How to Reduce Head CT Orders in Children with Hydrocephalus Using the Lean Six Sigma Methodology: Experience at a Major Quaternary Care Academic Children’s Center

Fellows’ Journal Club

The authors describe a Lean Six Sigma project with the goal of reducing the relative use of pediatric head CTs in their population of patients with hydrocephalus by 50% within 6 months. The existing baseline imaging practice for hydrocephalus was outlined in a Kaizen session, and potential interventions were discussed. An improved radiation-free workflow with ultrafast MR imaging was created. Baseline data were collected for 3 months by using the departmental radiology information system and data collection continued postintervention and during the control phase. The improved workflow resulted in a 75% relative reduction in the percentage of hydrocephalus imaging performed by CT between the pre- and postintervention/control phases. The authors conclude that the lean interventions in the pediatric hydrocephalus care pathway resulted in a significant reduction in head CT orders.

Abstract

Improved workflow for the hydrocephalus imaging pathway. Imaging technologists are required to respond in a timely fashion. In case they could not respond on time, their phone numbers are outlined so that the ordering units can follow-up on their orders. HMED indicates HealthMatics Emergency Department (Allscripts, Chicago, Illinois); POE, Physician Order Entry; EPIC, Epic Systems (Madison, Wisconsin); ASCOM, tel.
Improved workflow for the hydrocephalus imaging pathway. Imaging technologists are required to respond in a timely fashion. In case they could not respond on time, their phone numbers are outlined so that the ordering units can follow-up on their orders. HMED indicates HealthMatics Emergency Department (Allscripts, Chicago, Illinois); POE, Physician Order Entry; EPIC, Epic Systems (Madison, Wisconsin); ASCOM, tel.

BACKGROUND AND PURPOSE

Lean Six Sigma methodology is increasingly used to drive improvement in patient safety, quality of care, and cost-effectiveness throughout the US health care delivery system. To demonstrate our value as specialists, radiologists can combine lean methodologies along with imaging expertise to optimize imaging elements-of-care pathways. In this article, we describe a Lean Six Sigma project with the goal of reducing the relative use of pediatric head CTs in our population of patients with hydrocephalus by 50% within 6 months.

MATERIALS AND METHODS

We applied a Lean Six Sigma methodology using a multidisciplinary team at a quaternary care academic children’s center. The existing baseline imaging

Clinical Feasibility of Synthetic MRI in Multiple Sclerosis: A Diagnostic and Volumetric Validation Study

Editor’s Choice

SyMRI is a quantitative synthetic MR imaging method where a single saturation recovery TSE sequence is used to estimate the proton density, longitudinal relaxation rate, and transverse relaxation rate and allows for a free range of synthetic weightings. Twenty patients with MS and 20 healthy controls were enrolled and synthetic MR imaging was implemented on a Siemens 3T scanner. Diagnostic accuracy, lesion detection, and artifacts were assessed by blinded neuroradiologic evaluation, and CNR by manual tracing. Synthetic PD-, T1-, and T2-weighted images were of sufficient or good quality and were acquired in 7% less time than with conventional MRI. Synthetic FLAIR images suffered from artifacts. Also, synthetic MRI provided segmentations with the shortest processing time (16 seconds) and the lowest repeatability error for brain volume. Synthetic MRI can be an alternative to conventional MRI for generating diagnostic PD-, T1-, and T2-weighted images in patients with MS with fast and robust volumetric measurements.

Abstract

Conventional (top row) and synthetic (middle row) axial noncontrast MR imaging in a 49-year-old male patient with MS, from left to right: T1-, PD-, and T2-weighted, and FLAIR images. The bottom row shows brain tissue segmentations of the WM (cyan), GM (green), CSF (magenta), and other remaining brain tissues (yellow) from SyMRI.
Conventional (top row) and synthetic (middle row) axial noncontrast MR imaging in a 49-year-old male patient with MS, from left to right: T1-, PD-, and T2-weighted, and FLAIR images. The bottom row shows brain tissue segmentations of the WM (cyan), GM (green), CSF (magenta), and other remaining brain tissues (yellow) from SyMRI.

BACKGROUND AND PURPOSE

Quantitative MR imaging techniques are gaining interest as methods of reducing acquisition times while additionally providing robust measurements. This study aimed to implement a synthetic MR imaging method on a new scanner type and to compare its diagnostic accuracy and volumetry with conventional MR imaging in patients with MS and controls.

MATERIALS AND METHODS

Twenty patients with MS and 20 healthy controls were enrolled after ethics approval and written informed consent. Synthetic MR imaging was implemented on a Siemens 3T scanner. Comparable conventional and synthetic proton-density–, T1-, and T2-weighted, and

Neuroimaging Clinics of North America: Tinnitus: Imaging, Endovascular, and Surgical Approaches

Mukherji SK, consulting ed. Raghavan P, Gandhi D, guest eds. Tinnitus: Imaging, Endovascular, and Surgical Approaches. Elsevier, May 2016. Neuroimaging Clinics of North America; vol. 26; no. 2; pgs. 187–316; $360.00

Cover of Neuroimaging Clinics of North America: Tinnitus: Imaging, Endovascular and Surgical Approaches, edited Raghavan and GandhiThe May 2016 issue of Neuroimaging Clinics of North America addresses a topic, tinnitus, which confronts a neuroradiologist on a frequent basis. Because most requests for temporal bone imaging state simply “tinnitus” without additional potentially important clinical information, one is obliged to consider the entire gamut of diagnostic possibilities. In that regard, this 130-page issue of the Neuroimaging Clinics of North America is a valuable resource because it covers the spectrum of causes of tinnitus—even those which have no overt imaging findings. That is important for us to appreciate as we search for underlying structural abnormalities.

This book starts off with a 9-page description of the neuroscience of tinnitus, and a reading of this material helps one understand the central changes in the auditory pathways. While neuroradiologists do not have to understand the features of sound production, propagation, and modulation, one quickly appreciates how tinnitus, along with other associated symptoms, can have root causes beyond what we see on imaging. One also sees how difficult it is to treat many of the causes of primary tinnitus.

A chapter of the clinical evaluation of tinnitus follows, and it reinforces the concept of knowing whether the tinnitus is objective or subjective, what type of tinnitus one is dealing with, and whether somatosounds are present. The authors of this chapter nicely outline the types of imaging studies that should be obtained for the specific type of tinnitus.

The next 5 chapters, which constitute the bulk of the book, involve imaging findings, with topics in tinnitus that include systematic approaches to image interpretation, arterial abnormalities, venous abnormalities (particularly interesting and easily …

RadCases: Emergency Radiology

Yu E, Jaffer NM, Chung TB, Naraghi AM, Rajan DK, O’Malley ME, Rogalla P, Murphy K, eds. Emergency Radiology. RadCases. Thieme; 2015; 224 pp; 489 ill; $59.99

Cover of Radcases: Emergency Radiology, edited by Yu et alCase review books and series have a long history in radiology, nearly universally encountered during residency in preparation for our board examinations. Even though the board format has recently changed, you will still see residents with case review books and their electronic equivalents. Perhaps with the adoption of MOC, more seasoned radiologists will also turn to such books and databases prior to the MOC exam. It certainly seems that the number of case review selections appears to be increasing, both in written text and in online format. The topic of emergency radiology is one of the newer entries in Thieme’s RadCase series, now totaling 12 subspecialty topics in print. An emergency radiology case review book will be inherently somewhat different from the other subspecialty topics offered in such a series, as it cannot focus on just one body system or imaging modality but instead will have to cover a wide gamut of topics and modalities encountered on the front lines of our specialty.

RadCases: Emergency Radiology tackles these challenges with an understated but recognizable organization. While a table of contents doesn’t explicitly list divisions within the book, and in fact, none actually exist, the cases progress in an orderly fashion, beginning with neuroradiology cases. About one-quarter of the 100 cases presented in the book are neuroradiology-based. The balance of the book introduces a few vascular cases (≈5) with the remainder of the cases split roughly evenly between musculoskeletal, body, and thoracic topics. In such review books, case selection should be the preeminent concern, and in this particular book the collections of cases within the different divisions is not consistent.

The chosen emergent …

Journal Scan – This Month in Other Journals, June 2016

 

  1. Chen Z, Zheng Y, Yuan Y, et al. Modic Changes and Disc Degeneration Caused by Inoculation of Propionibacterium acnes inside Intervertebral Discs of Rabbits: A Pilot Study. Biomed Res Int. 2016;2016:9612437. doi:10.1155/2016/9612437.

Wild-type strain of P. acnes isolated from a patient associated with Modic change and disc degeneration was inoculated into the intervertebral discs of rabbits (n=8). S. aureus was injected into the discs to establish a model of discitis as a comparison.  A standard strain of P. acnes was inoculated as the control. MRI and histological change were evaluated. MRI was performed before and every two weeks after the inoculation until the end of follow-up at the eighth week. Both the P. acnes-inoculated and S. aureus-inoculated rabbits showed hyperintense signals at endplates and hypointense signals at nucleus pulposus on T2WI. However, P. acnes only resulted in moderate disc degeneration and endplates rupture in histological examination. They conclude that compared to S. aureus, the pathological change caused by P. acnes would be considered as Modic-I change and disc degeneration rather than a discitis.

They are of the opinion that the presented data satisfied the first, second, and third criteria of Koch’s Postulates and they extrapolate that P. acnes has a strong connection with Modic change and disc degeneration. 3 figures with histopathology.

In case you had forgotten Koch’s postulates:

  1. The pathogen must be found in abundance in all organisms suffering from the disease, but should not be found in healthy organisms.
  2. The pathogen must be isolated from a diseased host and grown in pure culture.
  3. The cultured microorganism should cause the disease when introduced into a healthy organism.
  4. The microorganism must be reisolated from the inoculated, diseased experimental host and identified as being identical to the original specific causative agent.
  1. Hall SS, Dougherty RF, Reiss AL.

ASNR 2016 Meeting Social Media Recap

The ASNR 54th Annual meeting is in the books and was a huge success, thanks to the efforts of Dr. Howard Rowley and many others. The ever increasing social media presence of the society and its members continues to complement the live educational content and connect members. This year we saw a large online presence, growing lecture series, and got a glimpse at the different directions social media will head in the years to come.

Online

By including the hashtag #ASNR16, users could participate in the meeting via platforms such as Facebook, Instagram, and Twitter. Social media activity continues to grow from past meetings. During the week of the 2016 meeting there were 2,589 tweets and 369 participants on Twitter alone. 1,2

2014 2015 2016
Hashtag #ASNR14 #ASNR15 #ASNR16
Participants 50 340 369
Tweets 393 2,388 2,589
Data Date Range 5/16 – 5/22/14 4/22 – 4/30/15 5/20 – 5/26/16

ASNR 2014-2016 Annual Meeting Twitter Activity. Data obtained from Symplur.com.

A new use of the online social media feed was trialed during the 2016 meeting — live tweeting of questions for panelists. This was successfully implemented for the Gadolinium symposium. Whether in the room or tweeting from home, Twitter users could ask Dr. Max Wintermark and panelists questions using the hashtag #GadSymposium announced at the start of the symposium.

Lectures

This year’s meeting also incorporated social media content into its Healthcare Policy programming and Young Professionals Section (YPS) programming tracks. Dr. Amy Kotsenas (@AmyKotsenas) presented the well-received “Technology Disrupters and the Impact of Social Media” Monday morning. The next day, the YPS track series began with inspiring leadership lectures from Drs. Robert Barr (@rmbxray) and Christine Glastonbury (@CMGlastonbury). This was followed by ‘Why’ and ‘How’ we do it sessions from Twitter super users …

Diagnostic Value of Prenatal MR Imaging in the Detection of Brain Malformations in Fetuses before the 26th Week of Gestational Age

Fellows’ Journal Club

The authors retrospectively evaluated 109 fetuses within 25 weeks of gestational age who had undergone both prenatal and postnatal MR imaging of the brain between 2002 and 2014, and using the postnatal MRI as the reference standard, they calculated the sensitivity, specificity, positive predictive value, and negative predictive value of the prenatal MRI in detecting brain malformations. Prenatal MR imaging failed to detect correctly 11 of the 111 malformations. They conclude that diagnostic value of prenatal MRI for brain malformations within 25 weeks of GA is very high, despite limitations of sensitivity in the early detection of disorders of cortical development, such as polymicrogyria and periventricular nodular heterotopias.

Abstract

fjc_conteBACKGROUND AND PURPOSE

In several countries, laws and regulations allow abortion for medical reasons within 24–25 weeks of gestational age. We investigated the diagnostic value of prenatal MR imaging for brain malformations within 25 weeks of gestational age.

MATERIALS AND METHODS

We retrospectively included fetuses within 25 weeks of gestational age who had undergone both prenatal and postnatal MR imaging of the brain between 2002 and 2014. Two senior pediatric neuroradiologists evaluated prenatal MR imaging examinations blinded to postnatal MR imaging findings. With postnatal MR imaging used as the reference standard, we calculated the sensitivity, specificity, positive predictive value, and negative predictive value of the prenatal MR imaging in detecting brain malformations.

RESULTS

One-hundred nine fetuses (median gestational age at prenatal MR imaging: 22 weeks; range, 21–25 weeks) were included in this study. According to the reference standard, 111 malformations were detected. Prenatal MR imaging failed to detect correctly 11 of the 111 malformations: 3 midline malformations, 5 disorders of cortical development, 2 posterior fossa anomalies, and 1 vascular malformation. Prenatal MR imaging misdiagnosed 3 findings as pathologic in the posterior fossa.

CONCLUSIONS

The diagnostic value of prenatal

Brain Structural and Vascular Anatomy Is Altered in Offspring of Pre-Eclamptic Pregnancies: A Pilot Study

Editor’s Choice

The authors assessed the brain structural and vascular anatomy in 7- to 10-year-old offspring of pre-eclamptic pregnancies compared with matched controls (n=10 per group). TOF-MRA and a high-resolution anatomic T1-weighted MPRAGE sequence were acquired for each participant. Offspring of pre-eclamptic pregnancies exhibited enlarged brain regional volumes of the cerebellum, temporal lobe, brain stem, and right and left amygdalae. These offspring displayed reduced cerebral vessel radii in the occipital and parietal lobes. The authors conclude that these structural and vascular anomalies may underlie the cognitive deficits reported in the pre-eclamptic offspring population.

Abstract

Visual 3D representation of the vessel radii calculated for a segmented TOF-MRA dataset of a single female, 8-year-old PE-F1 participant who was born at 34 weeks of gestation.
Visual 3D representation of the vessel radii calculated for a segmented TOF-MRA dataset of a single female, 8-year-old PE-F1 participant who was born at 34 weeks of gestation.

BACKGROUND AND PURPOSE

Pre-eclampsia is a serious clinical gestational disorder occurring in 3%–5% of all human pregnancies and characterized by endothelial dysfunction and vascular complications. Offspring born of pre-eclamptic pregnancies are reported to exhibit deficits in cognitive function, higher incidence of depression, and increased susceptibility to stroke. However, no brain imaging reports exist on these offspring. We aimed to assess brain structural and vascular anatomy in 7- to 10-year-old offspring of pre-eclamptic pregnancies compared with matched controls.

MATERIALS AND METHODS

Offspring of pre-eclamptic pregnancies and matched controls (n = 10 per group) were recruited from an established longitudinal cohort examining the effects of pre-eclampsia. Children underwent MR imaging to identify brain structural and vascular anatomic differences. Maternal plasma samples collected at birth were assayed for angiogenic factors by enzyme-linked immunosorbent assay.

RESULTS

Offspring of pre-eclamptic pregnancies exhibited enlarged brain regional volumes of the cerebellum, temporal lobe, brain stem, and right and left amygdalae. These offspring displayed reduced cerebral vessel radii in the occipital and parietal lobes. Enzyme-linked immunosorbent assay analysis revealed underexpression of the placental growth factor

Pipeline Embolization Device in the Treatment of Recurrent Previously Stented Cerebral Aneurysms

Fellows’ Journal Club

Twenty-one patients with previously stented recurrent aneurysms who later underwent Pipeline Embolization Device placement (group 1) were retrospectively identified and compared with 63 patients who had treatment with the Pipeline with no prior stent placement (group 2). Pipeline treatment resulted in complete aneurysm occlusion in 55.6% of patients in group 1 versus 80.4% of patients in group 2. The retreatment rate in group 1 was 11.1% versus 7.1% in group 2. The authors conclude that the Pipeline is less effective in the management of previously stented aneurysms than when used in nonstented aneurysms.

Abstract

A, A 54-year-old woman with a 6-mm left carotid ophthalmic artery aneurysm, which was initially treated with stent-assisted coiling but recurred. B, Treatment with the PED was performed. A 12-month follow-up angiogram shows incomplete occlusion.
A, A 54-year-old woman with a 6-mm left carotid ophthalmic artery aneurysm, which was initially treated with stent-assisted coiling but recurred. B, Treatment with the PED was performed. A 12-month follow-up angiogram shows incomplete occlusion.

BACKGROUND AND PURPOSE

The use of the Pipeline Embolization Device in the management of recurrent previously stented cerebral aneurysms is controversial. The aim of this study was to evaluate the efficacy and safety of the Pipeline Embolization Device in the treatment of recurrent, previously stented aneurysms.

MATERIALS AND METHODS

Twenty-one patients with previously stented recurrent aneurysms who later underwent Pipeline Embolization Device placement (group 1) were retrospectively identified and compared with 63 patients who had treatment with the Pipeline Embolization Device with no prior stent placement (group 2). Occlusion at the latest follow-up angiogram, recurrence and retreatment rates, clinical outcome, complications, and morbidity and mortality observed after treatment with the Pipeline Embolization Device were analyzed.

RESULTS

Patient characteristics were similar between the 2 groups. The mean time from stent placement to recurrence was 25 months. Pipeline Embolization Device treatment resulted in complete aneurysm occlusion in 55.6% of patients in group 1 versus 80.4% of patients in group 2 (P = .036). The retreatment rate in group 1

Mitotic Activity in Glioblastoma Correlates with Estimated Extravascular Extracellular Space Derived from Dynamic Contrast-Enhanced MR Imaging

Editor’s Choice

Twenty-eight patients with newly presenting glioblastoma multiforme underwent preoperative conventional imaging and T1 dynamic contrast-enhanced MRI. Parametric maps of the initial area under the contrast agent concentration curve, contrast transfer coefficient, estimate of volume of the extravascular extracellular space, and estimate of blood plasma volume were generated, and the enhancing fraction was calculated. High values of the estimate of volume of the extravascular extracellular space were associated with a fibrillary histologic pattern and increased mitotic activity. This finding is counterintuitive to the standard concept that more proliferative tumors would be more densely packed with cells and have less extracellular space. As the authors point out, this surprising finding requires more investigation to understand whether this relationship will hold, and what the underlying mechanism might be.

Abstract

Scatterplot of mitotic activity versus ve (P = .012, ρ = 0.470), marker shapes depict separate scores of cell density measures.
Scatterplot of mitotic activity versus ve (P = .012, ρ = 0.470), marker shapes depict separate scores of cell density measures.

BACKGROUND AND PURPOSE

A number of parameters derived from dynamic contrast-enhanced MR imaging and separate histologic features have been identified as potential prognosticators in high-grade glioma. This study evaluated the relationships between dynamic contrast-enhanced MRI–derived parameters and histologic features in glioblastoma multiforme.

MATERIALS AND METHODS

Twenty-eight patients with newly presenting glioblastoma multiforme underwent preoperative imaging (conventional imaging and T1 dynamic contrast-enhanced MRI). Parametric maps of the initial area under the contrast agent concentration curve, contrast transfer coefficient, estimate of volume of the extravascular extracellular space, and estimate of blood plasma volume were generated, and the enhancing fraction was calculated. Surgical specimens were used to assess subtype and were graded (World Health Organization classification system) and were assessed for necrosis, cell density, cellular atypia, mitotic activity, and overall vascularity scores. Quantitative assessment of endothelial surface area, vascular surface area, and a vascular profile count were made by using CD34 immunostaining. The relationships