Category Archives: Editor’s Choices

Cement Salvage of Instrumentation-Associated Vertebral Fractures

Editor’s Choice November 2014

(2 of 3)

The authors describe the treatment of 22 vertebral compression fractures in 11 patients with metastases and prior spinal instrumentation. Pain improved in all patients, only 1 patient needed additional surgery, and there were no vertebral cement augmentation–related complications.

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Abstract

BACKGROUND AND PURPOSE
Sacral insufficiency fractures are a common cause of severe low back pain and immobilization in patients with osteoporosis or cancer. Current practice guideline recommendations range from analgesia and physical therapy to resection with surgical fixation. We sought to assess the safety and effectiveness of sacroplasty, an emerging minimally invasive treatment.

MATERIALS AND METHODS
We performed a retrospective review of institutional databases for percutaneous sacroplasty performed between January 2004 and September 2013. Demographic and procedural data and pre- and posttreatment Visual Analog Scale, Functional Mobility Scale, and Analgesic Scale scores were reviewed. Overall response was rated by using a 4-point scale (1, complete resolution of pain; 2, improvement of pain; 3, no change; 4, worsened pain) assessed at short-term follow-up.

RESULTS
Fifty-three patients were included; most (83%) were female. Fracture etiology was cancer-related (55%), osteoporotic insufficiency (30%), and minor trauma (15%). No major complication or procedure-related morbidity occurred. There were statistically significant decreases in the Visual Analog Scale (P < .001), Functional Mobility Scale (P < .001), and Analgesic Scale scores (P < .01) in 27 patients with recorded data: pretreatment Visual Analog Scale (median [interquartile range], 9.0 [8.0–10.0]); Functional Mobility Scale, 3.0 (2.0–3.0); and Analgesic Scale scores, 3.0 (3.0–4.0) were reduced to 3.0 (0.0–5.8), 1.0 (0.25–2.8), and 3.0 (2.0–3.8) posttreatment. When we used the overall 4-point score at a mean of 27 days, 93% (n = 45) reported complete resolution or improvement in overall pain.

CONCLUSIONS
In this single-center cohort, sacroplasty was a safe and effective procedure.

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Leukoaraiosis Predicts a Poor 90-Day Outcome after Endovascular Stroke Therapy

Editor’s Choice November 2014

(1 of 3)

The authors explored the relationship between white matter changes and outcome in 129 patients who received endovascular therapy for acute stroke. Severe white matter changes were associated with poor outcomes at 90 days. Those who survived and had pre-existing severe white matter changes also showed significantly less improvement.

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Abstract

BACKGROUND AND PURPOSE
Leukoaraiosis is a common finding among patients with ischemic stroke and has been associated with poor stroke outcomes. Our aim was to ascertain whether the severity of pre-existing leukoaraiosis is associated with outcome in patients with acute ischemic stroke who are treated with endovascular stroke therapy.

MATERIALS AND METHODS
We retrospectively analyzed data from 129 consecutive, prospectively enrolled patients with stroke undergoing endovascular stroke therapy at a single tertiary care center between January 2006 and August 2013. Leukoaraiosis was assessed as supratentorial white matter hypoattenuation on admission head CT and graded as 0–2 (absent-to-moderate) versus 3–4 (severe) according to the van Swieten scale. We dichotomized the 90-day mRS into good (0–2 or return to baseline) versus poor (3–6) as the primary study outcome. Incremental multivariable logistic regression analyses were performed to identify independent predictors of a poor 90-day outcome.

RESULTS
In all multivariable models, severe leukoaraiosis was independently (P < .05) associated with a poor outcome at 90 days (fully adjusted model: OR, 6.37; 95% CI, 1.83–12.18; P = .004). The independent association between leukoaraiosis and a poor outcome remained when the analysis was restricted to patients who were alive at discharge (n = 87, P < .05). Last, among patients who were alive at discharge, those with severe leukoaraiosis had significantly less frequent improvement on the mRS from discharge to 90 days compared with patients with absent-to-moderate leukoaraiosis (P= .034).

CONCLUSIONS
The severity of pre-existing leukoaraiosis

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Distinguishing Imaging Features between Spinal Hyperplastic Hematopoietic Bone Marrow and Bone Metastasis

Editor’s Choice October 2014

(3 of 3)

MR, FDG-PET, and CT images from 8 patients with proven spinal findings of hyperplastic hematopoietic bone marrow were compared with those of 24 patients with spinal metastases. If a lesion was isointense to hyperintense to normal-appearing marrow on MR imaging or had a maximum standard uptake value of >3.6, the lesion was metastatic. A normal appearance on CT or bone scintigraphy excluded metastasis.

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Abstract

BACKGROUND AND PURPOSE
Systematic investigations of the distinguishing imaging features between spinal hyperplastic hematopoietic bone marrow and bone metastasis have not been reported, to our knowledge. The purpose of this study was to determine the distinguishing imaging features of the 2 entities.

MATERIALS AND METHODS
We retrospectively reviewed the radiologic images of 8 consecutive male patients (age range, 52–78 years; mean, 64 years) with suspected spinal metastasis on MR imaging and FDG-PET, which was later confirmed as hyperplastic hematopoietic bone marrow. MR imaging, FDG-PET, CT, and bone scintigraphy images were qualitatively and/or quantitatively evaluated. Imaging findings in 24 patients with spinal metastasis were compared, and differences were statistically analyzed.

RESULTS
All 8 vertebral hyperplastic hematopoietic bone marrow lesions were hypointense on T1- and T2-weighted images; lesions contiguous with the adjacent vertebra were significantly more often seen in hyperplastic hematopoietic bone marrow than in metastasis (P = .035). T2 signal intensity of the lesion was significantly different between the 2 entities (P = .033). FDG-PET showed slightly higher uptake in all hyperplastic hematopoietic bone marrow lesions; their maximum standard uptake value was significantly lower than that of metastatic lesions (P = .037). CT attenuation of hyperplastic hematopoietic bone marrow was equal to or slightly higher than that of adjacent normal-appearing vertebra; the CT appearances of hyperplastic hematopoietic bone marrow and metastasis were significantly different (P <

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MR Myelography for Identification of Spinal CSF Leak in Spontaneous Intracranial Hypotension

Editor’s Choice October 2014

(2 of 3)

Twenty-four patients with intracranial hypotension received CT myelography as well asintrathecal gadolinium MR myelography. Comparisons demonstrated a higher rate of leak detection with intrathecal gadolinium MR myelography. Although intrathecal gadolinium is an FDA off-label use, all patients tolerated the medication without evidence of complications.

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Abstract

BACKGROUND AND PURPOSE
CT myelography has historically been the test of choice for localization of CSF fistula in patients with spontaneous intracranial hypotension. This study evaluates the additional benefits of intrathecal gadolinium MR myelography in the detection of CSF leak.

MATERIALS AND METHODS
We performed a retrospective review of patients with spontaneous intracranial hypotension who underwent CT myelography followed by intrathecal gadolinium MR myelography. All patients received intrathecal iodine and off-label gadolinium-based contrast followed by immediate CT myelography and subsequent intrathecal gadolinium MR myelography with multiplanar T1 fat-suppressed sequences. CT myelography and intrathecal gadolinium MR myelography images were reviewed by an experienced neuroradiologist to determine the presence of CSF leak. Patient records were reviewed for demographic data and adverse events following the procedure.

RESULTS
Twenty-four patients met both imaging and clinical criteria for spontaneous intracranial hypotension and underwent CT myelography followed by intrathecal gadolinium MR myelography. In 3/24 patients (13%), a CSF leak was demonstrated on both CT myelography and intrathecal gadolinium MR myelography, and in 9/24 patients (38%), a CSF leak was seen on intrathecal gadolinium MR myelography (P = .011). Four of 6 leaks identified independently by intrathecal gadolinium MR myelography related to meningeal diverticula. CT myelography did not identify any leaks independently. There were no reported adverse events.

CONCLUSIONS
Present data demonstrate a higher rate of leak detection with intrathecal gadolinium MR myelography when investigating CSF leaks in our cohort of patients with spontaneous intracranial hypotension. Although intrathecal gadolinium is an FDA off-label use,

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Mechanical Embolectomy for Acute Ischemic Stroke in the Anterior Cerebral Circulation: The Gothenburg Experience during 2000–2011

Editor’s Choice October 2014

(1 of 3)

Safety and efficacy of intra-arterial treatment using the AmplatzGooseNeck device in acute anterior circulation strokes were assessed in 156 patients. High recanalization rates were obtained with the AmplatzGooseNeck snare without any device-related complications. Favorable outcome, mortality, and symptomatic intracerebral hemorrhage were comparable with results of newer embolectomy devices.

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Abstract

BACKGROUND AND PURPOSE
Intra-arterial treatment of proximal occlusions in the cerebral circulation have become an important tool in the management of acute ischemic stroke. Our goal was to evaluate the safety and efficacy of intra-arterial acute ischemic stroke treatment performed in our institution in consecutive patients with anterior circulation occlusion during 2000–2011.

MATERIALS AND METHODS
We identified, in our data base, 156 consecutive cases with anterior acute ischemic stroke treated intra-arterially during 2000–2011. Stroke severity was defined according to the National Institutes of Health Stroke Scale, the results of the procedure were defined according to the modified Thrombolysis in Cerebral Infarction score, and clinical outcome was defined according to the modified Rankin scale, with favorable outcome ≤2 at 90 days.

RESULTS
The mean admission NIHSS score was 19.4 (median, 20), with a mean time from stroke onset to groin puncture of 197 minutes (median, 171 minutes). The embolectomy tool of choice was the Amplatz GooseNeck snare (83%). Successful recanalization (modified TICI 2b +3) was seen in 74% of cases. A mRS ≤ 2 at 90 days was seen in 42% with a mortality rate of 17% and symptomatic intracerebral hemorrhage in 4%.

CONCLUSIONS
A high recanalization rate was obtained with the Amplatz GooseNeck snare without any device-related complications. Favorable outcome, mortality, and symptomatic intracerebral hemorrhage are comparable with results of newer embolectomy devices.

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Screening CT Angiography for Pediatric Blunt Cerebrovascular Injury with Emphasis on the Cervical “Seatbelt Sign”

Editor’s Choice September 2014

(3 of 3)

The authors investigated the significance of several clinical and imaging risk factors, most specifically the “cervical seatbelt sign,” in the anterior neck in pediatric patients with suspected blunt cerebrovascular injury as seen by CTA. They found that this common indication for neck CTA was not associated with blunt cerebrovascular injury. With the exception of Glasgow Coma Scale score, no single risk factor was statistically significant in predicting vascular injury.

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Abstract

BACKGROUND AND PURPOSE
There are no standard screening guidelines to evaluate blunt cerebrovascular injury in children. The purpose of this retrospective study was to understand the clinical and radiologic risk factors associated with pediatric blunt cerebrovascular injury on CTA of the neck with primary attention to the cervical “seatbelt sign.”

MATERIALS AND METHODS
Radiology reports from 2002 to 2012 were queried for the examination “CTA neck.” The electronic medical record was reviewed for mechanism of injury, Glasgow Coma Scale score, and physical examination findings. Radiology reports from adjunct radiographic studies were reviewed. CTA neck examinations with reported blunt cerebrovascular injury were reviewed to confirm imaging findings. Patients with penetrating injury or those without a history of trauma were excluded.

RESULTS
Four hundred sixty-three patients underwent CTA of the neck; 137 had blunt trauma. Forty-two of 85 patients involved in a motor vehicle collision had a cervical seatbelt sign; none had blunt cerebrovascular injury. Nine vessels (4 vertebral arteries, 4 ICAs, 1 common carotid artery) in 8 patients ultimately were diagnosed with various grades (I–IV) of blunt cerebrovascular injury, representing 5.8% (8/137) of the population screened for blunt neck trauma. The mean Glasgow Coma Scale score was significantly lower (P = .02) in the blunt cerebrovascular injury group versus the non-blunt cerebrovascular injury group. Although not statistically significant, patients with blunt cerebrovascular injury

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Brain Structure and Function in Patients after Metal-on-Metal Hip Resurfacing

Editor’s Choice September 2014

(2 of 3)

Malfunction of metal-on-metal hip prostheses may produce visual, hearing, and motor deficits. These authors compared brain volumes, metal deposition, and gray matter attenuation in 2 groups of patients 8 years after surgery. Whole blood cobalt and chromium levels were higher in patients with metal-on-metal prostheses and associated with subtle structural changes in the visual pathways and basal ganglia.

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Abstract

BACKGROUND AND PURPOSE
Hip prostheses that use a metal-on-metal articulation expose the brain to elevated metal concentrations that, in acute excess due to prosthesis malfunction, is associated with neurologic damage, including visual and hearing loss and motor deficits. Here, we examined whether chronic exposure to lower elevated metal levels, typical of well-functioning prostheses, also affects brain structure and function.

MATERIALS AND METHODS
We compared brain volumes, metal deposition, and gray matter attenuation by MR imaging and clinical neurologic function in patients 8 years after receiving a metal-on-metal hip resurfacing versus a matched group of patients with the same duration exposure to a conventional hip prosthesis.

RESULTS
Twenty-nine patients (25 men; mean, age 59 ± 7 years) after metal-on-metal hip resurfacing and 29 patients (25 men; 59 ± 8 years) after total hip arthroplasty were compared. Whole blood cobalt and chromium concentrations were 5–10 times higher in the metal-on-metal hip resurfacing group (P < .0001). Occipital cortex gray matter attenuation tended to be lower (P < .005 uncorrected, P > .05 corrected), and the optic chiasm area tended to be lower (mean difference, −2.7 mm2; P = .076) in the metal-on-metal hip resurfacing group. Subgroup analyses in 34 patients (17 per group), after exclusion of primary ocular pathology, showed the same trend in gray matter attenuation in the occipital cortex and basal ganglia and a smaller optic chiasm in the metal-on-metal

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Cost-Effectiveness of CT Angiography and Perfusion Imaging for Delayed Cerebral Ischemia and Vasospasm in Aneurysmal Subarachnoid Hemorrhage

Editor’s Choice September 2014

(1 of 3)

This comparative-effectiveness and cost-effectiveness study assessed the use of CT angiography and perfusion in patients with cerebral ischemia after aneurysmal SAH. The authors found that CTA and CTP should be the preferred imaging strategy in SAH, compared with transcranial Doppler ultrasound, leading to improved clinical outcomes and lower health care costs.

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Abstract

BACKGROUND AND PURPOSE
Delayed cerebral ischemia and vasospasm are significant complications following SAH leading to cerebral infarction, functional disability, and death. In recent years, CTA and CTP have been used to increase the detection of delayed cerebral ischemia and vasospasm. Our aim was to perform comparative-effectiveness and cost-effectiveness analyses evaluating CTA and CTP for delayed cerebral ischemia and vasospasm in aneurysmal SAH from a health care payer perspective.

MATERIALS AND METHODS
We developed a decision model comparing CTA and CTP with transcranial Doppler sonography for detection of vasospasm and delayed cerebral ischemia in SAH. The clinical pathways were based on the “Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage: A Guideline for Healthcare Professionals from the American Heart Association/American Stroke Association” (2012). Outcome health states represented mortality and morbidity according to functional outcomes. Input probabilities of symptoms and serial test results from CTA and CTP, transcranial Doppler ultrasound, and digital subtraction angiography were directly derived from an SAH cohort by using a multinomial logistic regression model. Expected benefits, measured as quality-adjusted life years, and costs, measured in 2012 US dollars, were calculated for each imaging strategy. Univariable, multivariable, and probabilistic sensitivity analyses were performed to determine the independent and combined effect of input parameter uncertainty.

RESULTS
The transcranial Doppler ultrasound strategy yielded 13.62 quality-adjusted life years at a cost of $154,719. The CTA and CTP strategy generated 13.89 quality-adjusted life years at a cost of $147,097, resulting in a gain of … Continue reading >>

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Reliability of the STIR Sequence for Acute Type II Odontoid Fractures

Editor’s Choice August 2014

(3 of 3)

Because STIR images are routinely used for evaluation of the posttraumatic cervical spine, these authors specifically looked at the ability of this sequence to differentiate acute vs. chronic odontoid type II fractures in 75 patients and compared the imaging findings with an equal number of age-matched controls. STIR fared poorly in the detection of fractures in individuals over 57 years of age. Therefore, older patients, particularly those with osteopenia, may have acute odontoid injuries without corresponding STIR hyperintensity.

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Abstract

BACKGROUND AND PURPOSE
The STIR sequence is routinely used to assess acute traumatic osseous injury. Because the composition of the odontoid in older individuals may be altered with osteopenia and decreased vascularity, the STIR sequence may not accurately depict the acuity of an odontoid fracture. The purpose of this study was to evaluate the reliability of the STIR sequence to differentiate acute-versus-chronic type II odontoid fractures in older patients, particularly those with osteopenia.

MATERIALS AND METHODS
A retrospective review was performed for patients with type II odontoid fractures during a 10-year period with both CT and MR imaging performed within 24 hours of injury. Patients were paired with controls of similar ages and were grouped by age. The STIR images were evaluated in a blinded fashion for the presence of hyperintensity in the odontoid. Demographic and clinical characteristics were also recorded.

RESULTS: Seventy-five patients with type II odontoid fracture and 75 healthy controls (mean and median age of 57 years) were identified. The sensitivity of STIR to detect fracture in the age group 57 years and older was significantly worse than that in the age group younger than 57 years (54% and 82%, respectively; P = .018).

CONCLUSIONS
Older patients, particularly those with osteopenia, may have acute odontoid injuries without corresponding STIR hyperintensity. Additionally, … Continue reading >>

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Effect of Direct Neuroradiologist Participation in Physician Marketing on Imaging Volumes in Outpatient Radiology

Editor’s Choice August 2014

(2 of 3)

This study assessed the benefits of using a sales representative and a neuroradiologistas a marketing and sales team for referrals in outpatient imaging. When referring practices were visited by the 2-person team, referral volumes were 2.5 times greater than when they were visited by the sales representative alone. This impact on imaging referral volumes with the use of the neuroradiologist for direct physician-to-physician marketing supports the concept that neuroradiologist visits are important in establishing and maintaining a relationship with the referring clinician’s office and maximizing imaging referrals.

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Abstract

BACKGROUND AND PURPOSE
Over the past several years, decreased demand for and increased supply of imaging services has increased competition among outpatient imaging centers in the United States. This study hypothesizes that using a radiology sales representative and neuroradiologist as a team in marketing and sales will increase imaging referrals in outpatient imaging.

MATERIALS AND METHODS
From January to December 2009, baseline monthly physician referral data of CT and MR scans of 19 referring clinicians (neurologists, neurosurgeons, and anesthesiologists) to an outpatient radiology group were collected. During that time, a nonphysician radiology sales representative visited the referring clinicians’ offices every 2 weeks. From January to June 2010, the same radiology sales representative visited the referring clinicians’ offices every 2 weeks but was accompanied by a neuroradiologist once a month. From July 2010 to June 2011, the same radiology sales representative visited the referring clinicians’ offices twice a month without a neuroradiologist.

RESULTS
Cross-sectional imaging referral volumes were approximately 2.5 times greater during the 6-month period using the neuroradiologist for direct physician-to-physician marketing when compared with the volumes achieved with the sales representative alone, and continued neuroradiologist involvement in marketing and sales is required to maintain referral volumes over time.

CONCLUSIONS
The impact on imaging referral … Continue reading >>

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