Validation of multiparametric MRI based prediction model in identification of pseudoprogression in glioblastomas.

BACKGROUND: Accurate differentiation of pseudoprogression (PsP) from tumor progression (TP) in glioblastomas (GBMs) is essential for appropriate clinical management and prognostication of these patients. In the present study, we sought to validate the findings of our previously developed multiparametric MRI model in a new cohort of GBM patients treated with standard therapy in identifying PsP cases. METHODS: Fifty-six GBM patients demonstrating enhancing lesions within 6 months after completion of concurrent chemo-radiotherapy (CCRT) underwent anatomical imaging, diffusion and perfusion MRI on a 3 T magnet. Subsequently, patients were classified as TP + mixed tumor (n = 37) and PsP (n = 19). When tumor specimens were available from repeat surgery, histopathologic findings were used to identify TP + mixed tumor (> 25% malignant features; n = 34) or PsP (< 25% malignant features; n = 16). In case of non-availability of tumor specimens, ≥ 2 consecutive conventional MRIs using mRANO criteria were used to determine TP + mixed tumor (n = 3) or PsP (n = 3). The multiparametric MRI-based prediction model consisted of predictive probabilities (PP) of tumor progression computed from diffusion and perfusion MRI derived parameters from contrast enhancing regions. In the next step, PP values were used to characterize each lesion as PsP or TP+ mixed tumor. The lesions were considered as PsP if the PP value was < 50% and TP+ mixed tumor if the PP value was ≥ 50%. Pearson test was used to determine the concordance correlation coefficient between PP values and histopathology/mRANO criteria. The area under ROC curve (AUC) was used as a quantitative measure for assessing the discriminatory accuracy of the prediction model in identifying PsP and TP+ mixed tumor. RESULTS: Multiparametric MRI model correctly predicted PsP in 95% (18/19) and TP+ mixed tumor in 57% of cases (21/37) with an overall concordance rate of 70% (39/56) with final diagnosis as determined by histopathology/mRANO criteria. There was a significant concordant correlation coefficient between PP values and histopathology/mRANO criteria (r = 0.56; p < 0.001). The ROC analyses revealed an accuracy of 75.7% in distinguishing PsP from TP+ mixed tumor. Leave-one-out cross-validation test revealed that 73.2% of cases were correctly classified as PsP and TP + mixed tumor. CONCLUSIONS: Our multiparametric MRI based prediction model may be helpful in identifying PsP in GBM patients.

Assessment of treatment response to dendritic cell vaccine in patients with glioblastoma using a multiparametric MRI-based prediction model.

PURPOSE: Autologous tumor lysate-loaded dendritic cell vaccine (DCVax-L) is a promising treatment modality for glioblastomas. The purpose of this study was to investigate the potential utility of multiparametric MRI-based prediction model in evaluating treatment response in glioblastoma patients treated with DCVax-L. METHODS: Seventeen glioblastoma patients treated with standard-of-care therapy + DCVax-L were included. When tumor progression (TP) was suspected and repeat surgery was being contemplated, we sought to ascertain the number of cases correctly classified as TP + mixed response or pseudoprogression (PsP) from multiparametric MRI-based prediction model using histopathology/mRANO criteria as ground truth. Multiparametric MRI model consisted of predictive probabilities (PP) of tumor progression computed from diffusion and perfusion MRI-derived parameters. A comparison of overall survival (OS) was performed between patients treated with standard-of-care therapy + DCVax-L and standard-of-care therapy alone (external controls). Additionally, Kaplan-Meier analyses were performed to compare OS between two groups of patients using PsP, Ki-67, and MGMT promoter methylation status as stratification variables. RESULTS: Multiparametric MRI model correctly predicted TP + mixed response in 72.7% of cases (8/11) and PsP in 83.3% (5/6) with an overall concordance rate of 76.5% with final diagnosis as determined by histopathology/mRANO criteria. There was a significant concordant correlation coefficient between PP values and histopathology/mRANO criteria (r = 0.54; p = 0.026). DCVax-L-treated patients had significantly prolonged OS than those treated with standard-of-care therapy (22.38 ± 12.8 vs. 13.8 ± 9.5 months, p = 0.040). Additionally, glioblastomas with PsP, MGMT promoter methylation status, and Ki-67 values below median had longer OS than their counterparts. CONCLUSION: Multiparametric MRI-based prediction model can assess treatment response to DCVax-L in patients with glioblastoma.

Metabolic and physiologic magnetic resonance imaging in distinguishing true progression from pseudoprogression in patients with glioblastoma.

Pseudoprogression (PsP) refers to treatment-related clinico-radiologic changes mimicking true progression (TP) that occurs in patients with glioblastoma (GBM), predominantly within the first 6 months after the completion of surgery and concurrent chemoradiation therapy (CCRT) with temozolomide. Accurate differentiation of TP from PsP is essential for making informed decisions on appropriate therapeutic intervention as well as for prognostication of these patients. Conventional neuroimaging findings are often equivocal in distinguishing between TP and PsP and present a considerable diagnostic dilemma to oncologists and radiologists. These challenges have emphasized the need for developing alternative imaging techniques that may aid in the accurate diagnosis of TP and PsP. In this review, we encapsulate the current state of knowledge in the clinical applications of commonly used metabolic and physiologic magnetic resonance (MR) imaging techniques such as diffusion and perfusion imaging and proton spectroscopy in distinguishing TP from PsP. We also showcase the potential of promising imaging techniques, such as amide proton transfer and amino acid-based positron emission tomography, in providing useful information about the treatment response. Additionally, we highlight the role of "radiomics", which is an emerging field of radiology that has the potential to change the way in which advanced MR techniques are utilized in assessing treatment response in GBM patients. Finally, we present our institutional experiences and discuss future perspectives on the role of multiparametric MR imaging in identifying PsP in GBM patients treated with "standard-of-care" CCRT as well as novel/targeted therapies.

Evaluation of Potential Cumulative Risk of Multiple 1.5-T MRI Examinations in Patients With Cardiac Implanted Electronic Devices.

Although professional societies now support MRI in patients with nonconditional (legacy) cardiac implanted electronic devices (CIEDs), concern remains regarding potential cumulative effects of serial examinations. We evaluated 481 patients with CIEDs who underwent 599 1.5-T MRI examinations (44.6% cardiac examinations), including 68 patients who underwent multiple examinations (maximum, seven examinations). No major events occurred. The minor adverse event rate was 5.7%. Multiple statistical evaluations showed no increase in adverse event rate with increasing number of previous examinations.

Dynamic contrast-enhanced MRI and Doppler sonography in patients with squamous cell carcinoma of head and neck treated with induction chemotherapy.

In view of the inherent limitations associated with performing dynamic contrast enhanced-magnetic resonance imaging (DCE-MRI) in clinical settings, current study was designed to provide a proof of principle that Doppler sonography and DCE-MRI derived perfusion parameters yield similar hemodynamic information from metastatic lymph nodes in squamous cell carcinomas of head and neck (HNSCCs). Strong positive correlations between volume fraction of plasma space in tissues (Vp ) and blood volume (r = 0.72, p = 0.02) and between Vp and %area perfused (r = 0.65, p = 0.04) were observed. Additionally, a moderate positive correlation trending towards significance was obtained between volume transfer constant (Ktrans ) and %area perfused (r = 0.49, p = 0.09).

Imaging endpoints of intracranial atherosclerosis using vessel wall MR imaging: a systematic review.

PURPOSE: The vessel wall MR imaging (VWI) literature was systematically reviewed to assess the criteria and measurement methods of VWI-related imaging endpoints for symptomatic intracranial plaque in patients with ischemic events. METHODS: PubMed, Scopus, Web of Science, EMBASE, and Cochrane databases were searched up to October 2019. Two independent reviewers extracted data from 47 studies. A modified Guideline for Reporting Reliability and Agreement Studies was used to assess completeness of reporting. RESULTS: The specific VWI-pulse sequence used to identify plaque was reported in 51% of studies. A VWI-based criterion to define plaque was reported in 38% of studies. A definition for culprit plaque was reported in 40% of studies. Frequently scored qualitative imaging endpoints were plaque quadrant (21%) and enhancement (21%). Frequently measured quantitative imaging endpoints were stenosis (19%), lumen area (15%), and remodeling index (14%). Reproducibility for all endpoints ranged from good to excellent (range: ICCT1 hyperintensity = 0.451 to ICCstenosis = 0.983). However, rater specialty and years of experience varied among studies. CONCLUSIONS: Investigators are using different criteria to identify and measure VWI-imaging endpoints for culprit intracranial plaque. Early awareness of these differences to address methods of acquisition and measurement will help focus research resources and efforts in technique optimization and measurement reproducibility. Consensual definitions to detect plaque will be important to develop automatic lesion detection tools particularly in the era of radiomics.

Mandibular Myalgia and Miniscule Meckel's Caves.

Trigeminal neuropathy manifests as episodic sharp, shooting pain in the maxillofacial region. Contributory etiologies are myriad, ranging from central pathology affecting its origin in the brainstem to peripheral processes affecting their distal-most insertion sites. We present a case of bilateral hypoplastic Meckel's caves in an adult patient leading to the clinical symptomology of trigeminal neuralgia. To the best of our knowledge, this is the only report of its kind highlighting this anatomic variant.

Prevalence of clinically silent corticotroph macroadenomas.

OBJECTIVE: The prevalence of clinically silent corticotroph macroadenomas is unknown. Our aim was to determine the prevalence of clinically silent corticotroph macroadenomas among all pituitary macroadenomas. DESIGN: Patients scheduled to have transsphenoidal surgery for any sellar mass were prospectively evaluated clinically and biochemically. PATIENTS: Adults who were scheduled for transsphenoidal surgery for a sellar mass at a single academic medical centre. MEASUREMENTS: Patients were assessed clinically prior to surgery and graded as having typical, mild or no Cushingoid features. They were assessed biochemically by plasma ACTH and 24-h urine free cortisol (UFC). Excised tissue was examined histologically, and pituitary macroadenomas, examined by immunohistochemistry. Patients with corticotroph macroadenomas were classified as clinically silent if they exhibited no Cushingoid features but had elevated plasma ACTH and/or 24-h UFC. They were classified as totally silent if they exhibited neither Cushingoid features nor elevated plasma ACTH or 24-h UFC. RESULTS: Of 124 patients who had pathologically confirmed pituitary macroadenomas, 20 (16%) had corticotroph macroadenomas. Eight (40%) of these were clinically silent, in that they had no Cushingoid features but could be identified biochemically by elevated plasma ACTH (seven) and/or 24-h UFC (three). Five (25%) were totally silent. CONCLUSIONS: A substantial minority (16%) of pituitary macroadenomas treated surgically are corticotroph adenomas. Of these, 40% are clinically silent but can be recognized by elevated plasma ACTH and/or 24-h UFC. Recognizing these adenomas may influence the surgical approach and provide a marker by which to follow the response to treatment.

Cranial Nerve Schwannomas: Diagnostic Imaging Approach.

Schwannomas are benign nerve sheath tumors that may arise along the complex course of the cranial nerves (CNs), anywhere in the head and neck. Sound knowledge of the CN anatomy and imaging features of schwannomas is paramount for making the correct diagnosis. In this article, we review approaches to diagnosing CN schwannomas by describing their imaging characteristics and the associated clinical presentations. Relevant anatomic considerations are highlighted by using illustrative examples and key differential diagnoses categorized according to regions, which include the anterior skull base, orbit, cavernous sinus, basal cisterns, and neck. The clinical presentations associated with CN schwannomas vary and range from no symptoms to symptoms caused by mass effect or CN deficits. Individuals with the inherited disorder neurofibromatosis type 2 are predisposed to multiple schwannomas. When a lesion follows the course of a CN, the radiologist's roles are to confirm the imaging features of schwannoma and exclude appropriate differential considerations. The characteristic imaging features of CN schwannomas reflect their slow growth as benign neoplasms and include circumscribed margins, displacement of local structures, and smooth expansion of osseous foramina. These neoplasms exhibit various degrees of solid enhancement, often with internal cystic spaces on magnetic resonance (MR) and computed tomographic (CT) images and heterogeneous high signal intensity specifically on T2-weighted MR images. Clinical and/or imaging evidence of end-organ compromise of the involved CN may exist and aid in the identification of the nerve of origin. With a detailed understanding of the course of the CNs, the diagnostic features of CN schwannomas, and the correlation between these data and the associated clinical presentations of these tumors, the radiologist can have a key role in the diagnosis of CN schwannomas and the treatment planning for affected patients. (©)RSNA, 2016.

US-guided Biopsy of Neck Lesions: The Head and Neck Neuroradiologist's Perspective.

Ultrasonographically (US) guided percutaneous biopsy of a neck lesion is a cost-effective, safe, and diagnostically effective procedure without radiation exposure. The benefit of real-time visualization of the needle location allows for instantaneous maneuvering of the needle trajectory for safe and accurate tissue sampling with short procedural time. Effective US-guided biopsy requires technical experience, strong clinical acumen, and skillful biopsy technique. A neuroradiologist's knowledge of head and neck anatomy and pathology allows correlation with cross-sectional imaging and enhances the understanding of US imaging evaluation. Familiarity with a spectrum of neck surgeries and reconstructions and expertise in imaging evaluation of the treated neck are invaluable in accurate identification of the target for biopsy in patients with treatment-related altered anatomy using US guidance. After thyroid nodules, the common adult neck masses are lymphadenopathy, head and neck cancer, salivary neoplasms, nerve sheath tumors, and inflammatory and infectious pseudomasses. Diagnostic expertise in the imaging characteristics of these individual pathologic conditions and their differential diagnoses also play an important role in choosing the biopsy technique and in procuring an adequate sample for diagnosis, including material for ancillary laboratory testing. Using an anatomic zone approach, this article illustrates the practical considerations in patient selection, the methodical analysis of preprocedure cross-sectional imaging and its correlation with real-time US evaluation, general principles for optimizing US instrumentation, and biopsy technique. In skillful hands, the versatility and portability of US make it the valuable modality for histologic sampling of superficial head and neck lesions. Online supplemental material is available for this article.

Salivary neoplasms presenting with radiologic venous invasion: an imaging pearl to diagnosing metastatic renal cell carcinoma.

We report the case of a 64-year-old otherwise healthy woman who presented with left facial swelling. Imaging of the neck revealed multiple masses in the salivary and thyroid glands. The mass in the left parotid gland was associated with an intravenous extension into the retromandibular, facial and internal jugular veins in the left neck. Based on multiplicity of these masses and the presence of radiologic venous invasion, the diagnosis of metastatic renal cell carcinoma (RCC) was suggested on imaging, which was subsequently confirmed on systemic workup and pathology findings. Although RCC metastasizes to the salivary glands, the primary presentation of RCC with both salivary and thyroid gland masses is extremely rare, with only a few reports. The above feature and its imaging diagnosis based on local venous invasion are the highlights of this report.

Implementation of a Clinical Vessel Wall MR Imaging Program at an Academic Medical Center.

BACKGROUND AND PURPOSE: The slow adoption of new advanced imaging techniques into clinical practice has been a long-standing challenge. Principles of implementation science and the reach, effectiveness, adoption, implementation, maintenance (RE-AIM) framework were used to build a clinical vessel wall imaging program at an academic medical center. MATERIALS AND METHODS: Six phases for implementing a clinical vessel wall MR imaging program were contextualized to the RE-AIM framework. Surveys were designed and distributed to MR imaging technologists and clinicians. Effectiveness was measured by surveying the perceived diagnostic value of vessel wall imaging among MR imaging technologists and clinicians, trends in case volumes in the clinical vessel wall imaging examination, and the number of coauthored vessel wall imaging-focused publications and abstracts. Adoption and implementation were measured by surveying stakeholders about workflow. Maintenance was measured by surveying MR imaging technologists on the value of teaching materials and online tip sheets. The Integration dimension was measured by the number of submitted research grants incorporating vessel wall imaging protocols. Feedback during the implementation phases and solicited through the survey is qualitatively summarized. Quantitative results are reported using descriptive statistics. RESULTS: Six phases of the RE-AIM framework focused on the following: 1) determining patient and disease representation, 2) matching resource availability and patient access, 3) establishing vessel MR wall imaging (VWI) expertise, 4) forming interdisciplinary teams, 5) iteratively refining workflow, and 6) integrating for maintenance and scale. Survey response rates were 48.3% (MR imaging technologists) and 71.4% (clinicians). Survey results showed that 90% of the MR imaging technologists agreed that they understood how vessel wall MR imaging adds diagnostic value to patient care. Most clinicians (91.3%) reported that vessel wall MR imaging results changed their diagnostic confidence or patient management. Case volumes of clinical vessel wall MR imaging performed from 2019 to 2022 rose from 22 to 205 examinations. Workflow challenges reported by MR imaging technologists included protocoling examinations and scan length. Feedback from ordering clinicians included the need for education about VWI indications, limitations, and availability. During the 3-year implementation period of the program, the interdisciplinary teams coauthored 27 publications and abstracts and submitted 13 research grants. CONCLUSIONS: Implementation of a clinical imaging program can be successful using the principles of the RE-AIM framework. Through iterative processes and the support of interdisciplinary teams, a vessel wall MR imaging program can be integrated through a dedicated clinical pipeline, add diagnostic value, support educational and research missions at an academic medical center, and become a center for excellence.

Combined Orbital and Cranial Vessel Wall Magnetic Resonance Imaging for the Assessment of Disease Activity in Giant Cell Arteritis.

OBJECTIVE: Acute visual impairment is the most feared complication of giant cell arteritis (GCA) but is challenging to predict. Magnetic resonance imaging (MRI) evaluates orbital pathology not visualized by an ophthalmologic examination. This study combined orbital and cranial vessel wall MRI to assess both orbital and cranial disease activity in patients with GCA, including patients without visual symptoms. METHODS: Patients with suspected active GCA who underwent orbital and cranial vessel wall MRI were included. In 14 patients, repeat imaging over 12 months assessed sensitivity to change. Clinical diagnosis of ocular or nonocular GCA was determined by a rheumatologist and/or ophthalmologist. A radiologist masked to clinical data scored MRI enhancement of structures. RESULTS: Sixty-four patients with suspected GCA were included: 25 (39%) received a clinical diagnosis of GCA, including 12 (19%) with ocular GCA. Orbital MRI enhancement was observed in 83% of patients with ocular GCA, 38% of patients with nonocular GCA, and 5% of patients with non-GCA. MRI had strong diagnostic performance for both any GCA and ocular GCA. Combining MRI with a funduscopic examination reached 100% sensitivity for ocular GCA. MRI enhancement significantly decreased after treatment (P < 0.01). CONCLUSION: In GCA, MRI is a sensitive tool that comprehensively evaluates multiple cranial structures, including the orbits, which are the most concerning site of pathology. Orbital enhancement in patients without visual symptoms suggests that MRI may detect at-risk subclinical ocular disease in GCA. MRI scores decreased following treatment, suggesting scores reflect inflammation. Future studies are needed to determine if MRI can identify patients at low risk for blindness who may receive less glucocorticoid therapy.

Pretreatment diffusion-weighted and dynamic contrast-enhanced MRI for prediction of local treatment response in squamous cell carcinomas of the head and neck.

OBJECTIVE: The objective of our study was to predict response to chemoradiation therapy in patients with head and neck squamous cell carcinoma (HNSCC) by combined use of diffusion-weighted imaging (DWI) and high-spatial-resolution, high-temporal-resolution dynamic contrast-enhanced MRI (DCE-MRI) parameters from primary tumors and metastatic nodes. SUBJECTS AND METHODS: Thirty-two patients underwent pretreatment DWI and DCE-MRI using a modified radial imaging sequence. Postprocessing of data included motion-correction algorithms to reduce motion artifacts. The median apparent diffusion coefficient (ADC), volume transfer constant (K(trans)), extracellular extravascular volume fraction (v(e)), and plasma volume fraction (v(p)) were computed from primary tumors and nodal masses. The quality of the DCE-MRI maps was estimated using a threshold median chi-square value of 0.10 or less. Multivariate logistic regression and receiver operating characteristic curve analyses were used to determine the best model to discriminate responders from nonresponders. RESULTS: Acceptable χ(2) values were observed from 84% of primary tumors and 100% of nodal masses. Five patients with unsatisfactory DCE-MRI data were excluded and DCE-MRI data for three patients who died of unrelated causes were censored from analysis. The median follow-up for the remaining patients (n = 24) was 23.72 months. When ADC and DCE-MRI parameters (K(trans), v(e), v(p)) from both primary tumors and nodal masses were incorporated into multivariate logistic regression analyses, a considerably higher discriminative accuracy (area under the curve [AUC] = 0.85) with a sensitivity of 81.3% and specificity of 75% was observed in differentiating responders (n = 16) from nonresponders (n = 8). CONCLUSION: The combined use of DWI and DCE-MRI parameters from both primary tumors and nodal masses may aid in prediction of response to chemoradiation therapy in patients with HNSCC.

Transoral robotic surgery in head and neck cancer: what radiologists need to know about the cutting edge.

The evolution of oncologic surgical technology has moved toward reducing patient morbidity and mortality without compromising oncologic resection or oncologic outcomes. The goals in treating head and neck cancer are to cure patients, as well as to provide quality of life by improving functional and social outcomes through organ-preservation therapies, which may include surgery, chemotherapy, and/or radiation therapy. Transoral robotic surgery (TORS) is an emerging technique that provides several benefits over existing treatment regimens and over open surgery for head and neck cancer, including reductions in operative times, blood loss, intensive care unit stays, and overall duration of patient hospitalization. Transoral robotic techniques allow wide-view, high-resolution, magnified three-dimensional optics for visualization of the mucosal surfaces of the head and neck through an endoscope, while avoiding the extensive external cervical incisions often required for open surgeries. Radiologists play an important role in the successful outcome of these procedures, both before and after TORS. Determining a cancer patient's surgical candidacy for TORS requires a thorough preoperative radiologic evaluation, coupled with clinical and intraoperative assessment. Radiologists must pay particular attention to important anatomic landmarks that are clinical blind spots for surgeons. Knowledge of the expected postoperative imaging appearances, so that they can be distinguished from recurrent disease and second primary tumors, is essential for all radiologists involved in the care of these patients.

Efficacy and Safety of Gadopiclenol for Contrast-Enhanced MRI of the Central Nervous System: The PICTURE Randomized Clinical Trial.

OBJECTIVES: Developing new high relaxivity gadolinium-based contrast agents (GBCAs) for magnetic resonance imaging (MRI) allowing dose reduction while maintaining similar diagnostic efficacy is needed, especially in the context of gadolinium retention in tissues. This study aimed to demonstrate that contrast-enhanced MRI of the central nervous system (CNS) with gadopiclenol at 0.05 mmol/kg is not inferior to gadobutrol at 0.1 mmol/kg, and superior to unenhanced MRI. MATERIALS AND METHODS: PICTURE is an international, randomized, double-blinded, controlled, cross-over, phase III study, conducted between June 2019 and September 2020. Adult patients with CNS lesions were randomized to undergo 2 MRIs (interval, 2-14 days) with gadopiclenol (0.05 mmol/kg) then gadobutrol (0.1 mmol/kg) or vice versa. The primary criterion was lesion visualization based on 3 parameters (border delineation, internal morphology, and contrast enhancement), assessed by 3 off-site blinded readers. Key secondary outcomes included lesion-to-background ratio, enhancement percentage, contrast-to-noise ratio, overall diagnostic preference, and adverse events. RESULTS: Of the 256 randomized patients, 250 received at least 1 GBCA administration (mean [SD] age, 57.2 [13.8] years; 53.6% women). The statistical noninferiority of gadopiclenol (0.05 mmol/kg) to gadobutrol (0.1 mmol/kg) was achieved for all parameters and all readers (n = 236, lower limit 95% confidence interval of the difference ≥-0.06, above the noninferiority margin [-0.35], P < 0.0001), as well as its statistical superiority over unenhanced images (n = 239, lower limit 95% confidence interval of the difference ≥1.29, P < 0.0001).Enhancement percentage and lesion-to-background ratio were higher with gadopiclenol for all readers ( P < 0.0001), and contrast-to-noise ratio was higher for 2 readers ( P = 0.02 and P < 0.0001). Three blinded readers preferred images with gadopiclenol for 44.8%, 54.4%, and 57.3% of evaluations, reported no preference for 40.7%, 21.6%, and 23.2%, and preferred images with gadobutrol for 14.5%, 24.1%, and 19.5% ( P < 0.001).Adverse events reported after MRI were similar for gadopiclenol (14.6% of patients) and gadobutrol (17.6%). Adverse events considered related to gadopiclenol (4.9%) and gadobutrol (6.9%) were mainly injection site reactions, and none was serious. CONCLUSIONS: Gadopiclenol at 0.05 mmol/kg is not inferior to gadobutrol at 0.1 mmol/kg for MRI of the CNS, confirming that gadopiclenol can be used at half the gadolinium dose used for other GBCAs to achieve similar clinical efficacy.

Hypoglossal nerve palsy missed and misinterpreted: the hidden skull base.

OBJECTIVE: Dysarthria and tongue swelling may be seen with hypoglossal nerve palsy, and on cross-sectional imaging studies, tongue denervation can be misinterpreted as a primary base-of-tongue mass. Understanding radiological patterns of tongue denervation is important to prevent misinterpretation. Close evaluation of the skull base is critical as hypoglossal palsies resulting from pathology here are often overlooked. METHODS: Neck and brain magnetic resonance imaging studies obtained in 7 adult patients referred to our institution with clinically and/or radiologically suspected tongue base masses were retrospectively reviewed. Outside imaging evaluations were misinterpreted as base-of-tongue tumors in 3 patients, incorrectly read as normal in 2, and skull base pathologies were missed in 5. RESULTS: All 7 patients showed magnetic resonance imaging findings typical of tongue denervation: T2-weighted hyperintensity of involved hemitongue, protrusion of the tongue into oropharynx, variable fatty infiltration. All 5 skull base masses involved hypoglossal canal (4 metastases, 1 multiple myeloma; 4 newly diagnosed cancers). Two patients had internal carotid artery dissections at the skull base. CONCLUSIONS: To avoid misinterpretation of tongue denervation for tongue base mass, understanding of tongue innervations and classic imaging findings of hypoglossal denervation are essential. Careful inspection of skull base is paramount to avoid overlooking these hidden pathologies.

The diagnostic and economic yield of neuroimaging in neuro-ophthalmology.

BACKGROUND: Diagnostic studies such as computed tomography scans (CT) and magnetic resonance imaging (MRI) are ordered frequently in neuro-ophthalmic practice, although the diagnostic yield and cost-effectiveness of these tests have been studied for only a few conditions. We assessed the diagnostic and economic yield of CT and MRI across all patients evaluated in a neuro-ophthalmology practice. METHODS: This retrospective review included all patients referred by the division of neuro-ophthalmology at the Scheie Eye Institute for CT, CT angiography, MRI, MRA, or magnetic resonance venography over a 12-month period. Abnormal imaging findings were categorized as significant (one that elicited changes in management) and/or relevant (one that related to the patient's neuro-ophthalmic complaint or examination findings). The diagnostic yield of the test ordered was analyzed according to the patient's chief complaint, neuro-ophthalmic examination findings, and indication for imaging. The total costs for each diagnostic group and costs per significant finding were calculated using the global Resource-Based Relative Value Units for each examination from the Centers for Medicare and Medicaid Services Web site. RESULTS: Two hundred eleven imaging studies in 157 patients were evaluated. 28.9% (95% confidence interval, 22.5%-36.2%) of imaging studies had significant abnormalities relevant to the neuro-ophthalmic complaint. Imaging obtained for evaluation of progressive optic nerve dysfunction and cranial nerve palsy had statistically significant higher diagnostic yield than studies performed for other reasons. Total cost of all imaging studies performed was $107,615.72. Cost per clinically significant and relevant finding was $1,764.19. CONCLUSIONS: In comparison to the diagnostic yield of neuroimaging studies in other specialties, CT and MRI of the brain requested by neuro-ophthalmologists provide significant and relevant data at a reasonable cost.

Isolated sinonasal posttransplantation lymphoproliferative disorder: a clinical and radiographic invasive fungal sinusitis look-a-like.

Posttransplantation lymphoproliferative disorder (PTLD) is a known complication of solid organ transplantation with chronic immunosuppression. We present a unique case that illustrates PTLD mimicking invasive fungal sinusitis both clinically and radiographically. This report addresses the critical diagnostic evaluation and management of PTLD arising from the paranasal sinuses.