Here is the next educational presentation. This was also done by some of my previous fellows.  The topic is a bit unusual, but I think that the presentation is very good and should help our readers.

Branchial Cleft Cysts (NXPowerLite)

Physical examination showed no chemosis, vision loss or cranial nerve palsies.  Because of this the patient was brought back for repeat contrast enhanced CT of the orbits with Valsalva maneuver.  This study showed mild additional enlargement of the already prominent left superior ophthalmic vein and also of the right sided one (see below).  The combination of imaging and clinical findings was thought to be most compatible with orbital varices.  The patient opted for conservative management.

Orbital varices are hamartomas composed of slow flow, low pressure and thinned walled and distensible blood vessels.  As they communicate with the rest of the circulation, they enlarge with Valsava, bending or prone position, and coughing and straining.  They produce proptosis which may be painful and because they may bleed, their symptoms may become acutely exacerbated.  They may also erode adjacent bone.  Treatment is very difficult and is reserved for those with repeated hemorrhages, thrombosis, optic nerve compression and disfigurement.  Orbital vascular processes included in the differential diagnosis are carotid cavernous fistulas of both types and less likely, venous thrombosis.

In CC fistulas, the ipsilateral cavernous sinus may be enlarged particularly in the direct ones (see below).  Extra-ocular muscles may also be large and the retro-ocular fat may have a “dirty” appearance.  In most patients with direct CCFs, chemosis, decreased vision and cranial nerve palsies are present.  Acute thrombosis of the superior ophthalmic vein may present with symptoms that are similar to those of a direct CCF.  Indirect CCFs may have less acute symptoms and be clinically similar to varices.  The diagnosis is confirmed with catheter angiography as shown here.

Suggested readings:

YO Arat, ME Mawad, M Boniuk. Orbital Venous Malformations: Current Multidisciplinary Treatment Approach. Arch Ophthalmol 2004; 122: 1151 – 1158

N Islam, K Mireskandari, GE Rose. Orbital varices and orbital wall defects. Br J Ophthalmol 2004; 88: 1092 – 1093

A Weill, C Cognard, L Castaings, G Robert, J Moret. Embolization of an orbital varix after surgical exposure. AJNR Am. J. Neuroradiol. 1998; 19: 921 – 923

The quantification of the perfusion parameters in neck cancer is valuable as the quantitative results may facilitate an objective disease monitoring in the same institution and, under certain circumstances, an interchangeability across different institutions. Nowadays, theoretical models deliver quantitative information (of course under certain inevitable assumptions concerning the relationship between MR signal and contrast agent concentration) which are obviously superior to heuristic (semi-quantitative) DCE parameters, such as peak enhancement, maximum upslope, time-to-peak enhancement, and washout slope. In the future, DCE-MRI should be besides CT a major player in this field and combined with diffusion-weighted sequences and spectroscopy may face equally the PET/CT.

Kim et al. focused on the nodal disease, which is a rather unattended aspect in the DCE imaging of neck cancer. The authors found significantly elevated baseline Ktrans in responders, which presumably has led to a better distribution of the chemotherapeutics than in the non-responders who had lower Ktrans values. This seems logical but on the other hand we should bear in mind that high Ktrans may imply severe neoangiogenesis, which, in turn, implies a more aggressive tumor with possibly higher microvascular density. Lower Ktrans may also be the result of necrotic areas thus, poor oxygenation and poor response to radiotherapy. Apparently, the interpretation of the microcirculatory parameters should not be one-sided and in a concomitant chemoradiation setting is definitely difficult to separate the effects of each therapy and draw easily logical conclusions. The authors could not demonstrate except of any significant association between ve, τi and response to therapy. This is not necessarily a drawback of the method but may reflect the heterogeneity of the volume of the target node as well as the different induction chemotherapy regimens across the patients. In a point of view what actually play the most important role are not the baseline microcirculatory parameter values themselves but how they shift during the therapy and after its completion. Obviously, the nodal and tumor response to therapy may have different time points, which are crucial for the further treatment planning. As expected, patients with small nodes in the present study [1] were complete responders after the preoperative chemoradiation, however, some of them had distant metastasis after 6 months. In other words, the 6-month follow-up is more reliable time point for deciding the predictive value of the DCE-imaging parameters. Furthermore, Kim et al. by demonstrating the feasibility of their method posed a very important question: how shall we analyse the nodal disease by means of DCE-MRI? Shall we calculate the microcirculation parameters on a single target node, on a node-to-node basis, or shall we average them?

The results in the presented paper are initial and in a small patient population, thus, far from drawing definite thresholds, cut-off values and significant predictive parameters. Ideally, the work of Kim et al. should trigger DCE-MRI studies that would: 1) compare the microcirculation parameters of histologically confirmed metastatic and reactive lymph nodes, 2) investigate the alteration of microcirculation parameters during the course of chemoradiation, defining the optimal time points for monitoring, and 3) compare the microcirculation parameters of tumoral and nodal residual disease/recurrence and chemoradiated neck tissue. Only under these premises, we would be able to use DCE-MR imaging as a diagnostic clinical tool and, thus, estimate the real predictive value of the microcirculation parameters.

References:

1. Kim S, Loevner LA, Quon H, Kilger A, Sherman E, Weinstein G, Chalian A, Poptani H. Prediction of Response to Chemoradiation Therapy in Squamous Cell Carcinomas of the Head and Neck Using Dynamic Contrast-Enhanced MR Imaging. AJNR Am J Neuroradiol. 2009 Oct 1. [Epub ahead of print]
2. Cao Y, Popovtzer A, Li D, Chepeha DB, Moyer JS, Prince ME, Worden F, Teknos T, Bradford C, Mukherji SK, Eisbruch A. Early prediction of outcome in advanced head-and-neck cancer based on tumor blood volume alterations during therapy: a prospective study. Int J Radiat Oncol Biol Phys. 2008;72:1287-90.
3. Bisdas S, Baghi M, Wagenblast J, Vogl TJ, Thng CH, Koh TS. Gadolinium-enhanced echo-planar T2-weighted MRI of tumors in the extracranial head and neck: feasibility study and preliminary results using a distributed-parameter tracer kinetic analysis. J Magn Reson Imaging. 2008;27:963-9.

For Immediate Release
October 19, 2009

American Society of Head and Neck Radiology
Presents Gold Medal to Hugh D. Curtin, M.D. during 43^rd Annual Meeting

The American Society of Head and Neck Radiology (ASHNR) presented its 2009 Gold Medal to Dr. Hugh D. Curtin on October 8, 2009, during the ASHNR 43^rd Annual Meeting at the Sheraton New Orleans Hotel in New Orleans, Louisiana.

Dr. Hugh D. Curtin was born in Canton, New York.  He attended grade school and high school there before attending the University of Toronto, St. Michael’s College.  He then made a decision to become a physician and attended SUNY Upstate Medical University in Syracuse, New York.  Dr. Curtin next went to the University of Pittsburgh Medical Center where he was first an intern and then a Radiology Resident.  He also took a fellowship in Pediatric Radiology in Sweden and then he was a clinical fellow in radiology with Dr. Vignaud in Paris.

Dr. Curtin joined the radiology faculty in Pittsburgh where he rose to full Professor of Radiology in 1988.  Then about seven years later he moved to Boston in 1995 as the Chief of Radiology at the Massachusetts Eye and Ear Infirmary and was soon appointed as full Professor of radiology at the Harvard Medical School.

Dr. Curtin has lectured widely both nationally and internationally almost 350 times and he is well known as an excellent teacher.  In fact, he has received numerous awards for his teaching excellence.  He served as the Head and Neck Editor of the American Journal of Neuroradiology and has served on numerous committees for at least 14 societies, where he has been on the executive committees of many of these societies.  Dr. Curtin is a reviewer for at least 11 major journals and has received awards for the excellence of his reviewing.  He has participated in over 20 exhibits.  Last, but by far not the least, he has authored about 130 peer-reviewed articles and 71 chapters.  Many of these articles are considered sentinel articles as they have influenced the way images are interpreted in head and neck radiology.  He is the co-editor with Dr. Peter M. Som of Head and Neck Imaging, presently in preparation of the fifth edition.

Dr. Curtin has always been a calming resource to his family and colleagues and his good-natured persona has endeared him to all.  He is admired as a scholar and for his numerous contributions to the ASHNR.  Thus, the ASHNR is very proud to present its 2009 Gold Medal to Dr. Hugh D. Curtin, as a symbol of his outstanding achievements in head and neck radiology.

For more information on the ASHNR Gold Medal or on the Society in general, contact Business Manager Ken Cammarata at:

American Society of Head and Neck Radiology
2210 Midwest Road, Suite 207
Oak Brook, IL 60523-8205
Phone: 630/574-0220, ext. 226
FAX: 630/574-0661
Email: kcammarata@asnr.org

You may have heard that Propanolol is currently being used as treatment for some infantile hemangiomas of both types (RICH and NICH).  In this presentation prepared for our weekly case conference by Mr. Danilo Bernardo the results of such therapy are illustrated and discussed.

Here is another educational presentation.  It was shown at a previous ASNR meeting and authored by our Neuroradiology fellows of the time.  It deals with the imaging aspects of congenital and acquired hearing loss. Enjoy it!

With this post our readers will find a presentation (in Powerpoint format) that discusses the imaging findings of acute facial nerve paralysis.  This presentation was shown at a previous ASNR meeting and has been slightly modified to better fit in our blogsite.  I am not the sole author, it represents contributions from all the members of our Neuroradiology Division here at UNC. It is my hope that with this new type of activity (I will post more presentations soon)  the educational aspects of this site increase and improve.    Since the file is not protected, all are welcome to use its materials and hopefully will give us the appropriate credit.  The presentation is significantly compressed. Feedback is appreciated.

This patient had left central retinal artery occlusion and acute ischemic optic neuropathy. There is restricted diffusion in the anterior left optic nerve which is much more obvious than the mild perineural enhancement on coronal postcontrast images.