Editor’s Choices

Fetuses with Ventriculomegaly Diagnosed in the Second Trimester of Pregnancy by In Utero MR Imaging: What Happens in the Third Trimester? • P.D. Griffiths, J.E. Morris, G. Mason, S.A. Russell, M.N.J. Paley, E.H. Whitby, and M.J. Reeves
Brain abnormalities may be difficult to identify in fetuses and early in life, becoming easier to see with time. In this interesting study, the authors evaluated 99 pregnancies between 20-24 weeks that revealed mildly large ventricles but no other brain abnormalities. Forty-six women came back for re-evaluation at 30-32 weeks. What happened to the brains of those fetuses? Of the ones that were restudied, 28 showed isolated mild ventriculomegaly initially and changes seen on follow-up studies were as follows: 5 became normal, 7 progressed to moderate, 3 became severe, and 13 remained mild. Of the 5 fetuses with VM and other brain abnormalities, only in 1 case was the abnormality seen during just the second study (hypogenesis of the corpus callosum). All measurements were judged to be highly consistent between studies. Conclusions: there is no need to repeat early MR imaging studies later in pregnancy and there is no need to delay studies until later in pregnancy if abnormalities are suspected.

Observer Agreement Regarding the Necessity of Retreatment of Previously Coiled Recurrent Cerebral Aneurysms • W.P. Daugherty, A. Ehteshami Rad, J.B. White, P.M. Meyers, G.L. Lanzino, H.J. Cloft, J. Gordon, and D.F. Kallmes
Do interventional neuroradiologists agree among each other regarding retreatment of previously coiled aneurysms? Because the need for retreatment is also used as a primary outcome measure in randomized studies, this observation extends well beyond individual patients. The well-known group from the Mayo Clinic addresses that question in this article. They identified 27 previously treated intracranial aneurysms and asked 5 readers to independently rate each on a 5-point scale, and in those cases needing retreatment to indicate which type of therapy would be best. There was only fair agreement regarding retreatment and a wide variation in the type of therapy chosen for the retreatment. The study demonstrates substantial variability among observers not only in whether to retreat a recurrent aneurysm but also in how to treat it. These findings suggest that patient management varies widely across treating physicians and also calls into question the use of “retreatment” as an objective end point in clinical trials.

Glasgow Coma Scale Does Not Predict Outcome Post-Intra-Arterial Treatment for Basilar Artery Thrombosis • R.V. Chandra, C.P. Law, B. Yan, R.J. Dowling, and P.J. Mitchell
When is it too late to treat patients with basilar artery thrombosis? The common sense answer is usually “never” because the prognosis is so poor in these patients if nothing is done. Can the Glasgow Coma Scale be used for this purpose? Does a low GCS score predict a poor outcome and negate the need for treatment? The authors addressed these questions by studying 40 patients with basilar artery thrombosis treated intra-arterially. Interventions were done on average 7 hours after onset of clinical symptoms in patients with median GCS of 9 and recanalization was accomplished in 82%. There was no correlation between the initial GCS score and modified Rankin Scale at 90 days. Thus, it is not appropriate to exclude patients with low initial GCS scores from intra-arterial treatment of a thrombosed basilar artery.

Fellows’ Journal Club

Differentiation between Glioblastomas, Solitary Brain Metastases, and Primary Cerebral Lymphomas Using Diffusion Tensor and Dynamic Susceptibility Contrast-Enhanced MR Imaging • S. Wang, S. Kim, S. Chawla, R.L. Wolf, D.E. Knipp, A. Vossough, D.M. O’Rourke, K.D. Judy, H. Poptani, and E.R. Melhem
More on the eternal question: what can we use to differentiate preoperatively glioblastomas, metastases, and lymphomas? Here, the authors investigated whether diffusion tensor imaging and gadolinium perfusion studies could be used for this purpose. They evaluated 26 GBMs, 25 brain metastases, and 16 primary cerebral lymphomas with these techniques. Basically, GBMs showed lower fractional anisotropy and higher perfusion patterns. The best predictive data obtained were the apparent diffusion coefficients from enhancing tumor regions and the perfusion (cerebral blood volume) from the peritumoral regions. Although this is probably something that we all use on a daily basis, it is nice to see it reported in such an organized and careful fashion.

Identification and Clinical Impact of Multiple Sclerosis Cortical Lesions as Assessed by Routine 3T MR Imaging • A. Mike, B.I. Glanz, P. Hildenbrand, D. Meier, K. Bolden, M. Liguori, E. Dell’Oglio, B.C. Healy, R. Bakshi, and C.R.G. Guttmann
It is possible that many if not most clinical symptoms of multiple sclerosis patients are due to plaques in the gray matter and not in the white matter as commonly believed (remember that myelinated fibers are found in cortical and deep gray matter). Could it be that because cortical plaques are not routinely seen at 1.5T we do not think about this issue? Here, the authors studied 26 patients with 3D FLAIR and inversion recovery spoiled gradient recalled sequences at 3T and found cortical plaques in 24 of them. The volume and load of these cortical plaques correlated with those seen in white matter. Cortical lesions also correlated with verbal learning test disability scale results better than white matter lesion load. Conclusion: routinely detectable cortical lesions were related to physical disability and cognitive impairment.

Type of Edema in Posterior Reversible Encephalopathy Syndrome Depends on Serum Albumin Levels: An MR Imaging Study in 28 Patients • A. Pirker, L. Kramer, B. Voller, B. Loader, E. Auff, and D. Prayer
The causes of posterior reversible encephalopathy syndrome continue to be debated and other underlying issues are being added to its etiology. In this short and retrospective study, the authors assessed the role of low serum albumin in the development of PRES. The causes of PRES varied and the authors used diffusion-weighted and fluid-attenuated inversion recovery sequences to characterize the edema as vasogenic (N=22) or cytotoxic (N=6). All studies were done within 3 days of the onset of clinical symptoms. Review of laboratory values showed that during this time low serum albumin in 21 of 28 patients was more common and marked in those with vasogenic edema. Although all of this is simple and clear, the role of albumin is sort of like the “chicken and egg” question: Is there more leakage of fluids due to the low albumin, or is it low because it is actively leaking with fluid due to other processes affecting the blood vessel walls? Read the article to find out more!