White matter choking sign and its variants: an imaging sign
for detection and characterization of focal cortical dysplasia
Poster No.:
C-1192
Congress:
ECR 2015
Type:
Scientific Exhibit
Authors:
R. M. S. V. Vadapalli, S. J. JS, M. Panigrahi; Hyderabad/IN
Keywords:
Tissue characterisation, Developmental disease, Seizure
disorders, Diagnostic procedure, MR-Diffusion/Perfusion, MR,
Neuroradiology brain
DOI:
10.1594/ecr2015/C-1192
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Aims and objectives
To describe two new signs called "White Matter Choking Sign" and "WM Choking sign
extended" useful for diagnosis of FCD.
Methods and materials
165 patients in age group of 6-44 years with refractory epilepsy, who underwent epilepsy
surgery, were included in the retrospective study imaged using Both TLE and ETLE (extra
temporal lobe epilepsy) protocols on a 3T MRI system with a 3D T1 , 3D T2 , 3D T2
FLAIR for detection of occult dysplasia..
The data was viewed and post-processed to generate 3D corticographs of normal,
abnormal areas and correlated with multimodal imaging ( DTI, inter-ictal , ictal VEEG,
Ictal SPECT, Inter ictal FDG PET and pathology.
Three patterns were book marked on structural MR Images which were coregistered with
metabolic Inter ictal FDG PET Images.
Pattern 1: White matter choking sign
Pattern 2:White matter choking sign Extended
Pattern 3:White matter choking sign in depth of Sulcus
All Patients with refractory epilepsy
with above patterns of cortical abnormalities were correlated with Histopathological sub
types of FCD
Page 2 of 17
Results
Results: Three patterns emerged in our series of histopathologically proved FCD. The
FCDS analysed were as follows: 1B(56), IIA(33), IIB(27), III(39).
1.White Matter Choking sign
Sudden truncation or choking of sub-cortical white matter with blurring of interface (White
Matter Choking sign) has positively correlated with Focal cortical dysplasia in 82%.
2.Cortical laminar architectural abnormality.
3.White Matter choking Extended sign
WM choking sign underlying a cortical laminar architectural abnormality has positively
correlated with type IB and Type IIA- 92%.
Abnormal Medullary Spike Pattern was seen in Cingulate gyral FCD (n=4), Para sagittal
Cortical Ribbon dysplasia of type IB (n=7).
Pattern 1(WM choking sign): showed a 78% positive correlation with Type IB
Pattern 2(White matter choking sign Extended):showed 74% positive correlation with
Type IIA
Pattern 3:(WM choking sign in depth of Sulcus) showed 83% positive correlation with
Type IIA FCD.
FCD sub types of IIB with Classical Transmantel sign were excluded from the study.
Type 1B and IIA: sensitivity 92%, specificity 81%, Type IIB sensitivity 92%, specificity
70%; specificity of type IIB improved with presence of trans mantel sign (n=27) to 95%.
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Images for this section:
Fig. 1: White matter choking sign and trans mantel signs of FCD
Page 4 of 17
Fig. 2: White Matter Choking sign and White matter choking extended and Choking sign
in Depth of Sulcus
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Fig. 3: Right temporal lobe FCD: White matter choking Sign
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Fig. 4: Left Mesial Frontal IIA FCD with white matter choking sign and additional DTI
findings. Pathology after surgical resection showed a type IIA FCD.
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Fig. 5: Type IB FCD T1 and 3D FLAIR Axial sequences showing White Matter choking
Sign and White matter choking sign extended.
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Fig. 6: Type IB FCD on left (marked) with bottom of Sulcus FCD on Right.
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Fig. 7: Left Pre-central lateral cortical laminar FCD Type IB
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Fig. 8: Right Superior Anterior Cingulate and Left Middle frontal Type IB FCD : White
Matter choking sign
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Fig. 9: Left superior parietal pre central FCD Type IIA
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Fig. 10: FCD Type IIA Histopathology
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Fig. 11: Results
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Fig. 12: Results
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Fig. 13: Results
Page 16 of 17
Conclusion
White Matter Choking Sign and White Matter choking Extended sign offer optimal
sensitivity and specificity for MRI detection of FCD type I and IIA and Characterization
of FCD.
Personal information
[email protected]
References
Prayson RA, Estes ML, Morris HH. Coexistence of neoplasia and cortical dysplasia in
patients presenting with seizures. Epilepsia1993; 34 :609 -615.
Mischel PS, Nguyen LP, Vinters HV. Cerebral cortical dysplasia associated with pediatric
neoplasia: review of neuropathologic features and proposal for a grading system. J
Neuropathol Exp Neurol1995; 54 :137 -153
Lee BC, Schmidt RE, Hatfield GA, Bourgeois B, Park TS. MRI of focal cortical dysplasia.
Neuroradiology1998; 40 :675 -683
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