Measurement of cortical porosity of the proximal femur improves identification of women with nonvertebral fragility fractures.

UNLABELLED: We tested whether cortical porosity of the proximal femur measured using StrAx1.0 software provides additional information to areal bone mineral density (aBMD) or Fracture Risk Assessment Tool (FRAX) in differentiating women with and without fracture. Porosity was associated with fracture independent of aBMD and FRAX and identified additional women with fractures than by osteoporosis or FRAX thresholds. INTRODUCTION: Neither aBMD nor the FRAX captures cortical porosity, a major determinant of bone strength. We therefore tested whether combining porosity with aBMD or FRAX improves identification of women with fractures. METHODS: We quantified femoral neck (FN) aBMD using dual-energy X-ray absorptiometry, FRAX score, and femoral subtrochanteric cortical porosity using StrAx1.0 software in 211 postmenopausal women aged 54-94 years with nonvertebral fractures and 232 controls in Tromsø, Norway. Odds ratios (ORs) were calculated using logistic regression analysis. RESULTS: Women with fractures had lower FN aBMD, higher FRAX score, and higher cortical porosity than controls (all p < 0.001). Each standard deviation higher porosity was associated with fracture independent of FN aBMD (OR 1.39; 95% confidence interval 1.11-1.74) and FRAX score (OR 1.58; 1.27-1.97) in all women combined. Porosity was also associated with fracture independent of FRAX score in subgroups with normal FN aBMD (OR 1.88; 1.21-2.94), osteopenia (OR 1.40; 1.06-1.85), but not significantly in those with osteoporosis (OR 1.48; 0.68-3.23). Of the 211 fracture cases, only 18 women (9%) were identified using FN aBMD T-score < -2.5, 45 women (21%) using FRAX threshold >20%, whereas porosity >80th percentile identified 61 women (29%). Porosity identified 26% additional women with fractures than identified by the osteoporosis threshold and 21% additional women with fractures than by this FRAX threshold. CONCLUSIONS: Cortical porosity is a risk factor for fracture independent of aBMD and FRAX and improves identification of women with fracture.

The paediatric wrist revisited: redefining MR findings in healthy children.

OBJECTIVES: During a multicentre study on juvenile idiopathic arthritis, wide variations were observed in bone shape, signal intensity and volume of joint fluid as shown by MRI which in part appeared to be unrelated to disease activity. A study was undertaken to examine these features in a cohort of healthy children. METHODS: 88 children of mean age 9.8 years (range 5-15) underwent MRI imaging (T1-weighted Spin Echo and Spectral Selection Attenuated Inversion Recovery (SPAIR)) of the left wrist. The number of bony depressions, distribution and amount of joint fluid and the presence of bone marrow changes were assessed. RESULTS: Bony depressions were present in all children, increasing with age from a mean of 4.0 in children aged 4-6 years to 9.2 in those aged 12-15 years (p<0.001)). 45 of 84 children (53.6%) had a high signal on SPAIR with a corresponding low signal on T1 in at least one bone. No associations were seen between bone marrow change (present or not) and sex (p=0.827) or sports club membership (p=0.616). All children had visible joint fluid in at least one of the joints assessed. No associations were seen between the presence of joint fluid and age group, except for the radius/scaphoid and capitate-scaphoid joints and a recess lateral to the hamate. CONCLUSIONS: It is important to be aware of the high prevalence of bony depressions, signal changes suggestive of bone marrow oedema and the volume of joint fluid seen in normal children. Such findings must be interpreted with care in children with suspected disease such as juvenile arthritis.

Spinal cord magnetic resonance imaging in autosomal dominant hereditary spastic paraplegia.

Hereditary spastic paraplegia (HSP) is a genetically heterogeneous group of neurodegenerative disorders characterized by progressive lower extremity weakness and spasticity. HSP pathology involves axonal degeneration that is most pronounced in the terminal segments of the longest descending (pyramidal) and ascending (dorsal columns) tracts. In this study, we compared spinal cord magnetic resonance imaging (MRI) in 13 HSP patients with four different types of autosomal dominant hereditary spastic paraplegia (SPG3A, SPG4, SPG6, and SPG8) with age-matched control subjects. The cross-section area of HSP subjects at cervical level C2 was 59.42 +/- 12.57 mm2 and at thoracic level T9 was 28.58 +/- 5.25 mm2. Both of these values were less than in the healthy controls (p < 0.001). The degree of cord atrophy was more prominent in patients with SPG6 and SPG8 who had signs of severe cord atrophy (47.60 +/- 6.58 mm2 at C2, 21.40 +/- 2.4 mm2 at T9) than in subjects with SPG3 and SPG4 (66.0 +/- 8.94 mm2 at C2, p < 0.02; 31.75 +/- 2.76 mm2 at T9, p < 0.001). These observations indicate that spinal cord atrophy is a common finding in the four genetic types of HSP. Spinal cord atrophy was more severe in SPG6 and SPG8 HSP subjects than in other types of HSP we studied. This may suggest a different disease mechanism with more prominent axonal degeneration in these two types of HSP when compared with HSP due to spastin and atlastin mutations.

Spastic paraplegia, ataxia, mental retardation (SPAR): a novel genetic disorder.

OBJECTIVE: To describe a kindred with a dominantly inherited neurologic disorder manifested either as uncomplicated spastic paraplegia or ataxia, spastic paraplegia, and mental retardation. METHODS: Neurologic examinations and molecular genetic analysis (exclusion of known SCA and HSP genes and loci; and trinucleotide repeat expansion detection [RED]) were performed in six affected and four unaffected subjects in this family. MRI, electromyography (EMG), and nerve conduction studies were performed in three affected subjects. RESULTS: The phenotype of this dominantly inherited syndrome varied in succeeding generations. Pure spastic paraplegia was present in the earliest generation; subsequent generations had ataxia and mental retardation. MRI showed marked atrophy of the spinal cord in all patients and cerebellar atrophy in those with ataxia. Laboratory analysis showed that the disorder was not caused by mutations in genes that cause SCA-1, SCA-2, SCA-3, SCA-6, SCA-7, SCA-8, and SCA-12; not linked to other known loci for autosomal dominant ataxia (SCA-4, SCA-5, SCA-10, SCA-11, SCA-13, SCA-14, and SCA-16); and not linked to known loci for autosomal dominant hereditary spastic paraplegia (HSP) (SPG-3, SPG-4, SPG-6, SPG-8, SPG-9, SPG-10, SPG-12, and SPG-13) or autosomal recessive HSP SPG-7. Analysis of intergenerational differences in age at onset of symptoms suggests genetic anticipation. Using RED, the authors did not detect expanded CAG, CCT, TGG, or CGT repeats that segregate with the disease. CONCLUSIONS: The authors describe an unusual, dominantly inherited neurologic disorder in which the phenotype (pure spastic paraplegia or spastic ataxia with variable mental retardation) differed in subsequent generations. The molecular explanation for apparent genetic anticipation does not appear to involve trinucleotide repeat expansion.

Sensory nerve somatosensory evoked potentials as add-on diagnostic procedure to imaging procedures in patients with sciatica.

The aim of the present study was to evaluate the ability of sensory nerve somatosensory evoked potentials (SEP) to discriminate between lumbar spine computed tomography (CT) findings with and without relevance for the radiating sensory symptoms in patients with sciatica in whom myelography does not have such discriminatory capacity. Forty consecutive sciatic patients in whom CT without intrathecal contrast showed degenerative changes which did not cause probable compression in at least one symptomatic nerve root, or caused probable compression in at least one asymptomatic nerve root, and in whom there were corresponding discrepancies between the radiating sensory symptoms and myelographic nerve root compression, were studied. Sensory nerve SEP representing nerve roots L4, L5 and S1, were performed in all patients. The sensory nerve conduction velocity (SNCV) and the amplitude of the sensory nerve action potential (SNAP) were recorded from the stimulated nerves. The odds ratios (OR 95% CI) of the association of positive SEP to symptomatic nerve roots were 24.0 (4.8 to 54.5) in nerve roots with probable and 39.0 (5.9 to 258.9) with possible CT compression. The corresponding associations between myelography and sciatic symptoms were not statistically significant. Comparisons of SNCVs and SNAP amplitudes did not indicate that postganglionic nerve dysfunction contributed to the sensory symptoms or to the SEP results. SEP examination may be used to discriminate between CT findings with and without relevance to the radiating sensory symptoms in patients with sciatica in whom myelography does not show this discriminatory capacity.

Acoustic droplet vaporization for therapeutic and diagnostic applications.

A phase shift droplet emulsion is introduced as an aid to unusual ultrasound (US) applications. The transpulmonary droplet emulsion (90% < 6 microm diameter) is made by mixing saline, bovine albumin and dodecafluoropentane. It has been observed that an acoustic pressure threshold exists, above which the droplets vaporize into bubbles approximately 25 times the original diameter. For frequencies between 1.5 and 8 MHz, the threshold decreases from 4.5 to 0.75 MPa peak rarefactional pressure. This paper presents preliminary results for droplet preparation and their evaporation as a function of applied acoustic pressure and frequency, as well as simulations of the lifetime of these gas bubbles based on gas diffusion. In vivo experiments were simulated by the evaporation of droplets in blood flowing under attenuating material. We propose that this agent might be useful for tissue occlusion in cancer treatment, as well as for phase aberration corrections in acoustic imaging.

Improving postoperative MR imaging of pituitary macroadenomas: comparison of full and reduced dose of gadopentetate dimeglumine.

The aim of this study was to evaluate the efficacy of contrast-medium (CM)-ehanced MR imaging of operated pituitary macroadenomas with reduced dose of gadopentetate dimeglumine. In a prospective study 18 patients were examined with coronal T1-weighted MR imaging prior to and following intravenous CM injections. Two sets of contrast-enhanced coronal images were obtained in each patient; the first set after 50% of the recommended dose of 0.1 mmol/kg body weight (b.w.) had been administered, and the second set immediately after additional CM had been given to make up a total dose of 0.1 mmol/kg b.w. The images were evaluated by three neuroradiologists. The SIPAP classification system was used to evaluate tumour extension, whereas tumour margin conspicuity was scored using an arbitrary scale of 1-5 (1 = indistinct, 5 = well defined). Signal intensity measurements obtained from the most enhancing part of the adenomas demonstrated increased enhancement with increased CM dose. Tumour delineation scores were significantly better on the reduced- and full-dose images than on pre-CM injection images, but, with one exception, tumour extension was identified as the same on all imaging sequences. Postoperative MR imaging of large macroadenoma residues can routinely be performed without intravenous CM. When CM is indicated a reduced dose of gadopentetate dimeglumine should provide sufficient diagnostic information.

Sedation and general anaesthesia in children undergoing MRI and CT: adverse events and outcomes.

Quality assurance data were collected prospectively for children who were sedated (n = 922) or given general anaesthesia (n = 140) for magnetic resonance imaging (MRI) or computerized tomography (CT). The data included patient characteristics, concurrent medication, adequacy of sedation, adverse events and requirement for escalated care. The quality of scans was evaluated. Reasons for preselection of general anaesthesia included previously failed sedation (28%), potential for failed sedation (32%) and perceived medical risk (14%). Hypoxaemia occurred in 2.9% of sedated children, and was more common in children classified as ASA III or IV. Sedation was inadequate for 16% of children and failed in 7%. Failed sedation was associated with greater age (P = 0.009), higher ASA status (P = 0.04) and use of benzodiazepines as sole sedatives (P < 0.03). More of the children who underwent general anaesthesia were ASA III or IV than sedated children, yet the procedure was successful in all the children who underwent general anaesthesia, with one incident of laryngospasm. Excessive motion was noted in 12% of scans of sedated children and 0.7% of those completed with general anaesthesia. We conclude that sedation of children for MRI and CT is associated with risks of hypoxaemia and of inadequate or failed sedation. These adverse events were more likely to occur in older children, those with a higher ASA status and those in whom benzodiazepines had been used as sole sedatives. For a preselected high-risk group of children, general anaesthesia may make MRI and CT scans more successful with minimal adverse events.

Imaging findings in schwannomas of the jugular foramen.

BACKGROUND AND PURPOSE: Tumors of the cranial nerve sheath constitute 5% to 10% of all intracranial neoplasms, yet few articles have described their CT and MR characteristics. We report the imaging findings in a relatively large series of schwannomas of the jugular foramen, contrasting them with other disease entities, especially vestibular schwannomas and tumors of the glomus jugulare. METHODS: CT and/or MR studies of eight patients who underwent surgery for histologically proved schwannomas were reviewed retrospectively. One additional patient with an assumed schwannoma of the jugular foramen, who did not have surgery, was also included. RESULTS: Surgical findings showed schwannomas of the glossopharyngeal nerve in seven patients and tumor involvement of both the glossopharyngeal and vagal nerves in one patient. All tumors were partially located within the jugular foramen. Growth extending within the temporal bone was typical. Tumor extended into the posterior cranial fossa in all nine patients and produced mass effect on the brain stem and/or cerebellum in seven patients; in five patients, tumor extended below the skull base. On unenhanced CT scans, tumors were isodense with brain in six patients and hypodense in two. In seven patients, CT scans with bone algorithm showed an enlarged jugular foramen with sharply rounded bone borders and a sclerotic rim. On MR images, T1 signal from tumor was low and T2 signal was high relative to white matter in all patients. Contrast enhancement on CT and/or MR studies was strong in eight patients and moderate in one. CONCLUSION: Schwannoma of the jugular foramen is characteristically a sharply demarcated, contrast-enhancing tumor, typically centered on or based in an enlarged jugular foramen with sharply rounded bone borders and a sclerotic rim. Intraosseous extension may be marked.

Clinical consequences of misinterpretations of neuroradiologic CT scans by on-call radiology residents.

BACKGROUND AND PURPOSE: Studies have looked at the accuracy of radiologic interpretations by radiology residents as compared with staff radiologists with regard to emergency room plain films, emergency room body CT scans, and trauma head CT scans; however, to our knowledge, no study has evaluated on-call resident interpretations of all types of neuroradiologic CT scans. Both as a part of our departmental quality control program and to address concerns of clinical services about misinterpretation of neuroradiologic CT scans by on-call radiology residents, we evaluated the frequency of incorrect preliminary interpretations of neuroradiologic CT scans by on-call radiology residents and the effect of such misinterpretations on clinical management and patient outcome. METHODS: As determined by the staff neuroradiologist the next day, all potentially clinically significant changes to preliminary reports of emergency neuroradiologic CT scans rendered by on-call radiology residents were recorded over a 9-month period. A panel of neuroradiologists reviewed and graded all the changed cases by consensus. An emergency department staff physician reviewed medical records of all submitted cases to determine clinical consequences of the misinterpretations. RESULTS: Significant misinterpretations were made in 21 (0.9%) of 2388 cases during the study period. There was a significant change in patient management in 12 of the cases, with a potentially serious change in patient outcome in two cases (0.08%). CONCLUSION: On-call radiology residents have a low rate of significant misinterpretations of neuroradiologic CT scans, and the potential to affect patient outcome is rare.

Phenotypic analysis of autosomal dominant hereditary spastic paraplegia linked to chromosome 8q.

OBJECTIVE: To describe clinical, electrophysiologic, neuroimaging, and muscle biopsy features in a hereditary spastic paraplegia (HSP) kindred linked to a new HSP locus on chromosome 8q. BACKGROUND: HSP is a genetically diverse group of disorders characterized by insidiously progressive spastic weakness in the legs. We recently analyzed a Caucasian kindred with autosomal dominant HSP and identified tight linkage to a novel HSP locus on chromosome 8q23-24. METHODS: Clinical analysis, nerve conduction studies, electromyography, somatosensory evoked potentials, MRI of brain and spinal cord, and muscle biopsy for mitochondrial analysis were performed in members of the first HSP kindred linked to chromosome 8q. RESULTS: Fifteen individuals showed insidiously progressive spastic paraparesis beginning between ages 22 and 60 years (average, 37.2 years). Spinal cord MRI in 1 moderately affected subject showed significant atrophy of the thoracic spinal cord as determined by cross-sectional area measurements. Somatosensory evoked potential recording, electromyography, nerve conduction studies, and muscle biopsy, including histochemical and biochemical analysis of mitochondrial function, were normal. CONCLUSIONS: The phenotype in this family is that of typical, but severe, uncomplicated HSP. Other than apparently increased severity, there were no clinical features that distinguished this family from autosomal dominant HSP linked to loci on chromosomes 2p, 14q, and 15q. This clinical similarity between different genetic types of autosomal dominant HSP raises the possibility that genes responsible for these clinically indistinguishable disorders may participate in a common biochemical cascade. Normal results of muscle histochemical and biochemical analysis suggest that mitochondrial disturbance, a feature of chromosome 16-linked autosomal recessive HSP due to paraplegin gene mutations, is not a feature of chromosome 8q-linked autosomal dominant HSP and may not be a common factor of HSP in general.

Contrast enhancement in the craniopharyngioma cyst wall caused by irradiation.

PURPOSE: To report the occurrence, degree, frequency, and duration of contrast enhancement in the craniopharyngioma cyst wall as caused by irradiation. MATERIAL AND METHODS: Eight patients with cystic craniopharyngiomas had comparable CT or MR studies before and after either external irradiation of the cyst (n = 5) or 32P instillation into the cyst (n = 3). RESULTS: A minimal to marked increase in cyst-wall enhancement was seen at 66-157 days after 32P instillation in 3/3 cases and at 112-495 days after external irradiation in 3/5 cases. The increased enhancement was always associated with a variable interim increase in the thickness of the enhanced cyst wall. CONCLUSION: CT or MR imaging after the irradiation of cystic craniopharyngiomas usually demonstrated an increase in thickness and enhancement in the cyst wall. Such changes may be due to the irradiation alone and do not necessarily represent infection or increased neoplastic activity. The timing is uncertain as to the earliest possible development of such changes and their maximum duration, but they were seen as early as 66 days post-irradiation and as late as 495 days post-irradiation.

P1-latency interroot comparison enhances the validity of scalp-recorded somatosensory-evoked potentials to diagnose nerve root dysfunction in sciatica.

STUDY DESIGN: A prospective validity study was done of scalp-recorded somatosensory-evoked potentials as a diagnostic procedure to show lumbosacral radiculopathy in 100 consecutive patients with unilateral or bilateral sciatica. OBJECTIVE: To determine the validity gained by the use of P1-latency interroot comparison to show P1-latency prolongation. SUMMARY OF THE BACKGROUND DATA: The validity of scalp-recorded somatosensory-evoked potentials in diagnosing lumbosacral radiculopathy has been debated and is uncertain. METHOD: Sensory nerves representing nerve roots L4, L5, and S1 were stimulated bilaterally. Height-corrected P1-latency, two new P1-interroot comparison-based criteria, and absence of P1 were studied. The gold standard was defined as clinically-involved nerve roots with radiologic nerve root compression. The false-positive nerve root compression rate was determined, and the gold standard was corrected accordingly. Clinically relevant cut-off values were defined by multilevel likelihood ratio analysis. RESULTS: The positive and negative likelihood ratios of P1-latency prolongation were 6.79 and 0.53, respectively, for the gold standard, and 10.57 and 0.21, respectively, for the corrected gold standard. The validity was not reduced when scalp-recorded, somatosensory-evoked potentials were blinded to the radiologic results. Absence of P1 was associated to the gold standard and the corrected gold standard. Compared with the combined use of P1-latency interside difference and height-corrected latency, the combination of P1-interroot comparison and height-corrected P1-latency increased the sensitivity by 20% for the gold standard and 32% for the corrected gold standard, and when absent P1 was added, the overall sensitivity was 53% for the gold standard and 81% for the corrected gold standard. The corresponding specificity was 92%, and in asymptomatic nerve roots it was 98%. CONCLUSION: The P1-interroot comparison permits the use of scalp-recorded somatosensory-evoked potentials as a contributory "rule in" procedure in patients with sciatica.

Craniopharyngioma: radiologic and histologic findings and recurrence.

PURPOSE: To identify the CT and MR characteristics of craniopharyngiomas, to evaluate the histologic types of craniopharyngioma, and to compare the radiologic/histologic appearance and type of therapy with tumor recurrence. METHODS: We reviewed the records of 45 patients with craniopharyngiomas for which surgical specimens (n = 45), preoperative MR or CT studies (n = 27), or other MR or CT studies or reports (n = 18) were available. Radiologic appearance, histologic morphology, treatment, and tumor recurrence were studied. RESULTS: Adamantinomatous epithelium was found in 40 of 45 surgical specimens, keratin in 34 of 45, and squamous epithelium in 11 of 45. A continuum of mixed morphology rather than distinct subtypes of tumors was found. The radiologic appearance did not correlate with the histologic features. No statistically significant difference was found between children and adults with respect to tumor size, calcification, histology, or tumor recurrence. Patients treated with radiation after subtotal resection had far fewer tumor recurrences (n = 3) than patients treated with surgery alone (n = 18). CONCLUSION: Craniopharyngiomas could not be divided into distinct histologic types. No differentiating radiologic or histologic characteristics could be established for craniopharyngiomas in children versus adults. Radiation treatment was strongly associated with tumor regression or lack of recurrence.

Pre- and postoperative MR imaging of craniopharyngiomas.

PURPOSE: To compare the pre- and postoperative MR appearance of craniopharyngiomas with respect to lesion size, tumour morphology and identification of surrounding normal structures. MATERIAL AND METHODS: MR images obtained prior to and following craniopharyngioma resection were evaluated retrospectively in 10 patients. Tumour signal characteristics, size and extension with particular reference to the optic chiasm, the pituitary gland, the pituitary stalk and the third ventricle were evaluated. RESULTS: Following surgery, tumour volume was reduced in all patients. In 6 patients there was further tumour volume reduction between the first and second postoperative images. Two of these patients received radiation therapy between the 2 postoperative studies, while 4 had no adjuvant treatment to the surgical intervention. There was improved visualization of the optic chiasm in 3, the pituitary stalk in one, and the third ventricle in 9 of the 10 patients. The pituitary gland was identified preoperatively only in one patient, postoperatively only in another, pre- and postoperatively in 5, and neither pre- nor postoperatively in 3 patients. In 3 patients MR imaging 0-7 days postoperatively identified tumour remnants not seen at the end of the surgical procedure. The signal intensities of solid and cystic tumour components were stable from pre- to the first postoperative MR images. Optic tract increased signal prior to surgery was gone 28 days postoperatively in one patient, but persisted on the left side for 197 days after surgery in another. CONCLUSION: Postoperative MR imaging of craniopharyngiomas demonstrated tumour volume reduction and tumour remnants not seen at surgery. Early postoperative MR imaging of craniopharyngiomas may overestimate the size of residual tumour. Improved visualization of peritumoral structures may be achieved.

Magnetic resonance imaging of normal meningeal enhancement at 1.5 T.

RATIONALE AND OBJECTIVES: We examined patterns of intracranial meningeal enhancement on gadolinium chelate contrast media-enhanced 1.5-T spin-echo magnetic resonance (MR) imaging and developed criteria that might be useful for distinguishing between normal and abnormal meningeal enhancement. METHODS: The convexity, falx cerebri, tentorium cerebelli, and suprasellar cistern regions of 204 patients were prospectively evaluated for contrast enhancement with a grading system ranging from 0 (no enhancement) to 5 (diffuse, irregular, thickened enhancement). Meningeal findings were correlated with other MR abnormalities and pertinent clinical histories that have been associated previously with meningeal enhancement. RESULTS: Short-segment convexity meningeal enhancement was commonly seen and most likely represents intravascular contrast material in normal meningeal vessels. Such enhancement did not correlate with the presence of other MR abnormalities. Long-segment (> 3 cm) or diffuse convexity meningeal enhancement did correlate with other significant MR abnormalities and pertinent clinical history. Fine linear falcine and tentorial meningeal enhancement, as an isolated finding, did not correlate with other MR or clinical abnormalities. The suprasellar cistern and ventricular walls were rarely enhanced. CONCLUSION: Short-segment convexity meningeal contrast enhancement is a normal finding representing normal vascular structures. More extensive convexity meningeal enhancement is abnormal and should prompt careful examination of the remainder of an MR image as well as the patient's clinical history for an etiology of the enhancement.

Esophageal carcinoma metastatic to the brain: clinical value and cost-effectiveness of routine enhanced head CT before esophagectomy.

PURPOSE: To assess the value of screening enhanced head CT before esophagectomy for carcinoma, identify increased risk factor(s) for brain metastases, and determine metastasis incidence. METHODS: Thoracic surgery files of patients undergoing esophagectomies for squamous carcinomas, adenocarcinomas, and undifferentiated carcinomas between January 1984 and March 1993 were reviewed regarding sex, size (length) of neoplasm, and brain metastases. Surgical pathology and tumor registry files also were reviewed. Records of patients with brain metastases were reviewed in detail. RESULTS: Three hundred thirty-four esophagectomies were performed for 230 adenocarcinomas (202 male, 28 female) and 104 squamous carcinomas (61 male, 43 female). In 9 males and 1 female with adenocarcinomas and 1 male and 1 female with squamous carcinomas, brain metastases developed. Surgical pathology files identified 293 additional esophageal carcinomas, including 2 males with adenocarcinomas metastatic to brain. Tumor registry files identified I additional male with brain metastasis from an undifferentiated esophageal neoplasm. No statistically significant preoperative characteristic of esophageal carcinomas with proneness to brain metastases was found, except large size of primary neoplasm. Preoperative screening head CT done on approximately 240 patients who underwent esophagectomies showed no metastases. CONCLUSIONS: Brain metastases from carcinomas of the esophagus are relatively uncommon (3.6% in the esophagectomy cohort). They tend to occur in patients with large primary neoplasm, probably especially adenocarcinomas involving the esophagogastric junction, and with findings of local invasion and lymph node metastases by CT and/or microscopically. It may be reasonable to obtain head CT as a last preoperative staging procedure in such patients. Routine preoperative head CT for staging is not cost effective.