Search

Purpose: To assess utility of computed tomography perfusion (CTP) protocols for selection of patients with acute ischemic stroke (AIS) for reperfusive treatments and compare the diagnostic accuracy (ACC) in predicting follow-up infarction, using time-to-maximum (Tmax) maps. Methods: We retrospectively reviewed consecutive AIS patients evaluated for reperfusive treatments at comprehensive stroke center, employing a multimodal computed tomography. To assess prognostic accuracy of CTP summary maps in predicting final infarct area (FIA) in AIS patients, we assumed the best correlation between non-viable tissue (NVT) and FIA in early and fully recanalized patients and/or in patients with favorable clinical response (FCR). On the other hand, the tissue at risk (TAR) should better correlate with FIA in untreated patients and in treatment failure. Results: We enrolled 158 patients, for which CTP maps with Tmax thresholds of 9.5s and 16s, presented sensitivity of 82.5%, specificity of 74.6%, and ACC of 75.9%. In patients selected for perfusion deficit in anterior circulation territory, CTP-Tmax > 16s has proven relatively reliable to identify NVT in FCR patients, with a tendency to overestimate NVT. Similarly, CTP-Tmax > 9.5s was reliable for TAR, but it was overestimated comparing to FIA, in patients with unfavorable outcomes. Conclusions: In our experience, Tmax thresholds have proven sufficiently reliable to identify global hypoperfusion, with tendency to overestimate both NVT and TAR, not yielding satisfactory differentiation between true penumbra and benign oligoemia. In particular, the overestimation of NVT could have serious consequences in not selecting potential candidates for a reperfusion treatment.

Background: The essential features of Posterior Reversible Encephalopathy Syndrome (PRES) are headache, mental changes, seizures, visual symptoms and often arterial hypertension. Brain RMN typically shows cortico-sottocortical parieto-occipital edema, with a bilateral and symmetric distribution. PRES develops in clinical conditions as hypertensive encephalopathy, preeclampsia/ eclampsia, autoimmune diseases, after transplantation, infections and as an adverse effect of immunosuppressive drugs or chemotherapy. It usually completely reverses with treatment, although permanent sequelae are possible in case of delayed or missed diagnosis. Case report: We describe the case of a transsexual (M!F) and tetraplegic patient, admitted for neck and low back pain. She suddenly developed headache, confusion, seizures and severe hypertension with normal blood tests. RMN showed multiple cortico-sottocortical areas of vasogenic and citotoxic edema in temporo-occipital, parietal, frontal, and cerebellar regions. Soon after the beginning of the antihypertensive therapy, clinical recovery was observed, as well as the disappearance of edema at RMN. Discussion and conclusions: Although PRES is usually associated with definite pathological conditions, it is not always the case, as was for the patient here described, who had no predisposing factors in her past clinical history, and presented hypertension only in the acute phase of the syndrome. Since, moreover, PRES usually presents with acute non specific features and it can be misdiagnosed with other serious diseases, the clinician will be helped by the knowledge of this syndrome to promptly start diagnostic workup and treatments, and avoid permanent neurological deficits.

MR angiography5,17 is traditionally divided into “non-contrast enhanced” (NCE MRA) and “contrast-enhanced” (CE MRA) techniques. Contrast-enhanced techniques were initially developed to solve some of the problems encountered with non-contrast-enhanced methods, namely the long examination times, pulsatile flow artefacts, saturation when the mean blood flow is slow or when the imaging slice is parallel to the vessel, the characteristic problems of time of flight (TOF) acquisitions, and the need to define a priori beforehand the velocity sensitivity for phase contrast (PC) acquisitions. Currently used contrast-enhanced techniques 7,8,15,18 are based on the acquisition of 3D gradient-echo sequences synchronized at the first passage of contrast medium by different strategies (detection of a test bolus injection, automated triggering, fluoroscopic imaging). Basically, contrast medium is administered to counteract saturation induced by slow blood flow or flow directed parallel to the imaging slice. Contrast medium serves to obtain a “static” image of vascular structures with acquisitions times ranging from a few seconds to 1–2 minutes. To avoid venous contamination, different methods have been used to collect data (centric-approach, elliptical-centric phase encoding order, etc.) in an attempt to record first the information relating to low spatial frequencies (contrast data) with respect to high spatial frequencies (detail and contour data).

Case Report We observed a 20-year-old woman, with a negative medical and family history, referred to our Movement Disorder Clinic for belly twitching, restlessness, and insomnia. All symptoms had an abrupt onset 6 months before admission, some weeks after an antibioticresponsive sore throat. On admission, she presented motor hyperactivity, a variety of subtle choreic movements, involving neck and upper and lower limbs, and bilateral synchronous or asynchronous abdominal muscle contractions causing the umbilicus to move around the abdomen, without stimulus sensitiveness, uninfluenced by posture or voluntary movements. Brain and spine magnetic resonance imaging, EEG, and somatosensory evoked potentials were normal. Laboratory tests revealed an elevated antistreptolysin O titer (379 U, normal !200 U). Polygraphic evaluation showed intermittent involuntary bursts of marked variability in duration (800– 1,200 ms) with a semirhythmic low repetition (0.1 Hz) rate in the rectus abdominis muscles, synchronous on both sides, with synchronous or asynchronous bursts lasting 50–500 ms in both oblique muscles (fig. 1). Diazepam at an oral dose of 5 mg/day was followed by a slight clinical improvement. One year later, she became anxious and hyperkinetic; she started dreading poisoning and developed compulsive behaviors (changing her underclothes and washing her hands frequently) some days after a febrile illness. Physical examination disclosed variable motor and vocal tics like throat clearing, sniffing, shoulder shrugging, head and body swinging, piano-playing movements of her fingers, moving toes. The tics showed voluntary suppressibility with a subsequent rebound. Abdominal wall contractions were still present. Laboratory tests revealed elevated antideoxyribonuclease B (319 U, normal !200 U) and antistreptolysin O (277 U, normal !200 U) titers. Electrocardiographic findings were normal. Polygraphic recording showed pseudoperiodic (near 0.5 Hz) isolated or short trains of twitches in the oblique muscles (data not shown), sparse twitches, and isolated jerks or groups of clonic bursts of 250–1,000 ms duration with a repetition rate of 1–0.5 Hz on the paraspinal muscles of T8 level; asymmetric bursts with a duration of 800–1,200 ms, grouped in trains of 8–10 discharges, were recorded from electrodes placed at the intercostal level T6 (fig. 2). The involuntary movements disappeared during sleep.

A specific allele of the NACP-Rep1 polymorphism within the alpha-synuclein promoter was found to be associated both with Parkinson's disease and essential tremor. We repeated the association study on a large series of Italian patients with essential tremor using a panel of polymorphisms within the alpha-synuclein gene. Our results did not confirm the association reported previously and failed to identify a alpha-synuclein specific haplotype as susceptibility factor for essential tremor.

We describe a 17-year-old boy with a left extraventricular temporo-mesial neurocytoma associated with cortical dysplasia causing focal pharmacoresistant temporal lobe epilepsy. He presented with a long history of medically refractory, temporal complex partial seizures. MRI showed a left temporo-mesial lesion suspect to be a low-grade tumor. Based on the pre-operative non-invasive neurophysiological studies, the patient underwent a left tailored temporal antero-mesial resection. Histopathological examination showed an extraventricular neurocytoma associated with architectural dysplasia (Type 1a) of the temporal pole. The patient was seizure-free at 2 years follow-up. Extraventricular neurocytomas must be considered in the differential diagnosis of the plethora of low-grade tumors associated with focal epilepsy that typically involve the temporal lobe, and are frequently associated with focal cortical dysplasia.