E. Turgut Tali

Intrathecal gadolinium (gadopentetate dimeglumine) enhanced magnetic resonance myelography and cisternography: Results of a multicenter study

Turgut Tali E, Ercan N, Krumina G, et al. Intrathecal gadolinium (gadopentetate dimeglumine) enhanced magnetic resonance myelography and cisternography: results of a multicenter study. Invest Radiol 2002;37:152–159. rationale and objectives. This cooperative multicenter human study was designed to evaluate the safety, magnetic resonance (MR) imaging characteristics, and clinical response to a single gadolinium contrast agent: gadopentetate dimeglumine. material and methods. Ninety-five patients (age range: 1 month to 78 years; sex: 50 males, 45 females) were included in this prospective study. The patients presented clinically with a variety of cranial or spinal signs and symptoms for which an intrathecal contrast myelogram or cisternogram was requested by clinical staff. Via lumbar puncture (20–25 g needle), 3 to 5 mL/ml of cerebrospinal fluid were withdrawn and mixed with a single volume of 0.5 (n = 63), 0.7 (n = 13), 0.8 (n = 12), or 1.0 (n = 7) cc/mL of gadopentetate dimeglumine (Magnevist; Schering, Berlin, Germany). This was then injected into the subarachnoid space, and the needle was removed. Immediate and delayed (up to 96 hours) T1- and T2-weighted MR imaging was performed on super conductive, high-field (1.0–1.5 tesla) imaging units in two or three planes. All patients were hospitalized for an observation period of 24 hours following the procedure, and follow-up neurologic examinations were performed serially for 6 to 12 months afterward. results. No patient manifested gross behavioral changes, neurologic alterations, or seizure activity at any time following the procedure. Nineteen patients (20%) experienced postural postlumbar puncture headache, six patients had nausea (6%), and two patients had episodes of vomiting (2%), all which resolved within the first 24 hours of the lumbar puncture with conservative bed rest. conclusion. This cooperative study demonstrates the general safety and feasibility of low dose (0.5–1.0 mL/ml) intrathecal gadopentetate dimeglumine administration. The potential useful clinical applications include the evaluation of obstructions and communications of the various subarachnoid spaces, spontaneous or traumatic/postsurgical craniospinal cerebrospinal fluid leaks, and subarachnoid space CSF flow and parenchymal CNS interstitial diffusion dynamics. This worldwide cooperative study seeks to progressively perform human studies for further definitive evaluation of the practical clinical applications, of the relationship of this technique to other imaging studies and modalities, and the long-term safety of the procedure in a larger number of subjects.

MR imaging and MR angiography in popliteal artery entrapment syndrome.

Abstract. Popliteal artery entrapment (PAE) syndrome is an uncommon congenital anomaly seen in young adults causing ischemic symptoms in the lower extremities. It is the result of various types of anomalous relationships between the popliteal artery and the neighboring muscular structures. The purpose of this study was to define the role of MR imaging combined with MR angiography in the diagnosis of PAE cases. Four cases with segmental occlusion and medial displacement of popliteal artery in digital subtraction angiography (DSA) examinations were diagnosed as PAE syndrome by MR imaging and MR angiography. The DSA and MRA images are compared. All of the cases showed various degrees of abnormal intercondylar insertion of the medial head of the gastrocnemius muscle. The MR images showed detailed anatomy of the region revealing the cause of the arterial entrapment. Subclassification of the cases were done and fat tissue filling the normal localization of the muscle was evaluated. The DSA and MRA images demonstrated the length and localization of the occluded segment and collateral vascular developments equally. It is concluded that angiographic evaluation alone in PAE syndrome might result in overlooking the underlying cause of the arterial occlusion, which in turn leads to unsuccessful therapy procedures such as balloon angioplasty. Magnetic resonance imaging combined with MR angiography demonstrates both the vascular anatomy and the variations in the muscular structures in the popliteal fossa successfully, and this combination seems to be the most effective way of evaluating young adults with ischemic symptoms suggesting PAE syndrome.

Pituitary metastases: MR findings.

Tumors metastatic to the pituitary gland are uncommon, and they are difficult to differentiate radiologically from pituitary adenomas. We retrospectively reviewed the MR examinations and clinical records of nine patients with radiographic and/or clinical evidence of pituitary metastases. The most common clinical symptoms included cranial nerve deficits (67%) and/or pituitary dysfunction (30%). Both occurred acutely and progressed rapidly over 1–4 weeks in all patients. Cranial nerve involvement was predominantly multiple (83%), a reflection of involvement of the adjacent cavernous sinus. In contrast to previous reports indicating a predilection for symptoms related to posterior lobe involvement (71%), our study shows that symptoms related to the anterior lobe are as common as posterior lobe symptoms. Useful MR findings included a relatively small, enhancing pituitary lesion (⩽1.5 cm in 56%) that was relatively isointense to brain on both T1− and T2-weighted images (78%) and involvement of the hypothalamus/pituitary infundibulum (44%) or cavernous sinus (56%).

Vertebral osteoblastoma: are radiologic structural changes necessary for diagnosis?

BACKGROUND A case of osteoblastoma localized at the pedicle of the 10th thoracic vertebra is presented. CASE DESCRIPTION The patient complained of nocturnal back pain not relieved by salycilates, a typical symptom of osteoblastoma. Bone scintigraphy showed a lower thoracic focus of increased osteoblastic activity; however, X-rays, computed tomography, and magnetic resonance images (MRI) were within normal limits, showing only obscure changes that were also noted in the rest of the spine. Repeat MRI with contrast revealed a focal enhancement. After pediculectomy, histopathologic examination confirmed the diagnosis of osteoblastoma. Fifteen months postoperatively, the patient is symptom-free. CONCLUSION Our case demonstrates that some cases of osteoblastoma may not have the classical radiological appearance. Although non-contrast computed tomography and T1-weighted MRI are mildly positive in some instances, osteoblastoma is best visualized on MRI with gadolinium. Like any other neoplasm, osteoblastoma should be detected and removed early, before it can cause structural bony changes.

Assessment of third ventriculostomy patency with the 3D-SPACE technique: a preliminary multicenter research study

OBJECT The goal of this study was to determine the value of the 3D sampling perfection with application-optimized contrasts using different flip-angle evolutions (3D-SPACE) technique in the evaluation of endoscopic third ventriculostomy (ETV) patency. METHODS Twenty-six patients with ETV were examined using 3-T MRI units. Sagittal-plane 3D-SPACE with variant flip-angle mode, 3D T1-weighted (T1W), and 3D heavily T2-weighted (T2W) images were obtained with isotropic voxel sizes. Also, sagittal-axial plane phase-contrast cine (PC)-MR images were obtained. The following findings were evaluated: diameters of stoma and third ventricle, flow-void sign on 3D-SPACE and PC-MR images, integrity of the third ventricle on heavily T2W images, and quantitative PC-MRI parameters of the stoma. Obtained sequences were evaluated singly, in combination with one another, and all together. RESULTS The mean area, flow, and velocity values measured at the level of stoma in patients with patent stoma were significantly higher than those measured in patients with closed stoma (p < 0.05). There was significant correlation among PC-MRI, 3D-SPACE, and 3D heavily T2W techniques regarding assessment of ETV patency (p < 0.001). The 3D-SPACE technique provided the lowest rate of ambiguous results. CONCLUSIONS The 3D-SPACE technique seems to be the most efficient one for determination of ETV patency. The authors suggest the use of 3D-SPACE as a stand-alone first-line sequence in addition to routine brain MRI protocols in assessing patients with ETV, thereby decreasing scan time and reserving the use of a combination of additional sequences such as PC-MRI and 3D heavily T2W images in suspicious or complex cases.

Pyogenic spinal infections.

Spinal infections are a spectrum of disease comprising spondylitis, diskitis, spondylodiskitis, pyogenic facet arthropathy, epidural infections, meningitis, polyradiculopathy, and myelitis. Inflammation can be caused by pyogenic, granulomatous, autoimmune, idiopathic, and iatrogenic conditions. In an era of immune suppression, tuberculosis, and HIV epidemic, together with worldwide socioeconomic fluctuations, spinal infections are increasing. Despite advanced diagnostic technology, diagnosis of this entity and differentiation from degenerative disease, noninfective inflammatory lesions, and spinal neoplasms are difficult. Radiological evaluations play an important role, with contrast-enhanced MR imaging the modality of choice in diagnosis, evaluation, treatment planning, interventional treatment, and treatment monitoring of spinal infections.

Presurgical evaluation of mesial temporal lobe epilepsy with multiple advanced MR techniques at 3T

BACKGROUND AND PURPOSE Accurate localization of the epileptogenic zone is essential for successful surgical treatment of mesial temporal lobe epilepsy (MTLE). The aim of this study was to analyze and compare the hippocampal volumetry (HV), MR spectroscopy (MRS), Dynamic susceptibility contrast (DSC) and pulsed arterial spin labeling (pASL) perfusion techniques in a large sample size of refractory MTLE patients. MATERIALS AND METHODS Forty-two patients with medically refractory MTLE who underwent preoperative evaluation and eleven normal controls were studied. Pathologic and control hippocampi were compared in terms of hippocampal volume, metabolite ratios and relative hippocampal perfusion values. By using cut-off points and asymmetry indexes, percentages of performance indicators for each technique were calculated in groups of MR (+), MR (-) and bilateral MTLE. RESULTS For all techniques, a statistically significant difference was found between the pathologic and control hippocampus groups (P<0.001). Also, all of them except HV had diagnostic value in groups of MR (-) and bilateral MTLE. CONCLUSION HV, MRS, DSC and pASL have achieved comparable performance and each of them provides important information about the lateralization of epileptogenic focus. Among those, pASL and MRS may easily be used as an adjunct to conventional MR.

New Year's greetings from ESNR.

The year 2013 has been a very successful and fruitful year for the European Society of Neuroradiology (ESNR). For the past year, our society witnessed great accomplishments and developments regarding Neuroradiology education and continued to grow with many neuroradiologists and societies from all over the world joining our family. With 4,084 members, ESNR is one of the major societies. Currently, 23 countries are represented in the Institutional Members Council. In 2013, new partnerships were established with many national Neuroradiological Societies such as Australia–New Zealand, Austria, Bosnia Herzegovina, Croatia, Finland, Latvia, Norway, Serbia, South Africa, Sweden, Switzerland, and the UK. Alongside these Neuroradiological societies, ESNR has also been cooperating with many other medical institutions and organizations. Just as the previous years, our primary objective as a society has been maintaining the leadership in Neuroradiology training and certification in Europe. The European School Of Neuroradiology (ESONR) has gained a more structured and institutionalized status under the chairmanship of Prof. Pia Maly Sundgren. Examination and Accreditation Subcommittees were established within its body and aim to support the organization in standardizing Neuroradiology education throughout Europe. Under the leadership of Prof. Paul Parizel, the Accreditation Subcommittee has been working on the rules and guidelines for the accreditation of the training centers, while the Examination Subcommittee has been primarily focusing on the standardization of the examinations under the chairmanship of Prof. Majda Thurnher. Within the three levels of ESONR Neuroradiology training, European courses in Neuroradiology have gained worldwide acceptance. With a great number of people signed up in advance, every course has filled to capacity and established waiting lists for prospective participants. Many participants have attended from outside Europe, including the Americas, Asia, Australia, and Africa. Furthermore, higher qualification European Diplomas have been introduced as a representation of the standardized third level Neuroradiology training. Only neuroradiologists who attend the third level courses of ESONR and pass individual examinations of each course as well as the final examination fulfill the criteria and are therefore entitled to obtain these higher qualification European Diplomas. Among first level courses, the Galen Foundation Course was organized by Prof. Cem Calli in Izmir, Turkey. This course introduced the basics of neuroradiology to radiology residents. The Galen Foundation Course also represented one of the activities of “European Month of the Brain” (EMoB) of the European Brain Council (EBC). This course had the logo of EMoB and was included in the EMoB activity report. Under the 12th cycle of ECNR, the second course of “CNS Tumors” was organized in Athens, Greece, by Prof. Athanasios Gouliamos, and the third course, “Vascular Diseases”, was organized in Antalya, Turkey, by Prof. E. Turgut Tali respectively. Following these courses, participants who completed the cycle of four courses and fulfilled the eligibility criteria applied for the board examinations. Forty-one applicants passed the board examination and thus, they have received the European Diploma in Neuroradiology (EDiNR). At the third level, Pediatric Neuroradiology, Interventional Neuroradiology, and Spine Interventional Neuroradiology courses have been initiated while the Head and Neck Neuroradiology course is yet to be introduced. Under the leadership of Prof. Andrea E. T. Tali (*) Department of Radiology, Division of Neuroradiology, Gazi University School of Medicine, Besevler, Ankara 06510, Turkey e-mail: turgut.tali@gmail.com

Brain, Head, and Neck

MRI in neuroradiology has evolved in the last 30 years, becoming faster, more precise, and more specific. The latest additions, including magnetic resonance spectroscopy (MRS), diffusion imaging, diffusion tensor imaging, functional MRI, and dynamic susceptibility contrast perfusion imaging, have expanded the applications for MR imaging. Currently, fluid attenuation inversion recovery (FLAIR) imaging, thin-section 3D volumetric imaging with spoiled gradient techniques, and the others mentioned above permit not only the precise localization of brain lesions, but also the evaluation of their metabolic profile, their location relative to eloquent regions of the cortex and subcortical white matter, and the relative blood volume and permeability of the vasculature that supplies the lesion. Thus, cellular, vascular, functional and anatomic information are obtained in one examination session and are available to treating physicians in their office, operating room, or radiation therapy suite.

Giant Prolactinoma Mimicking Bone Tumor

Prolactinomas are the most common of the hormone-secreting pituitary tumours. Most of them are small in size <10 mm (microprolactinomas) and few are >10 mm (macroprolactinomas). It is well known that clinical presentations of prolactinomas are quite different between genders4,5. The vast majority (95%) of prolactinomas in women are microadenomas which present with the clinical manifestations of hyperprolactinaemia. In contrast, men with prolactinomas often present because of symptoms due to the size of the tumour rather than impotence, loss of libido or infertility1,3. Giant pituitary tumours (larger than 4 cm) are rare and most of them are nonfunctional. Giant prolactinomas with massive extrasellar extension are also rare and their clinical management is sometimes problematic. Radiological examinations are of great value in tumour evaluation.