John F. Boardman

Hemorrhage in Posterior Reversible Encephalopathy Syndrome: Imaging and Clinical Features

BACKGROUND AND PURPOSE: Hemorrhage is known to occur in posterior reversible encephalopathy syndrome (PRES), but the characteristics have not been analyzed in detail. The purpose of this study was to evaluate the imaging and clinical features of hemorrhage in PRES. MATERIALS AND METHODS: Retrospective assessment of 151 patients with PRES was performed, and 23 patients were identified who had intracranial hemorrhage at toxicity. Hemorrhage types were identified and tabulated, including minute focal hemorrhages (<5 mm), sulcal subarachnoid hemorrhage, and focal hematoma. Clinical features of hemorrhage and nonhemorrhage PRES groups were evaluated, including toxicity blood pressure, coagulation profile/platelet counts, coagulation-altering medication, and clinical conditions associated with PRES. Toxicity mean arterial pressure (MAP) groups were defined as normal (<106 mm Hg), mildly hypertensive (106–116 mm Hg), or severely hypertensive (>116 mm Hg). RESULTS: The overall incidence of hemorrhage was 15.2%, with borderline statistical significance noted between the observed clinical associations (P = .07). Hemorrhage was significantly more common (P = .02) after allogeneic bone marrow transplantation (allo-BMT) than after solid-organ transplantation. The 3 hemorrhage types were noted with equal frequency. A single hemorrhage type was found in 16 patients, with multiple types noted in 7. Patients undergoing therapeutic anticoagulation were statistically more likely to develop hemorrhage (P = .04). No difference in hemorrhage incidence was found among the 3 blood pressure subgroups (range, 14.9%–15.9%). CONCLUSIONS: Three distinct types of hemorrhage (minute hemorrhage, sulcal subarachnoid hemorrhage, hematoma) were identified in PRES with equal frequency. The greatest hemorrhage frequency was seen after allo-BMT and in patients undergoing therapeutic anticoagulation. Hemorrhage rate was independent of the toxicity blood pressure.

Recurrent posterior reversible encephalopathy syndrome: report of 3 cases--PRES can strike twice!

In a retrospective review, 3 (3.8%) of 78 patients developed recurrent posterior reversible encephalopathy syndrome. Underlying clinical conditions included sickle cell disease, antibody-positive autoimmune disease, and allogeneic bone marrow transplantation. Infection (bacterial/viral) was suspected or documented in both episodes in all 3 patients. Evidence of endothelial injury (schistocyte formation and increased lactate dehydrogenase) was documented in all patients, and multiple organ dysfunction syndrome developed during the hospital course of all admissions.

White matter lesions and brain gray matter volume in cognitively normal elders

Cerebral white matter lesions (WMLs) reflect small vessel disease, are common in elderly individuals, and are associated with cognitive impairment. We sought to determine the relationships between WMLs, age, gray matter (GM) volume, and cognition in the Cardiovascular Health Study (CHS). From the Cardiovascular Health Study we selected 740 cognitively normal controls with a 1.5 T magnetic resonance imaging (MRI) scan of the brain and a detailed diagnostic evaluation. WML severity was determined using a standardized visual rating system. GM volumes were analyzed using voxel-based morphometry implemented in the Statistical Parametric Mapping software. WMLs were inversely correlated with GM volume, with the greatest volume loss in the frontal cortex. Age-related atrophy was observed in the hippocampus and posterior cingulate cortex. Regression analyses revealed links among age, APOE*4 allele, hypertension, WMLs, GM volume, and digit symbol substitution test scores. Both advancing age and hypertension predict higher WML load, which is itself associated with GM atrophy. Longitudinal data are needed to confirm the temporal sequence of events leading to a decline in cognitive function.

Initial Experience in Using Continuous Arterial Spin-Labeled MR Imaging for Early Detection of Alzheimer Disease

BACKGROUND AND PURPOSE: MR imaging of the brain has significant potential in the early detection of neurodegenerative disorders such as AD. The purpose of this work was to determine if perfusion MR imaging can be used to separate AD from normal cognition in individual subjects. We investigated the diagnostic utility of perfusion MR imaging for early detection of AD compared with structural imaging. MATERIALS AND METHODS: Data were analyzed from 32 participants in the institutional review board−approved CHS-CS: 19 cognitively healthy individuals and 13 with clinically adjudicated AD. All subjects underwent structural T1-weighted SGPR and CASL MR imaging. Four readers with varying experience separately rated each CASL and SPGR scan finding as normal or abnormal on the basis of standardized qualitative diagnostic criteria for observed perfusion abnormalities on CASL or volume loss on SPGR and rated the confidence in their evaluation. RESULTS: Inter-rater reliability was superior in CASL (κ = 0.7 in experienced readers) compared with SPGR (κ = 0.17). CASL MR imaging had the highest sensitivity (85%) and accuracy (70%). Frontal lobe CASL findings increased sensitivity to 88% and accuracy to 79%. Fifty-seven percent of false-positive readings with CASL were in controls with cognitive decline or instability within 5 years. Three of the 4 readers revealed a statistically significant relationship between confidence and correct classification when using CASL. CONCLUSIONS: Readers were able to separate individuals with mild AD from those with normal cognition with high sensitivity by using CASL but not volumetric MR imaging. This initial experience suggests that CASL MR imaging may be a useful technique for detecting AD.

Posterior Reversible Encephalopathy Syndrome and Cerebral Vasculopathy Associated With Influenza A Infection: Report of a Case and Review of the Literature

Background and Purpose: Influenza A infection can precipitate encephalopathy, encephalitis, or Reye syndrome with the development of cerebral edema in children and is associated with an increased incidence of stroke in adults. The mechanism of these events is poorly understood. Posterior reversible encephalopathy syndrome (PRES) is seen in association with infection/sepsis, and cerebral vasculopathy has been demonstrated in PRES. We describe a case of PRES that develops in association with influenza A. Summary of Case: A normotensive 65-year-old woman presented with altered mentation and nausea in the setting of a viral prodromal illness ultimately confirmed as influenza A. Posterior reversible encephalopathy syndrome developed on the second day after admission. Catheter cerebral angiogram documented vasculopathy in PRES-involved regions with areas of focal vessel dilatation and string-of-bead appearance. Conclusions: The association between influenza A and PRES with documentation of cerebral vasculopathy suggests a common systemic vascular mechanism behind PRES and influenza-related encephalopathic edema and stroke.

Associations Between Serum Biomarkers and Pain and Pain‐Related Function in Older Adults with Low Back Pain: A Pilot Study

To examine the relationship between serum biomarkers and self‐reported pain intensity and pain‐related function, in addition to the contribution of magnetic resonance imaging (MRI) findings of lumbar spine degenerative changes, in older adults with chronic low back pain.

Influenza A Encephalopathy, Cerebral Vasculopathy, and Posterior Reversible Encephalopathy Syndrome: Combined Occurrence in a 3-Year-Old Child

SUMMARY: Encephalopathy is an uncommon complication of childhood influenza infection, typically recognized during influenza epidemics. Imaging hallmarks include characteristic thalamic lesions, thalamic necrosis and hemispheric edema. We describe a child with acute influenza A associated necrotizing encephalopathy with MR angiographic evidence of significant cerebral vasculopathy and a hemispheric edema pattern consistent with PRES. This case reinforces that significant cerebral vasculopathy can accompany influenza infection and that influenza is a likely trigger for PRES.

Lesions and Pseudolesions of the Cavernous Sinus and Petrous Apex

Endoscopic surgery using an expanded endonasal approach now allows surgical access to an increasing range of parasellar, suprasellar, clivus, and petrous apex lesions. Accurate preoperative planning requires proper interpretation of CT and MRI results. It is essential to identify important anatomic landmarks and to recognize the appearance of common lesions and pseudolesions. Postoperative imaging must evaluate for residual tumors and identify iatrogenic conditions.

Correlation of pain with objective quantification of magnetic resonance images in older adults with chronic low back pain.

Study Design. Cross sectional study. Objective. The goal of this study is to identify relationships between objectively measured and subjectively scored parameters and reported pain. Summary of Background Data. Studies have demonstrated the unreliability of magnetic resonance imaging (MRI)–based parameters to identify pathological pain generators of chronic low back pain, but they were based on visual inspection and subjective assessment of lumbar disc features. Advancements in computer image analysis provide objective measurements of lumbar disc features. Methods. Two radiologists evaluated 39 axial and sagittal T1- and T2-weighted MR images of patients with chronic axial low back pain (age, >65 yr) and graded 4 subjective lumbar disc parameters (T2 signal intensity, nucleus shape, Modic changes, and osteophyte formation) whose sum is the cumulative MRI score. Objective parameter, MRI index, was calculated as the product of the measured lumbar disc area and total disc MRI signal intensity. Discs were sorted from least to the most degenerated relative to each parameter. Pearson correlation coefficient and multiple linear regression analysis were performed between the reported pain score and each parameter. Results. The most and least degenerated discs in each patient, as assessed by MRI index, had the highest negative and positive correlation coefficient and regression weight contribution, respectively. All subjective parameters had low correlation coefficients and regression goodness of fit. Conclusion. Although limited by small sample size, the objective parameter, MRI index, can be a potential imaging biomarker used to identify possible pain generators. This study presents a potential new application of MR imaging in identifying pain generators of patients with chronic low back pain. Level of Evidence: N/A

Poster 177 Serum Biomarkers Relate to Pain and Pain Related Disability in Older Adults With Low Back Pain

Disclosures: I. Choi, No Disclosures. Objective: Regular aerobic exercise programs such as walking and swimming improved the cognitive function in healthy or aged persons. However, there is no evidence which exercise would be more effective on the cognitive function in stroke patients. The aim of this study was to compare the effects of treadmill exercise and swimming exercise on the cognitive function in cerebral infarction rats. Design: A prospective, experimental, group allocation design. Setting: An animal laboratory in the tertiary university hospital. Participants: Twenty-seven 10-week-old male Sprague-Dawley rats. Interventions: Rats were subjected to photothrombotic cerebral infarction on the left parietal lobe. All rats were randomly divided into 3 groups: control group (group A, n 9); swimming exercise group (group B, free swimming, 10 minutes a day, 5 days a week, for 4 weeks, n 9); treadmill exercise group (group C, maximal velocity of 24 m/min, 5 days a week, for 4 weeks, n 9). Main Outcome Measures: Morris water maze tests were performed for the evaluation of the cognitive function. The activity of superoxide dismutase (SOD) in the hippocampus was measured. Cresyl violet stain and immunohistochemistry for brain derived neurotrophic factor (BDNF) in the hippocampus were conducted. Results: After the exercise programs of 4 weeks, escape latencies on hidden platform trial were shorter in group B and C than in group A (P .006). However, there was no significant difference between group B and C. The activity of SOD was more increased in group B and C than in group A (P .000). However, there was no significant difference between group B and C. More normal neuronal cells were found in CA3 region of hippocampus of group B and C. Immunoreactivity for BDNF was more expressed in group B and C. Conclusions: Treadmill exercise and swimming exercise were not different in terms of the effect on the cognitive function. Both exercises would be useful for improving the cognitive function in photothrombotic cerebral infarction rats.