Cerebral venous thrombosis: state of the art diagnosis and management.

PURPOSE: This review article aims to discuss the pathophysiology, clinical presentation, and neuroimaging of cerebral venous thrombosis (CVT). Different approaches for diagnosis of CVT, including CT/CTV, MRI/MRV, and US will be discussed and the reader will become acquainted with imaging findings as well as limitations of each modality. Lastly, this exhibit will review the standard of care for CVT treatment and emerging endovascular options. METHODS: A literature search using PubMed and the MEDLINE subengine was completed using the terms "cerebral venous thrombosis," "stroke," and "imaging." Studies reporting on the workup, imaging characteristics, clinical history, and management of patients with CVT were included. RESULTS: The presentation of CVT is often non-specific and requires a high index of clinical suspicion. Signs of CVT on NECT can be divided into indirect signs (edema, parenchymal hemorrhage, subarachnoid hemorrhage, and rarely subdural hematomas) and less commonly direct signs (visualization of dense thrombus within a vein or within the cerebral venous sinuses). Confirmation is performed with CTV, directly demonstrating the thrombus as a filling defect, or MRI/MRV, which also provides superior characterization of parenchymal abnormalities. General pitfalls and anatomic variants will also be discussed. Lastly, endovascular management options including thrombolysis and mechanical thrombectomy are discussed. CONCLUSIONS: CVT is a relatively uncommon phenomenon and frequently overlooked at initial presentation. Familiarity with imaging features and diagnostic work-up of CVT will help in providing timely diagnosis and therapy which can significantly improve outcome and diminish the risk of acute and long-term complications, optimizing patient care.

Investigation of thyroid nodules: A practical algorithm and review of guidelines.

BACKGROUND: High resolution ultrasound has led to early detection of subclinical tumors and drastic increase in incidence of thyroid malignancy. To achieve a balance in appropriate investigation without perpetuating an overdiagnosis phenomenon, a concise set of evidence-based recommendations to stratify risk is required. METHODS: We sought to assemble an evidence-based diagnostic algorithm and accompanying pictorial review for workup of thyroid nodules that summarizes the most recent guidelines. In addition, we conducted a literature search and analysis of our imaging databases. RESULTS: Although many imaging features of benign and malignant nodules can be nonspecific, others, such as microcalcifications, lymphadenopathy, and peripheral invasion, are highly suggestive of malignancy. The predictive values of salient imaging characteristics are presented. CONCLUSION: Evidence-based guidelines are available such that a cost-effective algorithm for thyroid nodule workup can be devised. Conservative management with a focus on periodic monitoring is the working clinical consensus on the approach to thyroid nodules.

Embryology and Anatomy of the Jaw and Dentition.

Radiologists should possess working knowledge of the embryological development and anatomy of the jaw and dentition in order to aid in the diagnosis of both simple and complex disorders that affect them. Here, we review the elaborate process of odontogenesis, as well as describe in detail the anatomy of a tooth and its surrounding structures.

Long-and short-range functional connectivity density alteration in non-alcoholic cirrhotic patients one month after liver transplantation: A resting-state fMRI study.

PURPOSE: To longitudinally evaluate long- and short-range functional connectivity density (FCD) alteration in cirrhotic patients one month after liver transplantation (LT) and their correlation with cognitive changes by using resting-state functional magnetic resonance imaging (rs-fMRI). METHODS: Twenty seven candidates awaiting LT and 24 age-, gender-, and education-matched healthy controls (HCs) were studied. All 27 patients and HCs performed rs-fMRI examinations. Of 27 cirrhotic patients, 13 patients received LT underwent the repeated rs-fMRI examinations one month after LT. Laboratory and psychometric tests were carried out. The long- and short-range FCD maps derived from degree centrality calculation were compared. Correlations between FCD alteration and laboratory/psychometric changes were evaluated as well. RESULTS: In cirrhotic patients, most of the brain areas with altered long- and short-range FCD could reverse one month after LT, which was accompanied with cognitive and liver functional improvement. The reduced long-range FCD in right posterior cingulate cortex (PCC) and Left middle frontal gyrus (MFG), and reduced short-range FCD in right precuneus (PCu) persisted in the early period after LT. In addition, one month after LT, the post-LT group showed reduced long-range FCD in right rectus gyrus (REC) and left medial prefrontal cortex (MPFC), and reduced short-range FCD in left middle temporal gyrus (MTG), when compared with the pre-LT group. We found Δdigital symbol test (ΔDST) score positively correlated with long-range ΔFCD in right precentral gyrus (preCG) (r = 0.72, P < 0.01) and right supplementary motor area (SMA) (r = 0.59, P < 0.05). CONCLUSION: LT results in favorable effect on cognitive function in cirrhotic patient, which can be reflected by FCD alteration. However, persistence of PCC/PCu functional connectivity disturbance one month after LT indicates complete cognitive function restoration may need a longer time.

Computer-assisted staging of chronic rhinosinusitis correlates with symptoms.

BACKGROUND: The Lund-Mackay (LM) staging system for chronic rhinosinusitis (CRS) does not correlate with clinical parameters, likely due to its coarse scale. We developed a "Modified Lund Mackay" (MLM) system, which uses a three-dimensional (3D), computerized method to quantify the volume of mucosal inflammation in the sinuses, and sought to determine whether the MLM would correlate with symptoms and disease-specific quality of life. METHODS: We obtained Total Nasal Symptom Score (TNSS) and 22-item Sino-Nasal Outcome Test (SNOT-22) data from 55 adult subjects immediately prior to sinus imaging. The volume of each sinus occupied by mucosal inflammation was measured using MATLAB algorithms created using customized, image analysis software after manual outlining of each sinus. Linear regression was used to model the relationship between the MLM and the SNOT-22 and TNSS. Correlation between the LM and MLM was tested using Spearman's rank correlation coefficient. RESULTS: Adjusting for age, gender, and smoking, a higher symptom burden was associated with increased sinonasal inflammation as captured by the MLM (ß = 0.453, p < 0.013). As expected due to the differences in scales, the LM and MLM scores were significantly different (p < 0.011). No association between MLM and SNOT-22 scores was found. CONCLUSION: The MLM is one of the first imaging-based scoring systems that correlates with sinonasal symptoms. Further development of this custom software, including full automation and validation in larger samples, may yield a biomarker with great utility for both treatment of patients and outcomes assessment in clinical trials.

Multidetector computed tomography of maxillofacial fractures: the key to high-impact radiological reporting.

Maxillofacial fractures are very common. Recognizing patterns of facial fractures is helpful in assessing maxillofacial injury and accurately characterizing all fractures that may be present. Facial fractures are grouped into the following categories: nasal bone, naso-orbito-ethmoid, orbital, zygomatic, maxillary (including Le Fort-type fractures), mandibular, and frontal sinus fractures. Within each subgroup of facial fractures, there are key findings, whether of the fracture itself or of potential associated injuries, that are important factors in determining whether the patient is managed conservatively or with surgery. This article highlights the features of facial fractures that are the most important to the surgeons and provides a framework for effective radiological reporting.

Multidetector CT of temporal bone fractures.

Temporal bone fracture is a relatively common finding among trauma patients. Before the development of high-resolution multidetector computed tomography (MDCT) imaging, fractures of the skull base and temporal bone were a challenge to diagnose clinically. With current imaging technology, most such fractures are easily detected, and the challenge now lies in predicting the severity of injury and possible complications. In this review, we discuss the detection and classification of temporal bone fractures, their distinction from pseudofractures, and the role of imaging in establishing prognosis, particularly with respect to complications.

Digital subtraction CT angiography for detection of intracranial aneurysms: comparison with three-dimensional digital subtraction angiography.

PURPOSE: To evaluate the diagnostic accuracy of digital subtraction computed tomographic (CT) angiography in the detection of intracranial aneurysms compared with three-dimensional (3D) rotational digital subtraction angiography (DSA), as reference standard, in a large cohort in a single center. MATERIALS AND METHODS: The study was waived by the institutional review board because of its retrospective nature. A total of 513 patients clinically suspected of having or with known intracranial aneurysms and other cerebral vascular diseases underwent both digital subtraction CT angiography with a dual-source CT scanner and 3D DSA, with a median interval of 1 day; 436 patients (84.9%) had acute subarachnoid hemorrhage at presentation. The sensitivity, specificity, and accuracy of digital subtraction CT angiography in depicting aneurysm were analyzed on a per-patient and per-aneurysm basis, with 3D DSA as the reference standard. The sensitivity, specificity, and accuracy of digital subtraction CT angiography in depicting aneurysms of different diameter (ie, <3 mm, 3-5 mm, 5-10 mm, and >10 mm) and of aneurysms at different locations in the anterior and posterior circulation were calculated. Kappa statistics were calculated to quantify inter- and intrareader variability in detecting aneurysms by using digital subtraction CT angiography for 100 patients. RESULTS: Of 513 patients, 106 (20.7%) had no aneurysms, while 407 patients (79.3%) had 459 aneurysms at 3D DSA. Digital subtraction CT angiography correctly depicted 456 (99.3%) of the 459 aneurysms. By using 3D DSA as the standard of reference, the sensitivity and specificity of depicting intracranial aneurysms were 97.8% (398 of 407) and 88.7% (94 of 106), respectively, on a per-patient basis, and 96.5% (443 of 459) and 87.8% (94 of 107), respectively, on a per-aneurysm basis. Digital subtraction CT angiography had sensitivities of 91.3% (42 of 46), 94.0% (140 of 149), 98.4% (186 of 189), and 100% (75 of 75) in depicting aneurysms of less than 3 mm, between 3 mm but less than 5 mm, between 5 mm but less than 10 mm, and 10 mm or greater, respectively, and of 95.8% (276 of 288) and 97.7% (167 of 171) in depicting anterior circulation and posterior circulation aneurysms, respectively. Excellent inter- and intrareader agreement was found on a per-patient (κ=0.900 and 0.939, both P<.001) and per-aneurysm basis (κ=0.846 and 0.921, both P<.001) for the detection of intracranial aneurysms with digital subtraction CT angiography. CONCLUSION: Digital subtraction CT angiography has a high sensitivity and specificity in depicting intracranial aneurysms with different sizes and at different locations, compared with 3D DSA.

Automatic bone removal dual-energy CT angiography for the evaluation of intracranial aneurysms.

PURPOSE: To evaluate the diagnostic accuracy of dual-energy computed tomographic angiography (DE-CTA) in the detection of intracranial aneurysms and to determine whether DE-CTA provides adequate information to guide treatment choice. MATERIALS AND METHODS: Eighty patients (31 men and 49 women; mean [SD] ages of 52 [9] years) with spontaneous subarachnoid hemorrhage underwent DE-CTA. The performance of DE-CTA was compared with conventional CTA created from average weighted images and digital subtraction angiography (DSA). Sensitivity and specificity for aneurysm detection were determined on a per-patient and per-aneurysm basis. The treatment choice was assessed on the basis of aneurysm neck size and/or the dome/neck ratio. RESULTS: With DSA as reference standard (n = 61; 47 aneurysms in 41 patients), DE-CTA correctly detected 45 aneurysms in 41 patients corresponding to sensitivity and specificity of 100% and 95.0% on a per-patient basis versus 95.7% and 95.0% on a per-aneurysm basis, whereas conventional CTA correctly detected 43 aneurysms in 39 patients corresponding to sensitivity and specificity of 95.1% and 95.0% on a per-patient basis versus 91.5% and 95.0% on a per-aneurysm basis. No statistical difference between DE-CTA and conventional CTA was found for the diagnostic evaluation of intracranial aneurysms. Surgery was performed to treat 38 aneurysms, coiling in 26 aneurysms, stent in one patient, and follow-up in the remaining 5 aneurysms. Dual-energy CTA correctly predicted treatment choice in 44 aneurysms, with 15 aneurysms coiled and 29 aneurysms clipped. CONCLUSIONS: Compared with DSA, DE-CTA had a comparable diagnostic accuracy for the detection of intracranial aneurysms, visualization of the morphology of aneurysms at the skull base, and prediction of aneurysm treatment choice in most patients with spontaneous subarachnoid hemorrhage based on this study.

A brief commentary on cost-effectiveness analysis in radiologic research.

OBJECTIVE: This commentary provides a brief overview of cost-effectiveness analysis, which is increasingly applied in radiologic research. The purpose is to familiarize readers with the basic concepts in this topic and to provide help in appraising original articles in this area of research, as featured in this issue of the AJR. CONCLUSION: Despite some limitations, decision-analytic modeling provides a useful tool for cost-effectiveness analysis in emerging technologies and helps to direct future research and the practice of radiology.

Orbital lesions: differentiating vascular and nonvascular etiologic factors.

OBJECTIVE: Using a number of interesting cases, we illustrate how attention to vascular anatomic features and blood flow patterns can facilitate the diagnosis of an orbital lesion. True vascular lesions can be differentiated from nonvascular mimics, and normal variants of the orbital blood flow pattern can be differentiated from pathologic alterations. CONCLUSION: Accuracy of radiologic diagnosis can be improved by an understanding of orbital vascular anatomy and blood flow patterns and with optimal use of imaging techniques.

Radiologic diagnosis of cerebral venous thrombosis: pictorial review.

OBJECTIVE: Cerebral venous thrombosis is often associated with nonspecific clinical complaints. In addition, the imaging findings are often subtle. Underdiagnosis or misdiagnosis of cerebral venous thrombosis can lead to severe consequences, including hemorrhagic infarction and death. CONCLUSION: This article reviews the radiologic findings and diagnostic pitfalls of cerebral venous thrombosis. After completing this article, the readers should have an improved ability to diagnose cerebral venous thrombosis accurately, using the optimal imaging tools to achieve this goal.

Radiologic diagnosis of cerebral venous thrombosis: self-assessment module.

The educational objectives of this self-assessment module are for the participant to exercise, self-assess, and improve his or her understanding of the radiologic diagnosis of cerebral venous thrombosis.