Emergence of the natural history of Myhre syndrome: 47 patients evaluated in the Massachusetts General Hospital Myhre Syndrome Clinic (2016-2023).

Myhre syndrome is an increasingly diagnosed ultrarare condition caused by recurrent germline autosomal dominant de novo variants in SMAD4. Detailed multispecialty evaluations performed at the Massachusetts General Hospital (MGH) Myhre Syndrome Clinic (2016-2023) and by collaborating specialists have facilitated deep phenotyping, genotyping and natural history analysis. Of 47 patients (four previously reported), most (81%) patients returned to MGH at least once. For patients followed for at least 5 years, symptom progression was observed in all. 55% were female and 9% were older than 18 years at diagnosis. Pathogenic variants in SMAD4 involved protein residues p.Ile500Val (49%), p.Ile500Thr (11%), p.Ile500Leu (2%), and p.Arg496Cys (38%). Individuals with the SMAD4 variant p.Arg496Cys were less likely to have hearing loss, growth restriction, and aortic hypoplasia than the other variant groups. Those with the p.Ile500Thr variant had moderate/severe aortic hypoplasia in three patients (60%), however, the small number (n = 5) prevented statistical comparison with the other variants. Two deaths reported in this cohort involved complex cardiovascular disease and airway stenosis, respectively. We provide a foundation for ongoing natural history studies and emphasize the need for evidence-based guidelines in anticipation of disease-specific therapies.

Lowering Platelet Threshold to 20,000/µL for Fluoroscopy-Guided Lumbar Puncture Does Not Result in Observed Clinical Adverse Outcomes.

PURPOSE: Fluoroscopic-guided lumbar puncture (FG-LP) is a common neuroradiologic procedure. Traditionally, a minimum platelet count (MPC) of 50,000/µL for this procedure has been required; however, we recently adopted a lower MPC threshold of 20,000/µL. The purpose of this study was to compare adverse events in patients undergoing FG-LP with MPCs above to those below the conventional 50,000/µL threshold. MATERIALS: This was an institutional review board-approved, retrospective study on adult patients with hematologic malignancy undergoing FG-LP in the neuroradiology division between May 2021 and December 2022, after lowering the minimal required MPC to 20,000/µL. Recorded data included indication for FG-LP, preprocedure and postprocedure MPC, need for and number of platelet transfusions within 24 hours of FG-LP, presence of traumatic tap, FG-LP-related complications, and any platelet transfusion-related adverse event. Patients were classified into 2 groups based on MPC: (1) those above 50,000/µL and (2) those below 50,000/µL. Descriptive statistics were used comparing these 2 groups. RESULTS: One hundred twenty-eight patients underwent FG-LP, with 46 having an MPC between 20,000 and 50,000/µL and 82 having an MPC above 50,000/µL. No postprocedural complications were encountered in either group. Traumatic taps occurred in 10/46 (22%)​ with MPC below 50,000/µL versus 10/82 (12%)​ in those with MPC above 50,000/µL. Forty of 46 patients (87%) were transfused with platelets within 24 hours prior to FG-LP. One patient developed a transfusion-related reaction. CONCLUSION: Lowering the MPC threshold from 50,000/µL to 20,000/µL for FG-LP did not result in a higher incidence of spinal hematoma.

Coronal Diffusion-Weighted Imaging Does Not Improve Detection of Posterior Fossa Infarcts Compared With Conventional Axial Diffusion-Weighted Imaging.

PURPOSE: Recent publications have suggested incorporating coronal diffusion-weighted imaging (DWI) sequences and axial DWI sequences to enhance the detection of posterior fossa infarcts (PFIs). This study evaluated the utility of coronal DWIs compared with axial DWIs for assessing PFIs in the emergency department (ED). METHODS: A retrospective, institutional review board-approved study was conducted at a level I stroke center, including 118 patients who presented to the ED between 2016 and 2023 with suspected PFI. Inclusion criteria involved patients who underwent emergent 1.5 T magnetic resonance imaging (MRI) and had axial and coronal DWI sequences. Two neuroradiologists independently evaluated the DWI sequences for PFI detection in 2 rounds, with a 4-week interval between rounds. The neuroradiologists assessed the quality of axial and coronal DWIs using a 5-point Likert scale. Descriptive statistics, interrater reliability, and marginal homogeneity tests were performed. RESULTS: Among the 118 MRI scans, 23 (19%) showed PFI on axial and coronal DWI sequences. All 23 cases were identified on axial DWI, whereas 8 cases of PFI (35%) were not detected on coronal DWI (P value = 0.013). No PFIs were observed on coronal DWI that was not identified on axial DWI. The quality scores for both raters were significantly higher for axial DWIs than coronal DWIs (P value <0.00001). CONCLUSION: Despite recent recommendations advocating for the inclusion of coronal DWI in PFI detection, this study's findings indicate no improvement in PFI detection or image quality using coronal DWI. Further research is necessary to validate these results and explore the potential benefits of incorporating coronal DWI in assessing posterior fossa strokes.

Correlating Evans Index, Callosal Angle, and Lateral Ventricle Volume With Gait Response Outcomes in Idiopathic Normal Pressure Hydrocephalus Diagnosis.

OBJECTIVE: Radiological imaging is pivotal in diagnosing idiopathic normal pressure hydrocephalus (iNPH), given the similarity of its symptoms to other neurodegenerative diseases. We aimed to correlate the Evans index (EI), callosal angle (CA), and the volume of the lateral ventricles measured before cerebrospinal fluid removal with the resultant outcomes in gait response. METHODS: In our retrospective study, we identified 42 patients with a diagnosis of iNPH. These patients underwent gait analysis, imaging, and lumbar puncture. Radiological assessments included measurements of CA EI and lateral ventricular volume. Clinically, we assessed the following 4 gait parameters: cadence, gait speed, stride length, and timed up and go. Change in the 4 gait parameters was calculated, normalized, and compiled into a composite score, following which the group was divided into 'responders' and 'nonresponders' based on z score of 0.5. Our dependent variable was clinical improvement in gait, and our independent variables included lateral ventricular volume, EI, and CA. We performed a Wilcoxon rank-sum test to compare significant responder status using CA, EI, and lateral ventricle volume. A receiver operating characteristic analysis was employed to determine which volume measurement exhibited the strongest correlation with responder status. Determining the significant variables, a chi-square analysis was subsequently conducted.A significance threshold was set at P < 0.05. All our statistical evaluations were conducted in the Spyder environment, which is compatible with Python 3.10. RESULTS: There was a significant difference for responder status in EI and lateral ventricle volume. Evan index showing a statistic of 2.202 (P value = 0.02) and lateral ventricle volume demonstrating a statistic of 2.086 (P value = 0.03). Subsequent exploration using receiver operating characteristic analysis, with area under the curve of 0.71, identified 105.40 cm3 as the most robustly correlated volume threshold with responder status. CONCLUSIONS: The lateral ventricular volume demonstrates a stronger correlation with gait improvement compared to the CA or EI. These observations indicate that evaluating the lateral ventricle volume before lumbar puncture could serve as a predictor for gait response after lumbar puncture in individuals with normal pressure hydrocephalus.

Using Texture Analysis of Neck Computed Tomography Images to Differentiate Primary Hyperparathyroidism From Normal Controls.

OBJECTIVE: To investigate the utility of texture analysis in detecting osseous changes associated with hyperparathyroidism on neck CT examinations compared with control patients and to explore the best regions in the head and neck to evaluate changes in the trabecular architecture secondary to hyperparathyroidism. METHODS: Patients with hyperparathyroidism who underwent a 4D CT of the neck with contrast were included in this study. Age-matched control patients with no history of hyperparathyroidism who underwent a contrast-enhanced neck CT were also included. Mandibular condyles, bilateral mandibular bodies, the body of the C4 vertebra, the manubrium of the sternum, and bilateral clavicular heads were selected for analysis, and oval-shaped regions of interest were manually placed. These segmented areas were imported into an in-house developed texture analysis program, and 41 texture analysis features were extracted. A mixed linear regression model was used to compare differences in the texture analysis features contoured at each of the osseous structures between patients with hyperparathyroidism and age-matched control patients. RESULTS: A total of 30 patients with hyperparathyroidism and 30 age-matched control patients were included in this study. Statistically significant differences in texture features between patients with hyperparathyroidism and control patients in all 8 investigated osseous regions. The sternum showed the greatest number of texture features with statistically significant differences between these groups. CONCLUSIONS: Some CT texture features demonstrated statistically significant differences between patients with hyperparathyroidism and control patients. The results suggest that texture features may discriminate changes in the osseous architecture of the head and neck in patients with hyperparathyroidism.

Fully automated 3D machine learning model for HPV status characterization in oropharyngeal squamous cell carcinomas based on CT images.

BACKGROUND: Human papillomavirus (HPV) status plays a major role in predicting oropharyngeal squamous cell carcinoma (OPSCC) survival. This study assesses the accuracy of a fully automated 3D convolutional neural network (CNN) in predicting HPV status using CT images. METHODS: Pretreatment CT images from OPSCC patients were used to train a 3D DenseNet-121 model to predict HPV-p16 status. Performance was evaluated by the ROC Curve (AUC), sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and F1 score. RESULTS: The network achieved a mean AUC of 0.80 ± 0.06. The best-preforming fold had a sensitivity of 0.86 and specificity of 0.92 at the Youden's index. The PPV, NPV, and F1 scores are 0.97, 0.71, and 0.82, respectively. CONCLUSIONS: A fully automated CNN can characterize the HPV status of OPSCC patients with high sensitivity and specificity. Further refinement of this algorithm has the potential to provide a non-invasive tool to guide clinical management.

Multisystem factors contributing to redundant intracranial vascular imaging in the ED.

PURPOSE: To evaluate the multisystem factors contributing to redundant neurovascular orders in the ED. METHODS: This was an IRB-approved, retrospective study, performed at a single institution examining a 5-year history of redundant CTA/MRA head and neck (HN) exams performed in the ED for patients with no documented clinical change in mental status/neurological exam necessitating additional imaging. Factors contributing to redundant ordering including provider experience, synchronous order placement, and radiologist recommendations were examined. Additionally, the impact of duplicative imaging in terms of medical cost and ED length of stay was evaluated. RESULTS: 250 patients met inclusion criteria with both CTA/MRA of the HN performed during a single ED encounter (total 500 exams). 190 (76%) redundant exams were not recommended by a radiologist and contributed to an added ED length of stay of 3.6 h on average. Provider experience was not a significant contributing factor. 60 (24%) of redundant exams were recommended by a radiologist and were most frequently CTAs needed to clarify an area of artifact/high-grade stenosis/occlusion on a primary MRA exam. CONCLUSION: Evaluation of contributing factors to redundant CTA/MRA HN exams ordering has highlighted multiple associated factors including provider experience, recommendations by radiologists for clarification of MRA findings, as well as systems processes related to synchronous CTA/MRA order placement.

Atlantoaxial instability associated with ALDH18A1 mutation.

We report a 10-year-old boy with a de novo pathogenic variant in ALDH18A1, a rare form of metabolic cutis laxa, which was complicated by atlantoaxial instability and spinal cord compression following a fall from standing height. The patient required emergent cervical spine fusion and decompression followed by a 2-month hospitalization and rehabilitation. In addition to the core clinical features of joint and skin laxity, hypotonia, and developmental delays, we expand the connective tissue phenotype by adding a new potential feature of cervical spine instability. Patients with pathogenic variants in ALDH18A1 may warrant cervical spine screening to minimize possible morbidity. Neurosurgeons, geneticists, primary care providers, and families should be aware of the increased risk of severe cervical injury from minor trauma.

The "Crossing Collection Sign": A Diagnostic Tool on Spine Magnetic Resonance Imaging For Localizing Cerebrospinal Fluid Leak.

OBJECTIVE: The aim of the study is to determine whether the site of "cross" between ventral and dorsal spinal longitudinal extradural CSF collections (SLECs) seen on magnetic resonance imaging during initial workup of patients with suspected CSF leaks can predict the subsequently confirmed leakage site on computed tomography myelography or surgical repair. METHODS: This was an institutional review board-approved, retrospective study performed from 2006 to 2021. Patients with SLECs who underwent total spine magnetic resonance imaging at our institution, followed by myelography and/or surgical repair for CSF leak, were included. Patients with incomplete workup including lack of computed tomography myelography and/or surgical repair and patients severely motion degraded imaging were excluded from our study. The site of cross between ventral and dorsal SLECs was defined as the "crossing collection sign" and was compared with the anatomically confirmed site of leak on myelography and/or at surgical repair. RESULTS: Thirthy-eight patients met inclusion criteria with 18 females and 11 males ranging in age from 27 to 60 years (median, 40 years; interquartile range, 14 years). The crossing collection sign was seen in 76% of patients (n = 29). The distributions of confirmed CSF leak were as follows: cervical (n = 9), thoracic (n = 17), and lumbar spine (n = 3). The crossing collection sign predicted the site of CSF leak in 14 of 29 patients (48%) and was within 3-vertebral segments in 26 of 29 cases (90%). CONCLUSIONS: The crossing collection sign can help prospectively identify spinal regions with highest likelihood for CSF leak in patients with SLECs. This can potentially help optimize the more invasive subsequent steps in the workup for these patients, including dynamic myelography and surgical exploration for repair.

An ultrafast brain MRI technique for evaluating acute neurologic deficits in the emergency department.

Herein we share our preliminary experience with an ultrafast brain MRI technique for use in the ED consisting of axial T1-weighted (40 s), axial T2-weighted (62 s), axial diffusion-weighted (80 s), axial FLAIR (96 s), axial T2* (6 s), and axial susceptibility-weighted (108 s) imaging for a total scan time of 6 min and 53 s. Utilization of this ultrafast technique yields an efficient assessment of the brain, decreases ED length of stay and inpatient observation admissions, and may obviate the need for vascular imaging with either CTA or MRA in the ED.

Clinical utility of arterial spin labeling perfusion images in the emergency department for the work-up of stroke-like symptoms.

PURPOSE: To assess the utility of ASL in evaluating patients presenting to the ED with stroke-like symptoms. METHODS: ASL and DWI images from 526 consecutive patients presenting to the ED with acute stroke symptoms were retrospectively reviewed. DWI images were evaluated for volume of restricted diffusion using ABC/2. ASL maps were evaluated for decreased, normal, or increased signal. The volume of decreased ASL signal was calculated using the same ABC/2 technique. The volume of decreased ASL signal was correlated with the volume of DWI signal abnormality to identify cases of mismatch (DWI:ASL ratio > 1.8) and to correlate this mismatch with infarct growth on imaging follow-up. NIHSS, length of hospital stay, mRS, and future admission for acute stroke-like symptoms were recorded. Correlations between ASL abnormalities and clinical parameters were evaluated using a two-tailed t-test. RESULTS: Of the 526 patients presenting with acute stroke symptoms, 136 patients had an abnormal ASL scan and 388 patients had a normal ASL scan. Of the 136 patients with abnormal ASL, 84 patients had low ASL signal with 79 of these being related to acute infarcts. Elevated ASL signal was seen in 52 patients, of which 30 of these patients had reperfusion hyperemia related to acute infarctions. ASL had a negative predictive value of 94% for evaluating patients with acute ischemic stroke. A subset of patients with abnormal ASL scans with a discharge diagnosis of acute infarction were found to have an ASL:DWI mismatch (ratio > 1.8) and demonstrated significant lesion growth on follow-up imaging (57%). This included some patients who exhibited low ASL signal before development of diffusion restriction (infarction). CONCLUSION: In patients presenting to the ED with acute stroke symptoms, ASL provides information not available with DWI alone. The NPV of ASL for evaluating patients with acute ischemia was 94%.

Imaging, Clinical, and Demographic Differences in Patients With Type III Spinal Cerebrospinal Fluid Leak (Cerebrospinal Venous Fistulas) Compared With Patients With Types I and II Spinal Cerebrospinal Fluid Leak.

OBJECTIVE: Spinal cerebrospinal fluid (CSF) leaks are an underdiagnosed cause of neurologic symptoms. The most common types of spinal CSF leaks are from dural tears (type I) and meningeal diverticula (type II). Cerebrospinal fluid-venous fistulas (type III) are less common and underrecognized. The purpose of this study was to evaluate the intracranial and spinal imaging findings in patients with types I/II versus type III leaks. MATERIALS AND METHODS: This was a retrospective, institutional review board-approved study performed on adult patients between January 2020 to September 2021 with surgically confirmed type I/II/III spinal CSF leak. Patients had preoperative brain magnetic resonance imaging (MRI) with contrast and medical records detailing symptoms and clinical diagnoses. Patients were excluded for nondiagnostic brain MRIs. Demographic and clinical information were recorded. The presence of extra-axial collections, pachymeningeal thickening, brain sagging, and decreased pontomamillary distance were evaluated on MRI. RESULTS: Seven patients had type III leaks, and 16 had type I/II leaks. Patients with type III leaks were older ( P = 0.0003) and had higher rates of initial misdiagnosis (100% vs 31%) and longer times to correct diagnosis ( P = 0.03) compared with type I/II leaks. Intracranial extra-axial collections were never seen with type III leaks but were seen in 50% of type I/II leaks. Pachymeningeal thickening and brainstem sagging occurred in nearly equal frequency between groups. Smaller pontomamillary distances were seen in type III leaks versus type I/II leaks ( P = 0.047). CONCLUSIONS: When evaluating patients with suspected spinal CSF leak, findings of older age, absence of intracranial extra-axial collections, and small pontomamillary distances may raise suspicion for type III versus type I/II leak.

Clinical Correlation Between Vertical Gaze Palsy and Midbrain Volume in Progressive Supranuclear Palsy.

BACKGROUND: Supranuclear vertical gaze palsies and slowed vertical saccades are characteristic clinic features of progressive supranuclear palsy (PSP). The "hummingbird sign," reflective of midbrain atrophy, is a classic radiographic sign of PSP. Correlation between eye movement abnormalities and radiographic findings in PSP has been reported previously. However, due to the use of clinical criteria not commonly employed in neuro-ophthalmic practice and neuroimaging techniques that are not widely available, it remains unclear whether correlation between midbrain structure and characteristic ocular-motor disturbances can be helpful to neuro-ophthalmologists seeking to adjudicate difficult or unusual diagnostic cases. METHODS: Patients with a diagnosis of probable PSP according to Movement Disorders Society criteria were studied retrospectively. A neuroradiologist calculated brainstem volumes in enrolled participants and normal controls. Spearman correlations were used to correlate the extent of eye movement limitation as assessed by 2 neuro-ophthalmologists with brainstem volumes. RESULTS: Fourteen participants with PSP and 15 healthy controls with similar age and gender distribution were enrolled and evaluated retrospectively. All 14 participants with PSP had undergone MRIs. Midbrain atrophy significantly correlated with the PSP rating scale (P < 0.001). PSP patients had significantly reduced volumes in the midbrain (P -0.0026), tegmentum (0.0001), tectum (0.0001), and medulla (P = 0.0024) compared with normal controls. Notes documenting quantified ocular motor function were available in 7 of 14 participants with PSP. Midbrain atrophy significantly correlated with in the extent of upward gaze limitation (P = 0.03). CONCLUSIONS: The severity of upward gaze limitation correlates with the severity of midbrain atrophy in patients with PSP. Recognition of this correlation may help to adjudicate diagnostic dilemmas and guide further evaluation.

CT-based assessment of laryngeal fracture patterns and associated soft tissue abnormality.

OBJECTIVE: Acute traumatic injuries to the larynx, including fractures of the hyoid bone, cricoid, and thyroid cartilage, are uncommon injuries. The purpose of this study was to assess fracture and soft tissue patterns associated with laryngeal trauma. METHODS: This was a retrospective review of patients with laryngeal fractures who presented to two level I trauma centers and underwent CT imaging. Imaging findings, including fractures of the cartilaginous structures of the larynx and hyoid bone, and soft tissue abnormalities including focal hematoma, edema with non-focal hemorrhage, and additional penetrating injuries were recorded. Frequencies of fracture patterns were recorded. RESULTS: Thyroid cartilage fractures were most frequently observed occurring in 45/55 patients, followed by cricoid fractures in 13/55 patients. Hyoid fractures were encountered in 8/55 patients. Multi-site fractures were observed in 12/55 patients with thyroid-cricoid fractures occurring in 8/12 patients, followed by thyroid-hyoid fractures in 2/12 patients. Most multi-site fractures occurred in association with focal supraglottic hematomas (10/12), supraglottic edema and non-focal hemorrhage (11/12), and focal subglottic hematoma (5/12). All 13 cricoid fractures occurred with either focal supraglottic hematoma (7), focal subglottic hematoma (4), or edema with non-focal hemorrhage (13). CONCLUSIONS: Thyroid cartilage fractures were the most frequently encountered fracture, followed by cricoid cartilage fractures. Cricoid fractures always occurred with soft tissue abnormalities. Recognition of fracture patterns in the setting of laryngeal trauma and associated patterns of soft tissue injury is important for practicing radiologists for early diagnosis of these conditions and reduction of associated morbidity. KEY POINTS: • Acute fractures to the larynx may be isolated fractures or occur as multi-focal fractures. • Thyroid cartilage fractures are the most frequent fractures followed by cricoid cartilage fractures. • Cricoid cartilage fractures always occurred in association with soft tissue abnormalities.

Long-term neuroimaging follow-up of COVID-19-related leukoencephalopathy.

More than a year after the start of the COVID-19 pandemic, long-term neurological manifestations of COVID-19 are increasingly being reported. The long-term sequelae of COVID-19-related leukoencephalopathy, however, remain unclear. Here, we present long-term neuroimaging follow-up in two cases of COVID-19-related leukoencephalopathy. The two cases demonstrate the utility of brain MRI for evaluating neurologic symptoms in critically ill patients with COVID-19, for diagnosis of underlying neural injury and prognostication of future recovery. The presence of leukoencephalopathy may result in chronic neurologic manifestations and may represent a poor prognosticator of neurologic recovery. The presence of leukoencephalomalacia on follow-up neuroimaging is potentially an indicator of irreversible white matter damage, which may be associated with more severe chronic deficits.

Comparison between computed tomography and ultrasound for presurgical evaluation of oral tongue squamous cell carcinoma tumor thickness.

PURPOSE: To compare the accuracy of oral tongue squamous cell carcinoma (OTSCC) tumor thickness (TT) measured on CT to intraoperative ultrasound (US) and histopathology. METHODS AND MATERIALS: Twenty-six patients with OTSCC who underwent tumor resection by a single surgeon with simultaneous intraoperative US between 3/2016 and 4/2019 were prospectively identified, and their data reviewed. TT was independently measured in 19 patients who underwent preoperative CT (cTT) by two neuroradiologists blinded to US and histological results. The confidence level of interpretation of cTT was recorded by each reader using a 5-point Likert scale. The degree of dental artifact on CT was also scored. cTT was compared to TT measured on intraoperative US (uTT) and histopathologic assessment of TT (hTT). RESULTS: OTSCC was visualized on CT in 52% (10/19) and 63% (12/19) of cases for readers 1 and 2, respectively. Mean Likert score was 0.42 for reader 1 and 0.73 for reader 2. Mean cTT of OTSCCs was 5.8 mm +/- 1.7 mm (n = 11). In comparison, mean uTT and hTT were 7.6 mm±3.5 mm and 7.1 +/- 4.2 mm, respectively. The Pearson coefficient (95% confidence interval) was 0.10 (-0.53-0.66) between cTT and hTT (n = 11) and 0.93 (0.74-0.98) between uTT and hTT. CONCLUSIONS: Preoperative CT is not reliable for assessment of TT in OTSCC compared to US and histopathology, particularly for OTSCC under 10 mm. US offers a practical complementary imaging tool with a unique role for primary tumor assessment that can aid in pre-operative planning, especially for small tumors.

When real life conditions do not follow textbook diagnosis: A diagnostic challenge from a neuropsychiatric clinic.

We present the case of a 61-year-old retired catholic priest, who was adopted at a very young age, with psychiatric history of anxiety and depression presenting for evaluation of at least 4 year memory loss and word finding difficulties. Over the preceding couple of years his cognitive functions had rapidly declined. As a result, he became dependent on his elderly parents for most of his instrumental activities of daily living including administration of medication, financial management, and driving. He continues to be independent in his personal care. His presentation offered diagnostic challenges due to the interplay of anxiety and cognitive disorders involving both memory and language domains. In addition, he resisted to repeat formal neuropsychological evaluation. At the bedside, his poor effort on testing was often blamed on his severe anxiety confounding the clinical picture. Lack of knowledge of his family history and his childhood development, and unclear premorbid functioning complicated the diagnostic formulation. A differential diagnosis ranging from possible functional cognitive disorder to neurodevelopmental disorder and neurodegenerative disorders will be discussed.

Peering Into Peer Review: AJR Neuroradiology Reviewers Discuss Their Approaches to Assessing a Manuscript.

OBJECTIVE. This article provides comments from a small group of highly qualified reviewers of the American Journal of Roentgenology (AJR) regarding their approach to assessing manuscripts. The objective is to educate authors about the issues to which reviewers particularly attend and about errors that will decrease the likelihood of publication. CONCLUSION. By following the advice provided in this article, authors should be able to compose better manuscripts and reviewers should be able to generate better reviews.

Lung apical findings in coronavirus disease (COVID-19) infection on neck and cervical spine CT.

PURPOSE: To evaluate the prevalence and features of lung apical findings on neck and cervical spine CTs performed in patients with COVID-19. METHODS: This was a retrospective, IRB-approved study performed at a large academic hospital in the USA. Between March 3, 2020, and May 6, 2020, 641 patients with COVID-19 infection diagnosed by RT-PCR received medical care at our institution. A small cohort of patients with COVID-19 infection underwent neck or cervical spine CT imaging for indications including stroke, trauma, and neck pain. The lung apices included in the field of view on these CT scans were reviewed for the presence of findings suspicious for COVID-19 pneumonia, including ground-glass opacities, consolidation, or crazy-paving pattern. The type and frequency of these findings were recorded and correlated with clinical information including age, gender, and symptoms. RESULTS: Thirty-four patients had neck or spine CTs performed before or concurrently with a chest CT. Of this group, 17 (50%) had unknown COVID-19 status at the time of neck or spine imaging and 10 (59%) of their CT studies had findings in the lung apices consistent with COVID-19 pneumonia. CONCLUSION: Lung apical findings on cervical spine or neck CTs consistent with COVID-19 infection are common and may be encountered on neuroimaging performed for non-respiratory indications. For these patients, the emergency radiologist may be the first physician to suspect underlying COVID-19 infection.