Pretreatment ADC Values Predict Response to Radiosurgery in Vestibular Schwannomas.

BACKGROUND AND PURPOSE: The response rate of vestibular schwannomas to radiation therapy is variable, and there are surgical options available in the event of treatment failure. The aim of this study was to determine whether pre- and posttreatment ADC values can predict the tumor response to radiation therapy. MATERIALS AND METHODS: From a data base of 162 patients with vestibular schwannomas who underwent radiation therapy with gamma knife, CyberKnife, or fractionated stereotactic radiation therapy as the first-line therapy between January 2003 and December 2013, we found 20 patients who had pretreatment ADC values. There were 108 patients (including these 20) had serial MR images that included DWI allowing calculated ADC values from 2-132 months after radiation therapy. Two reviewers measured the mean, minimum, and maximum ADC values from elliptical ROIs that included tumor tissue only. Treatment responders were defined as those with a tumor total volume shrinkage of 20% or more after radiation therapy. RESULTS: The pretreatment mean minimum ADC for nonresponders was 986.7 × 10-6 mm2/s (range, 844-1230 × 10-6 mm2/s) and it was 669.2 × 10-6 mm2/s (range, 345-883 × 10-6 mm2/s) for responders. This difference was statistically significant (P < .001). Using a minimum ADC value of 800 × 10-6 mm2/s led to the correct classification of 18/20 patients based on pretreatment ADC values. The intraclass correlation between reviewers was 0.61. No posttreatment ADC values predicted response. CONCLUSIONS: Pretreatment ADC values of vestibular schwannomas are lower in responders than nonresponders. Using a minimum ADC value of 800 × 10-6 mm2/s correctly classified 90% of cases.

3D quantitative assessment of response to fractionated stereotactic radiotherapy and single-session stereotactic radiosurgery of vestibular schwannoma.

OBJECTIVES: To determine clinical outcome of patients with vestibular schwannoma (VS) after treatment with fractionated stereotactic radiotherapy (FSRT) and single-session stereotactic radiosurgery (SRS) by using 3D quantitative response assessment on MRI. MATERIALS: This retrospective analysis included 162 patients who underwent radiation therapy for sporadic VS. Measurements on T1-weighted contrast-enhanced MRI (in 2-year post-therapy intervals: 0-2, 2-4, 4-6, 6-8, 8-10, 10-12 years) were taken for total tumour volume (TTV) and enhancing tumour volume (ETV) based on a semi-automated technique. Patients were considered non-responders (NRs) if they required subsequent microsurgical resection or developed radiological progression and tumour-related symptoms. RESULTS: Median follow-up was 4.1 years (range: 0.4-12.0). TTV and ETV decreased for both the FSRT and SRS groups. However, only the FSRT group achieved significant tumour shrinkage (p < 0.015 for TTV, p < 0.005 for ETV over time). The 11 NRs showed proportionally greater TTV (median TTV pre-treatment: 0.61 cm(3), 8-10 years after: 1.77 cm(3)) and ETV despite radiation therapy compared to responders (median TTV pre-treatment: 1.06 cm(3); 10-12 years after: 0.81 cm(3); p = 0.001). CONCLUSION: 3D quantification of VS showed a significant decrease in TTV and ETV on FSRT-treated patients only. NR had significantly greater TTV and ETV over time. KEY POINTS: Only FSRT not GK-treated patients showed significant tumour shrinkage over time. Clinical non-responders showed significantly less tumour shrinkage when compared to responders. 3D volumetric assessment of vestibular schwannoma shows advantages over unidimensional techniques.

Quality control in neuroradiology: impact of trainees on discrepancy rates.

BACKGROUND AND PURPOSE: Prior studies have found a 2%-8% clinically significant error rate in radiology practice. We compared discrepancy rates of studies interpreted by subspecialty-trained neuroradiologists working with and without trainees. MATERIALS AND METHODS: Subspecialty-trained neuroradiologists reviewed 2162 studies during 41 months. Discrepancies between the original and "second opinion" reports were scored: 1, no change; 2, clinically insignificant detection discrepancy; 3, clinically insignificant interpretation discrepancy; 4, clinically significant detection discrepancy; and 5, clinically significant interpretation discrepancy. Faculty alone versus faculty and trainee discrepancy rates were calculated. RESULTS: In 87.6% (1894/2162), there were no discrepancies with the original report. The neuroradiology division had a 1.8% (39/2162; 95% CI, 1.3%-2.5%) rate of clinically significant discrepancies. In cases reviewed solely by faculty neuroradiologists (16.2% = 350/2162 of the total), the rate of discrepancy was 1.7% (6/350). With fellows (1232/2162, 57.0% of total) and residents (580/2162, 26.8% of total), the rates of discrepancy were 1.6% (20/1232) and 2.2% (13/580), respectively. The odds of a discrepant result were 26% greater (OR = 1.26; 95% CI, 0.38-4.20) when reading with a resident and 8% less (OR = 0.92; 95% CI, 0.35-2.44) when reading with a fellow than when reading alone. CONCLUSIONS: There was a 1.8% rate of clinically significant detection or interpretation discrepancy among academic neuroradiologists. The difference in the discrepancy rates between faculty only (1.7%), fellows and faculty (1.6%), and residents and faculty (2.2%) was not statistically significant but showed a trend indicating that reading with a resident increased the odds of a discrepant result.

Imaging characteristics of oligodendrogliomas that predict grade.

BACKGROUND AND PURPOSE: Oligodendrogliomas are tumors that have variable WHO grades depending on anaplasia and astrocytic components and their treatment may differ accordingly. Our aim was to retrospectively evaluate imaging features of oligodendrogliomas that predict tumor grade. MATERIALS AND METHODS: The imaging studies of 75 patients with oligodendrogliomas were retrospectively reviewed and compared with the histologic grade. The presence and degree of enhancement and calcification were evaluated subjectively. rCBV and ADC maps were measured. Logistic linear regression models were used to determine the relationship between imaging factors and tumor grade. RESULTS: Thirty of 75 (40%) tumors enhanced, including 9 of 46 (19.6%) grade II and 21 of 29 (72.4%) grade III tumors (P < .001). Grade III tumors showed lower ADC values compared with grade II tumors (odds ratio of a tumor being grade III rather than grade II = 0.07; 95% CI, 0.02-0.25; P = .001). An optimal ADC cutoff of 925 10(-6) mm(2)/s was established, which yielded a specificity of 89.1%, sensitivity of 62.1%, and accuracy of 78.7%. There was no statistically significant association between tumor grade and the presence of calcification and perfusion values. Multivariable prediction rules were applied for ADC < 925 10(-6) mm(2)/s, the presence of enhancement, and the presence of calcification. If either ADC < 925 10(-6) mm(2)/s or enhancement was present, it yielded 93.1% sensitivity, 73.9% specificity, and 81.3% accuracy. The most accurate (82.2%) predictive rule was seen when either ADC < 925 10(-6) mm(2)/s or enhancement and calcification were present. CONCLUSIONS: Models based on contrast enhancement, calcification, and ADC values can assist in predicting the grade of oligodendrogliomas and help direct biopsy sites, raise suspicion of sampling error, and predict prognosis.

Detection of intratumoral calcification in oligodendrogliomas by susceptibility-weighted MR imaging.

BACKGROUND AND PURPOSE: SWI is a unique pulse sequence sensitive to both hemorrhage and calcification. Our aim was to retrospectively assess the ability of SWI to detect intratumoral calcification in ODs compared with conventional MR imaging. MATERIALS AND METHODS: Using CT as criterion standard, the MR imaging findings from 71 patients (33 males, 38 females; mean age, 42.5 years) with pathologically proved OD were retrospectively evaluated. We classified the MR imaging data into SWI data (MRSWI) and traditional pulse sequences (MRnoSWI). The sensitivity and specificity of the MRnoSWI (n = 71) were compared with that of the MRSWI (n = 13) independently and also for matched-paired data (n = 13). The Fisher exact test was applied to the matched-pair data for statistical evaluation. RESULTS: For paired data of MRSWI and MRnoSWI (n = 13), there was significantly increased sensitivity of MRSWI (86%) for the detection of intratumoral calcification in OD compared with the MRnoSWI (14.3%) (P = .015, Fisher exact test) by using CT as the criterion standard. The overall accuracy of MRSWI for the paired data was also significantly greater (P = .048). The specificities were not significantly different (P = .773). The sensitivity of MRSWI (n = 13) was 86%, and for MRnoSWI (n = 71), it was 33.3%. Specificity of MRSWI was 83%, and for MRnoSWI, it was 95%. CONCLUSIONS: SWI is better able to detect calcification in ODs than conventional MR imaging pulse sequences.

Distinguishing between germinomas and pineal cell tumors on MR imaging.

BACKGROUND AND PURPOSE: Tumors of pineal cell origin have different prognosis and treatment than those of germ cell origin. The recent literature suggests that these tumors often look alike. Our study aimed to differentiate between pineal cell tumor and germinoma based on ADC values, the homogeneity of the mass, and MR imaging characteristics. MATERIALS AND METHODS: We enrolled 20 patients who had pretreatment MR imaging scans with histologic verification of tumors of pineal cell origin and germinomas. The tumors were measured for the ADC values and for homogeneity by the coefficient of variation of ADC values, and T1WI and T2WI signal intensity values. RESULTS: The 20 subjects (8 females and 12 males) ranged in age from 1.5-64.9 years, with a mean age of 23.9 years (SD 17.7 years). The mean age of those with germinomas was 13.7 years (SD 3.8 years), less than the mean of 29.4 years for those with pineal cell tumors (SD 19.9 years; P = .016). These 2 groups showed no significant difference in coefficients of variation on T1WI, T2WI, and ADC images. However, germinomas showed statistically significant higher ADC values (mean 1590.69 ± 532.96 × 10(-6) mm(2)/s) than pineal cell tumors (mean 883.58 ± 317.48 × 10(-6) mm(2)/s; P = .02). An accuracy of 89.5%, sensitivity of 83.3%, specificity of 92.3%, PPV of 83.3%, and NPV of 92.3% were yielded for an ADC threshold of 1250.00 × 10(-6) mm(2)/s. CONCLUSIONS: Germinomas showed higher ADC values than the pineal cell tumors (P = .02), and the patients were younger. Otherwise, there were no definitive imaging characteristics that distinguished pineal cell tumors from germinomas.

Quality control in neuroradiology: discrepancies in image interpretation among academic neuroradiologists.

Prior studies have found a 3%-6% clinically significant error rate in radiology practice. We set out to assess discrepancy rates between subspecialty-trained university-based neuroradiologists. Over 17 months, university neuroradiologists randomly reviewed 1000 studies and reports of previously read examinations of patients in whom follow-up studies were read. The discrepancies between the original and "second opinion" reports were scored according to a 5-point scale: 1, no change; 2, clinically insignificant detection discrepancy; 3, clinically insignificant interpretation discrepancy; 4, clinically significant detection discrepancy; and 5, clinically significant interpretation discrepancy. Of the 1000 studies, 876 (87.6%) showed agreements with the original report. The neuroradiology division had a 2.0% (20/1000; 95% CI, 1.1%-2.9%) rate of clinically significant discrepancies involving 8 CTs and 12 MR images. Discrepancies were classified as vascular (n = 7), neoplastic (n = 9), congenital (n = 2), and artifacts (n = 2). Individual neuroradiologist's scores ranged from 0% to 7.7% ± 2.3% (n = 18). Both CT and MR imaging studies had a discrepancy rate of 2.0%. Our quality assessment study could serve as initial data before intervention as part of a PQI project.

Asymmetric mineralization of the arytenoid cartilages in patients without laryngeal cancer.

BACKGROUND AND PURPOSE: Sclerosis of the arytenoid cartilage may be seen as an incidental finding in patients who do not have laryngeal cancer but may also be an early sign of neoplastic infiltration. Our purpose was to determine the frequency of asymmetric mineralization, in particular sclerosis, of the arytenoid cartilages on CT scans in adults who have no history of laryngeal cancer. MATERIALS AND METHODS: Cervical CT scans of 972 consecutive patients seen in our emergency department were retrospectively evaluated. Three hundred twenty-two patients were excluded who were younger than 18 years of age or whose arytenoids could not be reliably seen due to artifacts. Six hundred fifty patients (424 men, 226 women) were assessed, and their arytenoid cartilages were graded as nonmineralized, calcified, sclerotic, or ossified on each side separately. The mean age of patients was 44.3 ± 17.8 years (range, 18-97 years). RESULTS: The frequencies of asymmetric arytenoid cartilage sclerosis, calcification, and ossification were 4.9% (32/650), 4.4% (29/650), and 3.4% (23/650), respectively, with an overall asymmetric mineralization frequency of 12.9% (84/650). Asymmetric sclerosis was more common in women (16/226, 7.1%) than in men (16/424, 3.8%), but the difference was just at statistical significance (P = .05). The rate of unilateral arytenoid sclerosis was 4.6% in all subjects, 6.6% in women, and 3.5% in men. Unilateral sclerosis is much more frequently associated with the left arytenoid than the right. CONCLUSIONS: Asymmetric mineralization of the arytenoid cartilages was seen in 12.9% of our study population. This should be taken into account when evaluating CT scans of patients with laryngeal cancer for arytenoid cartilage invasion to avoid false-positive reads.

CT-guided injection of the anterior and middle scalene muscles: technique and complications.

BACKGROUND AND PURPOSE: Anterior scalene block is a helpful diagnostic test for NTOS and a good predictor of surgical outcome. The purpose of this study was to describe the technique, success rate, and complications associated with CT-guided anesthetic and botulinum toxin injection of the ASM/MSM in patients with NTOS symptoms. MATERIALS AND METHODS: One hundred six participants (mean age, 41.5 ± 10 years; 80 women) were identified via a retrospective review of medical records for CT-guided scalene blocks. The procedure was evaluated regarding the technical success, defined as satisfactory detection of the ASM/MSM; intramuscular needle placement; intramuscular injection of contrast; appropriate delivery of medication; and frequency of unintended BP block or other complications. We also determined the outcome of patients who underwent surgery following the block. RESULTS: Study participants underwent 146 scalene injections, 83 blocks, and 63 chemodenervations, which were included in this investigation. In all cases, detection of the ASM/MSM and intramuscular needle placement was satisfactory. Postprocedural complications included 5 (3.4%) temporary BP blocks, 1 patient with (0.7%) Horner sign, 7 (4.8%) needle-induced pain reports, 1 (0.7%) case of dysphagia, and 2 (1.4%) instances of muscle weakness. There were no major complications reported. The rate of good outcome following surgery was the same in patients with positive versus negative blocks, 30/43 (70%) versus 5/7 (71%), respectively. CONCLUSIONS: CT guidance is a useful adjunct in performing accurate ASM/MSM blocks with a low rate of minor complications.

Middle ear adenoma: a challenging diagnosis.

Middle ear adenomas are rare benign tumors, which can easily be mistaken for other conditions radiologically. They derive from the middle ear mucosa. We report the case of a 48-year-old man with a history of decreased left-sided hearing and intermittent pulsatile tinnitus. High-resolution CT of the temporal bones revealed a well-defined left middle ear soft-tissue attenuation abutting the head of the malleus. Surgical excision revealed a middle ear adenoma.

Radiologic findings in a patient with frontal parafalcine dendritic cell histiocytoma.

We report the case history and radiologic findings of a patient with a biopsy-proven dendritic cell histiocytoma presenting as a single intracranial extra-axial mass and no systemic disease. Even though this entity is relatively rare, it should nevertheless be considered in the differential diagnosis of dural-based space-occupying central nervous system lesions.

Magnetic resonance imaging findings in diffuse lymphangiomatosis: neuroradiological manifestations.

We report magnetic resonance (MR) findings in a patient with histologically proven lymphangiomatosis with a history of chylothorax, diffuse lung infiltrates, spinal involvement, cystic lesions of the mediastinum, and mesentery thickening. The patient also had diffuse infiltration of the right brachial plexus, with similar imaging findings as the spinal lesions. Although osseous and extraosseous involvement may be seen frequently with lymphangiomatosis, involvement of the brachial plexus has not been previously reported.

Resectability issues with head and neck cancer.

Head and neck surgeons often rely on imaging to determine if a neoplasm is resectable. Many of the critical issues are outlined in the American Joint Committee on Cancer Staging Manual, wherein T4a and T4b head and neck cancers are defined as resectable and unresectable, respectively. Even within the T4a advanced resectable classification, there are critical determinants that define whether the surgical option is such that major morbidity and mortality could be expected. This review article examines the imaging literature to determine the accuracy and diagnostic criteria of different modalities for evaluating these critical T4a and T4b factors, which include the following: 1) arterial encasement, 2) prevertebral fascia involvement, 3) mediastinal infiltration, 4) tracheal and esophageal extension, 5) laryngeal cartilage penetration, 6) pre-epiglottic fat involvement, 7) dural spread, 8) bone (mandible/maxilla and skull base) infiltration, 9) perineural spread, 10) orbital involvement, and 11) brachial plexus invasion. For the most part, the studies find MR imaging with higher sensitivity but lower specificity than CT. An ever-increasing role for PET/CT is suggested. Imaging is of great value in the determination of resectability issues listed previously for head and neck cancers, with the possible exception of prevertebral fascia involvement.

Imaging findings of a hibernoma of the neck.

Hibernoma is an uncommon benign fatty tumor that arises from the vestiges of fetal brown fat. We present a case report of a hibernoma of the neck in an asymptomatic 19-year-old girl and describe the important imaging findings. Computed tomography (CT) shows a well defined hypodense mass with septations. Magnetic resonance imaging (MRI) shows intermediate T1 and bright T2 signal of the mass and also demonstrates the characteristic marked contrast enhancement.

Giant cell reparative granuloma of the sphenoid bone.

We present 2 patients with giant cell reparative granuloma (GCRG) of the sphenoid bone. The first patient is an 8-year-old boy with involvement of the greater wing, and the second is a 53- year-old man with a lateral pterygoid plate mass. Both patients presented with rapid expansion of lytic bone lesions, which had solid and cystic components and lacked matrix calcification. Biopsies were indeterminate for definitive diagnoses. The radiologic appearance, location, and incidence of the lesions, and the patient's age and medical history are helpful aids in narrowing the differential diagnosis of sphenoid bone lesions. However, the imaging and, occasionally, even the histologic findings may not suggest the specific diagnosis of GCRG, which must be added into the differential diagnosis of rapidly enlarging cystic bone lesions of the sphenoid bone.

Imaging of the olfactory system.

The olfactory system consists of the primary olfactory nerves in the nasal cavity, the olfactory bulbs and tracts, and numerous intracranial connections and pathways. Diseases affecting the sense of smell can be located both extracranially and intracranially. Many sinonasal inflammatory and neoplastic processes may affect olfaction. Intracranially congenital, traumatic, and neurodegenerative disorders are usually to blame for olfactory dysfunction. The breadth of diseases that affect the sense of smell is astounding, yet the imaging ramifications have barely been explored.

MR imaging for predicting neoplastic invasion of the cervical esophagus.

BACKGROUND AND PURPOSE: Esophageal invasion (EI) by head and neck neoplasm has important prognostic and surgical management implications. Our purpose was to determine the accuracy of MR imaging for predicting neoplastic cervical esophageal invasion. METHODS: MR scans of the neck obtained from 22 patients with periesophageal masses were retrospectively reviewed independently and by consensus by two experienced head and neck radiologists who were unaware of surgical findings. The patients were selected from clinical, radiologic, or pathologic reports suggesting EI. The following imaging criteria for EI were evaluated: effacement of periesophageal fat planes, circumferential mass, paraesophageal lymph nodes, luminal size, wall thickening, increased T2 wall signal, and wall enhancement. There were eight patients with EI and 14 patients without EI, as confirmed by surgical findings or pathologic examination. RESULTS: The consensus criteria with the best sensitivities were any wall thickening (100%), effaced fat plane (100%), and any T2 wall signal abnormality (100%). The criteria with the best specificities were circumferential mass greater than 270 (100%) or 180 degrees (93%) and focal T2 wall signal abnormality (86%). The overall kappa value for the two readers for all criteria was 0.57 (moderate agreement). CONCLUSION: A circumferential mass or focal T2 signal abnormality on the esophageal wall suggests the presence of EI. An intact fat plane, absence of wall thickening, and no T2 wall signal abnormalities imply that the esophagus is not invaded.

Posttransplantation lymphoproliferative disorder of the head and neck: imaging features in seven adults.

PURPOSE: To determine the cross-sectional imaging findings of posttransplantation lymphoproliferative disorder (PTLD) of the head and neck. MATERIALS AND METHODS: Computed tomographic (CT) scans (n = 6) and magnetic resonance (MR) images (n = 2) in seven patients with histopathologically proved PTLD of the Waldeyer (lymphoid) ring or cervical lymph nodes were retrospectively reviewed for abnormalities. RESULTS: The interval between transplantation and PTLD onset was 3.5-108 months (mean, 30 months). All patients had imaging abnormalities involving the Waldeyer ring, and focal 2.0-4. 5-cm masses were present in six patients (unilateral oropharyngeal tonsil in two, bilateral oropharyngeal tonsils in one, nasopharyngeal adenoids in three, unilateral pharyngeal tonsil and ipsilateral nasopharynx in one). In three patients, the mass was centrally low attenuating at CT or isointense to fluid at MR imaging, with enhancing solid peripheral lymphoid tissue. Three patients also had nodal findings: one with a 7-cm low-attenuating nodal mass in the right neck and two with numerous bilateral lymph nodes (mostly normal sized) in the anterior and posterior cervical lymph chains. One patient also had a small mass in the upper mediastinum. CONCLUSION: In the setting of organ transplantation, findings of masses in the Waldeyer ring or an excessive number of cervical nodes should increase the index of suspicion of PTLD.

Preoperative imaging to predict orbital invasion by tumor.

BACKGROUND: Our purpose was to examine the accuracy of preoperative imaging in assessing tumor invasion of the orbit and nasolacrimal system. METHODS: Nineteen preoperative CT and 17 preoperative MR images from patients at risk for orbital invasion were retrospectively reviewed. Invasion was corroborated by pathologic and intraoperative assessment. RESULTS: Tumor adjacent to the periorbita was the most sensitive predictor of orbital invasion (90%) for both CT and MRI. Extraocular muscle involvement on MRI (100%) and orbital fat obliteration (80% MRI, 86% CT) had the highest positive predictive values of the criteria evaluated. Extraocular muscle displacement and enhancement were less accurate (<65%) predictors. No one criterion was >79% accurate in predicting orbital invasion. Six or more positive criteria predicted invasion with 67% sensitivity and 80% specificity (accuracy, 72%). CT was more accurate than MRI in seven of nine criteria. Invasion of the nasolacrimal system was predicted accurately (89%). CONCLUSIONS: Although preoperative imaging can aid in surgical planning, it should not replace intraoperative assessment in ambiguous cases of orbital invasion.