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Background: Migrainous aura (MA) represents the third most common stroke mimic (SM). Advanced neuroimaging is pivotal in the assessment of patients with focal neurological acute symptoms. We investigated brain perfusion alterations in MA-SM patients using a novel CT perfusion (CTP)-based quantitative approach in order to improve differential diagnosis between MA and acute stroke. Methods: We processed and analysed the clinical and neuroimaging CTP data, acquired within 4.5 h from symptom onset, of patients with acute focal neurological symptoms receiving a final diagnosis of MA. The differences between ROI, compatible with MA symptoms, and contralateral side were automatically estimated in terms of asymmetry index (AI%) by the newly developed tool for mean transit time (MTT), CBF, and cerebral blood volume (CBV) CTP parameters. The AI% ≥ 10% was considered significant. Results: Out of 923 admitted patients, 14 patients with MA were included. In 13 out of 14 cases, a significant pattern of hypoperfusion was observed by quantitative analysis in at least one of the CTP maps. In 7 patients, all three CTP maps were significantly altered. In particular, MTT-AI% increased in 11 (79%) cases, while CBF-AI% and CBV-AI% decreased in 12 (86%) and in 9 (64%) patients, respectively. All CBV values were above ischemic stroke core threshold and all MTT-AI were below ischemic penumbra threshold. Conclusions: Our data suggest that a novel CTP-quantitative approach may detect during MA a moderate hypoperfusion pattern in the cerebral regions compatible with aura symptoms. The use of this novel tool could support differential diagnosis between MA and acute stroke.

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Autoimmune limbic encephalitis (LE) is a neurological condition characterized by seizures and cognitive dysfunction. Fluorine-18 fluorodeoxyglucose (18F-FDG-PET) has recently proved to be an important diagnostic tool in this condition since it may highlight brain metabolism abnormalities in a very early stage of the disease. Two main 18F-FDG-PET patterns have been described: the mixed hypermetabolic/hypometabolic and the neurodegenerative one. Arterial spin labeling (ASL) is an MRI technique showing brain perfusion, rarely used in autoimmune neurological conditions. The aim of the present study was to study patients with LE with both techniques, in order to compare their results. Two patients with LE underwent to 18F-FDG-PET and ASL MRI scans using the pseudo-continuous arterial spin labeling (PCASL) technique. Areas of altered perfusion and metabolism were analyzed by visual inspection, and findings were compared between the two techniques. In the first patient, a relapsing LGI-1 LE, right hippocampal hypermetabolism was detected by 18F-FDG-PET (mixed hypermetabolic/hypometabolic pattern), while ASL MRI showed right hippocampal increased perfusion. In the second patient, a seronegative LE, 18F-FDG-PET scan detected a left hemispheric hypoperfusion (neurodegenerative pattern) and ASL MRI yielded similar results. The two 18F-FDG-PET patterns of altered metabolism were similarly detected by ASL imaging. ASL and 18F-FDG-PET findings are strongly concordant in LE. ASL imaging was able to detect the two main 18F-FDG-PET patterns previously described in patients with LE.

Background:Advanced neuroimaging can identify patients who can most benefit from reperfusion treatment, discriminating between ischemic core and penumbra area in a quick and accurate manner. Despite core-penumbra mismatch being an independent prognostic factor, computed tomography perfusion (CTP) assessment is still debated in hyperacute decision-making. The authors aimed to study a novel CTP mismatch score in emergency settings and to investigate its relation with clinical outcome in acute ischemic stroke patients treated with intravenous thrombolysis (IVT).Methods:Neuroimaging and clinical data of 226 consecutive acute ischemic stroke patients were analyzed. The study population was divided into 5 different CTP scores: (0) without perfusion deficit, (1) only penumbra, (2) penumbra > core, (3) core >= penumbra, (4) only core. For differences in outcome between treated and nontreated patients, and among CTP core-penumbra groups to be assessed, the authors have evaluated the outcome in terms of National Institutes of Health Stroke Scale (NIHSS) and modified Rankin scale (mRS) at discharge and symptomatic intracerebral hemorrhage.Results:A decrease in NIHSS was statistically greater in IVT-treated patients compared to nontreated patients showing only penumbra (Delta NIHSS%: 80.0% vs. 50.0%; P=0.0023) or no perfusion deficit (Delta NIHSS%: 89.4% vs. 61.5%; P=0.027) on CTP maps. The same trend was found in other groups without significant difference. A significant correlation was found in IVT patients between core/penumbra score and outcome in terms of Delta NIHSS (Kendall tau=-0.19; P=0.004).Conclusions:The authors proposed a novel immediate CTP assessment to score perfusion mismatch in emergency settings to guide clinicians' decision-making for aggressive treatment and to prevent stroke-related disability.

Brain electrical activity in acute ischemic stroke is related to the hypoperfusion of cerebral tissue as manifestation of neurovascular coupling. EEG could be applicable for bedside functional monitoring in emergency settings. We aimed to investigate the relation between hyper-acute ischemic stroke EEG changes, measured with bedside wireless-EEG, and hypoperfused core-penumbra CT-perfusion (CTP) volumes. In addition, we investigated the association of EEG and CTP parameters with neurological deficit measured by NIHSS. We analyzed and processed EEG, CTP and clinical data of 31 anterior acute ischemic stroke patients registered within 4.5 h from symptom onset. Delta/alpha ratio (DAR), (delta + theta)/(alpha + beta) ratio (DTABR) and relative delta power correlated directly (ρ = 0.72; 0.63; 0.65, respectively), while alpha correlated inversely (ρ = − 0.66) with total hypoperfused volume. DAR, DTBAR and relative delta and alpha parameters also correlated with ischemic core volume (ρ = 0.55; 0.50; 0.59; − 0.51, respectively). The same EEG parameters and CTP volumes showed significant relation with NIHSS at admission. The multivariate stepwise regression showed that DAR was the strongest predictor of NIHSS at admission (p < 0.001). The results of this study showed that hyper-acute alterations of EEG parameters are highly related to the extent of hypoperfused tissue highlighting the value of quantitative EEG as a possible complementary tool in the evaluation of stroke severity and its potential role in acute ischemic stroke monitoring.

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Objective: Advanced neuroimaging has proved to be pivotal in the management of acute ischemic stroke. The use of CT perfusion (CTP) core and penumbra parameters to predict the outcome in wake-up stroke (WUS) patients in everyday clinical scenarios has not yet been investigated. The aim of our study was to investigate the predictive power of CTP parameters on functional and morphological outcomes in WUS patients treated with recombinant tissue plasminogen activator (rTPA). Approach: We analyzed clinical data and processed CTP images of 83 consecutive WUS patients treated with rTPA. The predictive power of whole-brain CTP features and of the clinical stroke-related parameters to predict the National Institutes of Health Stroke Scale (NIHSS) score at the seventh day and ischemic lesion volume outcome was investigated by means of multivariate regression analysis as well as least absolute shrinkage and selection operator (LASSO) modeling. Main results: Multivariate analysis showed that CTP core volume (β = 0.403, p = 0.000), NIHSS at admission (β = 0.323, p = 0.005) and Alberta Stroke Program Early CT (ASPECT) score (β = -0.224, p = 0.012) predict NIHSS at 7 days, while total hypoperfused volume (β = 0.542, p = 0.000) and core volume on CTP (β =0.441, p = 0.000) predict infarct lesion volume at follow-up CT. The LASSO modeling approach confirmed the significant predictive power of CTP core volume, total hypoperfused CTP volume, NIHSS at baseline and ASPECT score, producing a sparse model with adequate reliability (the root mean square error on a previously unseen testing dataset was 3.68). Significance: Our findings highlight the importance of CT multimodal imaging features for decision-making and prediction in the hyperacute phase of WUS. The predictive model supports the hypothesis that an irreversible necrotic core rather than the extent of the penumbra is the main prognostic factor in WUS patients treated with rTPA.

Background and purpose: Diagnosis of posterior circulation stroke may be challenged. National Institutes of Health Stroke Scale (NIHSS) and brain imaging (non-contrast brain computed tomography-CT) are used for diagnosis; evaluation on posterior circulation stroke remains a limit of NIHSS, and the value of non-contrast CT (NCCT) is limited due to artifacts caused by the bones of the base of the skull. We tested the validity and prognostic value of posterior circulation Alberta Stroke Program Early CT Score (pc-ASPECTS) in patients with posterior circulation stroke. Methods: Pc-ASPECTS allots the posterior circulation 10 points. We studied 50 patients with posterior circulation stroke. We applied pc-ASPECTS to NCCT, CT angiography, and CT Perfusion. We evaluated the correlation of pc-ASPECT with outcome parameters for stroke. Results: Out of 50 patients, CTP showed abnormalities in 34 cases. The pc-ASPECT score calculated on brain CT and on the brain CT + angio CT had a sensibility of 24%, calculated on brain CT, angio CT and CTPerfusion gain a sensibility of 72%. Pc-ASPECT MTT resulted to be the more reliable parameter: outcome given by NIHSS score at discharge, mRS at discharge, and at 3 months was more severe in patients with Pc-ASPECT MTT alteration. Outcome given by NIHSS score at discharge and mRS at discharge and 1 at 3 months was more severe in patients with higher NIHSS score at admission. Conclusion: We evaluated the usefulness of pc-ASPECTS on CTP in predicting functional outcome in acute posterior circulation stroke that appears to be a powerful marker for predicting functional outcome.

Purpose Crossed cerebellar diaschisis (CCD) is a common finding in hyper-acute ischemic stroke, related to supratentorial dysfunction of the contralateral hemisphere. Several studies investigated a possible relationship between CCD and clinical outcomes but still no evidence emerged. We proposed a novel quantitative whole cerebellum analysis using CT perfusion (CTP) imaging to investigate the relationship between CCD and stroke severity, hypoperfused volume and outcome measures. Methods 55 patients with supratentorial ischemic stroke who underwent CTP evaluation within 4.5 h since symptom onset were enrolled. CCD was evaluated by CTP image-processing and by calculating the mean transit time (MTT)-map asymmetry index in the whole cerebellum. MTT asymmetry correlation with ischemic volume and clinical outcomes was investigated. Results MTT asymmetry was found in most of the included patients and significantly correlated with NIH Stroke Scale (NIHSS) score at baseline and CTP ischemic volume. MTT asymmetry was significantly correlated with hemorrhagic transformation, NIHSS and modified Rankin Scale (mRS) score on discharge in treated patients. Conclusions CCD was detectable by CTP in acute supratentorial ischemic stroke by processing the whole cerebellum volume. CCD perfusion asymmetry was significantly correlated with neurological and perfusion deficit on admission as well as with clinical outcomes in treated patients.

Headache is a very common clinical feature in daily practice. Most patients are affected by the so-called primary headache and do not require neuroimaging as the diagnosis is based on the history and clinical data. In patients noncompliant to therapy, with abnormal neurological examination or worsening of symptoms, imaging is useful. Imaging is especially mandatory to rule out underlying causes of headache.

Objectives The combined use of perfusion neuroimaging and brain oscillatory activity may provide a better clinical picture of neurovascular coupling of the injured area in ischemic stroke. The aim is to assess stroke-related topographic electroencephalography (EEG) changes during the earliest phase of ischemic stroke and to compare them with hypoperfusion identified by computer tomography perfusion (CTP). Patients and methods The study included 15 patients with ischemic stroke, who underwent both CTP and EEG recording within 4.5 h. Topographic representation of power for each band was calculated and compared with hypoperfusion areas estimated by CTP maps. Results Predominance of slow delta frequencies was found in all patients. The main finding is the agreement between slow rhythms hemispheric prevalence on EEG maps and cerebral hypoperfusion area identified using CTP. Conclusion The results of this preliminary study show that the combined use of EEG and CTP, as highly available techniques, in acute ischemic stroke may be helpful in clinical practice and provide information about functional and metabolic aspects of brain involvement. The joint use of these methodologies may give a better clinical insight of the functionality of injured area in the hyperacute phase.

BACKGROUND: The National Institutes of Health Stroke Scale (NIHSS) is the most adopted stroke patients' evaluation tool in emergency settings to assess the severity of stroke and to determine the patients' eligibility for specific treatments. Computed tomography perfusion (CTP) is crucial to identify salvageable tissue that can benefit from the reperfusion treatment. The aim of this study is to identify the relation between the NIHSS scores and the hypoperfused volumes evaluated by CTP in patients with hyperacute ischemic stroke. METHODS: This retrospective study was conducted on 105 patients with ischemic stroke who underwent NIHSS assessment and CTP in the hyperacute phase. Hypoperfused volume was evaluated by CTP maps processed with semi-automatic algorithm. An analysis was conducted to determine the degree of correlation between the NIHSS scores and the ischemic lesion volumes and to investigate the relation between the anterior and the posterior circulation strokes, as well as between the right and the left hemispheric strokes. RESULTS: A significant correlation was found between ischemic volume and NIHSS score at baseline (r = .82; P

Objectives The acute-onset of migrainuos aura (MA) can be erroneously diagnosed in Emergency Department (ED) as acute stroke (AS) and it can be classified as “stroke mimic” (SM). Perfusion computer tomography (PCT) may be useful to improve detection of infarcts. The aim of the study was to investigate the role in ED of PCT in improving diagnosis of migrainous aura. Data were compared with the well-defined perfusion patterns in patients with acute ischemic stroke. Patients and Methods A standardized Stroke Protocol was planned. The protocol consisted in centralizing in ED all the patients with acute-onset of neurological symptoms compatible with cerebrovascular disease and in performing a general and neurological examination, hematological tests, brain non-contrast computed tomography (NCCT), CT angiography (CTA) of the supra-aortic and intracranial arteries and cerebral PCT. Patients with diagnosis of definite or probable acute stroke were hospitalized in Stroke Unit (SU). A six-months retrospective analysis of all the patients included in the Stroke Protocol and discharged from ED or from SU with a diagnosis of migraine with aura was performed. Results 172 patients were included in the Stroke Protocol and 6 patients were enrolled. NCCT, CTA and PCT were performed after 60–90 min from symptoms onset and revealed normal perfusion. Intravenous thrombolysis was performed only in one patient. Conclusion Patients with acute-onset of neurological symptoms, who have rapid progressive improvement of symptoms, normal neuroimaging, in particular PCT, and preceding episodes of migraine with aura, may be considered as suffering from MA. In these cases, even if thrombolysis is safe, clinicians may defer a prompt aggressive treatment.

OBJECTIVE: To evaluate the accuracy of perfusion CT (pCT) in the definition of the infarcted core and the penumbra, comparing the data obtained from the evaluation of parametric maps [cerebral blood volume (CBV), cerebral blood flow (CBF) and mean transit time (MTT)] with software-generated colour maps. METHODS: A retrospective analysis was performed to identify patients with suspected acute ischaemic strokes and who had undergone unenhanced CT and pCT carried out within 4.5 h from the onset of the symptoms. A qualitative evaluation of the CBV, CBF and MTT maps was performed, followed by an analysis of the colour maps automatically generated by the software. RESULTS: 26 patients were identified, but a direct CT follow-up was performed only on 19 patients after 24-48 h. In the qualitative analysis, 14 patients showed perfusion abnormalities. Specifically, 29 perfusion deficit areas were detected, of which 15 areas suggested the penumbra and the remaining 14 areas suggested the infarct. As for automatically software-generated maps, 12 patients showed perfusion abnormalities. 25 perfusion deficit areas were identified, 15 areas of which suggested the penumbra and the other 10 areas the infarct. The McNemar's test showed no statistically significant difference between the two methods of evaluation in highlighting infarcted areas proved later at CT follow-up. CONCLUSION: We demonstrated how pCT provides good diagnostic accuracy in the identification of acute ischaemic lesions. The limits of identification of the lesions mainly lie at the pons level and in the basal ganglia area. Qualitative analysis has proven to be more efficient in identification of perfusion lesions in comparison with software-generated maps. However, software-generated maps have proven to be very useful in the emergency setting. Advances in knowledge: The use of CT perfusion is requested in increasingly more patients in order to optimize the treatment, thanks also to the technological evolution of CT, which now allows a whole-brain study. The need for performing CT perfusion study also in the emergency setting could represent a problem for physicians who are not used to interpreting the parametric maps (CBV, MTT etc.). The software-generated maps could be of value in these settings, helping the less expert physician in the differentiation between different areas.

Whether motor and linguistic representations of actions share common neural structures has recently been the focus of an animated debate in cognitive neuroscience. Group studies with brain-damaged patients reported association patterns of praxic and linguistic deficits whereas single case studies documented double dissociations between the correct execution of gestures and their comprehension in verbal contexts. When the relationship between language and imitation was investigated, each ability was analysed as a unique process without distinguishing between possible subprocesses. However, recent cognitive models can be successfully used to account for these inconsistencies in the extant literature. In the present study, in 57 patients with left brain damage, we tested whether a deficit at imitating either meaningful or meaningless gestures differentially impinges on three distinct linguistic abilities (comprehension, naming and repetition). Based on the dual-pathway models, we predicted that praxic and linguistic performance would be associated when meaningful gestures are processed, and would dissociate for meaningless gestures. We used partial correlations to assess the association between patients’ scores while accounting for potential confounding effects of aspecific factors such age, education and lesion size. We found that imitation of meaningful gestures significantly correlated with patients’ performance on naming and repetition (but not on comprehension). This was not the case for the imitation of meaningless gestures. Moreover, voxel-based lesion-symptom mapping analysis revealed that damage to the angular gyrus specifically affected imitation of meaningless gestures, independent of patients’ performance on linguistic tests. Instead, damage to the supramarginal gyrus affected not only imitation of meaningful gestures, but also patients’ performance on naming and repetition. Our findings clarify the apparent conflict between associations and dissociations patterns previously observed in neuropsychological studies, and suggest that motor experience and language can interact when the two domains conceptually overlap. * Abbreviations : AAT : Aachener Aphasie Test

The aims of this study were to determine fractional anisotropy (FA) and the fibre density index (FDi) in the cervical spinal cord of patients with multiple sclerosis (MS) by using diffusion-tensor magnetic resonance imaging (DT-MRI) to identify possible differences between MS patients and controls.We studied 27 patients with MS - nine with primary progressive (PPMS), nine with secondary progressive (SPMS) and nine with relapsing-remitting (RRMS) disease - and 18 healthy individuals as controls. Conventional and DTI sequences with diffusion gradients applied in 32 directions were obtained. The results were compared between healthy controls and patients, between healthy controls and individual forms of MS and between the three forms of MS. Statistical analysis was performed by analysis of variance (ANOVA) and Student's t test.The FDi in the three subgroups of patients and in controls showed a statistically significant difference. Using the t test, we found results from both PPMS and SPMS groups were different from controls. The correlation between FA and FDi was significant both in healthy controls and in MS patients evaluated as a single group. CONSLUCIONS: Despite the small group of patients, these findings suggest that FDi associated with FA is a sensitive parameter for assessing spinal cord damage in patients with MS.

Scopo del nostro lavoro e stato valutare l’attivazione corticale durante un compito motorio in pazienti con sclerosi multipla (SM) e fatica. Sono stati arruolati 24 pazienti destrimani con SM recidivante-remittente (12 senza e 12 con fatica) e 15 volontari sani. L’indagine in risonanza magnetica (RM) (1,5 T) e stata eseguita in tutti i soggetti mediante sequenze convenzionali ed echo-planar imaging (EPI) per lo studio funzionale. Il compito motorio consisteva nel finger tapping sequenziale con la mano dominante. Sono state ottenute mappe statistiche di attivazione motoria. Il confronto fra i gruppi e stato condotto mediante analisi della varianza (ANOVA) (p

Objective To assess spectral presaturation inversion-recovery MRI sequence with gadolinium to identify predictors of mesorectal fascia (MRF) invasion in patients with locally advanced rectal carcinoma after neoadjuvant therapy. Materials and methods Sixty-five patients underwent neoadjuvant concomitant radiation and chemotherapy and surgery. Magnetic resonance images were assessed by two radiologists. Results Linear (odds ratio, 95% confidence intervals: 19.33, 1.98–188.6) and reticular strands (odds ratio, 95% confidence intervals: 9.75, 1.45–67.77) reaching the MRF are predictors of MRF invasion. Conclusion Linear or reticular mesorectal strands reaching the MRF detected at contrast-enhanced MRI represent a predictor of MRF invasion.

An important issue in contemporary cognitive neuroscience concerns the role of motor production processes in perceptual and conceptual analysis. To address this issue, we studied the performance of a large group of unilateral stroke patients across a range of tasks using the same set of common manipulable objects. All patients (n = 37) were tested for their ability to demonstrate the use of the objects, recognize the objects, recognize the corresponding object-associated pantomimes, and imitate those same pantomimes. At the group level we observed reliable correlations between object use and pantomime recognition, object use and object recognition, and pantomime imitation and pantomime recognition. At the single-case level, we document that the ability to recognize actions and objects dissociates from the ability to use those same objects. These data are problematic for the hypothesis that motor processes are constitutively involved in the recognition of actions and objects and frame new questions about the inferences that are merited by recent findings in cognitive neuroscience.

Summary Fibrous dysplasia is a rare, benign disease even though clinical picture may assume severe aspects. It presents a progressive replacement of normal bone structures by fibrous tissue which can involve one or more bone segments and, in some cases, it could be associated with skin lesions and endocrinopathies (McCune–Albright syndrome). It manifests clinically with dysmorphic syndrome, ophtalmologic or otologic signs. Vertigo in an uncommon presentation symptom. We report a case of monostotic fibrous dysplasia of the temporal bone presenting as dizziness in an 11-year-old boy and review the scientific literature.

Purpose: To assess whether gadobenate dimeglumine (Gd-BOPTA)-enhanced MR imaging could predict hepatocellular carcinoma (HCC) diagnosis in small arterial enhancing-only nodules detected by contrast-enhanced computed tomography (CT) in patients with liver cirrhosis. Materials and Methods: We prospectively recruited 125 cirrhotic patients (67 males, and 58 females; age: 68 ± 12.36 years) with 151 small (

To the best of our knowledge, persistent visual symptoms, lasting months or years without evidence of infarction, a rare complication of migraine with aura, has been reported in only 20 patients. We report the case of a 43-year-old woman with a 31-year history of migraine with typical visual aura. At presentation, she experienced a visual aura in her right hemifield followed by a pulsating headache. The visual symptoms persisted. There were no abnormal findings on neurological and ophthalmological examinations, EEG, visual evoked potentials (VEPs), brain computed tomography and magnetic resonance imaging (MRI). Both brain single photon emission compted tomography (SPECT) and brain perfusion MRI revealed decreased left fronto-parieto-occipital and right occipital blood perfusion. A perfusion MRI, performed 7 months after symptom onset and almost complete extinction of symptoms, was normal. As previously reported, we demonstrated a cortical hypoperfusion by SPECT in a case of persistent visual aura. For the first time this finding was confirmed by perfusion MRI.

Summary Recent data indicate that patients with vascular dementia (VaD) show a cholinergic deficit. Having obtained good results in a previous study comparing rivastigmine, an inhibitor of acetylcholinesterase (AChE) and butyrylcholinesterase (BuChE), vs. aspirin, we aimed to compare the efficacy and tolerability of rivastigmine vs. aspirin plus nimodipine. Patients with a diagnosis of dementia and probable VaD received rivastigmine 3–6 mg/day (n = 32) or aspirin plus nimodipine (n = 32) in an open study for 16 months. Patients treated with rivastigmine showed superior benefits, compared with those receiving aspirin plus nimodipine, in attention, executive function, instrumental activities of daily living, and behavioural and psychotic disturbances. Side-effects in both groups were tolerable and there were no study withdrawals. The benefits observed with rivastigmine may reflect its inhibitory effects on AChE and BuChE, and the drug's affinity for frontal brain areas.

Persistent and intractable hiccups indicate multiple neurologic and extraneurologic disorders. Chronic hiccup is not so rare in patients suffering from stroke: its impact on quality of life and on rehabilitation management is substantial, and it may be closely related to aspiration pneumonia, respiratory arrest and nutritional depletion.Intractable hiccups can be associated with potentially fatal consequences and safe management may require inpatient rehabilitation. It has been suggested that hiccups could be a form of myoclonus, caused by repeated and abnormal activity of the solitary inspiratory nucleus. Because of this cause we decided to treat intractable hiccups in patients with ischemic lesions of the medulla with a short course of gabapentin.The results were promising, with the immediate disappearance of the hiccups, and the complete absence of side effects. The 36-months follow up was favorable to all the patients, who, after 6 days of treatment remain asymptomatic.

The objective of the study was to examine the relationship between HLA genotypes and disease severity as measured by brain MRI quantitative markers of demyelinating and destructive pathology in patients with multiple sclerosis (MS). We studied 100 patients with MS and 122 age, sex-, ethnic- and residence-matched controls. The DNA extraction and the genomic typing (A, B, DRB1 and DQB1 loci) were obtained with sequence-specific oligonucleotide method, using a commercially available reversible line blot assay (INNO-LIPA). All patients underwent a 1.5 tesla MRI examination of the brain. Disease severity was assessed by clinical (Expanded Disability Status Scale (EDSS)) and MRI (T2- and T1-lesion load (LL) and brain parenchymal fraction (BPF)) outcome measures. HLA-DQB1* 02 (OR 19.9, 95% C. I. 16.2-24.3, uncorrected (uncorr)- p

A challenging point in neuroimaging is the diagnosis of Alzheimer's disease (AD) during its asymptomatic phase. Among all the biomarkers proposed in the literature, a measure of the hippocampal atrophy via Magnetic Resonance Imaging (MRI) seems to be one of the most reliable. Refined image processing techniques were already proposed to automatically extract the hippocampal boxes from images acquired with the standard full brain acquisition protocol suggested by the Alzheimer's Disease Neuroimaging Initiative (ADNI). In order to enhance this approach, here we propose a high resolution (HR) MRI protocol focused on the medial temporal lobe (MTL) mainly conceived for 1.5T MRI device, hereafter referred as MTL-HR protocol. A preliminary characterization of its behavior when compared to the standard ADNI protocol is also presented.

Magnetic resonance (MR) urography has become an integral part of the recently emerging advances that involve clinical uroradiology. MR urography has received a relatively lower attention than multidetector CT (MDCT) urography, being hampered by the low spatial resolution which is crucial for calyceal evaluation and by the requirement of updated MR units. However, excellent contrast resolution and lack of ionizing radiation make MR urography a technique to be considered for noninvasively evaluating the entire urinary tract, especially when ionizing radiation is to be avoided, such as in pediatric or pregnant patients.

The aim of the present study was to investigate the relationship between involvement of specific areas of the brain and the occurrence of depression and anxiety in patients with multiple sclerosis. We studied 95 patients (62 women and 33 men, mean age 39.5 years, SD 11.2) with definite MS, 97 patients (65 women and 32 men, mean age 40.7, SD 11.9) suffering from chronic rheumatoid diseases and 110 healthy subjects (71 women and 39 men, mean age 40.1, SD 12.7). The disability, the independence, the cognitive performances, the depressive and anxiety symptoms were assessed. The diagnosis of major depression was made according to the DSM-IV. The patients with multiple sclerosis underwent a 1.5 Tesla magnetic resonance examination including T1 and T2 weighted images. Calculation of regional and total lesion loads and brain volumes were performed. The number (%) of subjects with a diagnosis of major depression was 18 (18.9) among MS cases, 16 (16.5) among controls with chronic disease (p=NS), and 4 (3.6) among healthy volunteers (p < 0.0001). The Hamilton Depression and Anxiety rating scales median scores were 5 and 18, respectively in the MS patients, 5 (p= NS) and 14 (p= NS) in the chronic rheumatoid diseases controls, and 3 (p= < 0.0001) and 6 (p= < 0.0001) in the healthy controls. Both severity of depressive symptoms and diagnosis of major depression correlated, albeit weakly, with right frontal lesion load (r=0.22, p=0.035, and r=0.23, p=0.026, respectively) and right temporal brain volume (r=0.22, p=0.005 and r=0.22, p=0.036, respectively). The severity of depression was related significantly also with total temporal brain volume (r=0.26, p=0.012), right hemisphere brain volume (r=0.25, p=0.015), disability (r=0.30, p=0.003) and independence of MS cases (r=-0.26, p=0.01). The anxiety did not correlate significantly with any of the measures of regional and total lesion loads and brain volume or with any of the considered clinical variables. The similar frequency of depression and severity of depressive symptoms in MS patients and in chronic disease patients, the significant difference in this respect with the normal controls, and the significant correlation between depression and the disability measures would suggest a psychological reaction to the impact of the disease but the relationship between depression and the alterations in the frontal and temporal lobes of the right hemisphere supports, on the contrary, the causative role of organic brain damage. The lack of any significant association between symptoms of anxiety and either MRI abnormalities or clinical variables led us to the opinion that anxiety is a reactive response to the psychosocial pressure put on the patients.

Background: The relative contribution to the olfactory dysfunction of the lesions in the specific brain regions involved in olfaction compared with the lesions scattered all over the rest of the brain has not been fully clarified yet in patients with multiple sclerosis (MS). The concurrent use of Magnetic Resonance Imaging (MRI) and a standardized test of odor identification ability now permits to study the relation between smell loss and the extent of white matter abnormalities. Methods: We tested the olfactory function of 40 patients with definite MS and of 40 age-sex- and smoking-habit-matched healthy controls by using the Cross Cultural Smell Identification Test. We measured also the lesion load on T2-weighted images in the inferior-frontal and temporal lobes and in the rest of the brain in MS patients. Therefore, we tried to correlate measures of lesion load and smell test scores. Results: A robust correlation was demonstrated between MR measures of lesion load in the white matter of the olfactory brain region and smell loss (r=70.739, P50.0001). A significant relationship has been found even after taking potential confounding factors, such as sex, age, disease duration, disability, anxiety and depression, into account (r=70.90, P50.0001). Conclusions: Our findings show, in MS patients with stable neurological impairment and no recent disease exacerbation, a correlation between smell loss and the lesion load in the regions of the brain involved in olfaction and support the theory that the extent and severity of MRI abnormalities in specific brain regions are related to the presence of selective neurologic and neuropsychologic impairment.

Lo studio dell'attivazione neuronale con RM funzionale (fMRI) è una delle tecniche che si va affermando sia nella pratica clinica che nella ricerca di neuroscienze. La non-riproducibilità quantitativa dei risultati pubblicati (numero di pixel attivati, intensità relativa del segnale) ha indotto gli autori ad un'analisi sistematica dei parametri di acquisizione per comprendere il loro effetto sulle mappe di attivazione, nel presente studio mappe di attivazione della corteccia motoria e visiva. è stata inoltre verificata l'importanza del contributo degli effetti di flusso nella microvascolatura alle mappe di attivazione. Gli studi si sono svolti complessivamente su 21 volontari sani. I parametri di acquisizione che sono stati presi in esame sono i seguenti: tempo di eco, spessore della fetta, angolo di flip, omogeneità di campo, orientazione spaziale delle fette. Si è quindi scelto un protocollo ritenuto ottimale per l'applicazione della tecnica di fMRI in ambiente clinico con un tomografo a 1,5 T: TE = 40 ms, TR = 60 ms, flip angle = 25°, spessore di strato = 4 mm, matrice di acquisizione = 128 × 128, matrice di ricostruzione = 256 × 256, compensazione per gli artefatti da flusso, tecnica di contrast enhancement = T1.

La risonanza magnetica è la tecnica fondamentale nello studio della sclerosi multipla. Lo scopo di questo lavoro è stato il confronto, in termini di sensibilità, tra alcune sequenze di RM attualmente disponibili con l'intento di individuare quella che consente la migliore dimostrazione delle lesioni tipiche della sclerosi multipla. Sono stati studiati 71 pazienti affetti da sclerosi multipla, inclusi nello studio in base ai criteri di Poser. Tutti sono stati sottoposti ad un esame di RM comprendente una sequenza SE pesata in densità protonica (DP) e T2, una sequenza TSE pesata in T2 e una sequenza IR. Il giudizio sulla visibilità delle lesioni demielinizzanti è stato espresso sia in termini soggettivi che in modo oggettivo. Dalla valutazione soggettiva è emerso che, in generale, la visibilità delle placche è risultata soddisfacente nella maggior parte dei casi, con punteggi particolarmente elevati a livello della sostanza bianca periventricolare, mentre punteggi più bassi sono stati attribuiti alle lesioni del cervelletto e del tronco encefalico. Prendendo in considerazione i punteggi attribuiti alle diverse lesioni in relazione al tipo di sequenza impiegata, nel complesso quella migliore è risultata la SE pesata in T2. Dalla valutazione oggettiva invece la sequenza con maggiore contrasto intrinseco è risultata essere la TSE pesata in T2 con una eccezione per quanto concerne il contrasto tra placca e liquor dove la sequenza più affidabile è risultata essere la DP. Dalla valutazione oggettiva emerge dunque un risultato in apparente contraddizione con quello della valutazione soggettiva. Per conciliare risultati così diversi bisogna ipotizzare che il contrasto intrinseco delle immagini non sia il fattore principale che determina l'adeguata visibilità delle lesioni demielinizzanti. Ad esempio, nelle sequenze TSE pesate in T2 alcuni fattori riducono la visibilità delle stesse. In conclusione, dalla nostra esperienza emerge che la sequenza che consente la migliore dimostrazione delle lesioni della sclerosi multipla è la SE pesata in DP e T2, che permette la valutazione di più parametri tissutali in un'unica acquisizione oltre ad essere dotata di un contrasto intrinseco soddisfacente.

OBJECTIVE: The purpose of this article is to assess whether unenhanced and gadobenate dimeglumine-enhanced MRI with dynamic and hepatobiliary phase may predict the diagnosis of dysplastic nodules in patients with liver cirrhosis. MATERIALS AND METHODS: We retrospectively analyzed 75 cirrhotic patients (47 men and 28 women; mean [± SD] age, 55 ± 12 years) with 82 hepatocellular nodules, including histology-proven dysplastic nodules (n = 25; diameter, 1-3 cm) and hepatocellular carcinomas (n = 57; diameter, 2-3 cm) scanned by MRI before and after gadobenate dimeglumine injection during hepatic arterial phase (HAP), portal venous phase (PVP), equilibrium phase, and hepatobiliary phase. Nodule T1 and T2 intensities before contrast agent injection and nodule HAP, PVP, equilibrium phase, and hepatobiliary phase intensities were compared with the adjacent liver. Univariate and multivariate logistic regression analysis was conducted to assess how the nodule could predict dysplastic nodule diagnosis. RESULTS: Some imaging findings were independent predictors of dysplastic nodule diagnosis-namely, nodule T2 isohypointensity (odds ratio [OR], 12.28; 95% CI, 3.88-38.82), T1 isohyperintensity (OR, 26.74; 95% CI, 7.53-94.90), HAP isohypointensity (OR, 97.16; 95% CI, 20.06-470.49), PVP-equilibrium phase isohyperintensity (OR, 20.53; 95% CI, 5.36-78.62), and hepatobiliary phase isohyperintensity (OR, 119.6; 95% CI, 21.59-662.40). Nodule T2 and HAP isohypointensity (OR 31.47; 95% CI, 7.88-125.58), nodule T2 isohypointensity and hepatobiliary phase isohyperintensity (OR, 28.77; 95% CI, 7.79-106.19), nodule T1 isohyperintensity and HAP isohypointensity (OR, 17.22; 95% CI, 4.85-61.14), and nodule T1 and hepatobiliary phase isohyperintensity (OR, 19.39; 95% CI, 5.38-69.90) were also predictors of dysplastic nodule diagnosis. CONCLUSION: The combination of nodule appearance on T2-weighted MRI and nodule enhancement after gadobenate dimeglumine injection may predict dysplastic nodule diagnosis in patients with liver cirrhosis.

Introduction MRI longitudinal studies have been proposed to detect abnormal brain changes in the early phase of the Alzheimer’s disease (AD) during its asymptomatic phase. Purpose In order to obtain a very high sensitivity in MRI longitudinal studies a number of technical issues have to be addressed. Materials and methods In the present study a high resolution MRI protocol focused on the medial temporal lobe mainly conceived for 1.5T MRI device is developed. A grey-level reference object was designed to be used during acquisition to help image post-processing when gray-level comparison is required. A prospective study on healthy volunteers is ongoing. An image analysis protocol for longitudinal studies has been developed, including pre-processing (gray level normalization, image registration) and voxel-based time-course analysis. The protocol has been tested on the MIRIAD dataset. Results The new acquisition and gray-level normalization technique was applied and comparison indexes (PSNR, SSI, NCC) have been calculated to demonstrate the increased reproducibility of the images. The image processing developed for this study demonstrates that the time-course of brain atrophy let us differentiate normal and AD subjects with repeated images acquired in less than 2 years. Conclusion Applying our imaging techniques, longitudinal studies will likely be more accurate than the study based on MIRIAD dataset. Therefore we expect that repeated images with our acquisition and normalization protocol will allow the discrimination between normal and AD subjects with a reduced number of images acquired in a period of about one year. Disclosure Nothing to declare.

Rationale and Objectives To retrospectively assess the value of spectral presaturation by inversion-recovery (SPIR) magnetic resonance (MR) imaging sequence after gadolinium injection to differentiate fibrotic scar tissue and tumoral infiltration within the mesorectal fat in patients with rectal carcinoma undergoing MR restaging after neoadjuvant chemo- and radiation therapy (CRT). Materials and Methods Forty-three consecutive patients (mean age, 65.8 years; range, 46–85 years; male:female, 29:14) with locally advanced rectal carcinoma underwent CRT followed by surgery. MR imaging was performed before and after completion of CRT by using T2-weighted turbo spin-echo and T1-weighted SPIR sequences before and after gadolinium injection, and MR images were assessed by two radiologists in consensus. Logistic regression was conducted to test the significance of the MR image findings with histology. Results After CRT the disease was either limited to the rectal wall (n = 18 patients) or presented perirectal infiltration (n = 25) on histology. In 21 patients, mesorectal enhancing strands were observed. Reticular-shaped enhancing strands reaching the mesorectal fascia presented the highest correlation with tumor infiltration of the mesorectal fat (OR 130.33, 95% CI: 4.1–4220.29; logistic regression), whereas linear-shaped enhancing strands either reaching or not reaching the mesorectal fascia (OR 0.25 or 0.1, 95% CI: 0.024–2.6 or 0.01–1.07) revealed the lowest correlation. Conclusions Reticular-shaped enhancing strands on SPIR MR imaging after gadolinium injection are associated with tumor infiltration of the mesorectal fat.

This chapter describes the imaging techniques for the examination of the kidney using magnetic resonance (MR), from the fundamental morphologic sequences to the advanced applications. The basic MR features of vascular and infectious renal diseases, solid benign and malignant renal tumors, and cystic renal tumors are described. Advanced MR applications are described as a general introduction to the following chapters describing the different renal pathologies.

The authors describe a case of a drug-associated hyperammonemia, central pontine myelinolysis and coma occurring in a patient with Sjögren's syndrome chronically treated with valproic acid for an underlying psychotic disorder. The possible differential diagnoses are reviewed and discussed.

The aim of this study is to investigate the consequences of using different gradient schemes, number of repeated measurements and voxel size on the fractional anisotropy (FA) value in a diffusion tensor imaging (DTI) sequence on the cervical tract of the spinal cord. Twenty healthy volunteers underwent a total of 86 DTI axial acquisitions performed by using different voxel size and number of diffusion gradient directions (NDGDs). Three different diffusion gradient schemes were applied, named 6, 15 and 32 according to the NDGD. Furthermore, some acquisitions were repeated to investigate the effects of image averaging on FA value. Our results indicate that the FA value in the cervical spinal cord decreases when increasing the NDGD for a fixed spatial resolution, or when identical acquisitions are repeated, thus, increasing the acquisition time. This effect is observed in all subjects without exceptions, and the differences result statistically significant: the average FA obtained from 6, 15 and 32 NDGD is 0.84 (range, 0.82-0.87), 0.75 (range, 0.68-0.80) and 0.70 (range, 0.65-0.77), respectively, for isotropic 8 mm3 voxel size. When varying the spatial resolution in a volume range of 2 to 8 mm3 for a fixed NDGD (6 or 15), the differences in FA values are smaller albeit still statistically significant: the smaller the voxel, the larger the FA. No significant dependence of the FA value from the spatial resolution is observed in the 32 NDGD acquisitions in the studied volume range. In conclusion, our results indicate that the value of the FA in the cervical tract of the spinal cord vary with regularity in intrasubject acquisitions when modifying the NDGD and when repeated acquisitions are used; these observations confirm that the signal-to-noise ratio introduces a systematic error in FA measurements that does not allow simple comparison of quantitative results obtained from separated studies. © 2010 Elsevier Inc. All rights reserved.

Objective: To evaluate the T2 mapping of patellar articular cartilage in patients with osteoarthritis using gradient and spin-echo (GRASE) magnetic resonance (MR) imaging. Materials and methods After the imaging of a phantom consisting of two sealed 50-ml test objects with different concentrations (30% and 90% weight/volume) of copper sulphate, the T2 mapping of patellar articular cartilage was performed in 35 patients (21 male and 14 female; mean age ± SD 42±17 years) with moderate degree of patellar osteoarthritis. Turbo-spin-echo (TSE) (TR milliseconds/ minimum–maximum TE milliseconds 3,000/15–120; total acquisition time 5 min 52 s) and GRASE (TR milliseconds/ minimum–maximum TE milliseconds 3,000/15–120; total acquisition time 1 min 51 s) were employed. In each patient patellar cartilage was segmented at nine locations (three superior, three central, and three inferior) by manually defined regions of interest. T2 relaxation times were calculated using a linear fit applied to the logarithm of signal intensity decay. Results In the phantom the T2 values measured by GRASE were similar to those measured by MR spectroscopy (test object 1: 48.1 ms vs 51 ms; test object 2: 66.8 ms vs 71 ms; P>0.05, Wilcoxon test). In patients GRASE and TSEderived T2 values demonstrated good agreement (mean difference ± SD, 1.81±3.63 ms). The within-patient coefficient of variation was 22% for TSE and 23% for GRASE. Conclusion Fast T2 mapping of the patellar articular cartilage can be performed with GRASE within a third of the time of that of standard sequences.

The corpora cavernosa consist of smooth muscle cells, loose areolar tissue, blood vessels, nerves and collagen fibers. All these components play a role in the complex physiologic event of erection, together with endocrinal, vascular, neural and psychogenic factors (Jevtich et al. 1990).

The most important confirmed genetic factor of susceptibility to multiple sclerosis (MS) has been identified in the HLA class II region. The hypothesis that several genes, including HLA class II, may influence the prognosis of patients with MS has been proposed. In a recent study, using low intermediate resolution typing, we found that some HLA alleles may predict disease severity as assessed by magnetic resonance imaging (MRI) measures. The aim of this study was to examine the relationship between high-resolution typing of HLA alleles and disease severity as measured by brain MRI quantitative markers of demyelinating and destructive pathology in patients with MS. In 41 MS patients (27 relapsing-remitting, 7 secondary progressive, and 7 primary progressive), we performed high-resolution typing of alleles HLA-DRB1*04, -DQB1*03, -DRB1*15, -DQB1*06, and of haplotypes -DRB1*04-DQB1*03 and -DRB1*15-DQB1*06. These alleles and haplotypes were associated with higher susceptibility to MS in a recently published case-control study conducted in the Friuli-Venezia-Giulia region, Italy. Of 41 included patients, 13 were men and 28 were women. Mean age was 43.3 (SD 11.4) years, mean disease duration 10.3 (SD 7.8) years, and mean EDSS 2.3. DNA extraction and genomic typing were obtained with the sequence-specific primers method using primer pairs that amplified the HLA alleles. All patients underwent a 1.5-T MRI examination of the brain. Disease severity was assessed by clinical measures [Expanded Disability Status Scale (EDSS)] and MRI measures. T2- and T1-lesion volumes (LVs) and brain atrophy measures [fractions of brain parenchyma (BPF), gray matter (GMF), and white matter (WMF)] were calculated. We used general linear model analysis (GML), controlled for age, disease duration, and treatment status, to compare the MRI measures according to allele and haplotype status. The following significant results were found: HLA-DRB1*1501 positive patients had significantly lower GMF (0.493 vs 0.526, p0.001), lower BPF (0.784 vs 0.815, p = 0.018), and higher T1-LV (2.8 vs 0.7ml, p = 0.036); -DQB1*0301 positive patients had significantly higher T2-LV (34.1 vs 0.7 ml, p = 0.041), and showed a trend for lower BPF (0.790 vs 0.846, p = 0.064); -DQB1*0302 positive patients had significantly lower T1-LV (2.4 vs 0.9 ml, p = 0.016); and -DQB1*0602 positive patients had significantly lower GMF (0.492 vs 0.521, p = 0.007) and lower BPF (0.781 vs 0.811, p = 0.023). No differences were found in the indices of MRI disease severity according to HLA haplotype associations. Both in correlation and in regression analyses, we observed significant associations between HLA-DRB1*1501 and lower GMF and BPF and higher T1-LV, between -DQB1*0301 and higher T2-LV and disease duration, between -DQB1*0302 and lower GMF and higher T1- and T2-LV, between -DQB1*0602 and lower GMF and BPF, and between -DQB1*0603 and higher T1-LV and EDSS. High-resolution HLA genotyping analysis revealed a robust relationship between alleles HLA-DRB1*1501, -DQB1*0301, -DQB1*0302, -DQB1*0602, and -DQB1*0603, and more severe damage on inflammatory and neurodegenerative MRI measures.