Marco Perri

MR assessment of lumbar disk herniation treated with oxygen-ozone diskolysis: the role of DWI and related ADC versus intervertebral disk volumetric analysis for detecting treatment response.

We prospectively assessed the diagnostic criteria of morphologic MRI study (MMS) and the accuracy of DWI and related ADC values (DWI-ADC) versus intervertebral disk volumetric analysis (IDVA) for predicting shrinkage of lumbar disk herniation treated with oxygen-ozone (O2-O3) diskolysis. Sixty-eight patients (36 men and 32 women; mean age 39) with lumbosciatica underwent O2-O3 diskolysis. The six-month MRI follow-up was performed with FSE-T2 and T2-fat, SE-T1 and DWI-weighted images. IDVA was determined using OsiriX®. Diagnostic criteria and accuracy were evaluated with regards to DWI and related ADC in detecting response to ozone therapy. Fifty-eight of 68 patients had successful outcomes (responders), whereas ten patients showed unsatisfactory outcomes (non-responders). MMS showed that a centrally located herniated disk and grade 1 nerve root compression were more common in the responder group (p < 0.05). DWI-ADC and IDVA showed statistically significant shrinkage in the sixth month of follow-up (p < 0.05) with a mean ADC value reduction of 2.10 × 10−3mm2/s +/− 0.19 SD in the second month of follow-up (p < 0.05). DWI-ADC had an accuracy of 0.81 in detecting response to therapy around the second month of follow-up. DWI-ADC appear to be useful adjuncts to MMS in the follow-up of patients undergoing O2-O3 diskolysis.

MRI DWI/ADC signal predicts shrinkage of lumbar disc herniation after O2-O3 discolysis.

Purpose Evaluate the discal morpho-structural changes as a predictive sign in the clinical outcome after ozone therapy in lumbar disc herniation using the T2–shine through effect in diffusion-weighted imaging (DWI). Method One hundred and fifty-four patients suffering from lumbosciatica (89 men and 65 women; age range, 23–62 years) were included, previous MR study performed with FSE-T2 and T2-fat, SE-T1 and DWI sequences, and were randomly assigned to two groups. Seventy-seven patients (control group) underwent conservative treatment with intraforaminal injection of steroid and anaesthetic. The remaining 77 patients (study group) underwent the same treatment with the addition of oxygen–ozone (O2–O3). During the following six months, a MRI follow-up with the same sequences was performed. An intervertebral disc volumetric analysis (IDVA), DWI signal score and post treatment clinical outcome evaluation were performed for an assessment of hernia reduction. χ2 test, Students t test and analysis of covariance were used for comparison of variables. Results In the study group, 58 of 77 patients had a successful outcome (responders). In the responders group, DWI T2–shine through effect was present during MRI follow-up and in particular in 53 of 77 patients in six months of follow-up (p < 0.05). Moreover, in the same group a statistically significant disc shrinkage was shown by IDVA in sixth months of follow-up (p < 0.05). Conclusions T2–shine through effect in DWI is present before morphological disc reduction and moreover could be considered as a predictive sign of response to oxygen–ozone treatment.

Vascular malformation mimicking multiple sclerosis active plaque: Usefulness of susceptibility weighted imaging (SWI) to perform correct diagnosis

Brain focal hyperdensity areas are common findings in computed tomography examinations, often further evaluated in magnetic resonance imaging exams. These are usually haemosiderin and calcified perivascular clusters known as cerebral microbleeds and may be secondary signs of brain disorders. Cerebral microbleeds are paramagnetic and ferromagnetic substances determining magnetic field inhomogeneity. Susceptibility weighted imaging (SWI) performed at 3T with phase post-processing is very useful in evaluating this field variation. In fact in the past decade SWI has been increasingly reported for its clinical value in adults with neurologic disorders, traumas, arterial venous malformations, occult venous diseases, tumours and functional brain imaging. The occasional computed tomography findings of single or multiple focal hyperdense areas can mimic many of these brain disorders and lead to misinterpretations. For these reason it is useful to have a more detailed diagnosis with MRI brain examination. The authors highlight the role of SWI sequence in the differential diagnosis among active plaque, vascular malformation and haemorrhagic lesion in a case report of a 41-year-old woman suffering from multiple sclerosis with a focal hyperdense area reported in a computed tomography brain examination.

Systemic metastases from central nervous system ependymoma: case report and review of the literature

Ependymal tumours in adults are rare, accounting for less than 4% of primary tumours of the central nervous system, and exceptionally metastasise outside the nervous system. In this study, we present a case of anaplastic ependymoma, which developed metastases outside the nervous system less than a year after its clinical onset. A healthy 65-year-old woman suddenly presented with drowsiness of unknown origin, accompanied by ingravescent fatigue, inability to maintain the upright posture, headache, nausea and vomiting. Computed tomography study performed in the emergency department showed the presence of an inhomogeneously hypodense area, with temporoparietal extension and median line deviation. After surgical excision, performed after two days, the bioptic examination demonstrated an anaplastic ependymoma with multiple areas of necrosis. The patient was submitted to adjuvant radiation therapy. At magnetic resonance imaging follow-up, performed three months after surgery, neither local recurrences nor typical ‘drop metastases’ to the spinal area were observed. Three months later, magnetic resonance imaging control revealed bone metastases and recurrences in the left insula and at the ipsilateral cerebellar hemisphere. Total body computed tomography examination showed metastases in the liver, vertebrae and pelvic bones, and involvement of paratracheal lymph nodes.

Advanced neuroimaging of carbon monoxide poisoning

Carbon monoxide (CO) inhalation is nowadays the most common cause of fatal poisoning worldwide. CO binds to haemoglobin 230–270 times more avidly than oxygen, thus leading to formation of carboxyhaemoglobin with subsequent reduction of tissue oxygenation. Brain is mainly affected due to its high oxygen requirement. Up to two-thirds of patients who survive the acute phase of this pathology present a delayed leukoencephalopathy, usually in a period ranging from two to 40 days. White matter damage closely relates to long-term prognosis of these patients. On the other hand CO seems to play a fundamental role as a possible neuro-protective agent in ischaemic stroke. Diagnostic imaging, with computed tomography and magnetic resonance imaging, especially magnetic resonance spectroscopy, is very useful to depict the presence and extension of this pathology, in both acute and late phase. Nevertheless, a correlation of imaging studies with clinical history and laboratory data is fundamental to perform the correct diagnosis. The purpose of this article is to highlight the imaging features of brain CO poisoning in acute and late phase, describing a case report of a 56-year-old man found unconscious at home.