Interreader Variability of Dynamic Contrast-enhanced MRI of Recurrent Glioblastoma: The Multicenter ACRIN 6677/RTOG 0625 Study.

Purpose To evaluate factors contributing to interreader variation (IRV) in parameters measured at dynamic contrast material-enhanced (DCE) MRI in patients with glioblastoma who were participating in a multicenter trial. Materials and Methods A total of 18 patients (mean age, 57 years ± 13 [standard deviation]; 10 men) who volunteered for the advanced imaging arm of ACRIN 6677, a substudy of the RTOG 0625 clinical trial for recurrent glioblastoma treatment, underwent analyzable DCE MRI at one of four centers. The 78 imaging studies were analyzed centrally to derive the volume transfer constant (Ktrans) for gadolinium between blood plasma and tissue extravascular extracellular space, fractional volume of the extracellular extravascular space (ve), and initial area under the gadolinium concentration curve (IAUGC). Two independently trained teams consisting of a neuroradiologist and a technologist segmented the enhancing tumor on three-dimensional spoiled gradient-recalled acquisition in the steady-state images. Mean and median parameter values in the enhancing tumor were extracted after registering segmentations to parameter maps. The effect of imaging time relative to treatment, map quality, imager magnet and sequence, average tumor volume, and reader variability in tumor volume on IRV was studied by using intraclass correlation coefficients (ICCs) and linear mixed models. Results Mean interreader variations (± standard deviation) (difference as a percentage of the mean) for mean and median IAUGC, mean and median Ktrans, and median ve were 18% ± 24, 17% ± 23, 27% ± 34, 16% ± 27, and 27% ± 34, respectively. ICCs for these metrics ranged from 0.90 to 1.0 for baseline and from 0.48 to 0.76 for posttreatment examinations. Variability in reader-derived tumor volume was significantly related to IRV for all parameters. Conclusion Differences in reader tumor segmentations are a significant source of interreader variation for all dynamic contrast-enhanced MRI parameters. © RSNA, 2018 Online supplemental material is available for this article. See also the editorial by Wolf in this issue.

The Rate of Magnetic Resonance Imaging in Patients with Deep Brain Stimulation.

BACKGROUND: For Parkinson's disease (PD), essential tremor (ET), and dystonia patients with deep brain stimulation (DBS) implants, magnetic resonance imaging (MRI) requires additional safety considerations due to potentially hazardous interactions. OBJECTIVE: A propensity-matched cohort of DBS-implanted patients was analyzed to determine the likelihood of needing MRI. METHODS: Patients with new DBS full-system implants (n = 576) were identified in the Truven Health MarketScan® Commercial Claims and Medicare Supplemental Databases (2009-2012). Patients diagnosed with PD, ET, or dystonia and no DBS implant were identified (DBS-indicated patients: n = 11,216). The DBS-indicated patients were continuously enrolled for 4 years and matched for age, gender, and propensity score based on comorbid conditions to DBS-implanted patients (n = 4,878 and 543, respectively). A Kaplan-Meier survival curve of time to first MRI was extrapolated to 10 years. RESULTS: An estimated 56-57% of DBS-indicated patients need an MRI within 5 years and 66-75% within 10 years after implantation. While 92% of DBS-implanted patients' MRI after implantation was of the head, for DBS-indicated patients, 62% of MRIs were of the body, potentially unrelated to the primary diagnosis. CONCLUSIONS: This analysis highlights the projected utilization of MRI in the DBS population for head and full-body images.

MRI for in vivo Analysis of Ablation Zones Formed by Cooled Radiofrequency Neurotomy to Treat Chronic Joint Pain Across Multiple Axial Spine Sites.

PURPOSE: Radiofrequency (RF) ablation is the targeted damage of neural tissues to disrupt pain transmission in sensory nerves using thermal energy generated in situ by an RF probe. The present study aims to evaluate the utility of magnetic resonance imaging (MRI) for in vivo quantitative assessment of ablation zones in human subjects following cooled radiofrequency neurotomy for chronic pain at spinal facet or sacroiliac joints. Ablation zone size and shape have been shown in animal models to be influenced by size and type of RF probe - with cooled RF probes typically forming larger, more spherical ablation zones. To date, MRI of RF ablation zones in humans has been limited to two single retrospective case reports. PATIENTS AND METHODS: A prospective, open-label pilot study of MRI for evaluation of cooled radiofrequency ablation zones following standard of care procedures in adult outpatients was conducted. Adult subjects (n=13) received monopolar cooled RF (CRF) ablation (COOLIEF™, Avanos Medical) of sensory nerves at spinal facet or sacroiliac joints, followed by an MRI 2-7 days after the procedure. MRI data were acquired using both Short Tau Inversion Recovery (STIR) and contrast-enhanced T1-weighted (T1C) protocols. T1C MRI was used to calculate 3-dimensional ellipsoid ablation zone volumes (V), where well-defined regions of signal hyperintensity were used to identify three orthogonal diameters (T, D, L) and apply the formula V=π/6×T×D×L. RESULTS: Among 13 patients, 96 CRF ablation zones were created at 4 different anatomic sites (sacroiliac, lumbar, thoracic and cervical). CRF ablation zone morphology varied by anatomical location and structural features of surrounding tissues. In some cases, proximity to bone and striations of surrounding musculature obscured ablation zone borders. The volumes of 75 of the 96 ablation zones were measurable from MRI, with values (mean±SD) ranging from 0.4679 (±0.29) cm3 to 2.735 (±2.62) cm3 for the cervical and thoracic sites, respectively. CONCLUSION: In vivo T1C MRI analysis of cooled RF ablation zones at spinal facet and sacroiliac joints demonstrated variable effects of local tissues on ablation zone morphology. Placement of the CRFA probe very close to bone alters the ablation zone in a negative way, causing non-spherical and incomplete lesioning. These new data may serve to inform practicing physicians about optimal cooled RF probe placement in clinical procedures.

Clinical and radiological outcome of anterior-posterior fusion versus transforaminal lumbar interbody fusion for symptomatic disc degeneration: a retrospective comparative study of 133 patients.

Abundant data are available for direct anterior/posterior spine fusion (APF) and some for transforaminal lumbar interbody fusion (TLIF), but only few studies from one institution compares the two techniques. One-hundred and thirty-three patients were retrospectively analyzed, 68 having APF and 65 having TLIF. All patients had symptomatic disc degeneration of the lumbar spine. Only those with one or two-level surgeries were included. Clinical chart and radiologic reviews were done, fusion solidity assessed, and functional outcomes determined by pre- and postoperative SF-36 and postoperative Oswestry Disability Index (ODI), and a satisfaction questionnaire. The minimum follow-up was 24 months. The mean operating room time and hospital length of stay were less in the TLIF group. The blood loss was slightly less in the TLIF group (409 vs. 480 cc.). Intra-operative complications were higher in the APF group, mostly due to vein lacerations in the anterior retroperitoneal approach. Postoperative complications were higher in the TLIF group due to graft material extruding against the nerve root or wound drainage. The pseudarthrosis rate was statistically equal (APF 17.6% and TLIF 23.1%) and was higher than most published reports. Significant improvements were noted in both groups for the SF-36 questionnaires. The mean ODI scores at follow-up were 33.5 for the APF and 39.5 for the TLIF group. The patient satisfaction rate was equal for the two groups.

Prognostic value of contrast enhancement and FLAIR for survival in newly diagnosed glioblastoma treated with and without bevacizumab: results from ACRIN 6686.

Background: ACRIN 6686/RTOG 0825 was a phase III trial of conventional chemoradiation plus adjuvant temozolomide with bevacizumab or without (placebo) in newly diagnosed glioblastoma. This study investigated whether changes in contrast-enhancing and fluid attenuated inversion recovery (FLAIR)-hyperintense tumor assessed by central reading prognosticate overall survival (OS). Methods: Two hundred eighty-four patients (171 men; median age 57 y, range 19-79; 159 on bevacizumab) had MRI at post-op (baseline) and pre-cycle 4 of adjuvant temozolomide (22 wk post chemoradiation initiation). Four central readers measured bidimensional lesion enhancement (2D-T1) and FLAIR hyperintensity at both time points. Changes from baseline to pre-cycle 4 for both markers were dichotomized (increasing vs non-increasing). Cox proportional hazards model and Kaplan-Meier survival estimates were used for inference. Results: Adjusting for treatment, increasing 2D-T1 (n = 262, hazard ratio [HR] = 2.07, 95% CI: 1.48-2.91, P < 0.0001) and FLAIR (n = 273, HR = 1.75, 95% CI: 1.26-2.41, P = 0.0008) significantly predicted worse OS. Median OS (days) was significantly shorter for patients with increasing versus non-increasing 2D-T1 for both bevacizumab (443 vs 535, P = 0.004) and placebo (526 vs 887, P = 0.001). Median OS was significantly shorter for patients with increasing versus non-increasing FLAIR for placebo (595 vs 872, P = 0.001), and trended similarly for bevacizumab (499 vs 535, P = 0.0935). Adjusting for 2D-T1 and treatment, increasing FLAIR represented significantly higher risk for death (HR = 1.59 [1.11-2.26], P = 0.01). Conclusion: Increased 2D-T1 significantly predicts worse OS in both treatment groups, implying absence of a substantial proportion of pseudoprogression 22 weeks after initiation of standard therapy. FLAIR adds value beyond 2D-T1 in predicting OS, potentially addressing the pseudoresponse effect by substratifying bevacizumab-treated patients with non-increasing 2D-T1.

West Nile virus infection: MR imaging findings in the nervous system.

BACKGROUND AND PURPOSE: West Nile virus (WNV) infection is an ongoing seasonal epidemic. We correlated the MR imaging findings with the clinical presentations and outcomes of WNV infection. METHODS: We reviewed 14 brain and three spinal MR images: nonenhanced and contrast-enhanced T1-weighted images (T1WIs) and T2-weighted images (T2WIs), nonenhanced fluid-attenuated inversion recovery (FLAIR) images (11 patients) and enhanced FLAIR images (three patients), with diffusion-weighted (DW) images and apparent diffusion coefficient maps. WNV infection was diagnosed by means of enzyme-linked immunosorbent assay with a plaque reduction neutralization test. We also correlated the MR findings with the clinical presentation, course, and outcome to determine their prognostic importance. RESULTS: MR imaging findings included: 1) normal (five patients); 2) DW imaging-only abnormalities in the white matter, corona radiata, and internal capsule (four patients); 3) hyperintensity on FLAIR images and T2WIs in the lobar gray and white matter, cerebellum, basal ganglia, thalamus and internal capsule, pons and midbrain (three patients); 4) meningeal involvement (two patients); and 5) spinal cord, cauda equina, and nerve root involvement (three patients). All patients with finding 1 and all but one with finding 2 recovered completely. Two patients with finding 3 died. Those with finding 4 or 5 had residual neurologic deficits that were severe or moderate to severe, respectively. CONCLUSION: Patients with normal MR images or abnormalities on only DW images had the best prognosis, while those with abnormal signal intensity on T2WI and FLAIR images had the worst outcomes. No definite predilection for any specific area of the brain parenchyma was noted.

Reference values for long echo time MR spectroscopy in healthy adults.

BACKGROUND AND PURPOSE: There is a lack of information with regard to normal metabolic ratios acquired with MR spectroscopy utilizing a long echo time technique. Our purpose was to measure metabolic ratios in healthy adults to determine whether the metabolites varied across brain regions and by sex. METHODS: Single voxel proton spectra were acquired with an echo time of 135 milliseconds in 10 brain regions of 72 healthy subjects ranging in age from 20 to 44 years. Six gray matter sites in the cerebrum included four cortical areas in the frontal, parietal, temporal, and occipital lobes, and two deep nuclear sites in the basal ganglia and the thalamus. Two subcortical white matter regions were in the parietal and the frontal lobes. Two posterior fossa sites included the pons and the cerebellum. All 10 brain regions were not studied in each subject. For each spectrum, the metabolites n-acetylaspartate (NAA), creatine (Cr), and choline (Ch) were identified and ratios of NAA/Cr and Ch/Cr calculated for each brain region. A multifactorial analysis of variance was performed with the two metabolic ratios as dependent variables and with brain region and sex as independent variables. Post hoc statistical analysis consisted of the Scheffé F statistic for significant difference between pairs of brain regions for both metabolic ratios. RESULTS: There was significant regional variation for both the NAA/Cr ratio (P < .0001) and the Ch/Cr ratio (P < .0001). The NAA/Cr ratio was consistent within cortical gray and white matter but differed between cortical gray (smaller ratio) and white matter (larger ratio). The Ch/Cr ratio was variable in the gray matter, differed between some but not all gray and white matter regions, but was consistent within subcortical white matter regions. There was no difference between men and women for either metabolic ratio. CONCLUSION: There was variation of the NAA/Cr ratio and the Ch/Cr ratio across brain regions, but no sex differences were found. These findings provide the requisite normative values to use single voxel, long-echo-time MR spectroscopy in adult patients with neurologic disorders.

The rate of magnetic resonance imaging in patients with spinal cord stimulation.

STUDY DESIGN: Analysis of use of magnetic resonance imaging (MRI) in the chronic back and leg pain spinal cord stimulation (SCS)-implanted population was conducted using a propensity-matched cohort population. OBJECTIVE: To project the percentage of patients with SCS expected to need at least 1 MRI within 5 years of implant. SUMMARY OF BACKGROUND DATA: Patients experiencing pain, including those who underwent implantation with SCS systems, are likely to have comorbidities and ongoing pain issues that may require diagnostic imaging. MRI is the most common diagnostic imaging modality for evaluating patients with new or worsening low back pain. However, patients with SCS are typically excluded from receiving MRI because of the safety risks related to the interactions of MRI fields and implantable devices. METHODS: To provide an accurate estimate of the need for MRI in the SCS-implanted population, Truven Health MarketScan Commercial Claims and Medicare Supplemental databases were used to perform analysis of SCS-implanted patients propensity score matched to a nonimplanted population-based cohort. Four years of paid and adjudicated claims data were used to determine the magnetic resonance (MR) images received, which was exponentially projected to estimate MRI within 5 and 10 years of implant. RESULTS: Approximately 82% to 84% of SCS-implanted patients are expected to need at least 1 MRI within 5 years of implant. Furthermore, 59% to 74% of patients will require nonspine MRI within 10 years. CONCLUSION: There is a high need for MRI in this chronic back and leg pain SCS population, with a significant portion being completed on locations outside of the spine. This analysis highlights a need for MRI-conditional SCS devices that grant access of patients with SCS to this imaging modality. LEVEL OF EVIDENCE: 3.

Diffusion MRI quality control and functional diffusion map results in ACRIN 6677/RTOG 0625: a multicenter, randomized, phase II trial of bevacizumab and chemotherapy in recurrent glioblastoma.

Functional diffusion mapping (fDM) is a cancer imaging technique that quantifies voxelwise changes in apparent diffusion coefficient (ADC). Previous studies have shown value of fDMs in bevacizumab therapy for recurrent glioblastoma multiforme (GBM). The aim of the present study was to implement explicit criteria for diffusion MRI quality control and independently evaluate fDM performance in a multicenter clinical trial (RTOG 0625/ACRIN 6677). A total of 123 patients were enrolled in the current multicenter trial and signed institutional review board-approved informed consent at their respective institutions. MRI was acquired prior to and 8 weeks following therapy. A 5-point QC scoring system was used to evaluate DWI quality. fDM performance was evaluated according to the correlation of these metrics with PFS and OS at the first follow-up time-point. Results showed ADC variability of 7.3% in NAWM and 10.5% in CSF. A total of 68% of patients had usable DWI data and 47% of patients had high quality DWI data when also excluding patients that progressed before the first follow-up. fDM performance was improved by using only the highest quality DWI. High pre-treatment contrast enhancing tumor volume was associated with shorter PFS and OS. A high volume fraction of increasing ADC after therapy was associated with shorter PFS, while a high volume fraction of decreasing ADC was associated with shorter OS. In summary, DWI in multicenter trials are currently of limited value due to image quality. Improvements in consistency of image quality in multicenter trials are necessary for further advancement of DWI biomarkers.

MR spectroscopy in the diagnosis of cerebral amyloid angiopathy presenting as a brain tumor.

We present two cases of focal, tumefactive, masslike lesions of diffuse cerebral amyloid angiopathy (CAA) that presented as areas of increased signal intensity on long TR sequences without contrast enhancement or restricted diffusion. MR spectroscopy revealed normal metabolite ratios and unremarkable spectra. Pathologic tissue showed CAA and CAA with angitis of the CNS. Tumefactive CAA is a rare condition, and we describe its characteristics at MR spectroscopy and diffusion-weighted imaging.

CT signs of urethral injury.

Computed tomography (CT) is the accepted frontline imaging modality for blunt abdominopelvic trauma. However, urethral injuries are traditionally diagnosed with retrograde urethrography. The CT appearances of urethral injuries and the signs associated with posterior urethral injuries are not well described in the literature. CT scans of patients with pelvic fractures and urethrographically proved posterior urethral injuries were evaluated. CT scans of patients with similar pelvic fractures who did not have urethral injuries were also evaluated. The CT findings of elevation of the prostatic apex, extravasation of urinary tract contrast material above the urogenital diaphragm (UGD), and extravasation of urinary tract contrast material below the UGD were specific for type I, II, and III urethral injuries, respectively. If extraperitoneal bladder rupture is present along with periurethral extravasation of contrast material, the possibility of type IV and IVA urethral injuries should be considered. In addition, the CT findings of distortion or obscuration of the UGD fat plane, hematoma of the ischiocavernosus muscle, distortion or obscuration of the prostatic contour, distortion or obscuration of the bulbocavernosus muscle, and hematoma of the obturator internus muscle were more common in patients with pelvic fractures and associated urethral injuries than in patients with uncomplicated pelvic fractures.

CT pulmonary angiography in the detection of pulmonary emboli: a meta-analysis of sensitivities and specificities.

OBJECTIVE: To determine the overall sensitivity and specificity for CT pulmonary angiography (CTPA) in the diagnosis of pulmonary emboli (PE) using a meta-analysis of the published literature. MATERIALS AND METHODS: A Medline search was constructed to include all English language publications indexed in the Index Medicus from 1990 to 2000, which included the terms CT, PE and pulmonary angiography. Studies selected were designed principally to compare CTPA in the overall detection of PE as confirmed by an abnormal fluoroscopic pulmonary angiogram or a high probability V:Q scan. Results were corrected for the patient sample size in the respective studies prior to pooling the data. In the absence of an accepted technique for calculating a ROC curve in the meta-analysis of imaging studies, a previously untested theoretical technique was used to obtain a composite ROC curve. RESULTS: Twelve studies of CTPA comprising a total of 1250 patients were analyzed. The overall sensitivity and specificity for CTPA after correction for study size was 74.1% and 89.5% with a range of 57-100% and 68-100%, respectively, for the detection of PE. No trend was detected with respect to the year of publication or sample size. CONCLUSIONS: CTPA has acceptable sensitivity and specificity with a strong ROC curve making it a good first line investigation for PE.

Safe magnetic resonance imaging scanning of patients with cardiac rhythm devices: a role for computer modeling.

BACKGROUND: Although there are several hazards for patients with implanted pacemakers and defibrillators in the magnetic resonance imaging (MRI) environment, evaluation of lead electrode heating is the most complex because of the many influencing variables: patient size, anatomy, body composition, patient position in the bore, scan sequence (radiofrequency power level), lead routing, and lead design. Although clinical studies are an important step in demonstrating efficacy, demonstrating safety through clinical trials alone is not practical because of this complexity. OBJECTIVE: The purpose of this study was to develop a comprehensive modeling framework to predict the probability of pacing capture threshold (PCT) change due to lead electrode heating in the MRI environment and thus provide a robust safety evaluation. METHODS: The lead heating risk was assessed via PCT change because this parameter is the most clinically relevant measure of lead heating. The probability for PCT change was obtained by combining the prediction for power at the electrode-tissue interface obtained via simulations with a prediction for PCT change as a function of radiofrequency power obtained via an in vivo canine study. RESULTS: The human modeling framework predicted that the probability of a 0.5-V PCT change due to an MRI scan for the Medtronic CapSureFix MRI SureScan model 5086 MRI leads is <1/70,000 for chest scans and <1/10,000,000 for either head scans or lower torso scans. CONCLUSION: The framework efficiently models millions of combinations, delivering a robust evaluation of the lead electrode heating hazard. This modeling approach provides a comprehensive safety evaluation that is impossible to achieve using phantom testing, animal studies, or clinical trials alone.

Magnetic resonance spectroscopy as an early indicator of response to anti-angiogenic therapy in patients with recurrent glioblastoma: RTOG 0625/ACRIN 6677.

BACKGROUND: The prognosis for patients with recurrent glioblastoma remains poor. The purpose of this study was to assess the potential role of MR spectroscopy as an early indicator of response to anti-angiogenic therapy. METHODS: Thirteen patients with recurrent glioblastoma were enrolled in RTOG 0625/ACRIN 6677, a prospective multicenter trial in which bevacizumab was used in combination with either temozolomide or irinotecan. Patients were scanned prior to treatment and at specific timepoints during the treatment regimen. Postcontrast T1-weighted MRI was used to assess 6-month progression-free survival. Spectra from the enhancing tumor and peritumoral regions were defined on the postcontrast T1-weighted images. Changes in the concentration ratios of n-acetylaspartate/creatine (NAA/Cr), choline-containing compounds (Cho)/Cr, and NAA/Cho were quantified in comparison with pretreatment values. RESULTS: NAA/Cho levels increased and Cho/Cr levels decreased within enhancing tumor at 2 weeks relative to pretreatment levels (P = .048 and P = .016, respectively), suggesting a possible antitumor effect of bevacizumab with cytotoxic chemotherapy. Nine of the 13 patients were alive and progression free at 6 months. Analysis of receiver operating characteristic curves for NAA/Cho changes in tumor at 8 weeks revealed higher levels in patients progression free at 6 months (area under the curve = 0.85), suggesting that NAA/Cho is associated with treatment response. Similar results were observed for receiver operating characteristic curve analyses against 1-year survival. In addition, decreased Cho/Cr and increased NAA/Cr and NAA/Cho in tumor periphery at 16 weeks posttreatment were associated with both 6-month progression-free survival and 1-year survival. CONCLUSION: Changes in NAA and Cho by MR spectroscopy may potentially be useful as imaging biomarkers in assessing response to anti-angiogenic treatment.

Early post-bevacizumab progression on contrast-enhanced MRI as a prognostic marker for overall survival in recurrent glioblastoma: results from the ACRIN 6677/RTOG 0625 Central Reader Study.

BACKGROUND: RTOG 0625/ACRIN 6677 is a multicenter, randomized, phase II trial of bevacizumab with irinotecan or temozolomide in recurrent glioblastoma (GBM). This study investigated whether early posttreatment progression on FLAIR or postcontrast MRI assessed by central reading predicts overall survival (OS). METHODS: Of 123 enrolled patients, 107 had baseline and at least 1 posttreatment MRI. Two central neuroradiologists serially measured bidimensional (2D) and volumetric (3D) enhancement on postcontrast T1-weighted images and volume of FLAIR hyperintensity. Progression status on all posttreatment MRIs was determined using Macdonald and RANO imaging threshold criteria, with a third neuroradiologist adjudicating discrepancies of both progression occurrence and timing. For each MRI pulse sequence, Kaplan-Meier survival estimates and log-rank test were used to compare OS between cases with or without radiologic progression. RESULTS: Radiologic progression occurred after 2 chemotherapy cycles (8 weeks) in 9 of 97 (9%), 9 of 73 (12%), and 11 of 98 (11%) 2D-T1, 3D-T1, and FLAIR cases, respectively, and 34 of 80 (43%), 21 of 58 (36%), and 37 of 79 (47%) corresponding cases after 4 cycles (16 weeks). Median OS among patients progressing at 8 or 16 weeks was significantly less than that among nonprogressors, as determined on 2D-T1 (114 vs 278 days and 214 vs 426 days, respectively; P < .0001 for both) and 3D-T1 (117 vs 306 days [P < .0001] and 223 vs 448 days [P = .0003], respectively) but not on FLAIR (201 vs 276 days [P = .38] and 303 vs 321 days [P = .13], respectively). CONCLUSION: Early progression on 2D-T1 and 3D-T1, but not FLAIR MRI, after 8 and 16 weeks of anti-vascular endothelial growth factor therapy has highly significant prognostic value for OS in recurrent GBM.

Gadolinium use in spine pain management procedures for patients with contrast allergies: results in 527 procedures.

INTRODUCTION: To review the safety and efficacy of gadolinium in spine pain management procedures in patients at high risk for a contrast reaction and who are not suitable candidates for the use of standard non-ionic contrast. METHODS: We reviewed records over a 61-month period of all image-guided spinal pain management procedures where patients had allergies making them unsuitable candidates for standard non-ionic contrast and where gadolinium was used to confirm needle tip placement prior to injection of medication. RESULTS: Three hundred and four outpatients underwent 527 procedures. A spinal needle was used in all but 41 procedures. Gadolinium was visualized using portable C-arm fluoroscopy in vivo allowing for confirmation of needle tip location. The gadolinium dose ranged from 0.2 to 10 ml per level. The highest dose received by one patient was 15.83 ml intradiscally during a three-level discogram. Three hundred and one patients were discharged without complication or known delayed complications. One patient had documented intrathecal injection but without sequelae and 2 patients who underwent cervical procedures experienced seizures requiring admission to the intensive care unit. Both the latter patients were discharged without any further complications. CONCLUSION: Based on our experience we recommend using gadolinium judiciously for needle tip confirmation. We feel more confident using gadolinium in the lumbar spine and in cervical nerve blocks. Gadolinium should probably not be used as an injectate volume expander. The indications for gadolinium use in cervical needle-guided spine procedures are less clear and use of a blunt-tipped needle should be considered.

Giant anterior cervicothoracic arachnoid cyst.

STUDY DESIGN: A case report with a review of the literature is presented demonstrating the imaging findings of a patient with recent onset, progressive spinal cord compression at T6 caused by a giant arachnoid cyst that was successfully treated. OBJECTIVE: To present the imaging findings of a giant anterior cervicothoracic intradural arachnoid cyst using several methods before and after treatment. SUMMARY OF BACKGROUND DATA: This case demonstrates the imaging findings of the largest described anterior cervical arachnoid cyst straddling the cervicothoracic junction. It presented with spinal cord compression in a 26-year-old diagnosed by MRI and successfully treated surgically. METHODS: The patient experienced progressive left-sided sensory and motor deficits below T6. Pain and temperature sensation were decreased. Reflexes were increased in both lower extremities with clonus. Preoperative MRI was followed by laminectomy and cyst fenestration with subsequent postoperative myelogram and CT. RESULTS: Imaging confirmed the presence of a giant arachnoid cyst straddling the cervicothoracic junction. Postoperative imaging documented relief of spinal cord compression. Symptoms improved progressively after surgery. By the time of discharge all residual neurologic deficits had resolved. CONCLUSION: Anterior arachnoid cysts straddling the cervicothoracic junction have yet to be reported, and arachnoid cysts involving the cervical region are extremely rare. Imaging demonstrated the cyst and its response to treatment. This patient responded well to surgery and was discharged without neurologic sequelae.