Imaging of musculoskeletal manifestations in sickle cell disease patients.

Sickle cell disease (SCD) is a hereditary red cell disorder with clinical manifestations secondary to sickling or crescent-shaped distortion of the red blood cells. Major clinical manifestations of SCD include haemolytic anaemia and vaso-occlusive phenomena resulting in ischaemic tissue injury and organ damage. Chronic sequelae of the anaemia and vaso-occlusive processes involving the musculoskeletal system include complications related to extramedullary haematopoiesis, osteonecrosis, myonecrosis and osteomyelitis. Sickle cell bone disease is one of the commonest clinical presentations. Awareness and knowledge of the imaging features related to these complications are essential for early diagnosis and prompt management. In this article, the pathophysiology and key imaging findings related to these complications are reviewed.

Simulation-Based Training May Improve Resident Skill in Ultrasound-Guided Biopsy.

OBJECTIVE: The purpose of this study was to determine whether simulation-based training can improve resident performance in ultrasound-guided biopsy. SUBJECTS AND METHODS: Forty radiology residents from a single academic institution enrolled in the study. Each resident performed an initial biopsy on an abdominal imaging phantom using direct ultrasound guidance. Twenty of the residents underwent a 30-minute training session with the phantom device, and 20 residents received no additional training. The residents performed a repeat biopsy of the same lesion and were graded on overall procedure time, number of skin surface punctures, number of gross needle adjustments, and subjective performance as determined by a blinded grader. RESULTS: Residents who participated in the training had a statistically significant 92.3-second reduction in procedure time (68% improvement, p = 0.01), 1.1 reduction in number of skin punctures per biopsy (50% improvement, p = 0.05), 2.5 reduction in number of needle adjustments (66% improvement, p = 0.04), and an increase of 0.85 points in score on a 5-point Likert grading scale (23% improvement, p < 0.01). Residents who did not receive any additional training did not improve in any performance metric. CONCLUSION: Simulation-based training improves overall procedure time, number of skin punctures and needle adjustments, and subjective performance.

Computed tomography-guided percutaneous biopsy for vertebral neoplasms: a department's experience and hybrid biopsy technique to improve yield.

OBJECTIVE Recent articles have identified the poor diagnostic yield of percutaneous needle biopsy for vertebral osteomyelitis. The current study aimed to confirm the higher accuracy of CT-guided spinal biopsy for vertebral neoplasms and to identify which biopsy technique provides the highest yield. METHODS Over a 9-year period, the radiology department at University Hospitals Case Medical Center performed 222 CT-guided biopsies of vertebral lesions, of which clinicians indicated a concern for vertebral neoplasms in 122 patients. A retrospective chart review was performed to confirm the higher sensitivity of the percutaneous intervention for vertebral neoplasms. RESULTS A core sample was obtained for all 122 biopsies of concern (100.0%). Only 6 cases (4.9%) were reported as nondiagnostic per histological sampling, and 12 cases (9.8%) were negative for disease. The question of vertebral neoplastic involvement warrants follow-up, and the current study was able to determine the subsequent diagnosis of each lesion. Of the 122 total, 94 (77.0%) core samples provided true-positive results, and the sensitivity of core biopsy measured 87.9%. The technical approach did not demonstrate any significant difference in diagnostic yield. However, when the vertebral cortex was initially pierced with a coaxial bone biopsy system and subsequently a 14-gauge spring-loaded cutting biopsy needle was coaxially advanced into lytic lesions, 14 true positives were obtained with a corresponding sensitivity of 100.0%. CONCLUSIONS This study confirms the higher sensitivity of image-guided percutaneous needle biopsy for vertebral neoplasms. In addition, it demonstrates how the use of a novel cutting needle biopsy approach, performed coaxially through a core biopsy track, provides the highest yield.

"What Program Directors Think" III: Results of the 2014/2015 Annual Surveys of the Association of Program Directors in Radiology (APDR).

RATIONALE AND OBJECTIVES: The Association of Program Directors in Radiology regularly surveys its members regarding issues of importance to support radiology residency programs and their directors. MATERIALS AND METHODS: This is an observational cross-sectional study using two Web-based surveys posed to the Association of Program Directors in Radiology membership in the fall of 2014 (49 items) and the spring of 2015 (46 items) on the subjects of importance to the members, including the Accreditation Council on Graduate Medical Education Milestones, the Non-Interpretative Skills Curriculum, the American Board of Radiology Core Examination, the effect of the new resident testing and program accreditation paradigms on training outcomes, the 2015 Residency Match, the Interventional Radiology/Diagnostic Radiology (IR/DR) Residency, and Program Director (PD)/Program Coordinator resources. RESULTS: Responses were collected electronically, results were tallied using SurveyMonkey software, and qualitative responses were tabulated or summarized as comments. Findings were reported during the 63rd annual meeting of the Association of University Radiologists. The maximal response rate was 33% in the fall of 2014 and 36% in the spring of 2015. CONCLUSIONS: PDs believed that the radiology Milestones, now largely implemented, did not affect overall resident evaluation, was not reflective of resident experience, and actually made evaluation of residents more difficult. PDs also felt that although the American Board of Radiology oral examination had been a better test for clinical practice preparedness, their new residents knew at least as much as before. There was little evidence of recall reemergence. The radiology training community saw a drop in residency applicant quality as demonstrated by the United States Medical Licensing Examination scores and clinical rotation grades. Because the new IR/DR Residency positions were to be funded at the expense of the traditional DR positions, the majority of PDs expected a negative effect of the impending IR/DR match on their DR recruitment. PDs were in favor of a unified clinical radiology curriculum similar to the Radiological Society of North America online physics modules.

Long-term clinical outcomes of dual-cycle radiofrequency ablation technique for treatment of osteoid osteoma.

PURPOSE: Radiofrequency ablation technique for treatment of OO including ablation time and temperature vary greatly between and within reported studies. This study evaluates the immediate and long-term efficacy and complication rate of a two sequential RFA technique for OO. MATERIALS AND METHODS: We retrospectively reviewed medical records and attempted interview follow-up for 25 patients treated with RFA for OO. Each treatment included 2 consecutive RFAs at 90 °C for 6 min with inter-ablation cooling to 40 °C and occasional inter-ablation probe adjustment. Additionally, we statistically compared the proportion of successful ablations using the DCRFA technique with published studies that utilized alternative OO ablation procedures. RESULTS: Long-term follow-up was obtained for 24 patients (96 %). Mean patient age at DCRFA was 17.2 years (range, 2.2-50.0 years). Mean time to follow-up was 60 ± 42 months (range 12-152 months). No acute DCRFA-related complications nor long-term recurrences were reported. All 24 interviewed patients reported partial relief of pre-procedural pain within 1 day of DCRFA and total relief within 1 week of DCRFA. One patient ultimately developed a major late complication (complex regional pain syndrome of the left ankle) after DCRFA of a cuboid lesion. Additionally, the DCRFA success rate was significantly higher when compared to two other published OO RFA treatment results. CONCLUSION: DCRFA employing two sequential 6-min cycles is an effective treatment of OO. The 100 % primary success rate, 0 % long-term recurrence rate, and low complication rate compare favorably and may be superior to results of prior reports.

Quantitative dynamic contrast-enhanced ultrasound for the functional evaluation of the skeletal muscle microcirculation in systemic sclerosis.

PURPOSE: The purpose was to evaluate skeletal muscle microcirculation by means of quantitative dynamic contrast-enhanced ultrasound (DCEUS) in patients with systemic sclerosis (SSc). METHODS: DCEUS imaging of the gastrocnemius muscle was performed with phospholipid-stabilized microbubbles filled with sulfur hexafluoride in 12 patients with SSc and 12 healthy volunteers. The fitted time intensity curves (TIC) during the first 3 minutes after administration of the contrast agent bolus were analysed. Time course parameters of the TIC were compared between patients and healthy volunteers. RESULTS: Peak enhancement, wash-in area under the curve and was-out area under the curve was decreased in the patient group versus healthy volunteers (168 versus 248 AU p = 0.291; 2193 versus 3314 p = 0.198; 4948 AU x sec versus 8948 AU x sec p = 0.037). In the SSc patients the mean transit time and wash-in perfusion index were numerically, but not statistically lower than in the healthy volunteers, but rise and fall time were similar. CONCLUSION: On the microvascular level in SSc patients versus their healthy counterpart key parameters related to blood volume were decreased and perfusion parameters showed a slight diminishment in the patient population. These results suggest a component of impaired skeletal muscle microcirculation in SSc patients.

Musculoskeletal/Radiological Manifestations of Mucolipidosis II (I-Cell disease) in late Adolescence/Early Adulthood.

Mucolipidosis type II (I-Cell disease) is a rare autosomal recessive lysosomal disorder, resulting from functional deficiency of lysosomal enzymes due to an impaired targeting of the enzymes to lysosomes, which leads to an abnormal cell architecture and the overflow of lysosomal enzymes into the body fluids. The life expectancy of the patients is poor, with multisystem deterioration leading to death in early childhood. According to the available reports, patients with I-cell disease do not survive beyond the first decade of life. Here, we describe and illustrate various radiological-musculoskeletal manifestations of a rare case of mucolipidosis II who has been a survivor up to now, 20 years old. The course of her disease has been complicated by early severe visual compromise due to optic nerve swelling, hearing loss and mitral valve regurgitation/stenosis, bilateral carpal tunnel, and severe growth impairment. Our case demonstrates several skeletal features of dysostosis multiplex. At the age of 20, she is wheelchair bound and her medical course is complicated by recurrent pneumonia, treated with multiple hospitalizations, antibiotics, and BiPAP. She is on outpatient palliative care, Do Not Resuscitate/Do Not Intubate (DNR/DNI) status.

Diffusion-weighted imaging in musculoskeletal radiology-clinical applications and future directions.

Diffusion-weighted imaging (DWI) is an established diagnostic tool with regards to the central nervous system (CNS) and research into its application in the musculoskeletal system has been growing. It has been shown that DWI has utility in differentiating vertebral compression fractures from malignant ones, assessing partial and complete tears of the anterior cruciate ligament (ACL), monitoring tumor response to therapy, and characterization of soft-tissue and bone tumors. DWI is however less useful in differentiating malignant vs. infectious processes. As of yet, no definitive qualitative or quantitative properties have been established due to reasons ranging from variability in acquisition protocols to overlapping imaging characteristics. Even with these limitations, DWI can still provide clinically useful information, increasing diagnostic accuracy and improving patient management when magnetic resonance imaging (MRI) findings are inconclusive. The purpose of this article is to summarize recent research into DWI applications in the musculoskeletal system.

Advanced Noncontrast MR Imaging in Musculoskeletal Radiology.

Multiple nonmorphologic magnetic resonance sequences are available in musculoskeletal imaging that can provide additional information to better characterize and diagnose musculoskeletal disorders and diseases. These sequences include blood-oxygen-level-dependent (BOLD), arterial spin labeling (ASL), diffusion-weighted imaging (DWI), and diffusion-tensor imaging (DTI). BOLD and ASL provide different methods to evaluate skeletal muscle microperfusion. The BOLD signal reflects the ratio between oxyhemoglobin and deoxyhemoglobin. ASL uses selective tagging of inflowing blood spins in a specific region for calculating local perfusion. DWI and DTI provide information about the structural integrity of soft tissue including muscles and fibers as well as pathologies.

"What Program Directors Think" II: Results of the 2013 and 2014 Annual Surveys of the Association of Program Directors in Radiology.

RATIONALE AND OBJECTIVES: The Association of Program Directors in Radiology (APDR) surveys residents' educational experiences, work responsibilities, and benefits to support radiology residency programs and their directors. MATERIALS AND METHODS: This is an observational cross-sectional study using three Web-based surveys posed to the APDR membership in the spring of 2013 (March 7-29, 2013; 44 items), the fall of 2013 (October 24 to November 15, 2013; 36 items), and the spring of 2014 (March 3-21, 2014; 49 items) on the American Board of Radiology (ABR) Core examination, organization of Clinical Competency Committees (CCCs), fellowship match, and interventional radiology (IR)-diagnostic radiology (DR) training programs. RESULTS: Responses were collected electronically, results were tallied using SurveyMonkey software, and qualitative responses were tabulated or summarized as comments. Findings were reported during the 60th and 61st annual meetings of the Association of University Radiologists, respectively. The maximal response rate was 35% in the spring 2013, 39% in the fall 2013, and 39% in the spring 2014. CONCLUSIONS: With the ABR Core examination, radiology educators increasingly included multiple choice questions in teaching conferences. "Boards frenzy" was alive and well. The number of programs with a CCC was growing, chaired primarily by the Program Director (PD), with the most commonly used tool being the rotation evaluation. In view of "fellowship frenzy" in the third year of residency, only a minority of PDs were against a fellowship match in the National Resident Matching Program (NRMP). The majority of respondents replied that the new IR/DR pathway would negatively affect the DR residency.

The effect of acetabular rim recession on anterior acetabular coverage: a cadaveric study using the false-profile radiograph.

BACKGROUND: The majority of rim recession for femoroacetabular impingement (FAI) is performed anteriorly and has traditionally been assessed by the lateral center-edge (CE) angle, which correlates most closely with lateral coverage. The radiographic false-profile view permits measurement of anterior coverage via the anterior CE angle and more closely correlates with anterior coverage. PURPOSE: To answer the following questions: (1) How does incremental anterior rim recession change lateral and anterior CE angles? and (2) Can these changes be predicted by a formula? STUDY DESIGN: Descriptive laboratory study. METHODS: Twelve cadaveric hips were dissected free of soft tissue to expose the anterior acetabular rim. Incremental resections of 2.5 mm (range, 0-10 mm) were performed from the 12- to 3-o'clock position using a Dremel rotary tool. Anteroposterior hip and false-profile radiographs were obtained at each interval using a fluoroscopic C-arm. The lateral and anterior CE angles were measured by 3 orthopaedic surgeons. RESULTS: The average preresection lateral CE angle was 35.1°, and the mean decrease in lateral CE angle from 0 to 10 mm was 9.9°; the average preresection anterior CE angle was 38.4° and the mean decrease in anterior CE angle from 0 to 10 mm was 18.2°. The anterior CE angle decreased by a factor of 1.9 when compared with the lateral CE angle (P = 2 × 10(-7)). The lateral CE angle decreased by approximately 1° (1.0°) per millimeter of rim recessed. The anterior CE angle decreased by approximately 2° (1.8°) per millimeter of rim recessed. CONCLUSION: The lateral CE angle should not be extrapolated to reflect anterior acetabular coverage. The anterior CE angle is a superior marker and predictably decreases with rim recession at double the rate of the lateral CE angle. CLINICAL RELEVANCE: The false-profile view is recommended in the perioperative workup for all patients undergoing arthroscopic treatment of pincer impingement.

Vertebral body enhancement mimicking sclerotic osseous lesions in the setting of bilateral brachiocephalic vein thrombosis.

Contrast enhancement of the vertebral body marrow may be seen secondary to collateral venous blood flow via the vertebral venous plexus in the setting of superior vena cava obstruction. We report a 48-year-old woman presenting with bilateral brachiocephalic vein obstruction and multilevel thoracic spine hyperdensities as seen on venous-phase CT angiography (CTA), initially concerning for sclerotic neoplastic lesions. A contrast-enhanced CT of the neck obtained 1 day prior to the chest CTA did not demonstrate any osseous abnormality, and inspection of the chest CTA demonstrated filling of perivertebral venous collateral vessels. The abnormal vertebral body enhancement was therefore feltsecondary to retrograde collateral venous flow via the basivertebral venous plexus in the setting of functional SVC obstruction. Vertebral body enhancement should be considered in patients with thoracic central venous obstruction when enhancement or apparent sclerosis of the vertebral bodies is seen on CTA.

Computed tomography-guided percutaneous biopsy for vertebral osteomyelitis: a department's experience.

OBJECT: Vertebral osteomyelitis has been reported to occur in approximately 0.2-2 cases per 100,000 annually. Elevated laboratory values such as erythrocyte sedimentation rate and C-reactive protein suggest inflammatory etiologies. Different imaging modalities, from radiography and CT scanning to nuclear medicine imaging and contrastenhanced MRI, can be employed to evaluate for osteomyelitis. Although MRI has a strong sensitivity and specificity for vertebral osteomyelitis, obtaining histological and microbiological samples remains the gold standard in diagnosis. Therapy can be geared toward the specific pathogen cultured, thereby preventing the need surgical intervention in the majority of cases. However, recent reports have questioned the percentage yield of image-guided percutaneous biopsy even when there is a high clinical suspicion for vertebral osteomyelitis. METHODS: After obtaining institutional review board approval, the authors performed a chart review of patients who had undergone image-guided percutaneous bone biopsies at University Hospitals Case Medical Center in Cleveland, Ohio. Data were filtered for patients in whom a biopsy sample of a vertebral body/disc was obtained. A total of 213 procedures were performed, of which clinicians indicated a concern for infection in 84, infection or neoplasm in 13, and a noninfectious etiology (the majority being neoplasms) in the remaining 116. RESULTS: Histological examination provided positive results in 25 (41.0%) of the 61 samples collected for suspected cases of osteomyelitis. Microbiology samples were less predictive, with only 16 of the 84 samples collected, or 19.0%, yielding a positive result. In 10 patients there were positive blood and/or urine cultures. Of these, 8 samples (80%) demonstrated the same pathogen identified by biopsy (for the remaining 2 positive systemic cultures, no pathogen was identified by the percutaneous intervention). In other words, half of the 16 cases that provided microbiological results from biopsy demonstrated the same results by systemic cultures. However, 89 (76.7%) of the 116 samples collected with the primary concern of neoplasm yielded results. CONCLUSIONS: Image-guided percutaneous biopsy for vertebral osteomyelitis demonstrates an extremely low probability of identifying specific microbes. Blood or urine cultures concurrently identified culprit pathogens in 50% of positive biopsy cultures. Therefore, in only 8 (9.5%) of 84 biopsies did the biopsy results provide additional information to clinicians as to the pathological microorganism present and how treatment might need to be adjusted.

Diagnostic accuracy in detecting tears in the proximal biceps tendon using standard nonenhancing shoulder MRI.

BACKGROUND: There is a paucity of data in the literature evaluating the performance of noncontrast MRI in the diagnosis of partial and complete tears of the proximal portion of the long head of the biceps (LHB) tendon. The objective of this study was to evaluate the accuracy of noncontrast magnetic resonance imaging (MRI) compared to arthroscopy for the diagnosis of pathology involving the intra-articular portion of the LHB tendon. METHODS: We conducted a retrospective review of 66 patients (mean age 57.8 years, range 43-70 years) who underwent shoulder arthroscopy and evaluation of the LHB tendon after having had a noncontrast MRI of the shoulder. Biceps pathology was classified by both MRI and direct arthroscopic visualization as either normal, partial tearing, or complete rupture, and arthroscopy was considered to be the gold standard. We then determined the sensitivity, specificity, and positive- and negative-predictive values of MRI for the detection of partial and complete LHB tears. RESULTS: MRI identified 29/66 (43.9%) of patients as having a pathologic lesion of the LHB tendon (19 partial and ten complete tears) while diagnostic arthroscopy identified tears in 59/66 patients (89.4%; 50 partial and 16 complete). The sensitivity and specificity of MRI for detecting partial tearing of the LHB were 27.7% and 84.2%, respectively (positive predictive value =81.2%, negative predictive value =32.0%). The sensitivity and specificity of MRI for complete tears of the LHB were 56.3% and 98.0%, respectively (positive predictive value =90.0%, negative predictive value =87.5%). CONCLUSION: Standard noncontrast MRI of the shoulder is limited in detecting partial tears and complete ruptures of the intra-articular LHB tendon. Surgeons may encounter pathologic lesions of the LHB tendon during arthroscopy that are not visualized on preoperative MRI.

Assessing the end-organ in peripheral arterial occlusive disease-from contrast-enhanced ultrasound to blood-oxygen-level-dependent MR imaging.

Peripheral arterial occlusive disease (PAOD) is a result of atherosclerotic disease which is currently the leading cause of morbidity and mortality in the western world. Patients with PAOD may present with intermittent claudication or symptoms related to critical limb ischemia. PAOD is associated with increased mortality rates. Stenoses and occlusions are usually detected by macrovascular imaging, including ultrasound and cross-sectional methods. From a pathophysiological view these stenoses and occlusions are affecting the microperfusion in the functional end-organs, such as the skin and skeletal muscle. In the clinical arena new imaging technologies enable the evaluation of the microvasculature. Two technologies currently under investigation for this purpose on the end-organ level in PAOD patients are contrast-enhanced ultrasound (CEUS) and blood-oxygen-level-dependent (BOLD) MR imaging (MRI). The following article is providing an overview about these evolving techniques with a specific focus on skeletal muscle microvasculature imaging in PAOD patients.

Hybrid PET/MR imaging in two sarcoma patients - clinical benefits and implications for future trials.

PET/MRI is an evolving hybrid imaging modality which combines the inherent strengths of MRIs soft-tissue and contrast resolution and PETs functional metabolic capabilities. Bone and soft-tissue sarcoma are a relatively rare tumor entity, relying on MRI for local staging and often on PET/CT for lymph node involvement and metastatic spread evaluation. The purpose of this article is to demonstrate the successful use of PET/MRI in two sarcoma patients. We also use these patients as a starting point to discuss how PET/MRI might be of value in sarcoma. Among its potential benefits are: superior TNM staging than either modality alone, decreased radiation dose, more sensitive and specific follow-up and better assessment of treatment response. These potentials need to be investigated in future PET/MRI soft-tissue sarcoma trials.

Clinical oncologic applications of PET/MRI: a new horizon.

Positron emission tomography/magnetic resonance imaging (PET/MRI) leverages the high soft-tissue contrast and the functional sequences of MR with the molecular information of PET in one single, hybrid imaging technology. This technology, which was recently introduced into the clinical arena in a few medical centers worldwide, provides information about tumor biology and microenvironment. Studies on indirect PET/MRI (use of positron emission tomography/computed tomography (PET/CT) images software fused with MRI images) have already generated interesting preliminary data to pave the ground for potential applications of PET/MRI. These initial data convey that PET/MRI is promising in neuro-oncology and head & neck cancer applications as well as neoplasms in the abdomen and pelvis. The pediatric and young adult oncology population requiring frequent follow-up studies as well as pregnant woman might benefit from PET/MRI due to its lower ionizing radiation dose. The indication and planning of therapeutic interventions and specifically radiation therapy in individual patients could be and to a certain extent are already facilitated by performing PET/MRI. The objective of this article is to discuss potential clinical oncology indications of PET/MRI.