FLAIR vascular hyperintensity, an early sign of stroke (case report)

Background Generally, Diffusion-weighted MR imaging (DWI) is known to be more sensitive in diagnosis of acute stroke than other MR sequences. However, fluid attenuated inversion recovery (FLAIR) MR sequence founded to be sometimes more sensitive compared to DWI for the diagnosis of hyperacute stroke. Case presentation An 84 years old female patient brought to ER by ambulance due to loss of speech, dizziness and confusion. Neurological examination showed that the patient can raise her left hand and leg while partially moving her right hand and right leg. The patient had slurred speech. Provisional diagnosis was acute stroke and the patient admitted in the hospital. Non contrast CT scan of the brain was done, was negative for stroke. Then MRI was done showed no areas of restricted diffusion at the DWI sequence or ADC map. Prominent high signal vessels at the left temporal region and on Sylvian fissure were noticed on FLAIR sequence that might have suggested early sign of ischemic vascular insult. Conclusions Arterial hyperintensity on FLAIR images can precede diffusion abnormalities and may provide a clue to the early detection of impending infarction.

Three - dimensional fluid attenuated inversion recovery sequence on 3 tesla magnetic resonace imaging in cranial nerve pathologies: Two case reports

Three - dimensional fluid attenuated inversion recovery sequence (3D-FLAIR) was introduced as a practical sequence which helps to reduce the cerebrospinal fluid pulsation and flow artefacts of conventional 2D acquisition and brings contiguous slices, ability in reformatting in variable planes which are typical features of 3D acquisition. 3D - FLAIR has been applied on assessing several neurologic pathologies. In this article, we introduce the application of 3D - FLAIR sequence without contrast enhancement on detecting abnormalities of cranial nerve pathology by presenting two cases, acute vestibular neuritis and facial nerve palsy. We suggest that 3D - FLAIR is the relatively useful sequence in detecting cranial nerve pathologies.

Abstract MP13: Evaluation Of The Effect Of Low Grade Inflammation And Hypertension On The Development Of White Matter Lesions

Introduction: The risk of degenerative disease development is closely linked to persistent and continuous systemic inflammation. Although relationships between chronic low-grade inflammation (LGI) measurements and the progression of cardiovascular diseases are becoming established, the burden of the cardio-pathology and LGI on the central nervous system has not been fully investigated. Specifically, there is limited data on how hypertension (HTN) and related LGI impact white matter lesion (WML) pathogenesis. Methods: We examined 448 subjects with a mean age of 69.3 ± 7.4 years, with 62% of the cohort being women (n=276), and 45% having hypertension (n=200). Components of the LGI score included white blood cell count, albumin levels, platelet counts, and granulocyte/lymphocyte ratio, modified after. Larger LGI scores represented an increase in measured LGI intensity at that time point. MR images were obtained on a 3T system using fluid attenuation inversion recovery (FLAIR) sequence. WML burden was ascertained using Fazekas scale, done separately for both deep WML and periventricular WML. Summated score of greater than or equal to 4 was considered high overall WML burden. Results: It was found that subjects with hypertension had significantly higher LGI score when compared to subjects without hypertension after accounting for sex and BMI (F=4.8, p=0.03). Using logistic regression. we found that LGI score was related to higher WML burden (p=0.047) within the entire cohort. However, further analyses have shown that this finding was driven by the normotensive group, in which the relationship between higher WML burden and respective LGI score was significant (p=0.007). This was not the case among hypertensive subjects. Conclusion: It is clear from the data presented that a relationship between LGI and hypertension exists, confirming that inflammation is an underlying process in cardiovascular pathogenesis. However, LGI scores were related to WML in only normotensive cohorts. We offer that the effects of chronic HTN (related to higher inflammatory score itself ) overshadow the effect of LGI among hypertensive subjects. It is worth emphasizing that even in subjects without HTN white matter damage is related to LGI

Sulcal FLAIR hyperintensity - Finding beyond meningitis

Introduction: The aim of this study was to enumerate the causes of Fluid-attenuated inversion recovery (FLAIR) hyperintensity in the sulcal space which could be due to cerebrospinal fluid (CSF) or non-CSF related pathologies. Methods and Materials: This is an observational retrospective study done in 100 patients in the department of Radio-diagnosis of Patna Medical College and Hospital, Patna from September 2019 to September 2020. Results: The mean age of patients was 40.13 +/- 13.88 years (Range 19 to 75 years). Male to female ratio was 1.32:1.00 (57:43). The most common cause of FLAIR sulcal hyperintensity was infection in 66% cases followed by meningeal tumor deposits in 16%, vascular cause in 6%, subarachnoid hemorrhage in 5%, mass effect in 5%, dermoid rupture in 1% and hyperoxygenation in 1%. Conclusion: Presence of sulcal hyperintensity on FLAIR images is a very strong sign to an underlying brain pathology. A keen observation of the same on FLAIR sequence in association with other findings can increase diagnostic confidence and thus lead to better patient care.

P14.12 Gyriform infiltration as imaging biomarker for adult diffuse astrocytic glioma, IDH wildtype, with molecular features of glioblastoma

BACKGROUND Diffuse astrocytic gliomas, IDH wildtype, with molecular features of glioblastoma (molecular glioblastomas) are associated with a poor prognosis. We previously found that these tumors frequently display gyriform infiltration, defined as areas of elective cortical hypersignal on MRI FLAIR sequence. The objective of the present study was to assess the diagnostic value of gyriform infiltration as an imaging marker for these tumors. MATERIAL AND METHODS MRI scans from 430 patients with newly diagnosed glioma (molecular glioblastoma n = 31, IDH wildtype glioblastoma n = 298, IDH-mutant astrocytoma n = 50, IDH-mutant and 1p19q codeleted oligodendroglioma n= 51) were evaluated for the presence of a gyriform infiltration by 2 independent reviewers. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated to assess the performance of the presence of a gyriform infiltration for identifying molecular glioblastoma. RESULTS A gyriform infiltration was observed in 16/31 (52%) patients with a molecular glioblastoma, 40/298 (13%) patients with an IDH-wildtype glioblastoma but in none of the patients with an IDH-mutant astrocytomas or an IDH-mutant and 1p19q codeleted oligodendroglioma. Among the 56 patients with a gyriform infiltration, 54 patients had an IDH wildtype pTERT mutant glioma and 2 an IDH wildtype pTERT wildtype glioma. Interrater agreement was good (κ= 0.68, P < 0.001). Specificity, sensitivity, PPV and NPV of the presence of a gyriform infiltration for the diagnosis of molecular glioblastoma were 90%, 29%, 52% and 96% and for the diagnosis of an IDHwt pTERT mutant glioma were 97%, 15%, 96% and 20%. The presence of a gyriform infiltration was associated with a worse prognosis in the entire cohort (13.6 months vs 29.3 months, P = .001). CONCLUSION Gyriform infiltration is a specific imaging marker of molecular glioblastomas and IDH wildtype pTERT mutant diffuse gliomas.

Role of contrast-enhanced FLAIR MRI in diagnosis of intracranial lesions

Background MR imaging plays a significant role in detection and characterization of different brain diseases. The role of the post-contrast T1-weighted image magnetic resonance imaging (T1W MRI) sequence has been widely established in previous studies and clinical practice. In this study, we aim to share our experience as regards the added value of contrast-enhanced fluid-attenuated inversion recovery (CE-FLAIR) sequence in the diagnosis of various intracranial pathological conditions and evaluate its usefulness in comparison with post-contrast T1W images. Results Based on the final radiological diagnosis, the total cases were subdivided into three categories, and the majority of our cases were tumors (81.2%), followed by multiple sclerosis (11.8%), and the least was central nervous system infection (7.1%). CE-FLAIR showed superior enhancement in 35 cases (50.7) and equal enhancement in 25 cases (36.3%). However, it showed less enhancement than post-contrast T1W images in 9 cases (13%). Excellent inter-observer agreement (97.65%) was noted. Regarding lesion conspicuity, good delineation was found in the majority of cases (64.7%), fair delineation in 12.9%, and no delineation in 22.4%. A statistically significant difference was found in signal intensity of lesion between pre- and post-contrast FLAIR sequences. Contrast to background ratio was statistically significant in CE FLAIR images in comparison to CE T1 images. Conclusion CE-FLAIR imaging should be used as a routine or adjunctive sequence to CE-T1WI to enhance early detection and increase the diagnostic confidence in MRI examination of different brain pathological conditions.

Diagnostic value of 3D-FLAIR MRI in children with sudden deafness caused by inner ear hemorrhage

ObjectiveTo investigate the diagnostic value of three-dimensional fluid-attenuated inversion recovery (3D-FLAIR) MRI in children with sudden deafness caused by inner ear hemorrhage.MethodsThe diagnostic efficacies of three different MRI sequences in the examination of the inner ear for 32 children with sudden deafness were compared. Hearing examination results and 3-month follow-up outcomes were analyzed.ResultsThe age of 32 children with sudden deafness ranged from 5 to 18 years. MRI was performed from 1 to 18 days after onset. Six cases of sudden deafness caused by inner ear hemorrhage were finally diagnosed clinically. For different MRI sequences, the 3D-FLAIR sequence detected five positive cases; the conventional T1-weighted image sequence also detected five positive cases; but the conventional T2-weighted image sequence only detected three positive cases. The sensitivity and specificity of the 3D-FLAIR sequence in the diagnosis of inner ear hemorrhage were 83.3% (5/6) and 96.2% (25/26), respectively, and the area under the curve value of the receiver operating characteristic curve was 0.897. In the hemorrhage group, all six cases had extremely severe sensorineural hearing loss, and the hearing recovery was ineffective after 3 months of follow-up. The degree of hearing impairment, 3-month short-term treatment efficacy, and 3D-FLAIR MRI in the diagnosis of inner ear hemorrhage between hemorrhage group and non-hemorrhage group were statistically significant (p=0.043, p=0.000, p=0.000).Conclusions3D-FLAIR MRI is helpful for the diagnosis of inner ear hemorrhage in children with sudden deafness. Besides, short-term treatment indicates poor effects on children with severe hearing impairment.

The diagnostic value of apparent diffusion coefficient to differentiate benign and malignant meningiomas

BACKGROUNDMeningiomas are the most common primary extra-axial non-glial intracranial tumors. The severe grade of meningioma, according to WHO, has the highest recurrence rate accompanied by high morbidity and mortality rates. Therefore, it is imperative to perform pre-operative assessments so the clinician can give prompt treatment to gain a better prognosis. It is a novel alternative way of predicting meningioma’s malignancy by calculating the tumor’s apparent diffusion coefficient (ADC) value. The objective of the study was to determine the value of ADC for differentiating benign and malignant meningiomas. METHODSThis cross-sectional study involved 32 subjects with clinically diagnosed or histologically verified meningioma (21 benign and 11 malignant). They underwent a head-magnetic resonance imaging (MRI) examination and biopsy. We calculated the ADC value by creating regions of interest (ROIs) on the solid part of the tumor, guided by contrast and fluid-attenuated inversion recovery (FLAIR) sequence. We analyzed the ADC value with independent t-test and Bland-Altman graphs, calculated the average difference, CI 95%, limit of agreement between observers, and ROC. RESULTSMean ADC of malignant meningiomas (0.877 ± 0.167 x 10-3 mm2/s) was significantly lower than that of benign meningiomas (0.990 ± 0.105 x 10-3 mm2/s) (p<0.05). The ADC threshold is 0.886 x 10-3 mm2/s with sensitivity 63.6%, specificity 85.7%, positive predictive value 70% and negative predictive value 81.8%. CONCLUSIONThe ADC value measurement provides a discriminative feature to differentiate between benign and malignant meningiomas. However, the clinical applicability still needs to be elucidated, as histopathological confirmation remains the mainstay of definitive diagnosis.