Addressing an unmet need in oncology patients: rehabilitation of upper aerodigestive tract function.

BACKGROUND: Laryngeal dysfunction in the oncology population is common and may detract from quality of life (QoL) due to vocal restriction and aspiration. Therapies to address this complex issue have not been explored to date. We examined the outcomes among oncology patients treated with a minimally invasive office-based surgical approach for the rehabilitation of laryngeal dysfunction. PATIENTS AND METHODS: A retrospective analysis was carried out of oncology patients referred for laryngeal dysfunction. Patients who underwent minimally invasive injection laryngoplasty (IL) were selected. Subjective outcome measures, objective voice analysis parameters, and swallowing studies were annotated. RESULTS: Sixty-one patients underwent IL for the management of laryngeal dysfunction. Lung cancer was the most common cancer diagnosis (39.3%), and 52% of patients had thoracic malignancies. All patients had a self-reported improvement in vocal function with a single injection, and 55 patients (90%) reported lasting effects at 3 months. In patients with pre- and postoperative voice analysis, phonatory function increased from 5.0 to 10.5 s, more than twofold improvement compared with baseline functioning. Seventy-one percent of patients who aspirated before injection no longer required a modified diet. There were no major complications. CONCLUSIONS: Interventions to improve the QoL in oncology patients continue to evolve. We report significant improvements in both subjective and objective measures of laryngeal function after IL for vocal fold dysfunction that are both immediate and sustained. We conclude that IL is a safe and efficacious procedure for the treatment of laryngeal dysfunction in oncology patients, resulting in palliation and improved QoL.

Evaluation of MR imaging guided steroid injection of the sacroiliac joints for the treatment of children with refractory enthesitis-related arthritis.

OBJECTIVES: To test the hypothesis that MR imaging guided triamcinolone acetonide injection into the sacroiliac joints of children with enthesitis-related arthritis is feasible, accurate and safe; and effectively reduces sacroiliac inflammation and disease progression. METHODS: A retrospective analysis of 14 children (6/14 [43%] female, 8/14 (57%) male; mean age, 13.2 years; range, 6-16 years) who received MR imaging guided sacroiliac joint injections at 0.2 Tesla or 1.5 Tesla for enthesitis-related arthritis and acute sacroilitis refractory to medical therapy was performed. 20 mg triamcinolone acetonide were injected. Assessed were intra-articular drug delivery; image quality, duration, and complications. Success of therapy was defined by change of sacroiliac inflammation. Remission time and erosions were assessed by follow-up MRI (range, 10-22 months). RESULTS: Twenty four procedures resulted in intra-articular injection. Image quality was sufficient. No complications occurred. Procedure time was 40 min. Sedation time was 22 min. Success of therapy was achieved in 11/14 (79%) children. Sacroiliac inflammation decreased significantly (-59%). Median remission time was 13.7 months. No erosions occurred. CONCLUSIONS: MR imaging guided steroid injection of the sacroiliac joints is feasible, accurate, and safe and can effectively reduce sacroiliac inflammatory activity and may therefore aid in the prevention of disease progression.

Magnetic resonance imaging-guided renal artery stent placement in a Swine model: comparison of two tracking techniques.

BACKGROUND: Magnetic resonance (MR)-guided interventions have evolved from a pure research application to a preclinical method over the last decade. Among the device-tracking techniques, susceptibility artifact-based tracking relies on the contrast between the surrounding blood and the device, and radiofrequency coil-based tracking relies on the local gradient field amplification in a resonating circuit attached to the interventional device. PURPOSE: To evaluate the feasibility and precision of susceptibility artifact-based and microcoil-based MR guidance methods for renal artery stent placement in a swine model. MATERIAL AND METHODS: MR imaging-guided renal artery stent placements were performed in six fully anesthetized pigs using a 1.5T short-bore MR scanner. Susceptibility artifact-based tracking with manual scan-plane adjustments and microcoil tracking with automatic scan-plane adjustments were used for renal artery stent placements in three pigs in each group. With both methods, near real-time steady-state free-precession (SSFP) imaging was used. Differences between the two tracking approaches on stenting time, total procedure time, and stent position were measured. RESULTS: The microcoil-based approach yielded a shorter mean procedure time (17 vs. 23 min). There was no relevant difference for the mean stenting time (12 vs. 13 min). The mean stent deviation from the aortic wall with the susceptibility approach was larger than with the microcoil approach (10 vs. 4.0 mm). CONCLUSION: For MRI-guided renal artery stent placement, the microcoil-based technique had a shorter procedure time and a higher stent placement precision than the susceptibility artifact-based approach.

CT assessment of vocal cord medialization.

BACKGROUND AND PURPOSE: Unilateral vocal cord paralysis (UVCP) occurs after iatrogenic injury or disease process and is associated with dysphonia and aspiration. Various surgical options are available for treatment of UVCP, including vocal cord medialization thyroplasty and injection laryngoplasty. These augmentative procedures improve phonation and airway protection. Our purpose was to demonstrate the CT appearance of implants used for the treatment of UVCP. METHODS: Twelve patients treated surgically for UVCP were studied with helical CT. The vocal cords were augmented by using Silastic implants (n = 7), polytetrafluoroethylene (Gore-Tex) implants (n = 2), Teflon injections (n = 2), or fat injection (n = 1). Augmented vocal cords were characterized by size, shape, and Hounsfield units (HU). Two other patients with failed medialization thyroplasty were evaluated for the position of the extruded implant relative to the paralyzed vocal cord. RESULTS: The 7 Silastic implants were triangular and hyperattenuated (293.4 +/- 90.4 HU). The 2 Gore-Tex implants were heterogeneous with lobulated medial margins and were hyperattenuating (320 and 414 HU). The injected materials demonstrated ovoid/masslike configurations: the 2 Teflon injections were hyperattenuated (107 and 429 HU), and the fat injection was hypoattenuated (-102 HU). Inferior displacement of the implant was demonstrated relative to the true vocal cord in 2 patients with failed Silastic thyroplasties. CONCLUSION: CT can distinguish various types of vocal cord augmentation. Silastic implants are recognized by their characteristic triangular configuration. The Gore-Tex implants had unique heterogeneous attenuation with lobulated medial margins. Fat and Teflon injections both appear ovoid/masslike. Teflon injection should not be mistaken for tumor.

Comparing Preliminary and Final Neuroradiology Reports: What Factors Determine the Differences?

BACKGROUND AND PURPOSE: Trainees' interpretations of neuroradiologic studies are finalized by faculty neuroradiologists. We aimed to identify the factors that determine the degree to which the preliminary reports are modified. MATERIALS AND METHODS: The character length of the preliminary and final reports and the percentage character change between the 2 reports were determined for neuroradiology reports composed during November 2012 to October 2013. Examination time, critical finding flag, missed critical finding flag, trainee level, faculty experience, imaging technique, and native-versus-non-native speaker status of the reader were collected. Multivariable linear regression models were used to evaluate the association between mean percentage character change and the various factors. RESULTS: Of 34,661 reports, 2322 (6.7%) were read by radiology residents year 1; 4429 (12.8%), by radiology residents year 2; 3663 (10.6%), by radiology residents year 3; 2249 (6.5%), by radiology residents year 4; and 21,998 (63.5%), by fellows. The overall mean percentage character change was 14.8% (range, 0%-701.8%; median, 6.6%). Mean percentage character change increased for a missed critical finding (+41.6%, P < .0001), critical finding flag (+1.8%, P < .001), MR imaging studies (+3.6%, P < .001), and non-native trainees (+4.2%, P = .018). Compared with radiology residents year 1, radiology residents year 2 (-5.4%, P = .002), radiology residents year 3 (-5.9%, P = .002), radiology residents year 4 (-8.2%, P < .001), and fellows (-8.7%; P < .001) had a decreased mean percentage character change. Senior faculty had a lower mean percentage character change (-6.88%, P < .001). Examination time and non-native faculty did not affect mean percentage character change. CONCLUSIONS: A missed critical finding, critical finding flag, MR imaging technique, trainee level, faculty experience level, and non-native-trainee status are associated with a higher degree of modification of a preliminary report. Understanding the factors that influence the extent of report revisions could improve the quality of report generation and trainee education.

Three-dimensional magnetic resonance-based morphometrics and ventricular dysmorphology in schizophrenia.

BACKGROUND: Recent methodological refinements in magnetic resonance (MR) imaging have led to brain averaging and morphometric approaches that are sensitive to subtle anatomical distinctions in schizophrenia. METHODS: Using a novel morphometric technique for surface analysis, 48 selected landmarks of the rendered ventricular system were extracted and compared between the ventricles of 20 patients with schizophrenia and 20 normal subjects. RESULTS: There was no significant difference in ventricular shape between groups, but significant (p = .015) and highly localized shape deformity was detected at the foramen of Monro and at the proximal temporal horn of the lateral ventricle of male (but not female) patients relative to controls. CONCLUSIONS: Three-dimensional MR-based morphometrics complements established volumetric approaches and can detect minute shape deformities that may be associated with schizophrenia.

An MRI study of adolescent patients with either schizophrenia or bipolar disorder as compared to healthy control subjects.

BACKGROUND: There are few imaging studies in adolescent patients with either schizophrenia or bipolar disorder. Such studies are of interest because adolescents may have a more severe illness and neurodevelopmental events may have a greater role in their pathophysiology. METHODS: We compared 20 patients with schizophrenia and 15 patients with bipolar disorder (10 to 18 years) to 16 normal adolescents on magnetic resonance imaging (MRI) measures of intracranial volume and ventricular and sulcal enlargement. Two planned comparison contrasts were employed, one comparing the two patient groups to each other (contrast 1), and one comparing both patient groups combined to control subjects (contrast 2). RESULTS: None of the contrast 1 comparisons (schizophrenia vs bipolar) were statistically significant. Contrast 2 comparisons (control subjects vs patients) were statistically significant for intracranial volume (reduced in patients) as well as frontal and temporal sulcal size (increased in patients). CONCLUSIONS: The patient groups were not statistically significantly different from each other on any measure. The combined patient groups were different from control subjects on intracranial volume and frontal and temporal sulcal size. Also, there was evidence for ventricular enlargement, after removal of a control subject with an extreme value. These findings indicate that the same abnormalities noted in adult populations are present in adolescents.

Good clinical outcome in a patient with a large CT scan hypodensity treated with intra-arterial urokinase after an embolic stroke.

Hypodense regions demonstrated by CT within 6 hours of the onset of stroke may reflect irreversibly damaged tissue, and some have suggested that patients with such findings should be spared the risks of thrombolytic therapy since they are unable to benefit from it. We report here a patient with a low-density area demonstrated by CT less than 6 hours after onset of symptoms who improved dramatically after successful intra-arterial thrombolysis.

Abnormal connectivity of the visual pathways in human albinos demonstrated by susceptibility-sensitized MRI.

We studied activation of the human visual cortex (VC) using susceptibility-sensitized MRI at 1.5 Tesla. Three albinos and six healthy controls underwent a series of monocular and binocular photic flash stimulation. Monocular stimulation in albinos caused predominant contralateral activation with a small, well-delineated area in the anterior part of the VC in the ipsilateral hemisphere. This finding was consistent with a chiasmal crossing anomaly in albinism. All controls had symmetric patterns of activation during monocular stimulation. Functional MRI represents a promising method for evaluation of the visual pathways in humans.

Time-of-flight magnetic resonance angiography of the aorta and renal arteries.

The evaluation of the aorta and renal arteries with time-of-flight (TOF) magnetic resonance angiographic (MRA) techniques has been the subject of several recent investigations, with both sequential two-dimensional and three-dimensional methods described. Although the data are preliminary, these techniques appear to allow the noninvasive evaluation of a variety of vascular abnormalities, including renal artery stenosis and occlusion. This report outlines the theoretical considerations of TOF MRA of the abdomen, and discusses differential characteristics of the available techniques along with their advantages and limitations.

Generation and observation of radio frequency thermal lesion ablation for interventional magnetic resonance imaging.

RATIONALE AND OBJECTIVES: Recently, there has been increased interest in interventional magnetic resonance (MR) imaging and minimally invasive cancer therapy via radio frequency (RF) thermal ablation. In this work, we examined RF thermal lesion generation in phantoms and ex vivo bovine liver and correlated them with MR images under a variety of conditions, which begins our assessment of the role of MR imaging in this new method for cancer treatment. METHODS: Radio frequency lesions were created in gel phantoms and ex vivo bovine liver, using stationary (bovine liver) and variable speed (gel) moving electrodes to create lesions with shapes mimicking tumors. Ex vivo bovine liver lesions were made with the tissue held at room temperature (n = 4) and in a 37 degrees C saline bath (n = 3) using a 16-gauge electrode (tip temperature: 70 degrees C, 80 degrees C, and 90 degrees C; ablation time: 1-13 minutes). Electrical impedance and RF power were plotted during ablation. After ablation, RF-induced lesions were imaged with a 0.2-tesla (T) MR system using a variety of pulse sequences. RESULTS: Complex shaped lesions were created successfully in phantoms. Averaged maximum ex vivo lesion volume made at 90 degrees C ablation experiments holding the tissue temperature at 37 degrees C and at room temperature were 1.58 +/- 0.35 cm3 and 1.0 +/- 0.26 cm3 respectively (confidence interval: 90%). The aspect ratios and RF power of the lesions decreased as ablations proceeded. Impedance dropped during the first 2 minutes of the ablation. Ex vivo lesions appeared as regions of low-signal amplitude in T2-weighted MR images. CONCLUSIONS: Phantom ablation experience may be useful and applicable in thermotherapy planning. Lesions made in ex vivo bovine liver held at 37 degrees C via a saline bath are larger than those created at room temperature. Lesions shapes are ablation time dependent until thermal equilibrium is reached. Impedance reduction and lesion formation are related; 0.2-T MR systems can image RF energy-induced thermal lesions.

Temporal patterns of uncoupling between oxidative metabolism and regional cerebral blood flow demonstrated by functional magnetic resonance imaging.

RATIONALE AND OBJECTIVES: Brain activation can be detected by functional magnetic resonance imaging. Termination of stimulation can cause drop of postactivation signal below preactivation baseline; the nature of this "undershoot" remains controversial. The authors investigated postactivation signal after stimulation of the visual cortex with photic stimuli of different duration. METHODS: Activation of visual cortex in 11 healthy subjects was studied. The authors underwent short and long stimulation. The relation between activation and postactivation signal was investigated after both durations of stimulation. RESULTS: Average postactivation signal after short stimulation was -1.71 +/- 2.66% and after long stimulation 0.82 +/- 1.59% (P < or = 0.01). Significant "undershoot" was detected after short stimulation in the majority of cases, although this was typically absent after long stimulation. CONCLUSIONS: The authors propose that "undershoot" is caused by decreased oxygen content in venous blood compared with the preactivation level and may reflect increased extraction of oxygen as a result of glycolytic metabolism. The absence of "undershoot" after longer stimulation suggests a gradual shift from uncoupling between regional cerebral blood flow and oxygen consumption toward a steady state.

Aggressive fibromatosis of the prevertebral and retropharyngeal spaces: MR and CT characteristics.

A 47-year-old man had aggressive fibromatosis, and CT and MR showed a large, multilobulated soft-tissue mass within the prevertebral and retropharyngeal spaces. On CT, the lesion was slightly higher in attenuation than adjacent muscle; on MR, it was intermediate between muscle and fat on unenhanced T1-weighted images, isointense with fat on intermediate-weighted images, hyperintense relative to fat on T2-weighted images, and markedly enhanced after administration of gadopentetate dimeglumine. Multiple small focal and linear areas of decreased signal intensity that did not enhance with gadopentetate dimeglumine were observed on all pulse sequences.

Intracranial MR angiography: a direct comparison of three time-of-flight techniques.

During the past few years, several time-of-flight MR angiographic techniques have been described for rapid, reliable, noninvasive vascular evaluation. This investigation was performed to directly compare three time-of-flight methods in imaging the intracranial vasculature: a single-volume method, a sequential two-dimensional slice technique, and a technique using the sequential acquisition of multiple thin volumes. Thirty-two normal volunteers were imaged, and direct comparisons of the three techniques were performed in 20 subjects. Analysis of the resulting images revealed optimal depiction of large vessels with the single-volume and multiple thin-volume methods, small vessels with the multiple thin-volume technique, and venous structures with the sequential two-dimensional slice acquisition. The effects of progressive spin saturation in time-of-flight MR angiography are discussed along with the individual benefits and disadvantages of each method. We conclude that the diagnostic value of intracranial time-of-flight MR angiography can be maximized through tailoring the angiographic method to the suspected abnormality based on the requirements for spatial resolution and slow-flow sensitivity, as suggested by the clinical history or prior imaging studies.

MR evaluation of epiglottic disruption.

Epiglottic disruption is an uncommon injury usually associated with significant supraglottic trauma. This injury may be overlooked because of the difficulty in examining the larynx or other associated severe injuries. We present two cases of clinically unsuspected epiglottic disruption that were first seen on MR images of the neck.

Benign expansile lesions of the sphenoid sinus: differentiation from normal asymmetry of the lateral recesses.

BACKGROUND AND PURPOSE: There is a wide range of normal variation is sphenoid sinus development, especially in the size of the lateral recesses. The purpose of this study was to determine imaging characteristics that may help differentiate between opacification of a developmentally asymmetric lateral recess and a true expansile lesion of the sphenoid sinus. METHODS: Coronal CT was performed in seven patients with expansile or erosive benign lesions of the sphenoid sinus, and results were compared to a control population of 72 subjects with unopacified sphenoid sinuses. The degree of asymmetry of lateral recess development was assessed with particular attention to the separation of vidian's canal and the foramen rotundum (vidian-rotundum distance). The images were also examined for evidence of: erosion, defined as loss of the normal thin bony margin on at least two contiguous sections; apparent thinning of the sinus wall, defined as a focal apparent decrease in thickness again on at least two contiguous sections; and for vidian's canal or foramen rotundum rim erosion or flattening. RESULTS: Of the seven patients with expansile lesions, vidian's canal margin erosion was present in seven, unequivocal sinus expansion in three, wall erosion in three, wall thinning in three, erosion of the foramen rotundum in two, and flattening in the foramen rotundum in four. Forty-one of the 72 controls had lateral recess formation, 28 of which were asymmetric. The distance between vidian's canal and the foramen rotundum (vidian-rotundum distance) relied on the presence or absence of pneumatization, with a significantly larger distance in the presence of greater wing pneumatization. Examination of 24 controls revealed apparent thinning of the sinus wall, typically at the carotid groove, but no flattening, thinning, or erosion of the vidian canal or of the foramen rotundum. CONCLUSION: Examination of controls and patients with expansile or erosive lesions of the sphenoid sinus revealed side-to-side asymmetry in the development of the sinus and lateral recess, making subtle expansion difficult to assess. Furthermore, variability in the vidian-rotundum distance correlated with degree of pneumatization, and did not necessarily reflect expansion. Thus, in the absence of gross sinus wall erosion, flattening or erosion of the rims of vidian's canal or the foramen rotundum provides the most specific evidence of an expansile or erosive process within the sinus.

Time-of-flight intracranial MR venography: evaluation of the sequential oblique section technique.

PURPOSE: To implement a time-of-flight MR angiographic technique using the oblique acquisition of thin gradient-echo sections to evaluate the intracranial venous system, and to assess the feasibility of application of this technique in a routine clinical setting. METHODS: The MR angiographic technique consisted of a two-dimensional gradient-echo technique with sequential overlapped sections obtained with an oblique orientation, angled from the sagittal toward the coronal plane. Parameters were evaluated during 41 measurements in 21 healthy volunteers with the section orientation varying from direct sagittal to direct coronal, followed by 64 examinations in 53 patients with an angle of obliquity of 15 degrees to 20 degrees from the sagittal toward the coronal plane. Confirmation of MR venographic findings was through correlation with clinical data and imaging studies. RESULTS: The volunteer data demonstrated optimal visibility of the smaller midline structures with an angle of obliquity of 15 degrees or greater. Patient examinations with this angle demonstrated sinus obstruction or thrombosis (n = 11), sinus compression (n = 2), and apparent sinus stenosis (n = 1). CONCLUSIONS: Oblique-acquisition time-of-flight MR venography seems to provide a rapid, robust technique for intracranial venous examination and can be applied as a useful adjunct to parenchymal MR in the evaluation of suspected venoocclusive disease. This oblique technique demonstrated improved vessel contrast over direct sagittal acquisition, required significantly fewer sections and thus a shorter acquisition time than direct coronal acquisition, and was applied without difficulty in the vast majority of patients in the clinical setting.

Cost-effectiveness of emergency intraarterial intracerebral thrombolysis: a pilot study.

PURPOSE: To assess the clinical efficacy and cost-effectiveness of emergency thrombolysis as a treatment strategy for thromboembolic intracerebral events. METHODS: Thirty-four patients with symptoms suggestive of middle cerebral artery occlusion were included. Eight of these patients were treated with intraarterial urokinase. Effectiveness was determined by comparing the admission National Institutes of Health stroke score to the 24-hour National Institutes of Health stroke score. The cost and length of stay of both populations were derived and used as measures of direct cost. The likelihood of admission to extended care facilities and estimated length cost of admission was used as a measure of indirect cost. RESULTS: The control population became slightly worse, with a change in National Institutes of Health score of -0.5, whereas the treated population improved slightly, with a change in National Institutes of Health score of +5.12. Analysis of the direct costs data between the two populations revealed a slight increased mean for the treated population ($15,202) as compared with the control population ($13,478). The unpaired t test, however, revealed no significant cost difference between the two groups. By reducing the number of completed strokes by one third or by decreasing the severity by the same factor (as shown in our study), the likelihood of admission to an extended nursing facility also is decreased. The cost saving per patient from extended care facilities is approximately $3435. CONCLUSION: The emergency application of intraarterial thrombolysis with urokinase results in a statistically significant positive change in National Institutes of Health score by at least five points. A statistically significant benefit is realized through the use of intraarterial urokinase. A statistically insignificant additional cost is shown by this study. This insignificant cost is more than offset by the saved nursing home costs.

Fast spin-echo imaging of the neck: comparison with conventional spin-echo, utility of fat suppression, and evaluation of tissue contrast characteristics.

PURPOSE: To determine whether fast spin-echo sequences could replace conventional spin-echo methods in the evaluation of head and neck neoplasms and associated adenopathy and to evaluate differences in tissue contrast characteristics between conventional spin-echo and fast spin-echo examinations of head and neck disease. METHODS: Twenty-seven patients with squamous cell carcinoma were imaged on a 1.5-T imager with both conventional spin-echo and fast spin-echo sequences with identical section thickness and position. Twenty-one of the 27 fast spin-echo studies were performed with frequency-selective fat suppression. Three radiologists independently evaluated the images using a five-point scale to compare primary lesion margin definition and conspicuity, lymph node margin definition and conspicuity, gross motion artifact, and flow artifact. Quantitative percent contrast and contrast-to-noise ratios were calculated and compared in 7 cases with fat-suppressed fast spin-echo. RESULTS: Fast spin-echo was preferred by all three readers for lesion margin conspicuity and lymph node conspicuity. Gross motion and flow artifact demonstrated trends toward reader preference for fast spin-echo. Quantitative contrast values for fast spin-echo were significantly greater than those for conventional spin-echo. CONCLUSIONS: Fast spin-echo with fat suppression can replace conventional spin-echo at a time savings of more than 50% and improves tissue contrast and the conspicuity and definition of margins for primary lesions and lymph nodes. Fat-suppression heterogeneity remains the major limitation of this technique. Thus, careful attention to fat-suppression failure and unwanted water saturation is essential.

Malignant hemangioendothelioma (angiosarcoma) of the skull: plain film, CT, and MR appearance.

Hemangioendothelioma is a rare neoplasm of bone that uncommonly involves the skull. We present a case of grade III malignant hemangioendothelioma (also known as angiosarcoma) of the skull in a 13-year-old boy and describe the plain film, CT, and MR appearance of this neoplasm as well as its histopathology.