Diagnostic and interventional neuroradiology training in the UK: a national trainee survey.

AIM: Training structure in neuroradiology can be variable, nationally and internationally. Globally, there is a trend towards standardised training pathways, curricula and targeted competencies. Currently, there is limited understanding of the structure of neuroradiology training in the UK. This survey aims to: [1] identify different contemporary models of neuroradiology training in the UK, [2] compare UK trainees' commitments against national and international standards, and [3] understand whether career expectations match the predicted future demands of neuroradiologists. MATERIALS AND METHODS: A survey was developed after consultation with BSNR and UKNG representatives. The eligibility criteria included current neuroradiology trainees in the UK with at least 3 months of experience or had recently completed neuroradiology training, but less than 18 months had elapsed since achieving a certificate of completion of training. RESULTS: A total of 50 trainees responded to the survey; 26 (52%) diagnostic neuroradiologists (DNRs) and 24 (48%) interventional neuroradiologists (INRs) with an overall mean age of 33 years. The mean duration of training at the time of survey was 18 months. The survey details trainee demographics, experience at work, research and teaching commitments and future goals. CONCLUSION: Most respondents are satisfied with their training and 90% want to remain in the UK after completion of training. There is room for improvement but the future of training and working in neuroradiology seems promising internationally, with ever-evolving techniques and developments. ADVANCES IN KNOWLEDGE: Advances in knowledge: This study evaluates neuroradiology training in the UK to enhance the training of future neuroradiologists, and safeguard the future of the speciality.

An approach to reporting paediatric leukoencephalopathy and leukodystrophies.

The leukodystrophies (LD) and leukoencephalopathies (LE) are a diverse group of conditions involving the cerebral white and grey matter. There is heterogeneity in the clinical presentations, imaging features, and biochemical dysfunction. Given the number of conditions and varied imaging appearances, this topic can be difficult for non-specialist radiologists who do not routinely work in dedicated paediatric neuroradiology centres. This article will aim to provide a simplified and step-wise approach to assessing suspected LD/LE, focussing on the more common diagnoses you may encounter in the UK. Additionally, it will highlight important non-LD/LE differentials, which if considered early, may significantly alter treatment and prognosis. By the end of this review, we hope the reader will begin to develop an awareness of physiological paediatric brain development in terms of normal myelination; the ability to recognise and categorise the distribution of abnormal signal based on the established diagnostic framework outlined by Schiffmann & Van der Knapp; and be aware of potential non-LD/LE radiological mimics.

How confident are general practitioners in interpreting neuroradiology reports?

AIM: To determine the level of confidence general practitioners (GPs) have in radiology reports provided by neuroradiologists and to elicit the preferences of GPs regarding report format and level of detail. MATERIALS AND METHODS: Electronic surveys comprising anonymised neuroradiology reports were sent to GP practices served by a tertiary neuroscience centre. After reviewing the reports, GPs were asked to complete a two-part questionnaire. Firstly, GPs indicated their level of confidence, using a five-tiered Likert scale, in their understanding of: (a) the body of text; (b) the meaning of the report; and (c) the significance of the report. Secondly, GPs provided free-text suggestions for improving the report and highlighted any phrases that they did not understand. RESULTS: One hundred GPs responded from a group of 439 that received a survey (response rate 23%). Although the majority of GPs were fairly confident in their understanding of reports, fewer than one-third of GPs were entirely confident. Approximately 10% of GPs were not confident at all in their understanding of the reports. Causes of confusion included the use of detailed anatomy, acronyms, radiological terminology, and a lack of a conclusion and an action plan. CONCLUSION: General practice is a time-sensitive discipline that demands clear communication. In neuroradiology reports, GPs do not find detailed anatomy, acronyms, or radiological terminology helpful. Rather, GPs want a clear conclusion and action plan.

Antenatal diagnosis of agenesis of the corpus callosum.

AIM: To estimate the diagnostic performance of ultrasound in detecting agenesis of the corpus callosum (ACC). MATERIALS AND METHODS: A retrospective review was performed of 1722 in utero MRI examinations. All cases were identified in which the fetus had been referred from ultrasonography with a diagnosis of ACC and those in which ACC was given as a diagnosis on the in utero MRI study. The MRI was assumed to provide the correct diagnosis of ACC and descriptive statistics of diagnostic accuracy for ultrasound were calculated. RESULTS: Of the 1722 ultrasound examinations performed, 121 had a diagnosis of ACC and approximately 50% were confirmed at MRI. Forty-two fetuses with ACC not suspected at ultrasonography were also identified at MRI. Ultrasonography had a positive predictive value of 47% (95% CI: 38-56%) and a negative predictive value of 97% (95% CI: 96-98%) for detecting ACC. CONCLUSION: Ultrasound is poor in diagnosing ACC and in utero MRI should be performed if there is any suspicion on antenatal ultrasonography.

Magnetic resonance imaging of epilepsy at 3 Tesla.

Patients with epilepsy often have a structural cause for their seizures and may benefit from surgical resection. As recommended in the National Institute of Health and Clinical Excellence (NICE) guidelines, magnetic resonance imaging (MRI) is used to screen for structural abnormalities in these patients and there is increasing evidence that 3T MRI has better sensitivity and specificity than 1.5T. This article reviews the imaging findings of many of the common diseases that can cause epilepsy.

Is there a role for radiotherapy in operable rectal cancer?

Most patients presenting with rectal cancer will have "operable" disease. The main aim in treating these patients is to achieve complete surgical resection while minimising the rate of local recurrence. The use of radiotherapy has been shown to decrease local recurrence rates and the evidence suggests that this should be used preoperatively. Here we summarise the important trials both before and after the introduction of mesorectal excision. We highlight some of the important issues, including treatment-related toxicity and patient selection for preoperative treatment.

Lymphoblastic leukaemia presenting as a carotid-cavernous fistula.

A carotid-cavernous fistula is a life-threatening condition characterised by an abnormal communication between the carotid arterial vessels and the cavernous venous system. Although these fistulae can arise spontaneously, they mainly occur after trauma, especially road traffic accidents, falls and penetrating cranial or orbital injuries. The mainstay of treatment involves endovascular embolization, but in those patients where this is not possible or where embolization fails, direct surgical intervention and ligation of the artery may be necessary. Here we describe an interesting case of a suspected carotid-cavernous fistula which turned out to be cavernous sinus syndrome secondary to lymphoma.

3.0 T MRI of 2000 consecutive patients with localisation-related epilepsy.

OBJECTIVES: Clinical guidelines suggest that all patients diagnosed with localised seizures should be investigated with MRI to identify any epileptogenic structural lesions, as these patients may benefit from surgical resection. There is growing impetus to use higher field strength scanners to image such patients, as some evidence suggests that they improve detection rates. We set out to review the detection rate of radiological abnormalities found by imaging patients with localised seizures using a high-resolution 3.0 T epilepsy protocol. METHODS: Data were reviewed from 2000 consecutive adult patients with localisation-related epilepsy referred between January 2005 and February 2011, and imaged at 3.0 T using a standard epilepsy protocol. RESULTS: An abnormality likely to be related to seizure activity was identified in 403/2000 (20.2%) patients, with mesial temporal sclerosis diagnosed in 211 patients. 313/2000 (15.6%) had lesions potentially amenable to surgery. Abnormalities thought unrelated to seizure activity were found in 324/2000 (16.1%), with 8.9% having evidence of ischaemic disease. CONCLUSIONS: Since the introduction of the then National Institute for Clinical Excellence guidelines in 2004, the detection rate of significant pathology using a dedicated 3.0 T epilepsy protocol has not fallen, despite the increased numbers of patients being imaged. This is the largest study of epilepsy imaging at 3.0 T to date and highlights the detection rates of significant pathology in a clinical setting using a high-strength magnet. The prevalence of ischaemic disease in this population is significantly higher than first thought, and may not be incidental, as is often reported.

Spontaneous closure of a type 2a dural arteriovenous fistula following late recanalization of the occluded sinus.

We describe the rare spontaneous resolution of a type 2a dural AVF that coincided with recanalization of the previously thrombosed sigmoid sinus after ten years of conservative management. The factors potentially responsible for spontaneous fistula obliteration are discussed and the therapeutic implication of this observation is considered.

Symptomatic perianeurysmal edema following bare platinum embolization of a small unruptured cerebral aneurysm.

There is considerable interest in the development of symptomatic inflammatory reactions following coil embolization of cerebral aneurysms. Patients have experienced a range of adverse events, usually after treatment of moderately large aneurysms with modified "bioactive" coils. More recently, it has been recognized that adverse inflammatory reactions can be associated with the use of "nonbioactive" coils, and we present a case of symptomatic perianeurysmal edema after treatment of a small unruptured aneurysm with bare platinum coils.

Omission of concurrent chemoradiation after a response to neoadjuvant chemotherapy in locally advanced rectal cancer with a synchronous liver metastasis: a note of caution.

There is clear evidence to support the use of pre-operative concurrent chemo-radiotherapy (CRT) in locally advanced rectal cancer. In the UK, most patients are selected for treatment if the resection margin is predicted to be involved. The selection criteria used includes primary tumours that threaten the resection margins on high-resolution pelvic MRI and low tumours requiring abdominoperineal excision. There is no consensus, however, to guide the treatment of patients who present with advanced rectal disease and synchronous, potentially resectable, metastatic disease. This case illustrates the potential risk of omitting radiation following a good response to neoadjuvant systemic chemotherapy.

Preoperative radiotherapy combined with 5 days per week capecitabine chemotherapy in locally advanced rectal cancer.

There is increasing evidence supporting the use of preoperative chemoradiotherapy in patients with locally advanced rectal cancer in an attempt to facilitate complete surgical resection with clear margins. We describe our experience of using a 5-day per week regime of preoperative capecitabine chemoradiotherapy. Between November 2004 and September 2006, 70 patients with MRI-defined locally advanced rectal cancer were selected for treatment. Capecitabine was given at a dose of 900 mg m(-2) for 5 days per week combined with 45 Gy of radiotherapy in 25 doses. This regime was well tolerated with 89% of our patients receiving the full dose of chemotherapy and 96% receiving the full dose of radiotherapy. Ninety-three per cent proceeded to macroscopically complete surgical resection. The pathological complete response rate was 9.2% with a node-negative rate of 66%. A negative circumferential margin was achieved by 79% of the patients who underwent resection. Compared to studies using a 7-day per week capecitabine schedule, our results show increased compliance and less dose reductions with comparable pathological outcome.