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Background and Purpose: Presurgical prediction of H3K27M mutation in diffuse midline gliomas (DMGs) on MRI is desirable. The purpose of this study is to elaborate conventional MRI (cMRI) features of H3K27M-mutant DMGs and identify features that could discriminate them from wild-type (WT) DMGs. Methods: CMRI features of 123 patients with DMG were evaluated conforming to the institutional research protocols. Multimodality MRI was performed on 1.5 or 3.0 Tesla MR Scanners with imaging protocol, including T1-weighted (w), T2w, fluid-attenuated inversion recovery, diffusion-weighted, susceptibility-weighted, and postcontrast T1w sequences. Pertinent cMRI features were annotated along the lines of Visually AcceSAble Rembrandt Images features, and Intra Tumoral Susceptibility Signal score (ITSS) was evaluated. R software was used for statistical analysis. Results: Sixty-one DMGs were H3K27M-mutant (mutant DMGs). The patients in the H3K27M-mutant DMG group were younger compared to the WT-DMG group (mean age 24.13 ± 13.13 years vs. 35.79±18.74 years) (p = 0.016). The two groups differed on five cMRI features--(1) enhancement quality (p = 0.032), (2) thickness of enhancing margin (p = 0.05), (3) proportion of edema (p = 0.002), (4) definition of noncontrast-enhancing tumor (NCET) margin (p = 0.001), and (5) cortical invasion (p = 0.037). The mutant DMGs showed greater enhancement and greater thickness of enhancing margin, while the WT DMGs exhibited significantly larger edema proportion with poorly defined NCET margins and cortical invasion. ITSS was not significantly different among the groups. Conclusion: CMRI features like enhancement quality, the thickness of the enhancing margin, proportion of edema, definition of NCET margin, and cortical invasion can discriminate between the H3K27M-mutant and WT DMGs.

We report the first case of a post-traumatic direct carotid cavernous fistula (CCF) treated with the XCalibur aneurysm occlusion device, which is a balloon mounted stent with flow diversion effect. Two devices were deployed across the fistula in an overlapping manner, resulting in complete occlusion of the fistula. Flow diversion with this device can provide a safe and alternative treatment option in direct CCF.

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We report a case of an unruptured, symptomatic, large right cavernous internal carotid artery aneurysm successfully treated with a new balloon-expandable flow diverter – Xcalibur Aneurysm Occlusion Device (AOD). Follow up imaging performed at six months demonstrated complete exclusion of the aneurysm and regression in dimensions, resulting in resolution of mass effect and clinical improvement.

Purpose Pre-surgical prediction of H3K27M mutation in diffuse midline gliomas (DMG) on MRI is desirable. The purpose of the study is to elaborate conventional MRI (cMRI) of H3K27M-mutant DMGs and identify features that could discriminate them from WT (wild type)-DMGs.Methods cMRI features of 123 patients with DMG were evaluated conforming to the institutional research protocols. Multimodality MRI was performed on 1.5 or 3.0 Tesla MR Scanners with imaging protocol including T1w, T2w, FLAIR, diffusion-weighted, susceptibility-weighted and post- contrast T1w sequences. Pertinent cMRI features were annotated along the lines of Visually AcceSAble Rembrandt Images (VASARI) features and Intra Tumoral Susceptibility Signal score (ITSS) were evaluated. R software was used for statistical analysis.Results Sixty-one DMGs were H3K27M-mutant (mutant DMGs). The patients in the H3K27M-mutant DMG group were younger compared to the WT-DMG group (WT DMGs) (mean age 24.13+13.13 years vs. 35.79+18.74 years) (P= 0.016). The two groups differed on 5 cMRI features– i) enhancement quality (P=0.032), ii) thickness of enhancing margin (P=0.05), iii) proportion of edema (P=0.002), iv) definition of non-contrast enhancing tumor (NCET) margin (P=0.001) and v) cortical invasion (P=0.037). The mutant DMGs showed greater enhancement and greater thickness of enhancing margin while the WT DMGs exhibited significantly larger edema proportion with poorly defined NCET margins and cortical invasion. ITSS was not significantly different among the groups. Conclusion cMRI features like enhancement quality, thickness of the enhancing margin, proportion of edema, definition of NCET margin and cortical invasion can discriminate between the H3K27M-mutant and WT DMGs.

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