Isolated Myeloperoxidase-Antineutrophil Cytoplasmic Antibody-Associated Hypertrophic Pachymeningitis.

ABSTRACT: A 65-year-old man with no pertinent medical history presented with 1 month of progressive holocephalic positional headaches (worse supine), photophobia, progressive gait instability resulting in multiple falls (ambulatory to walker in only 2 months), and weight loss. Testing found positive ANCA 1:160 perinuclear patter, myeloperoxidase >8.0. Cerebrospinal fluid found lymphocytic pleocytosis. We present his neuroimaging of isolated hypertrophic pachymeningitis with clinicoradiographic resolution after immunomodulatory pharmacotherapy along with histology from his meningeal biopsy. Isolated vasculitic myeloperoxidase-antineutrophil cytoplasmic antibody hypertrophic pachymeningitis is quite rare.

Dental caries on CT in the ER population: prevalence and reporting practices.

PURPOSE: Although dental caries can be identified on CT and may be treatable, the literature provides little, if any, guidance on the responsibility of a neuroradiologist in reporting them. Untreated dental caries can impact diet and nutrition and can result in a variety of complications such as an odontogenic abscess, tooth loss, sinusitis, and dental pain, which can impact quality of life. The estimated prevalence of untreated dental caries in adults is 27%. In our experience, the prevalence of untreated dental caries in patients presenting to the Emergency Department (ED) is higher but dental caries are often unmentioned or unrecognized. We aim to determine the frequency of unreported dental caries and propose a paradigm for reporting and management. METHODS: Our research was IRB-approved and HIPPA compliant. We searched the radiology database for adult patients who underwent a CT of the facial bones while in the Emergency Department between January 1, 2015 and June 30, 2015. The examinations were reviewed by a faculty neuroradiologist for the presence of untreated dental caries. Untreated dental caries were documented and characterized by depth. Caries that were partially or completely obscured by dental amalgam artifact were excluded. The radiology reports were reviewed to evaluate reporting frequency. Statistical analysis was performed using Statistical Package for the Social Sciences (SPSS) software. RESULTS: A total of 200 patients (113 male, 87 female; age 18-98 years) underwent 200 CT examinations of the facial bones. One hundred fourteen (57%) patients had at least one dental caries. When caries were present, 14.9% of radiology reports included caries in the findings section and 9.6% of the reports mentioned caries in the impression. CONCLUSIONS: The presence of dental caries should be mentioned in the radiology report. The prevalence of untreated dental caries is higher in our cohort than reported in the general population, and dental caries are underreported by neuroradiologists at our institution. A paradigm for reporting and management was created upon collaboration with faculty from the University of Vermont Dental and Oral Health practice. A visit with a dentist should be recommended within 6 months if caries are limited to the enamel, within 3 months if caries involve the dentin, and within 2 weeks if caries extend in to the pulp. Further research is necessary to determine the clinical impact of improved reporting.

Revisiting the indirect signs of a temporal bone fracture: air, air, everywhere.

BACKGROUND AND PURPOSE: The standard head CT protocol makes detection of a temporal bone fracture difficult. The purposes of our study are to revisit the finding of air in various locations around the temporal bone as an indirect sign of fracture and determine if findings could predict fracture pattern. MATERIALS AND METHODS: We searched the radiology reports for the keyword "temporal bone fracture." We recorded the presence of air in multiple locations around the temporal bone and pneumocephalus, opacification of the mastoid air cells or the middle ear cavity, and dominant fracture pattern. Statistical analyses were performed using statistical software. RESULTS: A total of 135 patients (mean age 40 ± 20.1 years, 101 male, 34 female, range 1-91) had 152 fractures. At least one indirect finding was present in 143 (94.1%) fractures. Air was present adjacent to the styloid process in 94 (61.8%), in the temporomandibular joint in 80 (52.6%), adjacent to the mastoid process in 57 (37.5%), and along the adjacent dural venous sinus in 33 (21.7%) fractures. Mastoid opacification was present in 139 (91.4%) fractures. Opacification of the middle ear cavity was present in 121 (79.6%) fractures. A complex fracture significantly and positively correlated with pneumocephalus. CONCLUSION: In the setting of trauma, air around the temporal bone and opacification of the mastoid air cells or middle ear cavity should prompt consideration of a temporal bone fracture even if the fracture line is not visible. The presence of pneumocephalus predicts a higher chance of complex fracture pattern.

Distinguishing Untreated Osteoblastic Metastases From Enostoses Using CT Attenuation Measurements.

OBJECTIVE: The purpose of this study was to determine whether CT attenuation thresholds can be used to distinguish untreated osteoblastic metastases from enostoses. MATERIALS AND METHODS: The study group comprised 62 patients with 279 sclerotic bone lesions found at CT (126 enostoses in 37 patients and 153 metastases in 25 patients). The cause of sclerotic lesions was assessed histologically or by clinical and imaging follow-up. None of the patients had undergone prior treatment for the metastases. The mean and maximum attenuation were measured in Hounsfield units. ROC analysis was performed to determine sensitivity, specificity, AUC, 95% CIs, and cutoff values of CT attenuation to differentiate metastases from enostoses. Interreader reproducibility was assessed using an intraclass correlation coefficient with 95% CI. RESULTS: The mean and maximum CT attenuation values of enostoses were 1190 ± 239 HU and 1323 ± 234 HU, respectively, and those of osteoblastic metastases were 654 ± 176 HU and 787 ± 194 HU, respectively. Using a cutoff of 885 HU for mean attenuation, the AUC was 0.982, sensitivity was 95%, and specificity was 96%. Using a cutoff of 1060 HU for maximum CT attenuation, the AUC was 0.976, sensitivity was 95%, and specificity was 96%. The mean attenuation intraclass correlation coefficient was 0.987 for enostoses and 0.81 for metastases. The maximum attenuation intraclass correlation coefficient was 0.814 for enostoses and 0.980 for metastases. CONCLUSION: CT attenuation measurements can be used to distinguish untreated osteoblastic metastases from enostoses. A mean attenuation of 885 HU and a maximum attenuation of 1060 HU provide reliable thresholds below which a metastatic lesion is the favored diagnosis.

Patient-Centered, Case-Based Education in Radiology: an Interactive Module Following a Patient Through Their Disease Course from an Imaging Perspective.

During typical radiology resident conferences, faculty presents images of a disease at a single juncture followed by relevant teaching points; however, the current generation of learners poses unique challenges given different learning preferences. We thus sought to demonstrate the benefits of a novel interactive case-based learning method following a patient through their disease. Twenty-four trainees completed an interactive glioblastoma module along with pre- and post-surveys. Findings revealed a significant increase of average scores for all knowledge-based questions and confidence levels related to glioblastoma and its treatment. Response was overwhelmingly positive with most considering this teaching method superior to traditional conferences. Supplementary Information: The online version contains supplementary material available at 10.1007/s40670-021-01441-5.

Brain abscess with pyogenic ventriculitis.

The authors present the case of a 57-year-old male with a large polymicrobial brain abscess complicated by eruption into the intraventricular space. He was treated with parenteral ampicillin, cefepime, and metronidazole and adjuvant intraventricular vancomycin/gentamicin as well as surgical debridement. The authors discuss the diagnosis, treatment, and prognosis of brain abscesses, with a focus on prior cases with pyogenic ventriculitis and those treated with intraventricular antimicrobials.

Limited Utility of Gadolinium Contrast Administration in Routine Multiple Sclerosis Surveillance.

BACKGROUND AND PURPOSE: Assess the incidence of enhancing lesions on follow-up MRIs in patients with multiple sclerosis (MS) to determine the utility of intravenous, gadolinium-based contrast agent (IV-GBCA) use in routine follow-up imaging. METHODS: We retrospectively identified head MRIs associated with an MS diagnosis acquired between January 1, 2015and January 10, 2018. Final reports were reviewed to determine the presence of (1) a new or larger lesion, (2) at least one enhancing lesion, and (3) if at least one enhancing lesion was new or larger on Fluid-Attenuation Inversion Recovery (FLAIR). For MRIs with at least one enhancing lesion, but no new or larger enhancing lesions, reports and images of the preceding MRI were reviewed. RESULTS: A total of 1,805 MRIs performed on 920 patients were included. 354/1,805 (20%) MRIs reported new or enlarging lesions. 138/1,805 (8%) MRIs reported at least one enhancing lesion. Of these, 117/138 (85%) reported at least one enhancing lesion that was new or larger. In the remaining 21 MRIs which contained an enhancing lesion but none of the enhancing lesions were reported as new or enlarging, at least one enhancing lesion was present on preceding MRI. CONCLUSIONS: Enhancing lesions are uncommon on follow-up MRIs in MS patients. Our data suggest that new enhancing lesions are not present on a follow-up MRI when two conditions are met: (1) preceding MRI does not demonstrate any enhancing lesions and (2) there is no interval change of the lesions on the current 3D-T2-FLAIR sequence compared to the preceding 3D-T2-FLAIR sequence. IV-GBCA should be reserved for instances when temporal knowledge of lesion formation is needed.

Aligning the Implicit Curriculum with the Explicit Curriculum in Radiology.

Physician education occurs through two mechanisms that operate in tandem: the explicit and the implicit curriculum. The explicit, or formal, curriculum is the official version that is usually taken as the one-and-only curriculum and which is detailed in official documentation; however, an implicit curriculum exists, comprised of subtle messaging about professional norms, values, and beliefs that are tacitly communicated through both positive and negative role modeling. Both contribute to the overall education of the medical student and physician-in-training. Despite its well-documented influence in medical education, much of the teachings of the implicit curriculum occurs in the shadows, unspoken and unarticulated, and outside the awareness of both teacher and student. As panel members of the The Implicit Curriculum in Radiology Task Force of the Association of University Radiologists-Radiology Research Alliance (AUR-RRA), we present a review of the implicit curriculum, exploring its origin and impact on medical education, and on the overall professional development of medical students, post-graduate medical trainees and practicing physicians. Strategies for recognizing and contending with the implicit curriculum in radiology training are discussed, with a special emphasis on opportunities to leverage its potential through positive role modeling.

Collaborative Learning in Radiology: From Peer Review to Peer Learning and Peer Coaching.

BACKGROUND: A Radiology Research Alliance Task Force was assembled in 2018 to review the literature on peer review and report on best practices for peer learning and peer coaching. FINDINGS: This report provides a historical perspective on peer review and the transition to peer collaborative learning and peer coaching. Most forms of current peer review have fulfilled regulatory requirements but have failed to significantly impact quality improvement or learning opportunities. Peer learning involves joint intellectual efforts by two or more individuals to study best practices and review error collaboratively. Peer coaching is a process in which individuals in a trusted environment work to expand, refine, and build new skills in order to facilitate self-directed learning and professional growth. We discuss the value in creating opportunities for peer learning and peer coaching. CONCLUSION: Peer collaborative learning combined with peer coaching provides opportunities for teams to learn and grow together, benefit from each other's expertise and experience, improve faculty morale, and provide more opportunities for collaborations between faculty.

Metastatic malignancy masquerading as neurocysticercosis.

Cystic brain lesions are a common clinical dilemma facing infectious disease providers. A broad differential diagnosis is required in the proper evaluation and care of patients facing such an illness. Here the authors describe the case of a 29-year-old woman who presented with seizures and was found to have multiple cystic brain lesions, with risk factors for neurocysticercosis. Ultimately, she was found to have a metastatic neuroendocrine malignancy. The authors review the ideal imaging and testing modalities in the diagnosis and exclusion of neurocysticercosis. This case serves as guidance for clinicians caring for patients with cystic brain lesions that may be infectious or non-infectious in etiology.

Perceptual and Interpretive Error in Diagnostic Radiology-Causes and Potential Solutions.

Interpretation of increasingly complex imaging studies involves multiple intricate tasks requiring visual evaluation, cognitive processing, and decision-making. At each stage of this process, there are opportunities for error due to human factors including perceptual and ergonomic conditions. Investigation into the root causes of interpretive error in radiology first began over a century ago. In more recent work, there has been increasing recognition of the limits of human image perception and other human factors and greater acknowledgement of the role of the radiologist's environment in increasing the risk of error. This article reviews the state of research on perceptual and interpretive error in radiology. This article focuses on avenues for further error examination, and strategies for mitigating these errors are discussed. The relationship between artificial intelligence and interpretive error is also considered.