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Pierpaolo Peruzzi, Rebecca J. Corbitt and Corey Raffel

Object

The use of fetal MR imaging for the in utero evaluation of pathological conditions of the CNS is widely accepted as an adjunct to fetal ultrasonography studies. Magnetic resonance imaging is thought to characterize CNS anomalies better, and to provide a more exact diagnosis and accurate prognosis. The purpose of this study was to determine the role of and indications for fetal MR imaging in evaluating fetuses with different CNS abnormalities that were seen initially on prenatal sonograms.

Methods

Over a 3-year period, fetuses with prior sonographic evidence of CNS abnormalities who consequently received prenatal MR imaging at Columbus Nationwide Children's Hospital within 2 weeks of the fetal ultrasonography study were included in this study. For each patient, radiological reports from both studies were reviewed, analyzed, and compared with the findings at postnatal imaging or physical examination. Results of the 2 modalities were then compared in terms of diagnostic accuracy.

Results

Twenty-six fetuses were included in this study on the basis of an in utero sonogram showing a CNS anomaly. Their gestational age ranged from 17 to 35 weeks, with a mean of 25 weeks at the time of fetal ultrasonography. Hydrocephalus was identified in 16 fetuses, 6 had evidence of a spinal dysraphic defect, 2 had holoprosencephaly, 1 had an encephalocele, and 1 had multiple body abnormalities requiring detailed CNS evaluation. Twenty-five of the fetuses were correctly evaluated as having abnormal CNS findings on both fetal ultrasonography and fetal MR imaging. Fetal ultrasonography provided a correct prenatal diagnosis in 20 cases, whereas fetal MR imaging was correct in 22 cases. There were 9 cumulative false-positive results for fetal ultrasonography and 7 for fetal MR imaging, whereas for false-negative results there were a total of 34 and 19, respectively.

Conclusions

Fetal MR imaging is more sensitive in detecting fetal CNS abnormalities, but its ability to provide a correct prenatal diagnosis is only marginally superior to fetal ultrasonography. Moreover, fetal MR imaging is not exempt from misdiagnosis, and still shows a significantly high rate of false-negative results. Particularly for spinal dysraphic defects, fetal MR imaging does not seem to add important diagnostic or prognostic details when compared with fetal ultrasonography.

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Pierpaolo Peruzzi, Abhik Ray-Chaudhuri, Wayne H. Slone, Hagop S. Mekhjian, Pierluigi Porcu and E. Antonio Chiocca

Neurolymphomatosis, the infiltration of the peripheral nervous system (PNS) by malignant lymphatic cells, is a rare condition whose prognosis and treatment are not fully characterized. The authors report the case of a 69-year-old, previously healthy man who had a 1-month history of progressive pain in his right arm and associated weakness of several muscles of the right upper extremity when they first examined him. Initial MR imaging of the right brachial plexus showed no abnormalities, but over 3 months, symptoms gradually progressed to almost complete plegia of his right upper extremity. Subsequent MR imaging of his right brachial plexus showed an enhancing mass of the posterior cord of the plexus that encroached on the other cords. Positron emission tomography confirmed the presence of a hypermetabolic lesion in the right axillary region and also detected an asymptomatic hot spot in the gastric wall. Biopsy of the gastric lesion demonstrated a CD20+, diffuse large B-cell lymphoma that was immunohistochemically positive for BCL-6 and negative for p16. The patient underwent 6 cycles of dose-adjusted etoposide-vincristine-doxorubicin-cyclophosphamide-prednisone (EPOCH) and rituximab, intermixed with 3 cycles of high-dose intravenous and intrathecal methotrexate, and followed by 6 monthly doses of rituximab for consolidation. Follow-up MR imaging and PET of the plexus showed complete radiological response after 3 months of treatment, as demonstrated by normalization of brachial plexus caliber, contrast enhancement, and metabolic activity.

Twenty-eight months after symptom onset and 20 months after beginning therapy, the patient was disease-free, had recovered most upper extremity neurological function, and had only minimal remaining weakness of the right wrist and finger extension.

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Pierpaolo Peruzzi, Sergio D. Bergese, Adolfo Viloria, Erika G. Puente, Mahmoud Abdel-Rasoul and E. Antonio Chiocca

Object

Glioma resection under conscious (“awake”) sedation (CS) is used for eloquent areas of the brain to minimize postoperative neurological deficits. The objective of this study was to compare the duration of hospital stay, overall hospital cost, perioperative morbidity, and postoperative patient functional status in patients whose gliomas were resected using CS versus general endotracheal anesthesia (GEA).

Methods

Twenty-two cases in 20 patients who underwent surgery for cerebral gliomas under CS and a matched cohort of 22 cases in 19 patients who underwent surgery under GEA over a 3-year period were retrospectively evaluated. Criteria for inclusion in the study were as follows: 1) a single cerebral lesion; 2) gross-total resection as evidenced by postoperative Gd-enhanced MR imaging within 48 hours of surgery; 3) a WHO Grade II, III, or IV glioma; 4) a supratentorial lesion location; 5) a Karnofsky Performance Scale score ≥ 70; 6) an operation performed by the same neurosurgeon; and 7) an elective procedure.

Results

The average hospital stay was significantly different between the 2 groups: 3.5 days for patients who underwent CS and 4.6 days for those who underwent GEA. This result translated into a significant decrease in the average inpatient cost after intensive care unit (ICU) care for the CS group compared with the GEA group. Other variables were not significantly different.

Conclusions

Patients undergoing glioma resection using CS techniques have a significantly shorter hospital stay with reduced inpatient hospital expenses after postoperative ICU care.