Contribution of advanced neuro-imaging (MR diffusion, perfusion and proton spectroscopy) in differentiation between low grade gliomas GII and MR morphologically similar non neoplastic lesions

Background Non-neoplastic brain lesions can be misdiagnosed as low-grade gliomas. Conventional magnetic resonance (MR) imaging may be non-specific. Additional imaging modalities such as spectroscopy (MRS), perfusion and diffusion imaging aid in diagnosis of such lesions. However, contradictory and overlapping results are still present. Hence, our purpose was to evaluate the role of advanced neuro-imaging in differentiation between low-grade gliomas (WHO grade II) and MR morphologically similar non-neoplastic lesions and to prove which modality has the most accurate results in differentiation. Results All patients were classified into two main groups: patients with low-grade glioma (n = 12; mean age, 38.8 ± 16; 8 males) and patients with non-neoplastic lesions (n = 27; mean age, 36.6 ± 15; 19 males) based on the histopathological and clinical–radiological diagnosis. Using ROC curve analysis, a threshold value of 0.93 for rCBV (AUC = 0.875, PPV = 92%, NPV = 71.4%) and a threshold value of 2.5 for Cho/NAA (AUC = 0.829, PPV = 92%, NPV = 71.4%) had 85.2% sensitivity and 83.3% specificity for predicting neoplastic lesions. The area under the curve (AUC) of ROC analysis was good for relative cerebral blood volume (rCBV) and Cho/NAA ratios (> 0.80) and fair for Cho/Cr and NAA/Cr ratios (0.70–0.80). When the rCBV measurements were combined with MRS ratios, significant improvement was observed in the area under the curve (AUC) (0.969) with improved diagnostic accuracy (89.7%) and sensitivity (88.9%). Conclusions Evaluation of rCBV and metabolite ratios at MRS, particularly Cho/NAA ratio, may be helpful in differentiating low-grade gliomas from non-neoplastic lesions. The combination of dynamic susceptibility contrast (DSC) perfusion and MRS can significantly improve the diagnostic accuracy and can help avoiding the need for an invasive biopsy.

EANM procedure guidelines for brain PET imaging using [18F]FDG, version 3

The present procedural guidelines summarize the current views of the EANM Neuro-Imaging Committee (NIC). The purpose of these guidelines is to assist nuclear medicine practitioners in making recommendations, performing, interpreting, and reporting results of [18F]FDG-PET imaging of the brain. The aim is to help achieve a high-quality standard of [18F]FDG brain imaging and to further increase the diagnostic impact of this technique in neurological, neurosurgical, and psychiatric practice. The present document replaces a former version of the guidelines that have been published in 2009. These new guidelines include an update in the light of advances in PET technology such as the introduction of digital PET and hybrid PET/MR systems, advances in individual PET semiquantitative analysis, and current broadening clinical indications (e.g., for encephalitis and brain lymphoma). Further insight has also become available about hyperglycemia effects in patients who undergo brain [18F]FDG-PET. Accordingly, the patient preparation procedure has been updated. Finally, most typical brain patterns of metabolic changes are summarized for neurodegenerative diseases. The present guidelines are specifically intended to present information related to the European practice. The information provided should be taken in the context of local conditions and regulations.

Childhood Malignant Brain Tumors: Balancing the Bench and Bedside

Brain tumors are the leading cause of childhood cancer deaths in developed countries. They also represent the most common solid tumor in this age group, accounting for approximately one-quarter of all pediatric cancers. Developments in neuro-imaging, neurosurgical techniques, adjuvant therapy and supportive care have improved survival rates for certain tumors, allowing a future focus on optimizing cure, whilst minimizing long-term adverse effects. Recent times have witnessed a rapid evolution in the molecular characterization of several of the common pediatric brain tumors, allowing unique clinical and biological patient subgroups to be identified. However, a resulting paradigm shift in both translational therapy and subsequent survival for many of these tumors remains elusive, while recurrence remains a great clinical challenge. This review will provide an insight into the key molecular developments and global co-operative trial results for the most common malignant pediatric brain tumors (medulloblastoma, high-grade gliomas and ependymoma), highlighting potential future directions for management, including novel therapeutic options, and critical challenges that remain unsolved.

Clinical Improvement of Cervical Disc Herniation 24 hours after a Single Oxygen-Ozone Injection

Oxygen-ozone therapy is a minimally invasive treatment for disc herniation, compared to surgery, which uses the beneficial biochemical properties of a gas mixture of ozone and oxygen. A satisfactory efficacy is usually obtained within one month after the injection. We assessed the therapeutic outcome of a single injection of oxygen-ozone in a symptomatic patient with C5-C6 cervical discal herniation with compression of the nerve roots. He experienced immediate pain relief seconds after the injection, and neuro-imaging improvement 24 hours afterwards. To our knowledge this is the fastest improvement ever reported in literature.

A Python toolbox for Automatic Face Alignment (AFA)

We describe AFA, an open-source Python package for automating the most common step in the preparation of facial stimuli for behavioral and neuro-imaging experiments – spatial alignment of faces (https://github.com/SourCherries/auto-face-align ). Face alignment is also important in the analysis of image statistics, and as a preprocessing step for machine learning. Automation of face alignment via AFA provides a reliable and efficient alternative to the very common practice of manual image-editing in graphics editors like Photoshop. As an open-source Python package, AFA encourages a clear and transparent specification of experimental method. AFA is based on facial landmark detection that is powered by the reliable and open-source DLIB library; and critical alignment code based on Generalized Procrustes Analysis (GPA) has been extensively unit-tested. AFA documentation and modularity provides opportunity for the modification and extensibility of AFA by the scientific community. As examples, we include functions for automatically generating image apertures that conceal areas outside the inner face; for image morphing between facial identities; and for shape-based averaging of facial identity. All of these are examples of stimulus preparation that have previously required manual landmark selection.

A case of moderate depression with somatic symptoms and incidental finding of retrocerebellar arachnoid cyst

Arachnoid cysts are benign space-occupying brain lesions that contain cerebrospinal fluid which is mostly congenital in origin. Cases are mostly detected incidentally on neuro-imaging and neuropsychiatric manifestations are less common and under-recognized. Arachnoid cyst sometimes may be associated with seizure, headache, cranial nerve deficits, hydrocephalus, etc. A 23-year-old married female from rural India presented with headache, insomnia, low mood, lethargy, persisting for the past 6 months without any obvious stress factors. She also informed that she had few episodes of unresponsiveness without any features such as tongue biting, confusion, injury, or involuntary micturition and defecation. Her EEG report was within normal limit and MRI report confirmed the presence of Retro-cerebellar Arachnoid cyst in and around midline. Detail neurological and ophthalmological examination was done and findings were within normal limits. She was treated with Amitriptyline, Pregabalin, and Paracetamol. Psychotherapy was initiated for adequate management of her depressive symptoms and responded well. It can be emphasized that patients who are reporting with symptoms such as headache a detail evaluation should be done to find out organic etiology. Depressive and cognitive symptoms and its association with arachnoid cyst may depend upon the location of the lesion and further research is required to establish its causal relationship.

P.095 The many clinical facets of pediatric occipital spikes and the predictive value of consistent EEG dipole

Background: Pediatric occipital epileptiform discharges (OEDS) occur in various clinical settings, including benign and symptomatic epilepsies. The study objective is to determine electro-clinical predictors for aetiology and prognosis in children with OEDs. Methods: 205 patients with OEDs were classified into seizure groups: symptomatic (n=98), idiopathic focal (IF) (n=57), idiopathic generalized (IG) (n=18), no-seizures (n=27) and febrile seizures (n=5). Results: The median age of seizure onset was 3 years (range: 0-19). There was more EEG background slowing (P<0.05) in the symptomatic; photosensitivity (P<0.0001) and GSW (P<0.0001) in IG; and presence of consistent EEG spike dipole in IF group. The symptomatic had more DD (P< 0.0001), autism (P <0.019), and school difficulties (P<0.001) than the IF and IG groups, but not different from the no-seizure group. Conclusions: OEDs with consistent dipole spike is predictive of IF epilepsy. In contrast to frontal and temporal lobe epilepsy, only 30% with symptomatic epilepsy had occipital-predominant neuro-imaging abnormalities. Notably, neuro-psychiatric co-morbidities were similar between the symptomatic and no-seizure group.

P.070 Introducing Stroke Endovascular Thrombectomy Into A Smaller Canadian Site, Is It Safe?

Background: Success of Endovascular Thrombectomy (EVT) requires ultra-fast access to specialized neuro imaging, neurological assessment and an angio suite with interventional radiologists. Prior access was via transport to Vancouver and outcomes were poor, with a high rate of disability or death. This appeared primarily due to long delays. Methods: Quality control process, in parallel to the introduction of a new intervention, EVT, to Vancouver Island, to determine if this intervention could be delivered with reasonable safety and good outcomes. Patients receiving EVT from May, 2016 until Sep, 2019 are included, with 90-day outcomes. Data was collected by stroke nurses. Results: The proportion of patients having a good outcome was comparable to that of the major clinical trial involving Canadian academic centres. The proportion sustaining a poor outcome was comparable to the control group in that trial population (who still received tPA treatment where possible). This was despite a median age 4.5 years greater than in that trial. Conclusions: EVT required coordination of multiple services. Victoria General Hospital performance in terms of speed to treatment was slower than in the published trials. This is a factor in determining outcome and is therefore an important quality improvement target moving forward.

P.104 Children with Trisomy 21 and Lennox-Gastaut Syndrome with predominant myoclonic seizures

Background: Lennox-Gastaut syndrome (LGS) is a severe form of pediatric epilepsy that is classically defined by a triad of drug-resistant seizures, characteristic EEG patterns, and intellectual disability. Long-term prognosis is generally poor with progressive intellectual deterioration and persistent seizures. At present, there are few reported cases of LGS and Trisomy 21 (T21) in the literature. To further delineate the spectrum of epilepsy in T21, we reviewed children with T21 and LGS at one center over 28 years. Methods: This is a retrospective case series. At our institution, all EEG results are entered into a database, which was queried for patients with T21 from 1992-2019. Pertinent electro-clinical data was obtained from medical records. Results: 63 patients with T21 and epilepsy, 6 (10%) had LGS and were included in the study. Four of the six patients were male and 5/6, had neuro-imaging, which was normal. Follow-up ranged from 3-20 years. Notably, 5/6 had predominant myoclonic seizures throughout the course of their epilepsy, associated with generalized spike-wave discharges. Conclusions: Myoclonic seizures appear to be a predominant seizure type in patients with T21, suggestive that T21 patients may have a unique pattern of LGS.

Does the second ischemic stroke herald a higher proportional risk for cognitive and physical impairment than the first-ever one?

Background Post-stroke cognitive and physical disabilities are common sequelae; however, it seems that the second ischemic stroke carries a higher proportional risk more than expected. In this study, we aimed to study second stroke sequelae over first-ever one with regard to cognition and physical competence. This study was conducted on two groups; the first composed of 40 patients with acute first lifetime ischemic stroke, and the second group composed of 40 acute second lifetime ischemic stroke. The study was done at menoufiya university hospitals from August 2017 to August 2018. Modified Rankin Scale (MRS), National Institute of Health Stroke Scale (NIHSS), and MINI-Cog Score, were performed at onset, 2 weeks and 3 months later. In addition, routine lab and neuro-imaging were also done. Results Size of infarction is larger in 2nd group (p < 0.001), MRS, and NIHSS are significantly higher in 2nd group. Also, there are significant differences between baseline, 2 weeks, and 3 months follow-up in MRS and NIHSS. Mini-Cog scale showed significant difference between the two groups in favor of better cognition in the 1st group. Atrial fibrillation (AF), p = 0.012 was a significant risk factor in the 1st group while smoking, p = 0.017 was the significant risk factor in the 2nd group. Large size stroke was found as independent risk factor in the 2nd group (p < 0.001). Conclusions There are significant cognitive and physical disabilities in the second recurrent ischemic stroke as compared to the first-ever one, and the second stroke tend to be more dangerous and carry more disability.