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Differentiation between Treatment-Induced Necrosis and Recurrent Tumors in Patients with Metastatic Brain Tumors: Comparison among 11C-Methionine-PET, FDG-PET, MR Permeability Imaging, and MRI-ADC—Preliminary Results

Editor’s Choice

The authors evaluated the feasibility of MR permeability imaging by comparison with 11C-methionine-PET, FDG-PET, and DWI for differentiating radiation necrosis from recurrent tumors in 15 patients with 18 lesions following gamma knife radiosurgery. The area under the ROC curve for differentiating radiation necrosis from recurrent tumors was the best for the 11C-methionine ratio (0.90) followed by the contrast-enhancement ratio (0.81), maximum slope of increase (millimole/second) (0.80), and the initial area under the signal intensity–time curve (0.78). They conclude that PET using 11C-methionine may be superior to MR permeability imaging, ADC, and FDG-PET for differentiating radiation necrosis from recurrent tumors after gamma knife radiosurgery for metastatic brain tumors.

TIPIC Syndrome: Beyond the Myth of Carotidynia, a New Distinct Unclassified Entity

Fellows’ Journal Club

This study included 47 patients from 10 centers presenting between January 2009 through April 2016with acute neck pain or tenderness and at least 1 cervical image showing unclassified carotid abnormalities. The authors conducted a systematic, retrospective study of their medical charts and diagnostic and follow-up imaging. All patients presented with acute neck pain, and 8 presented with transient neurologic symptoms. Imaging showed an eccentric pericarotidian infiltration in all patients. An intimal soft plaque was noted in 16 patients, and a mild luminal narrowing was noted in 16 patients. The authors conclude that this study improves the description of an unclassified, clinico-radiologic entity, which could be described by the proposed acronym: Transient Perivascular Inflammation of the Carotid artery (TIPIC) syndrome.

Temporary Stent-Assisted Coil Embolization as a Treatment Option for Wide-Neck Aneurysms

Editor’s Choice

The authors intended to treat 33 aneurysms between January 2010 and December 2015 with temporary stent-assisted coiling, which formed the series for this study. Incidental and acutely ruptured aneurysms were included. Sufficient occlusion was achieved in 97.1% of the cases. In 94%, the stent could be fully recovered. Complications occurred in 5 patients (14.7%). They conclude that temporary stent-assisted coiling is an effective technique for the treatment of wide-neck aneurysms. Safety is comparable with that of stent-assisted coiling and coiling with balloon remodeling.

Head and Neck Ultrasonography: Essential and Extended Applications, 2nd Edition

Orloff LA. Head and Neck Ultrasonography: Essential and Extended Applications. 2nd ed. Plural Publishing; 2017; 544 pp; $299.95

Cover of Orloff

The second edition of Head and Neck Ultrasonography: Essential and Extended Applications is an inclusive and detailed review of office-based and intraoperative ultrasonography. The book caters to a diverse audience, including radiologists, surgeons, and clinicians such as endocrinologists.

This publication is organized into 21 chapters covering a diverse range of topics. The initial chapters outline the history of head and neck ultrasonography, as well as basic US physics and current equipment and techniques, which builds on the knowledge base of the reader. There is also a chapter on healthy head and neck anatomy, which may serve as a good review for some before gaining access to more advanced material.

The diagnostic chapters may be of particular interest to general radiologists, neuroradiologists, and pediatric radiologists. These range from discussions of more common applications, such as thyroid and parathyroid disease, to more specialized knowledge, such as salivary gland and laryngeal ultrasonography.

Chapters on transesophageal and endobronchial ultrasound, as well as interventional ultrasonography, contain text covering anatomy, pathology, and procedural technical aspects that are geared towards a more procedurally inclined audience, including interventional radiologists, otolaryngologists, gastroenterologists, and pulmonologists, as well as endocrinologists who perform office-based diagnostic procedures, such as US-guided FNA.

One distinct characteristic throughout the book is its particular attention to descriptive and pictorial consideration of ultrasonographic technique, which might be of interest to the radiologist who is less experienced in head and neck “hands-on“ scanning.

Image quality is overall robust and representative illustrations are clear, with several containing 2 axes depicting the same finding. A few figures are rendered in lower resolution, likely due to inherent technique or the equipment utilized.

Sonographic dynamic clips are also included on the companion website, providing a …

Prevalence of Traumatic Findings on Routine MRI in a Large Cohort of Professional Fighters

Fellows’ Journal Club

Conventional 3T MR imaging was used to assess 499 fighters (boxers, mixed martial artists, and martial artists) and 62 controls for nonspecific WM changes, cerebral microhemorrhage, cavum septum pellucidum, and cavum vergae. Fighters had an increased prevalence of cerebral microhemorrhage (4.2% versus 0% for controls), cavum septum pellucidum (53.1% versus 17.7% for controls), and cavum vergae (14.4% versus 0% for controls). This study assessed MR imaging findings in a large cohort demonstrating a significantly increased prevalence of cavum septum pellucidum among fighters. Although cerebral microhemorrhages were higher in fighters than in controls, this finding was not statistically significant.

Diffusional Kurtosis Imaging and Motor Outcome in Acute Ischemic Stroke

Editor’s Choice

The authors evaluated 17 patients with stroke who underwent brain diffusional kurtosis imaging within 4 days after the onset of symptoms. Neurologic evaluation included the Fugl-Meyer Upper Extremity Motor scale in the acute phase and 3 months poststroke. The largest percentage signal changes of the lesioned hemisphere corticospinal tract were observed with axial kurtosis, with an average 12% increase compared with the contralateral corticospinal tract. The strongest associations between the 3-month Fugl-Meyer Upper Extremity Motor scale score and diffusion metrics were found for the lesioned/contralateral hemisphere corticospinal tract mean kurtosis and axial kurtosis ratios. They conclude that diffusion metrics related to kurtosis were found to be more sensitive than conventional diffusivity metrics to early poststroke corticospinal tract microstructural changes.

Baseline Survey of the Neuroradiology Work Environment in the United States with Reported Trends in Clinical Work, Nonclinical Work, Perceptions of Trainees, and Burnout Metrics

Fellows’ Journal Club

A voluntary survey was sent to practicing and out-of-training members of the ASNR. Four hundred thirty-two respondents across a broad range of experience reported: 93% with workdays extending at least 1 hour past expected; 71.9% reading more cases per hour compared with previous years; 79.5% sometimes-to-always interpreting cases faster than comfortable for optimal interpretation; and 67.8% sometimes or more often with inadequate time to discuss abnormal results. Burnout symptoms ranged between 49% and 75%. The trends and the correlations should be concerning to the leaders of radiology and warrant further monitoring.

The Use of Noncontrast Quantitative MRI to Detect Gadolinium-Enhancing Multiple Sclerosis Brain Lesions: A Systematic Review and Meta-Analysis

Editor’s Choice

The authors evaluated 37 journal articles that included 985 patients with MS who had MR imaging in which T1-weighted postcontrast sequences were compared with noncontrast sequences obtained during the same MR imaging examination by using ROI analysis of individual MS lesions. DTI-based fractional anisotropy values were significantly different between enhancing and nonenhancing lesions, with enhancing lesions showing decreased FA. None of the other most frequently studied MR imaging biomarkers (mean diffusivity, magnetization transfer ratio, or ADC) were significantly different between enhancing and nonenhancing lesions. They conclude that noncontrast MR imaging techniques, such as DTI-based FA, can assess MS lesion acuity without gadolinium.

Color Atlas of Brainstem Surgery

Spetzler RF, Kalani MYS, Nakaji P, Yagmurlu K. Color Atlas of Brainstem Surgery. Thieme; 2017; 416 pp; 850 ill; $249.99

cover of Spetzler

This recent publication is a unique work that emphasizes the structural and functional anatomy of the thalamus and brainstem and provides guidance for accessing these regions surgically for intrinsic lesions. The print atlas is accompanied by a large collection of online media, including animations and narrated surgical videos.

The book opens with an overview of anatomy, beginning with surface structures and perpendicular sections of whole fixed brains and progressing through focused dissections. To clarify specific relationships, it strategically incorporates diagrams of deep venous anatomy and cisterns around the brainstem. It summarizes the function and location of the long fiber tracts at the level of the cerebrum, midbrain, pons, medulla, and spinal cord, reviewing the clinically significant deficits incurred with lesions at each level. The discussion then integrates these concepts to introduce the safe entry zones of the brainstem, identifying both surface and deep structures that must be avoided. Fixed tissue dissections of varying depth demonstrate the three-dimensional relationships of adjacent tracts and nuclei. Full-color illustrations and dissection views of the associated vasculature are accompanied by axial slices depicting the territories of arterial supply. The combination of detailed sketches and meticulous dissections helps the reader bridge the conceptual gap between cross-sectional images and a surgeon’s view of the deeper structures that are imminently transgressed. The anatomy section finishes with a summary of the skull base foramina and traversing cranial nerves.

The next section of the book specifically describes the safe entry zones and nearby landmarks, with illustrations that depict the surface and cross-sectional anatomy of each zone. Some of this content is outlined in the preceding chapter, but this section provides a detailed rationale for the use of the safe …

Journal Scan – This Month in Other Journals, July 2017

Rabinstein AA. Treatment of Acute Ischemic Stroke. Continuum (Minneap Minn). 2017;23(1, Cerebrovascular Disease):62-81. doi:10.1212/CON.0000000000000420.

This is an excellent and comprehensive review of current acute stroke treatment.  The three main principles of acute stroke care are: (1) achieve timely recanalization of the occluded artery and reperfusion of the ischemic tissue, (2) optimize collateral flow, and (3) avoid secondary brain injury. The author states there is incontrovertible evidence that IV thrombolysis with rtPA and endovascular thrombectomy with a retrievable stent improve neurologic outcomes in patients with acute ischemic stroke. Both treatments should be administered as quickly as possible after stroke onset, can be combined, and are safe in appropriately selected candidates. IV thrombolysis with rtPA is proven to be effective in improving functional outcomes after an ischemic stroke up to 4.5 hours after symptom onset. IV rtPA infused within 3 hours of symptom onset increases the chances of functional independence at 3 months by one-third. The benefit is time dependent and much stronger when the drug is administered within the first 90 minutes after symptom onset.

Regarding mechanical thrombectomy, the six positive trials shared the requirement of CT angiograms for patient screening (only patients with documented internal carotid artery or proximal middle cerebral artery occlusions could be entered into the studies), emphasized the importance of prompt intervention, and almost exclusively used retrievable stents to achieve reperfusion. All of the trials enrolled patients with severe neurologic deficits and good prestroke functional status who presented mostly within 6 hours of symptom onset. Major early ischemic changes on the baseline CT scan were a reason for exclusion. Patients treated with mechanical thrombectomy had high rates of reperfusion and much better functional outcomes at 90 days. Mechanical thrombectomy was also proven to be quite safe, with a pooled rate of