To emphasize the utility of contrast enhanced MRI for identifying the extent of disease in herpes zoster ophthalmicus with intracranial extension to help determine proper management. We present a rare case of herpes zoster ophthalmicus (HZ/HZO) with intracranial extension and MRI demonstration of involvement of the trigeminal nerve, the trigeminal nucleus, and the spinal trigeminal nucleus and tract. Herpes zoster is caused by reactivation of varicella zoster virus. Herpes zoster ophthalmicus with involvement of the ophthalmic division of the trigeminal nerve has been estimated to account for 10-20% of the cases (Yawn et al. in Mayo Clin Proc 88:562-570, 2013). While postherpetic neuralgia is the most common complication, HZ/HZO can rarely manifest in a more sinister manner resulting in multi-dermatomal involvement, disseminated disease, cranial arteritis (Walker in Radiology 107:109-110, 1973), cranial nerve paresis (O.d in Clinical Eye and Vision Care 11:75-80, 1999), hemiplegia (Cavaletti in The Italian Journal of Neurological Sciences 11:297-300, 1990), ocular/dysfunction (Kocaoğlu in Türk Oftalmoloji Dergisi 48:42-46, 2018), and intracranial extension (Chen in BMC Infectious Diseases 17:213, 2017; Yawn in Mayo Clin Proc. 88:562-570, 2013). Contrast enhanced MRI (CE-MRI) can be of great benefit to elucidate the extent of disease and intracranial involvement for institution of more aggressive management to prevent further complications.
Introduction Hybrid PET-MR is a relatively new imaging modality with its major strength being the MR component offering superior soft tissue contrast. While PET/MRI offers the inherent advantage of reduced radiation dose, it has been shown to result in a markedly prolonged examination time becoming a challenge in children and sick patients. "Low dose MRI" is a term used in the nuclear medicine community to describe fast acquired PET-MR scan protocols that rely heavily on PET images for diagnosis. In this study, we sought to determine if the Dixon sequences obtained for attenuation correction could be used as a diagnostic sequence for interpreting PET-MRI lymphoma cases, potentially reducing scan time. Materials and Methods We retrospectively identified 40 patients who underwent 88FDG PET-MR body imaging studies for staging or restaging lymphoma. A radiologist and nuclear medicine physician initially reviewed top of the head to mid thigh PET images, attenuation correction coronal Dixon MRI sequences, and PET-MR fusion with Dixon sequence. The same physicians reviewed the PET images, multi-sequence MR including the attenuation correction Dixon, and multi-sequence PET-MR fusion images The lesions were further characterized based on their imaging characteristics, size, SUVmax, and malignant potency. A consensus read followed. Results All patients were adults with an average study age of 43.8 years. Our study consisted of 40 females and 48 males out of which 7 were for staging and 81 were for re-staging. All patients had systemic lymphoma. Thirty-seven of the studies had active lymph nodes on Dixon PET-MR that agreed with multi-sequence PET-MR which identified 33 positive cases (89.1%) having an average SUV 10.2 ± 7.74 SD. Four Dixon PET-MR cases did not detect lesions, with an average SUV 2.3 ± 0.55 SD, which was read as minimal residual activity. Multi-sequence MR identified 11 patients with enlarged lymph nodes without FDG uptake, which were not seen on Dixon MR. All 5 studies with bones lesions were detected by Dixon PET-MR as well as 2 soft tissue organ lesions. Multi-sequence MR identified 1 patient with non-active, healed bone lesion. Fifty-five of these studies were true negatives. Compared to multi-sequence PET-MR, Dixon PET-MR demonstrated 89.2% sensitivity, 100% specificity with no false positive studies. Conclusion The present study investigated the diagnostic potential of a fast protocol for integrated PET/MRI used for dedicated tumor staging of patients with lymphoma. In this retrospective study, Dixon PET-MR was shown to be sensitive and specific compared to multi-sequence PET-MR in the detection of lymphoma. The low number of these cases not detected had minimally active lymph nodes that resolved on subsequent imaging and probably were not clinically important.
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