint. MRI plays a key role in the evaluation of post-treatment changes, both in the immediate post-operative period and during follow-up. There are many different treatment's lines and many different neuroradiological findings according to the treatment chosen and the clinical timepoint at which MRI is performed. Structural MRI is often insufficient to correctly interpret and define treatment-related changes. For that, advanced MRI modalities, including perfusion and permeability imaging, diffusion tensor imaging, and magnetic resonance spectroscopy, are increasingly utilized in clinical practice to characterize treatment effects more comprehensively. This article aims to provide an overview of the role of advanced MRI modalities in the evaluation of treated glioblastomas. For a didactic purpose, we choose to divide the treatment history in three main timepoints: post-surgery, during Stupp (first-line treatment) and at recurrence (second-line treatment). For each, a brief introduction, a temporal subdivision (when useful) or a specific drug-related paragraph were provided. Finally, the current trends and application of radiomics and artificial intelligence (AI) in the evaluation of treated GB have been outlined. [ABSTRACT FROM AUTHOR]

The oculomotor cistern (OMC) is a cerebrospinal fluid space bound by meningeal layers that surrounds the oculomotor nerve as it crosses the oculomotor triangle to reach the lateral wall of the cavernous sinus at the level of the anterior clinoid process. Although several anatomical and radiological studies are available, its anatomy and relationship with pituitary adenomas (PAs) are still matter of discussion. The aim of the study is to provide an updated and focused overview of the OMC, highlighting the different perspectives and descriptions from anatomical, radiological, and clinical points of view. A scoping review was conducted up to 29th October 2022, according to PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) criteria. PubMed, Web of Science, Scopus databases, and correlated citations were investigated. Of the 562 records identified, 22 were included in the present analysis. There were 13, 5, and 4 anatomo-surgical, radiological, and clinical studies, respectively. Though there is general consensus on its definition, data are variable on different features of OMC. Defects or absence of dural layers adjacent to the oculomotor nerve were described in only 4 papers. The transition from meningeal to neural layers is still unclear. PAs with OMC involvement are poorly studied and have unique clinical characteristics. To date, 21 patients have been described; the reported prevalence of OMC involvement by PAs ranges from 4.1% to 14.6%. Clarifying the OMC features with further systematic studies may not only broaden theoretical knowledge but also have implications on endoscopic transnasal pituitary surgery. [ABSTRACT FROM AUTHOR]

Subcortical brain mapping in awake glioma surgery might optimize the extent of resection while minimizing neurological morbidity, but it requires a correct interpretation of responses evoked during surgery. To define, with a systematic review: 1) a comprehensive 'map' of the principal white matter bundles involved in awake surgery on language-related networks, describing the most employed tests and the expected responses; 2) In linguistics, a false friend is a word in a different language that looks or sounds like a word in given language but differs significantly in meaning. Similarly, our aim is to give the surgeons a comprehensive review of potentially misleading responses, namely "false friends", in subcortical language mapping. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. Standardized data extraction was conducted. Out of a total of 224 initial papers, 67 were included for analysis. Expected responses, common tests, and potential "false friends" were recorded for each of the following white matter bundles: frontal aslant tract, superior and inferior longitudinal fascicles, arcuate fascicle, inferior fronto-occipital fascicle, uncinate fascicle. Practical examples are discussed to underline the risk of intraoperative fallouts ("false friends") that might lead to an early interruption (false positive) or a risky surgical removal (false negative). This paper represents a critical review of the present status of subcortical awake mapping and underlines practical "false-friend" in mapping critical crossroads in language-related networks. [ABSTRACT FROM AUTHOR]

Predictive factors for response to regorafenib in recurrent glioblastoma, IDH-wildtype, are scarcely recognized. The objective of this study was to identify molecular predictive factors for response to regorafenib using a clinically available platform. We analyzed a prospective cohort of 30 patients harboring recurrent glioblastoma, IDH-wildtype, and treated with regorafenib. Next-generation sequencing (NGS) analysis was performed on DNA extracted from paraffin-embedded tissues using a clinically available platform. Moreover, MGMT methylation and EGFRvIII expression analyses were performed. Six-month progression-free survival (PFS) was 30% and median overall survival (OS) was 7.5 months, in line with literature data. NGS analysis revealed a mutation in the EGFR pathway in 18% of cases and a mutation in the mitogen-activated protein-kinase (MAPK) pathway in 18% of cases. In the remaining cases, no mutations were detected. Patients carrying MAPK pathway mutation had a poor response to regorafenib treatment, with a significantly shorter PFS and a nonsignificantly shorter OS compared to EGFR-mutated patients (for PFS, 2.5 vs 4.5 months, p = 0.0061; for OS, 7 vs 9 months, p = 0.1076). Multivariate analysis confirmed that MAPK pathway mutations independently predicted a shorter PFS after regorafenib treatment (p = 0.0188). The negative prognostic role of MAPK pathway alteration was reinforced when we combined EGFR-mutated with EGFRvIII-positive cases. Recurrent glioblastoma tumors with an alteration in MAPK pathway could belong to the mesenchymal subtype and respond poorly to regorafenib treatment, while EGFR-altered cases have a better response to regorafenib. We thus provide a molecular selection criterion easy to implement in the clinical practice. [ABSTRACT FROM AUTHOR]

Brain shift may cause significant error in neuronavigation, leading the surgeon to possible mistakes. Intraoperative magnetic resonance imaging (MRI) is the most reliable technique in brain tumor surgery. Unfortunately, it is highly expensive and time consuming and, at the moment, it is available only in few neurosurgical centers. In this case series the surgical workflow for brain tumor surgery is described where neuronavigation of preoperative MRI, intraoperative computed tomography (CT) scan, and ultrasound (US) as well as rigid and elastic image fusion between preoperative MRI and intraoperative US and CT, respectively, was applied to 4 brain tumor patients in order to compensate for surgically induced brain shift by using a commercially available software (Elements Image Fusion 4.0 with Virtual iMRI Cranial; Brainlab AG, München, Germany). Four illustrative cases demonstrated successful integration of different components of the described intraoperative surgical workflow. The data indicate that intraoperative navigation update is feasible by applying intraoperative 3-dimensional US and CT scanning as well as rigid and elastic image fusion applied depending on the degree of observed brain shift. Integration of multiple intraoperative imaging techniques combined with rigid and elastic image fusion of preoperative MRI may reduce the risk of incorrect neuronavigation during brain tumor resection. Further studies are needed to confirm the present findings in a larger population. [ABSTRACT FROM AUTHOR]

The semantic variant of a primary progressive aphasia (svPPA) is characterized by progressive disruption of semantic knowledge. This study aimed to compare the semantic features of words produced during a narrative speech in svPPA and the logopenic variant of PPA (lvPPA) and to explore their neuroanatomical correlates. Six patients with svPPA and sixteen with lvPPA underwent narrative speech tasks. For all the content words, a semantic depth index (SDI) was determined based on the taxonomic structure of a large lexical database. Study participants underwent an MRI examination. Cortical thickness measures were extracted according to the Desikan atlas. Correlations were computed between SDI and the thickness of cortical regions. Mean SDI was lower for svPPA than for lvPPA. Correlation analyses showed a positive association between the SDI and the cortical thickness of the bilateral temporal pole, parahippocampal and entorhinal cortices, and left middle and superior temporal cortices. Disruption of semantic knowledge observed in svPPA leads to the production of generic terms in narrative speech, and the SDI may be useful for quantifying the level of semantic impairment. The measure was associated with the cortical thickness of brain regions associated with semantic memory. [ABSTRACT FROM AUTHOR]

Background: JAM3 gene, located on human chromosome 11q25, encodes a member of the junctional adhesion molecule (JAM) family. Mutations of this gene are associated with hemorrhagic destruction of the brain, subependymal calcification, and congenital cataracts (HDBSCC). Case report: Herein, we present a newborn male with a prenatal suspicion of bilateral cataracts but without fetal ultrasound findings of cortical malformations. He was postnatally diagnosed with a clinical picture of HDBSCC and Early-onset Developmental and Epileptic Encephalopathy (DEE), associated to a homozygous variant of JAM3 gene. Conclusion: Identification of this variant in affected individuals has implications for perinatal and postnatal management and genetic counseling. To the best of our knowledge, this is the first case reported of a child with a JAM3 variant in Italy, from a different ethnic background than the other reported children until now (Saudi Arabian, Turkish, Afghani, and Moroccan origin). JAM3 screening could be requested in prenatal diagnosis of fetal congenital cataracts and included in Next-Generation DNA Sequencing panels. [ABSTRACT FROM AUTHOR]

Purpose: Psychological distress in primary malignant brain tumour (PMBT) patients is associated with poorer outcomes. Radiotherapy (RT) often induces side effects that significantly influence patients' quality of life (QoL), with potential impact on survival. We evaluated distress, anxiety, depression, and QoL over time to identify patients with difficulties in these areas who required more intense psychological support. Methods: Psychological questionnaires—Distress Thermometer (DT), Hospital Anxiety and Depression Scale (HADS), and Functional Assessment of Cancer Therapy (FACT-G and FACT-Br)—were completed at the beginning (T0), in the middle (T1), directly after RT (T2), and 3 months after RT (T3). We personalised the psychological support provided for each patient with a minimum of three sessions ('typical' schedule) and a maximum of eight sessions ('intensive' schedule), depending on the patients' psychological profiles, clinical evaluations, and requests. Patients' survival was evaluated in the glioblastoma multiforme (GBM) patients, with an explorative intent. Results: Fifty-nine consecutive PMBT patients receiving post-operative RT were included. For patients who were reported as 'not distressed' at T0, no statistically significant changes were noted. In contrast, patients who were 'distressed' at T0 showed statistically significant improvements in DT, HADS, FACT-G, and FACT-Br scores over time. 'Not distressed' patients required less psychological sessions over the study duration than 'distressed' patients. Interestingly, 'not distressed' GBM patients survived longer than 'distressed' GBM patients. Conclusions: Increased psychological support improved distress, mood, and QoL for patients identified as 'distressed', whereas psychological well-being was maintained with typical psychological support in patients who were identified as being 'not distressed'. These results encourage a standardisation of psychological support for all RT patients. [ABSTRACT FROM AUTHOR]

Ability to thrive after invasive and intensive treatment is an important parameter to assess in patients with glioblastoma multiforme (GBM). Karnofsky Performance Status (KPS) is used to identify those patients suitable for postoperative radiochemotherapy. The aim of the present study is to investigate whether machine learning (ML)-based models can reliably predict patients' KPS 6 months after surgery. A cohort of 416 patients undergoing surgery for a histopathologically confirmed GBM were collected from a multicentric database and split into a training and hold-out test set in an 80:20 ratio. Worsening of KPS at 6 months after surgery (compared with preoperative KPS) occurred in 138 patients (33.2%). Relevant preoperative, intraoperative, and immediately postoperative variables were selected by a recursive features selection algorithm (Boruta) and used to build 2 ML-based predictive models. A random forest classifier and a random forest regressor were trained to predict 6 months postoperative KPS as a categorical (worsening vs. stable/improving) and continuous variables; they achieved, respectively, an area under the curve of 0.81 (95% confidence interval, 0.76–0.84) and a mean absolute error of 4.4 (95% confidence interval, 4.0–4.7). Leveraging the predictive value resulting from the combination of independent variables, the random forest classifier outperformed conventional statistics (area under the curve improvement of +21%). Two robust ML-based prediction models were successfully trained and internally validated. Considerable effort remains to improve the interpretation of the results when these predictions are used in a patient-centered care context. [ABSTRACT FROM AUTHOR]

We describe the case of a male newborn presenting with a prenatal diagnosis of persistent hyperextension of the fetal neck and severe hypotonia and respiratory insufficiency at birth. Facial weakness, increased serum creatine kinase levels, and abnormal feeding, together with other signs, such as severe contractures, also classically associated with congenital myopathies prompted to perform a muscle biopsy showing internal rods suggestive of a possible nemaline myopathy. These findings suggest that a careful neurological examination should be performed in infants with persistent hyperextension of the fetal neck to exclude weakness and a possible underlying muscle disorder. [ABSTRACT FROM AUTHOR]

Purpose: Craniosynostostic syndromes are due to multisuture synostoses and affect the entire craniofacial skeleton. This study analyzed the facial complex and airways to quantify the relationship between insufficient facial growth, airways obstruction, and the sutural pattern of the splanchnocranium and cranial fossae.Methods: Preoperative high-resolution CT images in 19 infants with syndromic craniosynostosis were quantitatively analyzed. Because all children showed involvement of minor sutures/synchondroses coursing in the posterior cranial fossa, they were divided into three groups according to the synostotic involvement of “minor” sutures/synchondroses coursing in anterior (ACF) and middle (MCF) cranial fossae: group 1 (ACF), group 2 (MCF), and group 3 (ACF-MCF). Analysis of the facial complex and airway was performed. Each group was compared with age-matched healthy subjects.Results: Premature closure of skull base synchondroses of ACF and MCF was found only in groups MCF and ACF-MCF. Group MCF showed synostosis in the posterior branch of the coronal ring and reduced anterior hemifossae lengths while group ACF-MCF showed synostosis in the anterior branch of the coronal ring and reduced middle hemifossae lengths. No group showed reduced maxillary or mandibular volumes but group MCF showed synostosis of the zygomaticomaxillary sutures and maxillary retrusion. All groups showed reduced airway volume but group 2 had a higher degree of airway hypoplasia.Conclusion: The skull base synostotic process drives the changes in facial complex growth and airway obstruction. Premature closure of synchondroses/sutures in the posterior branch of the coronal ring causes insufficient facial growth, maxillary retrusion, and more severe airway reduction. [ABSTRACT FROM AUTHOR]

Purpose: The study aimed to identify premature synostosis of 'major' and 'minor' sutures of the coronal sutural arch and splanchnocranium sutures to evaluate the relationship between craniofacial dysmorphology and the sutural pattern in children with anterior plagiocephaly. Methods: A quantitative analysis of the skull base and facial changes was performed on preoperative high-resolution CT images in 18 children with anterior synostotic plagiocephaly and compared with imaging findings in 18 age-matched healthy subjects. Results: All patients had patent splanchnocranium sutures. Fifteen out of 18 children showed early and isolated synostosis of the unicoronal suture (the major suture of the coronal ring) and were classified in groups II and III according to the classification scheme of anterior synostotic plagiocephaly based on the severity of craniofacial dysmorphology. Premature fusion of the unilateral coronal suture in groups II and III caused a marked asymmetry and reduced growth of the anterior and middle fossae on the synostotic side and a secondary varying severity in terms of asymmetric growth of the facial complex. Although both groups showed anterior displacement of the mandibular articulation on the synostotic side, group II showed only maxillary asymmetry, while group III showed maxillary and mandibular asymmetry. Conclusions: In anterior synostotic plagiocephaly, the severity of skull base changes and asymmetric growth of the facial complex is not caused by skull base sutural synostotic involvement but is probably related to the different timing of unilateral coronal suture closure. [ABSTRACT FROM AUTHOR]

Objective: The oculomotor cistern (OMC) is a meningeal cuff filled with CSF that contains the oculomotor nerve (cranial nerve [CN] III) at the level of the lateral wall of the cavernous sinus. Only a few studies have investigated the involvement of the OMC by pituitary adenomas (pituitary neuroendocrine tumors [PitNETs]), mainly with relatively small case series. The aim of this study was to perform a histomorphological description of the OMC and systematically analyze its involvement by PitNETs from radiological, clinical, and surgical perspectives., Methods: Ten hemisellae from formalin-fixed specimens were studied with 3-µm sections. Digital image analysis software was used for morphological and quantitative assessments. Clinical, radiological, surgical, and histological data of patients undergoing endoscopic transsphenoidal surgery for PitNETs at the University of Brescia, Italy, between 2014 and 2021 were recorded. OMC involvement was graded as not compressed, compressed, and invaded. The same surgical team operated on all patients., Results: The OMC had an elliptical shape with an average area of 3.1 mm2 and a length of 5.5 mm. No cisternal points of weakness were recognized in the histomorphological study. Of 315 patients, 246 had complete data: apoplexy and CN III palsy were documented in 6.9% and 8.5%, respectively. OMC compression and invasion were recorded in 106 (43.1%) and 23 (9.3%) patients. Significant associations between OMC involvement and PitNET dimensions (p < 0.001), Knosp grade (p < 0.001), preoperative oculomotor palsy (p < 0.001), Ki-67 percentage (p = 0.009), and recurrence/progression of residual tumor (p = 0.008) were found. A new postoperative CN III palsy was evident in 2%: transient in 4 cases, and persistent in 1 patient treated for a recurrent PitNET who experienced a local infection complication. Preoperative CN III palsy improved in 10 cases., Conclusions: Significant OMC involvement by PitNETs might be underrecognized, but it can be treated using the endoscopic transsphenoidal approach, and it affects patient outcomes.

Introduction: Hypophysitis is a rare inflammatory disorder of the pituitary gland. Symptoms and signs of hypophysitis can be various, progressing insidiously, and its recognition may be challenging., Case Presentation: We report the clinical history and therapeutic management of a 59-year-old man diagnosed with arginine vasopressin deficiency (AVP-D) due to an infundibulo-neurohypophysitis (INH) that occurred after the patient had inhaled spray film containing toluene. In consideration of the clinical signs and radiological imaging suggestive of INH, therapy with desmopressin and corticosteroids was instituted, with gradual improvement of polyuria and resolution of the radiological features of INH., Conclusion: To our knowledge, we described the first case of INH, manifested with AVP-D, secondary to toluene exposure. In addition, the endocrine effects of toluene inhalation were discussed. Finally, given the scarcity of data available, an overview of all the known toxic substances inducing AVP-D was also provided., (Copyright© Bentham Science Publishers; For any queries, please email at epub@benthamscience.net.)

Background: The management of recurrent Rathke's cleft cysts (RCCs) remains challenging. The off-label application of steroid-eluting bioabsorbable or nonabsorbable intracystic stents has been recently described. Early outcomes and complications of this treatment have been described as well, but long-term data are lacking., Observations: A 31-year-old woman who had undergone 3 prior transsphenoidal surgeries for recurrent RCC at other institutions was admitted for methicillin-susceptible Staphylococcus aureus meningitis. Five years earlier, a nonabsorbable stent had been placed in the cyst using a microsurgical transsphenoidal approach. RCC recurrence had been radiologically evident after 2 years but was clinically asymptomatic. Acute cerebrospinal fluid leakage and other causes of meningitis were ruled out; the stent was occluded. After antibiotic therapy and resolution of the meningitis, the patient underwent endoscopic removal of the catheter, excision of the cyst, and reconstruction with a nasoseptal flap. At the 18-month follow-up, she remained neurologically intact, under replacement therapy, and with no signs of recurrence., Lessons: The authors report the first case of late meningitis due to a nonabsorbable stent positioned for the treatment of a recurrent RCC. Currently, data on the long-term outcomes, failure rates, and complications of stents for RCC are limited. https://thejns.org/doi/10.3171/CASE2477.

Background: The Multidisciplinary Tumor Board (MTB) is a collaborative platform involving specialists in oncology, surgery, radiology, pathology, and radiotherapy, and aims to optimize diagnostics and treatments. Despite MTB's widespread benefits, limited literature addresses its application in pediatric neuro-oncology. After a literature revision on pediatric neuro-oncology MTB, our study describes our institute's pediatric neuro-oncology MTB, focuses on evaluating its impact and the neuroradiologist's role in patient-centric approaches, considering recent genetic insights into pediatric brain tumors., Materials and Methods: Literature Review concerning pediatric neuro-oncology MTB from January 2002 to June 2024., Clinical Data: retrospective study of all patient files presented in the pediatric neuro-oncology MTB (pnMTB) between 2019 and 2022. Statistical analysis was mainly carried out by directly comparing the absolute or relative values of the respective parameters examined; qualitative variables compared mainly with the chi-square test, quantitative variables mainly with the t-test., Results: Literature Review: 7 papers encompass a multidisciplinary approach for the pediatric CNS tumors., Clinical Data: A total of 236 discussions were analyzed representing 107 patients. Median age was 14,3 years (range: 6 months - 17 years). The requests for case evaluations primarily came from the pediatric oncologists (83%) and neurosurgeons (14.8%), and they were mainly addressed to the neuroradiologists (70.3%). Proposals during pnMTB mainly involved imaging follow-up (47.8%) and management with chemotherapy (34.7%). Changes in patient treatment (CPT) occurred in 115 cases, and pediatric neuroradiologist intervention contributed to 72.4% of these changes., Conclusion: Thanks to their multidisciplinarity, high number of cases discussed, and usual respect for their proposals, the pnMTB has made it possible to improve the coordination among specialties involved in patient management, to apply the recent protocols, and to exchange knowledge among teams managing pediatric CNS tumors., (© 2024. The Author(s).)

The review explores the 2022 update to the World Health Organization (WHO) classification of pituitary adenomas, now referred to as pituitary neuroendocrine tumors (PitNETs), and his possible impact on the clinical management of PitNET patients. The review highlights the differences and the evolution from the 2017 to 2022 version, with the current classification considering the lineage of the tumor cells, cell type, hormones produced, and other auxiliary characteristics for a comprehensive histological classification. The revision in terminology reflects a broader perspective on neuroendocrine neoplasia. The new approach based on transcription factors, hormone expression and other biomarkers has allowed a major revision of the nomenclature and a more accurate classification of pituitary adenomas. Furthermore, in some cases this approach is also assuming a prognostic value, useful in clinical practice. However, despite this elaborate classification and stratification, the review points out the lack of a robust grading or staging system and suggests the need for further research and validation of diagnostic methods. Despite these limitations, the revised classification presents a significant step towards understanding and managing PitNETs patients.

Objective: The potential advantages of exoscopy have been discussed theoretically for a long time. Such a concept holds significance, especially in the specific setting of the posterior cranial fossa (PCF), characterized by complex anatomy and long and narrow surgical corridors with relatively extreme working angles. We aimed to: 1) analyze the institutional preliminary case-based data on the use of the Robotic 3D Exoscope AEOS Aesculap in three different PCF approaches: retrosigmoid (RSA), midline suboccipital (MSA), and supracerebellar infratentorial via feedbacks was collected using a 20-point questionnaire, and 2) perform a comprehensive review of the literature concerning the use of EX in PCF surgery., Results: A total of 38 patients with neurosurgical pathologies underwent a neurosurgical procedure using the EX (Robotic 3D exoscope AEOS Aesculap) at our institution between January and March 2022. 21 surgeons were involved in the abovementioned PCF surgeries and answered the questionnaire. The main perceived advantages were in terms of ergonomics (67%), magnification (52%), and visualization of extreme angles. The main reported disadvantage was color vision (16, 76%), followed by manual mobility (24%). Concerning the review, the search of the literature yielded a total of 177 results. Upon full-text review, 17 articles were included, including 153 patients., Conclusions: In conclusion, our study provides a comprehensive evaluation of the advantages and challenges associated with using the exoscope in posterior fossa surgery, setting a precedent as the first to report on a questionnaire-based analysis of exoscope utilization in this specific domain., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Hypophysitis is a rare inflammatory disorder of the pituitary gland. Symptoms and signs of hypophysitis can be various, and its recognition may be challenging. Arginine vasopressin deficiency (AVP-D) due to exposure to a variety of drugs and toxic substances is rare, but some cases have been reported. Only 2 cases of AVP-D following toxic exposure to toluene, an aromatic hydrocarbon, have been reported in the literature. To our knowledge, our case represents the first description of an infundibulo neurohypophysitis (INH), manifested with AVP-D, secondary to inhalation of toluene., Case Report: A 59-year-old man with an unremarkable medical history was referred to our department for headache, polyuria, and polydipsia after the inhalation of spray film containing toluene. The blood tests revealed a hyperosmolar plasma hypernatremia with normal kidney function. A desmopressin test was performed, with an improvement in water balances, blood electrolytes, and diuresis contraction. A pituitary MRI detected the absence of a normal hyperintense signal of the neuro-pituitary in the T1-weighted images. In consideration of the clinical signs and radiological imaging suggestive of INH, a therapy with desmopressin and corticosteroids was instituted, with gradual improvement of polyuria and resolution of the radiological features of INH., Conclusion: The exceptional finding of INH, manifested with AVP-D, following toluene inhalation could represent a new secondary cause of hypophysitis. The possibility that drugs or toxic substances never reported before could induce INH should not be excluded since the study on hypophysitis is relatively recent but emerging, predictably destined to increase exponentially in the coming years., (Copyright© Bentham Science Publishers; For any queries, please email at epub@benthamscience.net.)

The primary treatment for glioblastoma (GBM) is removing the tumor mass as defined by MRI. However, MRI has limited diagnostic and predictive value. Tumor-associated macrophages (TAM) are abundant in GBM tumor microenvironment (TME) and are found in peripheral blood (PB). FKBP51 expression, with its canonical and spliced isoforms, is constitutive in immune cells and aberrant in GBM. Spliced FKBP51s supports M2 polarization. To find an immunologic signature that combined with MRI could advance in diagnosis, we immunophenotyped the macrophages of TME and PB from 37 patients with GBM using FKBP51s and classical M1-M2 markers. We also determined the tumor levels of FKBP51s, PD-L1, and HLA-DR. Tumors expressing FKBP51s showed an increase in various M2 phenotypes and regulatory T cells in PB, indicating immunosuppression. Tumors expressing FKBP51s also activated STAT3 and were associated with reduced survival. Correlative studies with MRI and tumor/macrophages cocultures allowed to interpret TAMs. Tumor volume correlated with M1 infiltration of TME. Cocultures with spheroids produced M1 polarization, suggesting that M1 macrophages may infiltrate alongside cancer stem cells. Cocultures of adherent cells developed the M2 phenotype CD163/FKBP51s expressing pSTAT6, a transcription factor enabling migration and invasion. In patients with recurrences, increased counts of CD163/FKBP51s monocyte/macrophages in PB correlated with callosal infiltration and were accompanied by a concomitant decrease in TME-infiltrating M1 macrophages. PB PD-L1/FKBP51s connoted necrotic tumors. In conclusion, FKBP51s identifies a GBM subtype that significantly impairs the immune system. Moreover, FKBP51s marks PB macrophages associated with MRI features of glioma malignancy that can aid in patient monitoring., Significance: Our research suggests that by combining imaging with analysis of monocyte/macrophage subsets in patients with GBM, we can enhance our understanding of the disease and assist in its treatment. We discovered a similarity in the macrophage composition between the TME and PB, and through association with imaging, we could interpret macrophages. In addition, we identified a predictive biomarker that drew more attention to immune suppression of patients with GBM., (© 2024 The Authors; Published by the American Association for Cancer Research.)

Context: The prompt control of acromegaly is a primary treatment aim for reducing related disease morbidity and mortality. First-generation somatostatin receptor ligands (fg-SRLs) are the cornerstone of medical therapies. A non-negligible number of patients do not respond to this treatment. Several predictors of fg-SRL response were identified, but a comprehensive prognostic model is lacking., Objective: We aimed to design a prognostic model based on clinical and biochemical parameters, and pathological features, including data on immune tumor microenvironment., Methods: A retrospective, monocenter, cohort study was performed on 67 medically naïve patients with acromegaly. Fifteen clinical, pathological, and radiological features were collected and analyzed as independent risk factors of fg-SRLs response, using univariable and multivariable logistic regression analyses. A stepwise selection method was applied to identify the final regression model. A nomogram was then obtained., Results: Thirty-seven patients were fg-SRLs responders. An increased risk to poor response to fg-SRLs were observed in somatotropinomas with absent/cytoplasmatic SSTR2 expression (OR 5.493 95% CI 1.19-25.16, P = .028), with low CD68+/CD8+ ratio (OR 1.162, 95% CI 1.01-1.33, P = .032). Radical surgical resection was associated with a low risk of poor fg-SRLs response (OR 0.106, 95% CI 0.025-0.447 P = .002). The nomogram obtained from the stepwise regression model was based on the CD68+/CD8+ ratio, SSTR2 score, and the persistence of postsurgery residual tumor and was able to predict the response to fg-SRLs with good accuracy (area under the curve 0.85)., Conclusion: Although our predictive model should be validated in prospective studies, our data suggest that this nomogram may represent an easy to use tool for predicting the fg-SRL outcome early., (© The Author(s) 2023. Published by Oxford University Press on behalf of the Endocrine Society. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objective: Self-assessment scales are broadly used to evaluate empathy in neurological patients, but it is conceivable that some discrepancy with caregiver evaluation may emerge as consequence of reduced self-awareness. The aim of the present study was to verify the presence of discrepancies in the self-assessment of empathy in subjects with mild cognitive impairment (MCI) and to explore their neural correlates., Method: Twenty MCI patients and 38 healthy controls (HCs) underwent the Interpersonal Reactivity Index (IRI), exploring the following four aspects of empathy: perspective taking (PT), fantasy, empathic concern, and personal distress. The questionnaire was administered in two modalities: self-administered, and administered to an informant, and the scores were compared. The correlation between discrepancies and regional cortical thickness was assessed., Results: The self-administered version of IRI showed higher PT scores in MCI as compared to HC ( p = .017), with no differences detected in the other subscales. The difference between the scores obtained in the self-administered and in the informant-administered IRI-PT was significantly higher in MCI than in HCs ( p = .006)., Conclusion: The self-assessment of empathy in subjects with MCI may be misleading because of a tendency toward an overestimation of the PT ability, typically considered as a cognitive component of empathy. Our results may reflect a particular aspect of reduced self-awareness in MCI subjects. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Growth Hormone-secreting adenomas exhibits variable biological behavior and heterogeneous natural history, ranging from small adenomas and mild disease, to invasive and aggressive neoplasms with more severe clinical picture. Patients not cured or controlled after neurosurgical and first-generation somatostatin receptor ligands (SRL) therapy could require multiple surgical, medical and/or radiation treatments to achieve disease control. To date, no clinical, laboratory, histopathological, or neuroradiological markers are able to define the aggressiveness or predict the disease prognosis in patients with acromegaly. Therefore, the management of these patients requires careful evaluation of laboratory assessments, diagnostic criteria, neuroradiology examinations, and neurosurgical approaches to choose an effective and patient-tailored medical therapy. A multidisciplinary approach is particularly useful in difficult/aggressive acromegaly to schedule multimodal treatment, which includes radiation therapy, chemotherapy with temozolomide and other, recent emerging treatments. Herein, we describe the role of the different members of the multidisciplinary team according to our personal experience; a flow-chart for the therapeutic approach of difficult/aggressive acromegaly patients is proposed., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Bianchi, Chiloiro, Giampietro, Gaudino, Calandrelli, Mazzarella, Caldarella, Rigante, Gessi, Lauretti, De Marinis, Olivi, Pontecorvi and Doglietto.)

MRI is undoubtedly the cornerstone of brain tumor imaging, playing a key role in all phases of patient management, starting from diagnosis, through therapy planning, to treatment response and/or recurrence assessment. Currently, neuroimaging can describe morphologic and non-morphologic (functional, hemodynamic, metabolic, cellular, microstructural, and sometimes even genetic) characteristics of brain tumors, greatly contributing to diagnosis and follow-up. Knowing the technical aspects, strength and limits of each MR technique is crucial to correctly interpret MR brain studies and to address clinicians to the best treatment strategy. This article aimed to provide an overview of neuroimaging in the assessment of adult primary brain tumors. We started from the basilar role of conventional/morphological MR sequences, then analyzed, one by one, the non-morphological techniques, and finally highlighted future perspectives, such as radiomics and artificial intelligence.

The management of myelomeningocele study trial showed significant prognostic improvement in fetal repair before 26 weeks of gestation. Hence, surgery in utero represents the best treatment option for open-neural tube defects (NTDs). Fetal surgery of open-NTDs has specific inclusion and exclusion criteria, which can be adequately studied with fetal MRI. The main concern: the spine (spinal defects other than Myelomeningocele and Myeloschisis, the level of the lesion higher than T1 or lower than S1 and the degree of kyphosis ≥ 30°), the skull/brain (no cerebellum herniation and Chiari II malformation and the presence of any intracranial abnormality unrelated to open NTDs), the uterus (cervix length less than 2 cm, multiple gestations and placental and uterine abnormalities) and any other fetal abnormality not attributed to spinal defect. In this review, we describe the fundamental role of fetal MRI in supporting therapeutic decisions in pre-surgery intrauterine planning through the accurate and comprehensive description of findings, providing a proposal of a structured report. In addition, we describe how post-surgical MRI is important in investigating the effectiveness of surgery and detecting repairing complications., (© 2022. Italian Society of Medical Radiology.)

Carotid artery disease is a cause of ischemic stroke and is associated with cognitive decline. Besides the evaluation of the degree of stenosis, it is also crucial to assess the morphology of the atherosclerotic plaque, for a prompt and accurate diagnosis, and to make the best decision for the patient. On top of noninvasive duplex ultrasound (DUS) and invasive digital subtraction angiography (DSA), compute tomography angiography (CTA) and magnetic resonance angiography (MRA) are often used effectively as noninvasive imaging tools to study carotid stenoses. This review describes the fundamental characteristics of carotid artery plaques, and how they can be best evaluated with currently available imaging methods.

Neuroimaging studies often lack reproducibility, one of the cardinal features of the scientific method. Multisite collaboration initiatives increase sample size and limit methodological flexibility, therefore providing the foundation for increased statistical power and generalizable results. However, multisite collaborative initiatives are inherently limited by hardware, software, and pulse and sequence design heterogeneities of both clinical and preclinical MRI scanners and the lack of benchmark for acquisition protocols, data analysis, and data sharing. We present the overarching vision that yielded to the constitution of RIN-Neuroimaging Network , a national consortium dedicated to identifying disease and subject-specific in-vivo neuroimaging biomarkers of diverse neurological and neuropsychiatric conditions. This ambitious goal needs efforts toward increasing the diagnostic and prognostic power of advanced MRI data. To this aim, 23 Italian Scientific Institutes of Hospitalization and Care (IRCCS), with technological and clinical specialization in the neurological and neuroimaging field, have gathered together. Each IRCCS is equipped with high- or ultra-high field MRI scanners (i.e., ≥3T) for clinical or preclinical research or has established expertise in MRI data analysis and infrastructure. The actions of this Network were defined across several work packages (WP). A clinical work package (WP1) defined the guidelines for a minimum standard clinical qualitative MRI assessment for the main neurological diseases. Two neuroimaging technical work packages (WP2 and WP3, for clinical and preclinical scanners) established Standard Operative Procedures for quality controls on phantoms as well as advanced harmonized quantitative MRI protocols for studying the brain of healthy human participants and wild type mice. Under FAIR principles, a web-based e-infrastructure to store and share data across sites was also implemented (WP4). Finally, the RIN translated all these efforts into a large-scale multimodal data collection in patients and animal models with dementia (i.e., case study). The RIN-Neuroimaging Network can maximize the impact of public investments in research and clinical practice acquiring data across institutes and pathologies with high-quality and highly-consistent acquisition protocols, optimizing the analysis pipeline and data sharing procedures., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Nigri, Ferraro, Gandini Wheeler-Kingshott, Tosetti, Redolfi, Forloni, D'Angelo, Aquino, Biagi, Bosco, Carne, De Francesco, Demichelis, Gianeri, Lagana, Micotti, Napolitano, Palesi, Pirastru, Savini, Alberici, Amato, Arrigoni, Baglio, Bozzali, Castellano, Cavaliere, Contarino, Ferrazzi, Gaudino, Marino, Manzo, Pavone, Politi, Roccatagliata, Rognone, Rossi, Tonon, Lodi, Tagliavini, Bruzzone and The RIN–Neuroimaging.)

Purpose: To assess the accuracy of dynamic susceptibility contrast-enhanced perfusion-weighted magnetic resonance imaging in glioma grading and brain tumor characterization of infratentorial tumors, and to investigate differences from supratentorial tumors., Methods: This retrospective study, approved by the institutional review board, included 246 patients with brain tumors (184 supratentorial, 62 infratentorial), grouped by tumor type: high-grade gliomas (HGG), low-grade gliomas (LGG), metastases (Met), and primary central nervous system lymphoma (PCNSL). Relative cerebral blood volume (rCBV) and mean percentage of signal recovery (PSR) were calculated. For statistical analyses, lesions were grouped by location and histology. Differences were tested with Mann-Whitney U tests. From ROC curves, we calculated accuracy, sensitivity, specificity, PPV, and NPV, for rCBV and PSR., Results: For infratentorial tumors, rCBV was highly accurate in differentiating HGG from LGG (AUC = 0.938). Mean PSR showed high accuracy in differentiating PCNSL and HGG from Met (AUC = 0.978 and AUC = 0.881, respectively). Infratentorial and supratentorial tumors had similarly high rCBV in HGG, high mean PSR in PCNSL, and low mean PSR in Met. The main differences were the optimum threshold rCBV values (3.04 for supratentorial, 1.77 for infratentorial tumors) and the mean PSR, which was significantly higher in LGG than in HGG in supratentorial (p = 0.035), but not infratentorial gliomas. Using infratentorial rCBV threshold values for supratentorial tumors decreased the sensitivity and specificity., Conclusion: rCBV and mean PSR were useful in grading and differentiating infratentorial tumors. Proper cutoff values were important in the accuracy of perfusion-weighted imaging in posterior fossa tumors.

Primary autoimmune hypophysitis (PAH) is considered an underdiagnosed disease, due to the difficulty in reaching a definitive diagnosis. PAH clinical diagnosis remains an exclusion diagnosis. We aimed to correlate PAH neuro-radiological signs to endocrine features and evaluate their prognostic role. 24 PAH cases were enrolled and classified according to neuro-radiological signs: in 12 adeno-hypophysitis (AHs), 8 infundibulo-neuro-hypophysitis (INHs) and 4 pan-hypophysitis (PHs). Secondary hypogonadism developed more frequently in INHs as compared to AHs (54.5% vs. 27.3%, p = 0.05), without no difference with PHs (p = 0.6). Diabetes insipidus occurred more frequently in INHs cases (72.7%, p < 0.001) and in PHs cases (27.3%, p = 0.007), as compared to AHs cases (0%). Similarly, all cases of GHD occurred in INHs (100%) as compared to AHs (0%, p < 0.001) and PHs (0%, p < 0.001). The pituitary stalk (PS) showed a pseudo-triangular shape (larger at the optical chiasma) in INHs and a pseudo-cylindrical shape (larger both at the optical chiasma and at the pituitary insertion) in PHs. The PS pseudo-triangular shape correlated to the occurrence of GHD and diabetes insipidus (p < 0.001/p = 0.03). At the 1-year follow-up, improvement of baseline radiological features positively correlated with the loss of the neuro-pituitary "bright spot" on T1-weighted images (OR 0.16; 95% CI 0.03-0.9 p = 0.02) and with a PS diameter at the optical chiasma level larger than 4.1 mm (AUC 0.97, sensibility 80%, specificity 100%, OR 6; 95% CI1.1-28.8, p = 0.01) Our data suggest that neuro-radiological PAH classification in PH, AH and INH can predict pituitary dysfunction and that some neuro-radiological features, such as the pituitary stalk diameter and the loss of the neuro-pituitary bright spot on T1w images can play a role as a positive prognostic marker of the radiological hypophysitis outcome.

Objective: To report the clinical and immunological characteristics of 22 new patients with glial fibrillar acidic protein (GFAP) autoantibodies., Methods: From January 2012 to March 2017, we recruited 451 patients with suspected neurological autoimmune disease at the Catholic University of Rome. Patients' serum and cerebrospinal fluid (CSF) samples were tested for neural autoantibodies by immunohistochemistry on mouse and rat brain sections, by cell-based assays (CBA) and immunoblot. GFAP autoantibodies were detected by immunohistochemistry and their specificity confirmed by CBA using cells expressing human GFAPα and GFAPδ proteins, by immunoblot and immunohistochemistry on GFAP-/- mouse brain sections., Results: Serum and/or CSF IgG of 22/451 (5%) patients bound to human GFAP, of which 22/22 bound to GFAPα, 14/22 to both GFAPα and GFAPδ and none to the GFAPδ isoform only. The neurological presentation was: meningoencephalomyelitis or encephalitis in 10, movement disorder (choreoathetosis or myoclonus) in 3, anti-epileptic drugs (AED)-resistant epilepsy in 3, cerebellar ataxia in 3, myelitis in 2, optic neuritis in 1 patient. Coexisting neural autoantibodies were detected in five patients. Six patients had other autoimmune diseases. Tumours were found in 3/22 patients (breast carcinoma, 1; ovarian carcinoma, 1; thymoma, 1). Nineteen patients were treated with immunotherapy and 16 patients (84%) improved. Histopathology analysis of the leptomeningeal biopsy specimen from one patient revealed a mononuclear infiltrate with macrophages and CD8+ T cells., Conclusions: GFAP autoimmunity is not rare. The clinical spectrum encompasses meningoencephalitis, myelitis, movement disorders, epilepsy and cerebellar ataxia. Coexisting neurological and systemic autoimmunity are relatively common. Immunotherapy is beneficial in most cases., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Human transmissible spongiform encephalopathies (TSEs), or prion diseases, are invariably fatal conditions associated with a range of clinical presentations. TSEs are classified as sporadic [e.g. sporadic Creutzfeldt-Jakob disease (sCJD), which is the most frequent form], genetic (e.g. Gerstmann-Straussler-Scheinker disease, fatal familial insomnia, and inherited CJD), and acquired or infectious (e.g. Kuru, iatrogenic CJD, and variant CJD). In the past, brain imaging played a supporting role in the diagnosis of TSEs, whereas nowadays magnetic resonance imaging (MRI) plays such a prominent role that MRI findings have been included in the diagnostic criteria for sCJD. Currently, MRI is required for all patients with a clinical suspicion of TSEs. Thus, MRI semeiotics of TSEs should become part of the cultural baggage of any radiologist. The purposes of this update on the neuroradiology of CJD are to (i) review the pathophysiology and clinical presentation of TSEs, (ii) describe both typical and atypical MRI findings of CJD, and (iii) illustrate diseases mimicking CJD, underlining the MRI key findings useful in the differential diagnosis.

Background: Pilocytic astrocytoma (PA) is the most common pediatric brain glioma and is considered the prototype of benign circumscribed astrocytoma. Despite its low malignancy, the CT and MRI features of brain PA may resemble those of much more aggressive brain tumors. Misdiagnosis of PA is particularly easy when it demonstrates MR morphological and non-morphological findings that are inconsistent with its non-aggressive nature and that overlap with the features of more aggressive brain tumors., Method: Basing on the evidence that the variation in the histological, genetic, and metabolic "fingerprint" for brain PA is dependent on tumor location, and the hypothesis that tumor location is related to the broad spectrum of morphological and non-morphological MR imaging findings, the authors discuss the MR imaging appearance of brain PA using a location-based approach to underline the typical and less typical imaging features and the main differential diagnosis of brain PA. A brief summary of the main pathological and clinical features, the natural history, and the treatment of brain PA is also provided., Result: A combination of morphological and non-morphological MR imaging features and a site-based approach to differential diagnosis are required for a pre-operative diagnosis. The new "cutting-edge" MR imaging sequences have the potential to impact the ease and confidence of pediatric brain tumor interpretation and offer a more efficient diagnostic work-up., Conclusions: Although the typical imaging features of brain pilocytic astrocytoma make radiological diagnosis relatively easy, an atypical and more aggressive appearance can lead to misdiagnosis. Knowing the broad spectrum of imaging characteristics on conventional and advanced MR imaging is important for accurate pre-operative radiological diagnosis and correctly interpreting changes during follow-up.

Introduction: Advanced magnetic resonance imaging (MRI) techniques is an umbrella term that includes diffusion (DWI) and diffusion tensor (DTI), perfusion (PWI), spectroscopy (MRS), and functional (fMRI) imaging. These advanced modalities have improved the imaging of brain tumors and provided valuable additional information for treatment planning. Despite abundant literature on advanced MRI techniques in adult brain tumors, few reports exist for pediatric brain ones, potentially because of technical challenges., Review of the Literature: The authors review techniques and clinical applications of DWI, PWI, MRS, and fMRI, in the setting of pediatric hemispheric low-grade gliomas., Personal Experience: The authors propose their personal experience to highlight benefits and limits of advanced MR imaging in diagnosis, grading, and presurgical planning of pediatric hemispheric low-grade gliomas., Discussion: Advanced techniques should be used as complementary tools to conventional MRI, and in theory, the combined use of the three techniques should ensure achieving the best results in the diagnosis of hemispheric low-grade glioma and in presurgical planning to maximize tumor resection and preserve brain function., Future Perspectives: In the setting of pediatric neurooncology, these techniques can be used to distinguish low-grade from high-grade tumor. However, these methods have to be applied on a large scale to understand their real potential and clinical relapse, and further technical development is required to reduce the excessive scan times and other technical limitations.

Background Context: Involvement of the cauda equina in Ewing sarcoma (ES) is extremely rare, and only few cases are reported in literature. However, ES of cauda equina shares some neuroradiological features with other neoplasms that can involve the intradural space. Therefore, differential diagnosis with other tumors of cauda equina should be considered by neuroradiologists and neurosurgeons to provide appropriate treatment., Purpose: To present a rare case of intradural extramedullary primary ES., Study Design: Case report., Methods: We report a case of a 44-year-old woman presenting with the rapid onset of cauda equina syndrome. Radiological analysis showed multiple intradural masses, extending from L1 to S3 level. After radical surgery, lesions were histologically defined as ES. We present a literature review, analyzing magnetic resonance image (MRI) features of primary intradural ES of the cauda equina., Results: Four cases of primitive ES arising from the cauda equina have been reported in the literature., Conclusions: Because of the low number of reported cases, it is not possible to describe pathognomonic MRI findings for intradural ES of the cauda equina. However, few tumors show similar MRI features. Therefore, despite its rarity, intradural ES should be taken into account in the differential diagnosis of spinal tumors involving cauda equina., (Copyright © 2014 Elsevier Inc. All rights reserved.)

The lack of radiation, high soft tissue contrast and capacity for multiplanar and three-dimensional imaging have made magnetic resonance imaging (MRI) the imaging modality of choice for evaluating spinal cord diseases. In diagnostic imaging of the spine, MRI is clearly superior to both conventional radiography (CR) and computed tomography (CT) and it should be preferred as first diagnostic examination when degenerative spine pathologies are suspected.The other technological equipments (CT, CR, dynamic orthostatic X-ray, myelography, discography and skeletal scintigraphy) have to be selectively chosen and adapted to the individual patient.Both "container" and "contents" of the spine should be primly evaluated. Finally, a correlation between clinical and radiological features seems to be mandatory for selecting the correct therapeutic choice, since the reliability of the MRI as potential prognostic indicator has been demonstrated.

The case of a 70-year-old female patient with family history of breast cancer come to the breast Unit for the presence of a nodular swelling in the right breast is discussed. On mammography and US a gross cystic neoformation with vascularized mural nodes was identified. Another contralateral solid nodular neoformation suggestive of malignancy was also present. Diagnostic completion with MRI confirmed the mixed solid, partly cystic nature of the right lesion, leading to the differential diagnosis with cystosarcoma phylloides and intracystic tumor. On the left side, MRI confirmed the presence of the second lesion whose morphologic and dynamic characteristics suggested a neoplastic lesion. At the anatomopathological examination the left lesion was shown to be an infiltrating ductal carcinoma; the right lesion was shown to be an intracystic tumor.

The typical presentation of breast cancer in a young woman is discussed. Diagnostic imaging of the breast showed the presence of an extensive pathological area, approximately 5 cm in size, at the level of the upper quadrants of left breast. On mammography the pathological sign was represented by numerous regional granular microcalcifications. On sonography an inhomogeneously hypoechoic area with intralesional hyperechoic spots was identified. On MRI a large area of pathological enhancement was visualized. For the tumor extent and the patient's young age neoadjuvant chemotherapy was performed. Post-treatment assessment showed good response to therapy, suggestive of possible better prognosis.

The case of a male patient with gynecomastia of the left mammary gland is discussed. The differential diagnosis was considered in relation to other possible benign and malignant lesions where there is swelling of the mammary gland in men. US was the examination of first choice. To complete the study of the diagnostic pattern, mammography was also performed. The definitive diagnosis was true nodular gynecomastia caused by chronic liver disease.

The case of a female patient with a normal mammography of first level screening and a control mammography showing the presence of a cluster of microcalcifications, is discussed. The case history is carefully examined also based on previous investigations. The patient decided to undergo stereotactic vacuum-assisted biopsy (mammotome biopsy) that was performed elsewhere. Indications, advantages and possible complications of the procedure are analyzed.

A case of a patient with neurologic symptoms is reported. Baseline MRI findings were inconclusive to establish a definitive diagnosis. The worsened neurologic and neuroradiologic pattern directed towards a diagnosis of tumor. A second MRI examination and MR-spectroscopy confirmed the hypothesis based on both the diagnosis of nature of the lesion and the histological characterization of the surgical specimen. The technique of MR-spectroscopy is briefly described.

The case of a woman on day four post partum with sensorimotor deficit of the right side and CT evidence of a left temporofrontal hemorrhagic lesion, is presented. Attending physicians requested cerebral angiography. To better evaluate the clinical justification of requested imaging procedure the patient medical history and performed CT examination were carefully revised. According to this analysis and based on a clinicoradiological methodology, the request of a cerebral angiography was considered appropriate. The examination showed several radiological signs but a definitive diagnosis could not be established. Second choice imaging procedures were analyzed and MRI completed with MR-angiography was performed. It allowed to document transverse and sigmoid sinus thrombosis. Therefore, in the diagnosis of venous sinus thrombosis, MRI combined with MR-angiography was shown to be a method of first choice while angiography plays a major role in therapy for intravascular thrombolysis.

Diffusion (DWI) and perfusion weighted (PWI) MR imaging, have come to have an increasingly important clinical role, especially in neurovascular imaging. Diffusion MR imaging does not evaluate hemodynamic parameters, but can be considered a functional technique because it provides information about the tissue functional structure at a microscopic level. In this technique, image contrast to a large extent depends on the diffusion coefficient, a parameter indicative of the characteristics of the stochastic thermic translational motion of water molecules (Brownian motion). Clinical perfusion measurement has been performed in almost all organs with different techniques. Over the last ten years, with the use of contrast media, considerable experience has been gained in the measurement of hemodynamics with MRI. At present, perfusion-MR imaging is one of the clinically most relevant procedures of functional MRI, whose application is gaining ground, owing to the increasing availability of necessary hardware and software. Physical and hemodynamic principles of the two techniques, pulse sequences necessary for their implementation and main applications in the imaging of CNS disorders are illustrated. While DWI and PWI alone can address numerous questions, their information is for the most part complementary to that provided by conventional MRI and their combination seems extremely promising.