A comparison of ultrasound-guided rotator interval and posterior glenohumeral injection techniques for MR shoulder arthrography.

PURPOSE: The aim of this prospective, randomized study was to compare the performance of a rotator interval approach with the posterior glenohumeral approach for ultrasound-guided contrast injection prior to MR shoulder arthrography. METHOD: This study was approved by the institutional review board. One hundred and twenty consecutive patients referred for MR shoulder arthrography were randomized into four groups: rotator interval approach in-plane (n = 30); rotator interval approach out-of-plane (n = 30); posterior approach in-plane (n = 30); and posterior approach out-of plane (n = 30). Outcome measures included procedure time, number of injection attempts, patient-reported pain score (0-10), and radiologist-reported technical difficulty (0-10). MR arthrograms were assessed for adequacy of joint distension, diagnostic utility, and extra-capsular contrast leakage. RESULTS: All 120 patients had a successful ultrasound-guided injection with adequate joint distension and diagnostic utility for MR arthrography. In-plane needle guidance was less technically demanding, quicker, required fewer injection attempts, and had a lower frequency of contrast leakage than out-of-plane needle guidance. The posterior glenohumeral approach was less technically demanding though had a higher frequency of contrast leakage and caused more patient discomfort than the rotator interval approach. CONCLUSION: For ultrasound-guided shoulder joint injection, an in-plane approach is preferable. The posterior glenohumeral approach is less technically demanding though causes more patients discomfort than the rotator interval approach possibly due to the longer needle path.

MRI criteria for diagnosis and predicting severity of carpal tunnel syndrome.

OBJECTIVE: To study MRI criteria for diagnosing and predicting severity of carpal tunnel syndrome (CTS). METHODS: Sixty-nine wrists in 41 symptomatic CTS patients and 32 wrists in 28 asymptomatic subjects were evaluated by MRI. Circumferential surface area (CSA), flattening ratio, relative median nerve signal intensity, and retinacular bowing were measured. CTS severity was classified as mild, moderate, or severe. Parameters for patients with and without CTS and for the three severity groups were compared. ROC curves were plotted to assess accuracy for CTS diagnosis and severity prediction. RESULTS: Significant differences were found between CTS and control wrists for median nerve CSA, flattening ratio at inlet, relative median nerve signal intensity, and retinacular bowing. ROC curve analysis revealed a sensitivity, specificity, and accuracy of median nerve CSA > 15 mm2 proximal to the tunnel (CSAp) of 85.5, 100, and 90.1%. Using either CSAp or CSAd > 15 mm2 as a diagnostic criterion, MRI could achieve a sensitivity of 100% and specificity of 94% for diagnosis of CTS while overall accuracy was 98%. Significant differences were found among the three severity groups. Sensitivity, specificity, and accuracy of prediction of severe CTS using for CSAp > 19 mm2 were 75.0, 65.9, and 69.6%, respectively. CONCLUSIONS: MRI is highly accurate at diagnosing CTS and moderately accurate at determining CTS severity. We recommend using CSA > 15 mm2 either proximal to or distal to the tunnel as a diagnostic criterion for CTS and CSA > 19 mm2 proximal to the tunnel as a marker for severe CTS.

Ankle Traction During MRI of Talar Dome Osteochondral Lesions.

OBJECTIVE: The objective of our study was to assess the impact of axial traction during MRI of talar dome osteochondral lesions using a small-FOV coil. SUBJECTS AND METHODS: A prospective study of 33 patients undergoing high-resolution MRI of the ankle using a microscopy coil with and without axial traction was performed. Two radiologists independently measured the tibiotalar joint space width and semiquantitatively graded intraarticular joint fluid dispersion, cartilage surface visibility of the osteochondral lesion, and cartilage surface visibility elsewhere in the tibiotalar joint before and after traction. Patients were instructed to report any discomfort during ankle traction. RESULTS: None of the patients reported discomfort or other symptoms during ankle traction. The tibiotalar joint space significantly increased (increase in cartilage-cartilage distance, 0.5-0.7 mm; all, p < 0.05) after traction compared with before traction. The degree of intraarticular joint fluid dispersion and the cartilage surface visibility at the osteochondral lesion and elsewhere in the tibiotalar joint improved after traction (all, p < 0.05). CONCLUSION: Traction MRI of the ankle is safe and technically feasible. This study is the first to date to investigate the effect of ankle traction on the MRI assessment of talar dome osteochondral lesions. Traction improves cartilage surface visibility of talar dome osteochondral lesions.

Intrinsic carpal ligaments on MR and multidetector CT arthrography: comparison of axial and axial oblique planes.

PURPOSE: To compare axial and oblique axial planes on MR arthrography (MRA) and multidetector CT arthrography (CTA) to evaluate dorsal and volar parts of scapholunate (SLIL) and lunotriquetral interosseous (LTIL) ligaments. METHODS: Nine cadaveric wrists of five male subjects were studied. The visibility of dorsal and volar parts of the SLIL and LTIL was graded semi-quantitatively (good, intermediate, poor) on MRA and CTA. The presence of a ligament tear was determined on arthrosocopy and sensitivity, specificity and accuracy of tear detection were calculated. RESULTS: Oblique axial imaging was particularly useful for delineating dorsal and volar parts of the LTIL on MRA with overall 'good' visibility increased from 11 % to 78 %. The accuracy of MRA and CTA in revealing SLIL and LTIL tear was higher using the oblique axial plane. The overall accuracy for detecting SLIL tear on CTA improved from 94 % to 100 % and from 89 % to 94 % on MRA; the overall accuracy of detecting LTIL tear on CTA improved from 89 % to 100 % and from 72 % to 89 % on MRA CONCLUSION: Oblique axial imaging during CT and MR arthrography improves detection of tears in the dorsal and volar parts of both SLIL and LTIL. KEY POINTS: • Oblique axial imaging improves SLIL and LTIL visibility and tear detection. • This improvement is greater for the LTIL than for the SLIL ligament. • Overall, CT arthrography performed better than MR arthrography.

CT pre-operative planning of a new semi-implantable bone conduction hearing device.

PURPOSE: Accommodating a novel semi-implantable bone conduction hearing device within the temporal bone presents challenges for surgical planning. This study describes the utility of CT in pre-operative assessment of such an implant. METHODS: Retrospective review of pre-operative CT, clinical and surgical records of 16 adults considered for device implantation. Radiological suitability was assessed on CT using 3D simulation software. Antero-posterior (AP) dimensions of the mastoid bone and minimum skull thickness were measured. CT planning results were correlated with operative records. RESULTS: Eight and five candidates were suitable for device placement in the transmastoid and retrosigmoid positions, respectively, and three were radiologically unsuitable. The mean AP diameter of the mastoid cavity was 14.6 mm for the transmastoid group and 4.6 mm for the retrosigmoid group (p < 0.05). Contracted mastoid and/or prior surgery were predisposing factors for unsuitability. Four transmastoid and five retrosigmoid positions required sigmoid sinus/dural depression and/or use of lifts due to insufficient bone capacity. CONCLUSION: A high proportion of patients being considered have contracted or operated mastoids, which reduces the feasibility of the transmastoid approach. This finding combined with the complex temporal bone geometry illustrates the importance of careful CT evaluation using 3D software for precise device simulation. KEY POINTS: • Preoperative temporal bone CT is essential for determining Bonebridge device suitability. • Mastoid under-pneumatisation and prior mastoidectomy predict a retrosigmoid Bonebridge position. • 3D simulation software is recommended for precise device positioning.

Atypical intracranial epidermoid cysts: rare anomalies with unique radiological features.

Epidermoid cysts are benign slow growing extra-axial tumours that insinuate between brain structures, while their occurrences in intra-axial or intradiploic locations are exceptionally rare. We present the clinical, imaging, and pathological findings in two patients with atypical epidermoid cysts. CT and MRI findings for the first case revealed an intraparenchymal epidermoid cyst that demonstrated no restricted diffusion. The second case demonstrated an aggressive epidermoid cyst that invaded into the intradiploic spaces, transverse sinus, and the calvarium. The timing of ectodermal tissue sequestration during fetal development may account for the occurrence of atypical epidermoid cysts.

Radiological diagnosis and management of idiopathic spontaneous intra-abdominal haemorrhage (abdominal apoplexy): a case series.

PURPOSE: Idiopathic spontaneous intraperitoneal haemorrhage (ISIH), historically known as abdominal apoplexy, is spontaneous haemorrhage due to rupture of an intra-abdominal visceral vessel in the absence of trauma or underlying pathology. It is an exceptionally rare condition, with mostly scattered case reports available. The aim of this study was to describe this rare condition, possible associated risk factors, and usefulness of multislice-CT (MS-CT) angiogram in its diagnosis prior to intervention. METHODS: A retrospective review of patients diagnosed with ISIH. Radiological records of haemoperitoneum from a single tertiary hospital in 2006-2013 were analysed, and the cases of ISIH were identified. Demographics (including pre-morbid hypertension status), abdominal aortic calcification as a measure of atherosclerotic changes, MS-CT angiogram +/- conventional digital subtraction angiograph images, surgical records and outcomes were reviewed. RESULTS: 425 cases of haemoperitoneum were retrieved from hospital radiology database from 2006 to 2013, and 5 patients (1.1%) diagnosed with ISIH were identified (4 males, 1 female, mean age of 64 years). 4 out of 5 patients (80%) had a history of hypertension (mean 150/90 mmHg) and 3 patients had moderate abdominal aortic atherosclerosis. MS-CT angiogram was able to diagnose the bleeding source in 4 out of 5 patients, while the bleeding source remained occult in the last patient even with both MS-CT and traditional DSA angiography. Patients who underwent either embolization or surgery had no further re-bleeding in clinical follow up, ranging from 5 to 8 years. CONCLUSIONS: Hypertension and abdominal aortic atherosclerosis appear to be associated risk factors for ISIH, and MS-CT angiogram has a high sensitivity in detecting the site of haemorrhage. An integrated angiographic and surgical approach is important in managing patients with ISIH.

Spinal nerve root haemangioblastoma associated with reactive polycythemia.

Haemangioblastomas are uncommon tumours that usually occur in the cerebellum and, less commonly, in the intramedullary spinal cord. The extramedullary spinal canal is an uncommon location for these tumours. Also haemangioblastoma at this site is not known to be associated with polycythemia. We present the clinical, imaging, and histological findings of an adult patient with extramedullary spinal haemangioblastoma and reactive polycythemia. Radiography and computed tomography (CT) revealed a medium-sized tumour that most likely arose from an extramedullary spinal nerve root. This tumour appeared to be slow growing as evidenced by the accompanying well-defined bony resorption with a sclerotic rim and mild neural foraminal widening. Magnetic resonance imaging revealed prominent flow voids consistent with tumoural hypervascularity. CT-guided biopsy was performed. Although preoperative angiographic embolisation was technically successful, excessive intraoperative tumour bleeding necessitated tumour debulking rather than complete tumour resection. Histology of the resected specimen revealed haemangioblastoma. Seven months postoperatively, the patients back pain and polycythemia have resolved.