Traumatic brain injury (TBI) is the main cause of death in trauma victims and causes high rates of disability and neurological sequelae. Approximately 38-65% of traumatic brain contusions (TBC) demonstrate hemorrhagic expansion on serial computed tomography (CT) scans. Thus far, however, no single variable can accurately predict the hemorrhage expansion of a TBC. Our purpose was to evaluate contrast extravasation (CE) as a predictor of expansion, mortality, and poor outcome in TBC in a Brazilian cohort. After Institutional Review Board approval, we used multidetector CT angiography (MDCTA) to study 121 consecutive patients (106 men, 87.6%) with ages varying from 10 to 85 years. Informed consent was obtained from all subjects. The clinical and imaging findings were correlated with the findings on the initial MDCTA using either the Fisher exact test or Student t test and a multivariate logistic regression model. Of the persons who presented CE in TBC, 21.8% died (in-hospital mortality), whereas in the absence of this sign, the mortality rate was 7.6% (p = 0.014). In addition, expansion of the hemorrhagic component of the TBC was detected in 61.1% of the CE-positive patients, whereas expansion was only observed in 10% of the CE-negative patients (p < 0.001). Poor outcome was observed in 24.2% of the patients in the CE-negative group, but in the presence of CE, 72.7% evolved with poor outcome (p < 0.001). The CE was a strong independent predictor of expansion, poor outcome, and increased risk of in-hospital mortality in our series of patients with TBC.

Alcohol consumption seems to affect corpus callosum morphometry irrespectively of an alcohol use disorder (AUD) diagnosis. The present study examined the relationship between corpus callosum (CC) subregion volumes and alcohol use patterns in AUD and non-AUD subjects. Twenty-two male AUD patients and 23 healthy matched non-AUD subjects were recruited from March 2016 to July 2017. Volumetric data were acquired through Magnetic Resonance and analyzed by the FreeSurfer software. AUD subjects were in abstinence for 45.1 days ± 36.8 (SD), consumed higher amounts of alcohol and presented higher AUDIT scores than controls ( p < 0.0001). A multivariate analysis corrected by age and tobacco use indicated that AUD patients presented smaller CC volumes compared to non-AUD subjects ( p < 0.01), except for the posterior subregion. A multiple regression analysis corrected by age and tobacco use including CC volumes from all subjects and the amount of daily alcohol ingestion as variables indicated that anterior CC volume was negatively ( p < 0.001) associated to alcohol consumption. This study demonstrated that CC subregions were smaller in AUD subjects, as expected, and that the volume of the anterior segment was inversely associated to increasing daily amounts of alcohol, indicating greater frontal region vulnerability to harmful alcohol effects.

Intracerebral hemorrhage (ICH) causes high rates of disability and neurological sequelae Objective To evaluate spot signs as predictors of expansion and worse prognosis in non-traumatic ICH in a Brazilian cohort. Method We used multidetector computed tomography angiography to study 65 consecutive patients (40 men, 61.5%), with ages varying from 33 to 89 years (median age 55 years). Clinical and imaging findings were correlated with the findings based on the initial imaging. Results Of the individuals who presented a spot sign, 73.7% died (in-hospital mortality), whereas in the absence of a spot sign the mortality rate was 43.0%. Although expansion of ICH was detected in 75% of the patients with a spot sign, expansion was observed in only 9.0% of the patients who did not present a spot sign. Conclusions The spot sign strongly predicted expansion in non-traumatic ICH and an increased risk of in-hospital mortality.

Excessive and long-term alcohol consumption produce metabolic changes, such as of choline, in many brain regions in alcohol use disorder (AUD) and in non-AUD subjects as well. This study examined the association of choline proportion in the prefrontal cortex with pattern of alcohol use in AUD patients. The choline metabolite was acquired through a single voxel Proton Magnetic Resonance Spectroscopy (1H MRS). Between-groups comparison corrected by age showed that the ratio of Choline/Creatine (Cho/Cr) was significantly smaller (p = 0.005) in the Left Prefrontal (LPF) of AUD patients when compared to paired non-AUD subjects. A multiple regression analysis corrected by age showed that decreasing ratios of Cho/Cr in the LPF was associated with increasing amount of alcohol consumption in drinks per day (p < 0.01) in AUD patients. Rates of Cho/Cr in the LPF was inversely related to amounts of alcohol consumption possibly indicating the severity of the AUD. Thus, low proportion of Cho/Cr in the LPF could indicate more severe AUD (higher alcohol intake).

Tumors of the pineal region are rare and can be challenging to differentiate by imaging. Papillary tumor of the pineal region (PTPR) was recently recognized as a neoplasm in the World Health Organization (WHO) 2007 classification, arising from specialized ependymocytes in the subcommissural organ, which is located in the pineal region. It is a rare histological type of pineal tumor with only a few cases reported. Here, we describe a case of histologically confirmed PTPR in a 17-year-old man who presented with a headache. A literature review was performed to clarify the clinical, radiological, and pathological features of PTPR. Pineal neoplasms do not have pathognomonic imaging findings; however, we discuss T1 hyperintensity, which is a key for imaging diagnosis according to recent reports. In particular, if the hyperintensity in T1 is not due to fat, calcification, melanin, or hemorrhage in a mass of the posterior commissure or pineal region, the diagnosis of a PTPR may be suggested, as observed in this case.

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Isolated hypothalamic hamartomas (HH) have a distinct clinical phenotype from that of PallisterHall syndrome (PHS), as HH consist of more severe seizures and cognitive, behavioral, and endocrine disorders.1 The imaging features help one to distinguish these conditions (figures 1 and 2).Isolated HH are hyperintense on fluid-attenuated inversion recovery and cause precocious puberty (PP) when they are oriented downward (parahypothalamic lesion), while seizures predominate in sessile intrahypothalamic HH.2 PHS is associated with isointense to gray matter HH, polydactyly, cutaneous syndactyly, bifid epiglottis, imperforate anus, and panhypopituitarism, resulting from GLI3 frameshift mutations (which map to chromosome 7p13) as an autosomal dominant trait. AUTHOR CONTRIBUTIONSDr. Rocha was responsible for the study concept, writing the manuscript, and the interpretation of data. Dr. Rosa Jr. was responsible for the interpretation of data and image selection. Dr. Arita was responsible for the clinical study concept and critical revision of the manuscript. REFERENCES MYSTERY CASE RESPONSESThe Mystery Case series was initiated by the Neurology Resident & Fellow Section to develop the clinical reasoning skills of trainees. Residency programs, medical student preceptors, and individuals were in-

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