Standardized reporting for Head CT Scans in patients suspected of traumatic brain injury (TBI): An international expert endeavor.

BACKGROUND AND PURPOSE: Traumatic brain injury (TBI) is a major source of health loss and disability worldwide. Accurate and timely diagnosis of TBI is critical for appropriate treatment and management of the condition. Neuroimaging plays a crucial role in the diagnosis and characterization of TBI. Computed tomography (CT) is the first-line diagnostic imaging modality typically utilized in patients with suspected acute mild, moderate and severe TBI. Radiology reports play a crucial role in the diagnostic process, providing critical information about the location and extent of brain injury, as well as factors that could prevent secondary injury. However, the complexity and variability of radiology reports can make it challenging for healthcare providers to extract the necessary information for diagnosis and treatment planning. METHODS/RESULTS/CONCLUSION: In this article, we report the efforts of an international group of TBI imaging experts to develop a clinical radiology report template for CT scans obtained in patients suspected of TBI and consisting of fourteen different subdivisions (CT technique, mechanism of injury or clinical history, presence of scalp injuries, fractures, potential vascular injuries, potential injuries involving the extra-axial spaces, brain parenchymal injuries, potential injuries involving the cerebrospinal fluid spaces and the ventricular system, mass effect, secondary injuries, prior or coexisting pathology).

Surveillance Imaging with PET/CT and CT and/or MRI for Head and Neck Cancer and Mortality: A Population-based Study.

Background To the knowledge of the authors, no strong evidence supports surveillance imaging in patients with head and neck cancer (HNC). Purpose To investigate the association between surveillance imaging and mortality using a population-based study design with statewide cancer registry data, all-payer claims data, and health care facility data. Materials and Methods The retrospective population-based study identified patients with HNC diagnosed between January 2012 and December 2017. Current Procedural Terminology codes were used to search surveillance imaging procedures. Cox proportional hazards models were used to estimate hazard ratios (HRs) and 95% CIs for mortality with adjustment for sex, ethnicity, age, health insurance status, cancer site, stage, and treatment. Results The study identified 1004 patients (mean age, 61 years ± 12 [SD]; 753 men), including 902 patients with squamous cell carcinoma (SCC) HNC and 102 patients with non-SCC. The effect of imaging on mortality among patients with SCC was not statistically significant when the entire sample was analyzed (HR, 0.76; 95% CI: 0.57, 1.02; P = .07). However, in stratified analyses by cancer stage, surveillance imaging was associated with lower mortality among patients with SCC for regionalized cancer stage (HR, 0.55; 95% CI: 0.36, 0.83; P = .005) and distant cancer stage (HR, 0.40; 95% CI: 0.19, 0.83; P = .01). Among patients with non-SCC, surveillance imaging was associated with lower mortality versus no surveillance imaging (HR, 0.19; 95% CI: 0.04, 0.94; P = .04). PET/CT was associated with lower mortality for patients with SCC (HR, 0.29; 95% CI: 0.09, 0.94; P = .04), and CT and/or MRI was associated with lower mortality for patients with non-SCC (HR, 0.11; 95% CI: 0.01, 0.94; P = .04). Conclusion Surveillance imaging was associated with lower mortality among patients with head and neck squamous cell carcinoma with regionalized or distant disease. The surveillance imaging protective association was observed up to 2 years after treatment completion. © RSNA, 2023 Supplemental material is available for this article. See also the editorial by Branstetter in this issue.

Glymphatic MRI techniques in sleep and neurodegenerative diseases.

PURPOSE OF REVIEW: The purpose of this review article is to summarize the current in-vivo imaging techniques for the evaluation of the glymphatic function and discuss the factors influencing the glymphatic function and research directions in the future. RECENT FINDINGS: The glymphatic system allows the clearance of metabolic waste from the central nervous system (CNS). The glymphatic pathway has been investigated using intrathecal or intravenous injection of a gadolinium-based contrast agent (GBCA) on MRI, so-called glymphatic MRI. The glymphatic MRI indirectly visualizes the dynamic CSF flow and evaluated the glymphatic function in the animal and human models. Several clinical and preclinical studies using glymphatic MRI have confirmed that the glymphatic function is impaired in neurodegenerative diseases, including Alzheimer's disease, Parkinson's disease, and idiopathic normal pressure hydrocephalus. Furthermore, physiologic process such as sleep facilitates the glymphatic clearance, thus clearing accumulation of protein deposition, such as amyloid or tau, potentially delaying the progression of neurodegenerative diseases. SUMMARY: The glymphatic system plays a crucial role in clearing metabolic wastes in the brain. Glymphatic MR imaging using GBCA administration serves as a functional imaging tool to measure the glymphatic function and investigate various pathophysiologies of neurodegenerative diseases.

Current Controversies in Radiology on Cost, Reimbursement, and Price Transparency: AJR Expert Panel Narrative Review.

Many believe that fundamental reform of the U.S. health care system is overdue and necessary given rising national health care expenditures, poor performance on key population health metrics, meaningful health disparities, concerns about potential financial toxicity of care, inadequate price transparency, pending insolvency of Medicare Part A, increasing commercial insurance premiums, and large uninsured and underinsured populations. The Medicare Payment Advisory Commission, an independent congressional agency, believes that part of this reform includes redistribution of reimbursements away from specialties such as radiology. Thus, despite an increase in the Medicare population and spending, Medicare payments for medical imaging have been decreasing for years. Further, the No Surprises Act, a federal law intended to curb the problem of surprise medical billing, was repurposed in federal rulemaking to reduce reimbursement from commercial payers to certain specialties, including radiology. In this article, we examine challenges facing the U.S. health care system, focusing on cost, reimbursement, and price transparency and the role of radiology in addressing such challenges. Medical imaging is a minor contributor to national health care expenditures but has an outsized impact on patient care. The radiology community should work together to reinforce the value of medical imaging and reduce inappropriate utilization of low-value care.

Carotid artery plaque characteristics: current reporting practices on CT angiography.

PURPOSE: Extracranial ICA imaging has largely focused on the degree of luminal stenosis, but recent advances suggest specific plaque features are crucial in stroke risk assessment. We evaluated the current state of reporting carotid plaque features on neck CTAs at an academic institution. METHODS: In this retrospective observational study, we included neck CTAs performed on patients over age 50 with any reported carotid plaque. We evaluated reports for mention of the following: degree of luminal stenosis, soft plaque, calcified plaque, plaque thickness, quantification of soft and calcified plaque, plaque ulceration, and increased risk associated with specific features. We used Fisher's exact test to compare how often each feature was mentioned. RESULTS: We included a total of 651 reports from unique patients (mean age, 68.1 ± 13.3 years). A total of 639 reports (98.1%) explicitly mentioned degree of stenosis per NASCET criteria. Specific plaque features were less frequently characterized: soft plaque in 116 (17.8%); calcified plaque in 166 (25.5%); quantification of the amount of soft plaque and calcified plaque in 24 (3.7%) and 16 (2.5%) reports, respectively; plaque thickness in 12 (1.8%); plaque ulceration in 476 (73.1%); and increased risk associated with plaque in 2 (0.3%). Degree of stenosis was statistically more likely to be mentioned than any other plaque feature (p < 0.001). CONCLUSION: Currently, nearly all reports mention the degree of luminal stenosis on neck CTAs while a significant minority mention specific plaque features. Despite mounting evidence of the importance of carotid plaque features in stroke risk assessment, radiology reports do not routinely report these findings.

ADC on Diffusion Imaging: The MR Analog of SUV on FDG-PET: Perfect Is the Enemy of Good.

LEVEL OF EVIDENCE: 5 Technical Efficacy Stage: 3 J. Magn. Reson. Imaging 2020;51:286-287.

Head and Neck Cancers, Version 2.2020, NCCN Clinical Practice Guidelines in Oncology.

Treatment is complex for patients with head and neck (H&N) cancers with specific site of disease, stage, and pathologic findings guiding treatment decision-making. Treatment planning for H&N cancers involves a multidisciplinary team of experts. This article describes supportive care recommendations in the NCCN Guidelines for Head and Neck Cancers, as well as the rationale supporting a new section on imaging recommendations for patients with H&N cancers. This article also describes updates to treatment recommendations for patients with very advanced H&N cancers and salivary gland tumors, specifically systemic therapy recommendations.

Virtual and augmented reality: potential applications in radiology.

The modern-day radiologist must be adept at image interpretation, and the one who most successfully leverages new technologies may provide the highest value to patients, clinicians, and trainees. Applications of virtual reality (VR) and augmented reality (AR) have the potential to revolutionize how imaging information is applied in clinical practice and how radiologists practice. This review provides an overview of VR and AR, highlights current applications, future developments, and limitations hindering adoption.

Enhancing Value of MRI: A Call for Action.

As national healthcare spending has spiraled out of control, payment reform that moves from volume to value-based payment has been introduced as a practical solution. Under alternative value-based payment models, physicians and clinical teams must deliver the best care possible at a lower cost. Medical imaging has changed the way we diagnose disease, evaluate severity, assess treatment effects, and provide biological insights for the pathophysiology of many diseases. Over the past 50 years, imaging techniques have become increasingly advanced-from X-ray to computed tomography (CT), magnetic resonance imaging (MRI), positron emission tomography (PET), and multi-modal imaging. Advanced imaging such as MRI has given clinicians remarkable insights into medical conditions and saved innumerable lives. Under the value proposition, however, we must ask if each imaging study changes treatment decisions, improves patient outcomes, and is cost-effective. Imaging research has been focused on developing new technologies and clinical applications to assess diagnostic accuracy. What is needed is the higher-level technology assessment. In this article we review why we need to demonstrate the value of MRI, how we define value, what strategies can enhance MR value through partnership with various stakeholders, and how imaging scientists can contribute to healthcare delivery in the future. Level of Evidence: 5 Technical Efficacy: Stage 3 J. Magn. Reson. Imaging 2019;49:e40-e48.

Value of MRI in medicine: More than just another test?

There is increasing scrutiny from healthcare organizations towards the utility and associated costs of imaging. MRI has traditionally been used as a high-end modality, and although shown extremely important for many types of clinical scenarios, it has been suggested as too expensive by some. This editorial will try and explain how value should be addressed and gives some insights and practical examples of how value of MRI can be increased. It requires a global effort to increase accessibility, value for money, and impact on patient management. We hope this editorial sheds some light and gives some indications of where the field may wish to address some of its research to proactively demonstrate the value of MRI. Level of Evidence: 5 Technical Efficacy: Stage 5 J. Magn. Reson. Imaging 2019;49:e14-e25.

Is Ultrasound a Useful Adjunct in the Management of Oral Squamous Cell Carcinoma?

PURPOSE: In patients with oral squamous cell carcinoma (OSCC), depth of tumor invasion (DOI) is correlated with prognosis. Tumor thickness (TT) is often used as a surrogate measurement of DOI. The aim of this study was to estimate TT in a sample of patients with OSCC using ultrasound sonography (USS), magnetic resonance imaging (MRI), and clinical assessment and compare these estimates with TT of the final surgical specimen. MATERIALS AND METHODS: The authors designed and implemented a prospective cohort study and enrolled patients presenting for management of OSCC. Eligible subjects had biopsy-proved OSCC and received clinical assessment, staging by MRI, and USS. The predictor variable was measurement technique by clinical assessment, USS, or MRI. The primary outcome variable was the maximal TT (centimeters) obtained from the final histopathologic specimen. Appropriate uni- and bivariate statistics were computed. RESULTS: The sample included 10 patients (mean age, 62.7 ± 13.6 yr; 70% men). Two of the 10 tumors (20%) were not adequately visualized with USS. Three of the 10 tumors (30%) were not seen with MRI because of dental artifact. These 3 patients' tumors were visualized by USS. One of the 10 tumors (10%) could not be palpated clinically. Three of the 10 patients (30%) did not go to surgery and were treated with chemoradiation because of the high tumor stage or the patient's health status. USS, MRI, and clinical TT measurements were underestimates compared with the specimen TT measurement (-0.6, -0.5, and -0.3 cm, respectively; P = .9). CONCLUSIONS: All 3 measurement modalities (clinical examination, MRI, and USS) underestimated OSCC TT compared with the final surgical specimen. There were no statistical differences in mean measurement or absolute value mean differences among measurement modalities. Notably, USS visualized the OSCC in the 3 patients (30%) whose tumors were poorly visualized or not visualized with MRI.

Progressive T1 Shortening of the Dentate Nucleus in Patients With Multiple Sclerosis: Result of Multiple Administrations of Linear Gadolinium Contrast Agents Versus Intrinsic Disease.

OBJECTIVE: The purpose of this article is to study the effect of the administration of multiple IV doses of gadolinium-based contrast agent on the intrinsic T1 hyperintensity in the dentate nucleus and globus pallidus in patients with multiple sclerosis (MS). MATERIALS AND METHODS: A retrospective review of imaging in patients with relapsing-remitting MS was performed. Images of 20 patients who received four or more doses of gadolinium-based contrast agent were reviewed. Patients received the linear agent gadopentetate dimeglumine before 2011 and the macrocyclic agent gadobutrol from 2011 onward. Dentate nucleus-to-pons and globus pallidus-to-thalamus signal intensity (SI) ratios were evaluated. SI ratios were compared over time with multiple injections of gadolinium. Similar SI ratios were evaluated for six patients who received gadopentetate dimeglumine and then underwent multiple subsequent MRI studies without contrast agent administration. RESULTS: The increase in the dentate nucleus-to-pons SI ratio after multiple administrations of the linear agent gadopentetate dimeglumine (mean = 1.44; SD = 2.50) was significantly higher than that with the macrocyclic agent gadobutrol (mean = -0.11; SD = 2.33) (p < 0.001). The globus pallidus-to-thalamus and dentate nucleus-to-CSF ratios also increased with multiple contrast injections over time, but the changes were not found to be statistically significant. The increase in SI in the dentate nucleus was not observed in patients who stopped receiving contrast injections, after showing a previous increase over time with gadolinium. CONCLUSION: In patients with MS, SI within the dentate nucleus and globus pallidus increased on unenhanced T1-weighted images and was significantly greater with the administration of a linear agent than with a macrocyclic agent. This increase in SI over time is likely a reflection of gadolinium deposition and not due to intrinsic disease, as previously postulated.

Qualitative Comparison of Noncontrast Head Dual-Energy Computed Tomography Using Rapid Voltage Switching Technique and Conventional Computed Tomography.

OBJECTIVES: Dual-energy computed tomography (DECT) allows image reconstruction along a spectrum of virtual monochromatic energy levels. We sought to determine the optimal energy level(s) for viewing supratentorial brain and posterior fossa and compare those to polychromatic conventional CT (CCT). Furthermore, we compared 2 groups scanned with separate DECT imaging protocols. In addition, we quantify the radiation dose of DECT versus CCT. METHODS: Forty-four nonacute patients underwent noncontrast DECT and recent CCT on the same scanner. Dual-energy CT images of the head were reconstructed at 5 keV intervals from 50 to 100 keV and randomized with CCT for blinded reader analysis. Evaluation of gray-white matter differentiation, posterior fossa artifact, and overall image noise was performed in consensus using a 5-point scale. In addition, the CTDIvol was compared with CCT examinations. RESULTS: Optimal monochromatic viewing levels in evaluating gray-white matter differentiation were 50 to 55 keV and 50 to 60 keV, using regular-dose DECT (R-DECT) and low-dose DECT (L-DECT), respectively. The optimal levels for mitigating posterior fossa artifacts were 80 to 100 keV utilizing both R-DECT and L-DECT, whereas the optimal viewing levels for improved overall image noise were 60 to 65 keV and 65 to 70 keV for R-DECT and L-DECT, respectively. Readers favored both DECT techniques over CCT. The CTDIvol for DECT was 10% and 37% lower than CCT without a statistically significant reduction in image quality. CONCLUSIONS: Optimized noncontrast DECT compared favorably to CCT, with a significant dose reduction benefit.

Implementation of a Value-Driven Outcomes Program to Identify High Variability in Clinical Costs and Outcomes and Association With Reduced Cost and Improved Quality.

IMPORTANCE: Transformation of US health care from volume to value requires meaningful quantification of costs and outcomes at the level of individual patients. OBJECTIVE: To measure the association of a value-driven outcomes tool that allocates costs of care and quality measures to individual patient encounters with cost reduction and health outcome optimization. DESIGN, SETTING, AND PARTICIPANTS: Uncontrolled, pre-post, longitudinal, observational study measuring quality and outcomes relative to cost from 2012 to 2016 at University of Utah Health Care. Clinical improvement projects included total hip and knee joint replacement, hospitalist laboratory utilization, and management of sepsis. EXPOSURES: Physicians were given access to a tool with information about outcomes, costs (not charges), and variation and partnered with process improvement experts. MAIN OUTCOMES AND MEASURES: Total and component inpatient and outpatient direct costs across departments; cost variability for Medicare severity diagnosis related groups measured as coefficient of variation (CV); and care costs and composite quality indexes. RESULTS: From July 1, 2014, to June 30, 2015, there were 1.7 million total patient visits, including 34 000 inpatient discharges. Professional costs accounted for 24.3% of total costs for inpatient episodes ($114.4 million of $470.4 million) and 41.9% of total costs for outpatient visits ($231.7 million of $553.1 million). For Medicare severity diagnosis related groups with the highest total direct costs, cost variability was highest for postoperative infection (CV = 1.71) and sepsis (CV = 1.37) and among the lowest for organ transplantation (CV ≤ 0.43). For total joint replacement, a composite quality index was 54% at baseline (n = 233 encounters) and 80% 1 year into the implementation (n = 188 encounters) (absolute change, 26%; 95% CI, 18%-35%; P < .001). Compared with the baseline year, mean direct costs were 7% lower in the implementation year (95% CI, 3%-11%; P < .001) and 11% lower in the postimplementation year (95% CI, 7%-14%; P < .001). The hospitalist laboratory testing mean cost per day was $138 (median [IQR], $113 [$79-160]; n = 2034 encounters) at baseline and $123 (median [IQR], $99 [$66-147]; n = 4276 encounters) in the evaluation period (mean difference, -$15; 95% CI, -$19 to -$11; P < .001), with no significant change in mean length of stay. For a pilot sepsis intervention, the mean time to anti-infective administration following fulfillment of systemic inflammatory response syndrome criteria in patients with infection was 7.8 hours (median [IQR], 3.4 [0.8-7.8] hours; n = 29 encounters) at baseline and 3.6 hours (median [IQR], 2.2 [1.0-4.5] hours; n = 76 encounters) in the evaluation period (mean difference, -4.1 hours; 95% CI, -9.9 to -1.0 hours; P = .02). CONCLUSIONS AND RELEVANCE: Implementation of a multifaceted value-driven outcomes tool to identify high variability in costs and outcomes in a large single health care system was associated with reduced costs and improved quality for 3 selected clinical projects. There may be benefit for individual physicians to understand actual care costs (not charges) and outcomes achieved for individual patients with defined clinical conditions.