Proton Density MRI Increases Detection of Cervical Spinal Cord Multiple Sclerosis Lesions Compared with T2-Weighted Fast Spin-Echo.

BACKGROUND AND PURPOSE: There is a paucity of literature that supports the Consortium of Multiple Sclerosis Centers guideline that proton density MR imaging is a core spinal cord sequence. We hypothesized that proton density fast spin-echo imaging is superior to T2 fast spin-echo MR imaging for the detection of cervical cord MS lesions. This study compared the detection rate and conspicuity of cervical cord MS lesions on sagittal 1.5T proton density fast spin-echo and T2 fast spin-echo MR imaging. MATERIALS AND METHODS: One hundred consecutive patients with MS imaged with 1.5T sagittal proton density fast spin-echo and T2 fast spin-echo cervical cord MR imaging between September 2012 and October 2013 were retrospectively included. The number of MS lesions detected on each sequence was recorded; conspicuity was assessed quantitatively with the lesion-to-cord contrast ratio and lesion-contrast-to-noise ratio. Statistical analysis was performed by using the Wilcoxon signed rank test. RESULTS: Seventy-eight patients had MS cord lesions detected. Proton density fast spin-echo imaging detected a greater number of lesions (n = 181) compared with T2 fast spin-echo imaging (n = 137, P < .001). Fifteen patients (19%) with abnormal findings on proton density fast spin-echo imaging had normal findings on T2 fast spin-echo imaging; no patient with abnormal T2 fast spin-echo imaging findings had normal proton density fast spin-echo imaging findings. Although proton density fast spin-echo and T2 fast spin-echo imaging had similar lesion-to-cord contrast ratios (proton density fast spin-echo, 0.32 ± 0.01, versus T2 fast spin-echo, 0.33 ± 0.01; P = .43), proton density fast spin-echo had greater lesion-contrast-to-noise ratio (proton density fast spin-echo, 82 ± 3.0, versus T2 fast spin-echo, 64 ± 2.6; P < .001). CONCLUSIONS: Proton density fast spin-echo imaging is superior to T2 fast spin-echo MR imaging for the detection of cervical cord MS lesions. Proton density fast spin-echo detects cord lesions in patients in whom T2 fast spin-echo findings appear normal. This study forms the evidentiary base for the current Consortium of Multiple Sclerosis Centers guideline that proton density imaging is a core spinal cord sequence.

Risedronate in adults with osteogenesis imperfecta type I: increased bone mineral density and decreased bone turnover, but high fracture rate persists.

UNLABELLED: Bisphosphonates can increase bone mineral density (BMD) in children with osteogenesis imperfecta (OI). In this study of adults with OI type I, risedronate increased BMD at lumbar spine (but not total hip) and decreased bone turnover. However, the fracture rate in these patients remained high. INTRODUCTION: Intravenous bisphosphonates given to children with OI can increase BMD and reduce fracture incidence. Oral and/or intravenous bisphosphonates may have similar effects in adults with OI. We completed an observational study of the effect of risedronate in adults with OI type I. METHODS: Thirty-two adults (mean age, 39 years) with OI type I were treated with risedronate (total dose, 35 mg weekly) for 24 months. Primary outcome measures were BMD changes at lumbar spine (LS) and total hip (TH). Secondary outcome measures were fracture incidence, bone pain, and change in bone turnover markers (serum procollagen type I aminopropeptide (P1NP) and bone ALP). A meta-analysis of published studies of oral bisphosphonates in adults and children with OI was performed. RESULTS: Twenty-seven participants (ten males and seventeen females) completed the study. BMD increased at LS by 3.9% (0.815 vs. 0.846 g/cm(2), p = 0.007; mean Z-score, -1.93 vs. -1.58, p = 0.002), with no significant change at TH. P1NP fell by 37% (p = 0.00041), with no significant change in bone ALP (p = 0.15). Bone pain did not change significantly (p = 0.6). Fracture incidence remained high, with 25 clinical fractures and 10 major fractures in fourteen participants (0.18 major fractures per person per year), with historical data of 0.12 fractures per person per year. The meta-analysis did not demonstrate a significant difference in fracture incidence in patients with OI treated with oral bisphosphonates. CONCLUSIONS: Risedronate in adults with OI type I results in modest but significant increases in BMD at LS, and decreased bone turnover. However, this may be insufficient to make a clinically significant difference to fracture incidence.

Multicentric/multifocal cerebral lesions: can fluid-attenuated inversion recovery aid the differentiation between glioma and metastases?

The purpose of the study was to assess whether non-enhancing adjacent cortical signal intensity abnormality detected on fluid-attenuated inversion recovery (FLAIR) can differentiate between multicentric and/or multifocal glioma and non-glioma pathology in patients with multiple enhancing cerebral lesions. Nineteen MR studies were reviewed after a database search and exclusion criteria applied, to detect areas of FLAIR cortex involvement without enhancement. Statistical analysis was carried out using a 2 x 2 contingency table and Fischer's exact ratio. Non-enhancing adjacent cortical T2 signal abnormality was seen in eight of eight multicentric and/or multifocal gliomas and four of 11 of the non-glioma pathologies (10 metastatic disease and 1 lymphoma). The presence of non-enhancing adjacent cortical T2 signal abnormality had a sensitivity of 100% and specificity of 63% for glioma. The positive predictive value was 67% and negative predictive value 100%. Fischer's exact probability test was P = 0.01 when applied to the glioma versus non-glioma categories, indicating a significant difference. Non-enhancing adjacent cortical T2-weighted FLAIR signal appears to be more frequently seen in patients with glioma and multiple enhancing lesions compared with those with glioma and a solitary enhancing cerebral lesion. The absence of this sign favours metastatic disease and the presence suggests that multicentric and/or multifocal glioma should remain a consideration.

T1 hyperintense vertebral column melanoma metastases.

We report a case of T1 hyperintense vertebral column metastatic disease in a 24-year-old man with metastatic melanoma. Radiologic work-up revealed multiple lytic vertebral metastases on CT with corresponding T1 hyperintensity on MR imaging. Whereas T1 hyperintensity associated with melanoma has been well documented, to our knowledge, this is the first described case of widespread T1 hyperintense metastatic bone disease. T1 hyperintense bone lesions are virtually always benign. However, correlation with the lesion appearances on other MR imaging sequences and imaging modalities as well as with the clinical history may occasionally suggest otherwise.

Metastatic choriocarcinoma: a rare cause of stroke in the young adult.

A 20-year old woman presented with acute right hemiplegia 10 weeks after intrauterine fetal death at 34-weeks gestation (G1P0). A brain MRI showed a typical acute infarct in the left middle cerebral artery territory. A CT pulmonary angiography carried out 1 week later for sudden cardiopulmonary deterioration showed disseminated pulmonary metastases. The CT was extended to the abdomen and pelvis, which showed a uterine mass with bilateral theca lutein cysts. The radiological diagnosis of metastatic choriocarcinoma was made and was subsequently confirmed with the markedly increased serum beta-human chorionic gonadotrophin. A serum beta-human chorionic gonadotrophin is therefore considered worthwhile in any young female adult who presents with stroke.

Perihepatitis associated with systemic lupus erythematosus: computed tomography findings.

The imaging findings of a 29-year-old woman with known systemic lupus erythematosus, and a clinical presentation and CT appearances consistent with perihepatitis are presented.

Cost effectiveness of adding magnetic resonance imaging to the usual management of suspected scaphoid fractures.

OBJECTIVE: To determine the cost effectiveness of a magnetic resonance imaging scan (MRI) within 5 days of injury compared with the usual management of occult scaphoid fracture. METHODS: All patients with suspected scaphoid fractures in five hospitals were invited to participate in a randomised controlled trial of usual treatment with or without an MRI scan. Healthcare costs were compared, and a cost effectiveness analysis of the use of MRI in this scenario was performed. RESULTS: Twenty eight of the 37 patients identified were randomised: 17 in the control group, 11 in the MRI group. The groups were similar at baseline and follow up in terms of number of scaphoid fractures, other injuries, pain, and function. Of the patients without fracture, the MRI group had significantly fewer days immobilised: a median of 3.0 (interquartile range 3.0-3.0) v 10.0 (7-12) in the control group (p = 0.006). The MRI group used fewer healthcare units (median 3.0, interquartile range 2.0-4.25) than the control group (5.0, 3.0-6.5) (p = 0.03 for the difference). However, the median cost of health care in the MRI group (594.35 dollars AUD, 551.35-667.23 dollars) was slightly higher than in the control group (428.15 dollars, 124.40-702.65 dollars) (p = 0.19 for the difference). The mean incremental cost effectiveness ratio derived from this simulation was that MRI costs 44.37 dollars per day saved from unnecessary immobilisation (95% confidence interval 4.29 dollars to 101.02 dollars). An illustrative willingness to pay was calculated using a combination of the trials measure of the subjects' individual productivity losses and the average daily earnings. CONCLUSIONS: Use of MRI in the management of occult scaphoid fracture reduces the number of days of unnecessary immobilisation and use of healthcare units. Healthcare costs increased non-significantly in relation to the use of MRI in this setting. However, when productivity losses are considered, MRI may be considered cost effective, depending on the individual case.

Longitudinal study of changes in tibial and femoral cartilage in knee osteoarthritis.

OBJECTIVE: Despite the increasing interest in knee cartilage volume as an outcome measure in studies of osteoarthritis (OA), it is unclear what components of knee cartilage will be most useful as markers of structural change in the tibiofemoral joint. This study was undertaken to longitudinally compare changes in femoral and tibial cartilage volume in patients with OA. METHODS: One hundred seventeen patients with knee OA (58.1% women; mean +/- SD age 63.7 +/- 10.2 years) were examined. Femoral and tibial cartilage volumes (medial and lateral tibiofemoral joints) were determined from T1-weighted fat-saturated magnetic resonance images of the knee from coronal views. RESULTS: The study population was followed up for a mean +/- SD of 1.9 +/- 0.2 years. In the medial tibiofemoral joint, the mean +/- SD loss of cartilage was 0.15 +/- 0.30 ml/year for femoral cartilage and 0.10 +/- 0.25 ml/year for tibial cartilage. In the lateral tibiofemoral joint, the average loss was 0.15 +/- 0.22 and 0.12 +/- 0.16 ml/year for femoral and tibial cartilage, respectively. There was a significant correlation between the degree of loss of tibial cartilage and the degree of loss of femoral cartilage, in both tibiofemoral joints (r = 0.81, P < 0.001 at the medial tibiofemoral joint; r = 0.71, P < 0.001 at the lateral tibiofemoral joint). CONCLUSION: Longitudinal changes in tibial cartilage and those in femoral cartilage are strongly related to one another. This suggests that in tibiofemoral disease, measuring tibial cartilage alone may be adequate, given the facts that measurements of the total femoral cartilage are less reproducible and there are difficulties inherent in identifying the most appropriate component of femoral cartilage to measure.

Effect of estrogen replacement therapy on patella cartilage in healthy women.

OBJECTIVES: Patellofemoral osteoarthritis (OA) is a significant cause of morbidity. Epidemiological data suggests that the use of oestrogen replacement therapy (ERT) may protect against tibiofemoral knee OA. However, the effect on patellofemoral OA is unknown. The aim of this study was to test the hypothesis that long term ERT (greater than 5 years) is associated with increased patella cartilage in post menopausal women. METHODS: We studied 81 women (42 current users (> 5 yrs) of oestrogen replacement therapy and 39 never users). Articular cartilage volumes were determined by post-processing images acquired in the sagittal plane using a T1-weighted fat suppressed magnetic resonance sequence on an independent workstation. RESULTS: There was no difference in the amount of patella cartilage in women on ERT compared to women on no ERT. After adjusting for patella bone size, years since menopause, body mass index, age of menopause and smoking, ERT users had 2.07 +/- 0.76 ml of patella cartilage compared to 1.93 +/- 0.89 ml in non-users (P = 0.24 for difference). CONCLUSIONS: This study suggests that use of ERT for more than 5 years does not have a significant effect on patella cartilage, in contrast to the previously described effect on tibial cartilage. The reasons for this are unknown, but may indicate that there are differences in the mechanisms for development of knee OA at these sites.

Tibial and femoral cartilage changes in knee osteoarthritis.

BACKGROUND: Despite the increasing interest in using knee cartilage volume as an outcome measure in studies of osteoarthritis (OA), it is unclear what components of knee cartilage will be most useful as markers of structure in the tibiofemoral (TF) joint. OBJECTIVE: To compare the changes that occur in femoral and tibial cartilage volume in normal and osteoarthritic knees and how they relate to radiological grade. METHODS: 82 subjects (44 female, 38 male, age range 35-69 years) with a spectrum of radiological knee OA were examined. Each subject had femoral and tibial cartilage volume in the medial and lateral TF joint determined from T(1) weighted fat saturated magnetic resonance images of the knee. Radiological grade of OA was determined from standing knee radiographs. RESULTS: There was strong correlation between femoral and tibial cartilage volume measured in both the medial (R=0.75, p<0.001) and lateral TF joint (R=0.77, p<0.001). Similar correlations persisted when those with normal and those with OA joints were examined separately at both the medial and lateral TF joint. For each increase in radiological grade of joint space narrowing (0-3), there was a mean (SD) reduction in tibial cartilage volume of 1.00 (0.32) ml in the medial compartment and 0.53 (0.25) ml in the lateral compartment, after adjusting for differences in bone size. Similar changes were seen in the femoral cartilage. CONCLUSIONS: The amounts of tibial and femoral cartilage are strongly related. It may be that for TF joint disease, measuring tibial cartilage alone may be adequate, given that measurements of the total femoral cartilage are less reproducible and the difficulties inherent in identifying the most appropriate component of femoral cartilage to measure.

Users of oestrogen replacement therapy have more knee cartilage than non-users.

BACKGROUND: Osteoarthritis (OA) is increasingly prevalent in the years after menopause. Epidemiological data suggest that the use of oestrogen replacement therapy (ERT) may protect against knee OA. AIM: To test the hypothesis that long term ERT (longer than five years) is associated with increased knee cartilage in postmenopausal women. METHODS: The study involved 81 women (42 current users (> or = five years) of ERT and 39 who had never used it). Articular cartilage volumes were determined by processing images acquired in the sagittal plane using a T1 weighted fat suppressed magnetic resonance sequence on an independent work station. RESULTS: After bone size had been accounted for, ERT users had higher tibial cartilage volume than non-users. Total tibial cartilage volume was 7.7% (0.23 ml) greater in the group of ERT users (2.98 (0.47) ml; mean (SD)) than in the untreated group (2.75 (0.50) ml). The difference, after adjustment for the significant explanatory factors (years since menopause, body mass index, age at menopause, and smoking), between the ERT users and non-users increased from 0.23 ml to 0.30 ml (95% confidence interval 0.08 to 0.52, p=0.008). These differences persisted after exclusion of women with OA. CONCLUSIONS: After adjustment for multiple confounders, women using long term ERT have more knee cartilage than controls. This may indicate that ERT prevents loss of knee articular cartilage.

Cardiac blood-pool imaging in oncology more than an ejection fraction?

Cardiac function is commonly evaluated in patients with cancer in most nuclear medicine departments. At their dedicated cancer facility, the authors routinely perform a dynamic right anterior oblique first-pass study and a 4-minute left anterior oblique static planar study in addition to the routine equilibrium gated scanning in appropriate projections. Here they show the range of noncardiac disease encountered using this protocol. Useful unexpected information can be obtained from left ventricular ejection studies, and further data may be gained from these simple additions to this common test.

Dilated venous plexus of the hypoglossal canal mimicking disease.

This article describes a case of prominent emissary veins of the hypoglossal canal protruding into the cerebellomedullary cistern mimicking disease, such as a nerve sheath tumor. The diagnosis and differentiation in this instance were confirmed by MR angiography and a review of alternative imaging planes. A diagnosis of hypoglossal canal lesions should be made with caution, as these lesions are quite rare, and vascular anomalies, such as those described, may mimic disease in this region.

Mycobacterium avium complex spinal epidural abscess in an HIV patient.

Although Mycobacterium avium complex (MAC) is the most common opportunistic bacterial infection in AIDS patients, epidural involvement is rare. A case of MAC spinal epidural abscess without vertebral osteomyelitis, that was continuous with presacral and bilateral piriformis muscle inflammation, is reported.

Bone scan findings in Kienböck's disease. A case report with atypical findings and literature review.

The authors present an 18-year-old man who had a 5-month history of a painful left wrist. Despite the prolonged history, discrete photopenia on the blood-pool phase and photopenia relative to the remainder of the ipsilateral carpus on the delayed phase of a bone scan in the region of the lunate was shown. When Kienböck's disease is seen in its late phase, the bone scan findings may be atypical in that they may not show the usual three-phase bone scintigraphic evidence of bone remodeling expected in delayed diagnosis avascular necrosis. A review of the previous literature is presented.

Detection of acoustic schwannoma: use of constructive interference in the steady state three-dimensional MR.

PURPOSE: To compare constructive interference in the steady state (CISS) three-dimensional Fourier transform (3DFT) MR imaging with contrast-enhanced T1-weighted spin-echo MR imaging for accuracy in detecting acoustic schwannoma. METHODS: One hundred twenty-five consecutive patients with possible acoustic schwannoma were examined. The accuracy of CISS-3DFT MR imaging in detecting abnormalities of the cerebellopontine angle, the internal auditory canal, and the inner ear was compared with T1-weighted contrast-enhanced spin-echo MR imaging by independent assessment of both image sets by two observers. RESULTS: The postcontrast T1-weighted MR images revealed 18 cases of unilateral disease of the cerebellopontine angle and/or the internal auditory canal and no case of an abnormal bilateral cerebellopontine angle and/or internal auditory canal. Twelve cases were pathologically proved acoustic schwannomas. One meningioma of the cerebellopontine angle and one metastatic ependymoma to the cerebellopontine angle and the internal auditory canal was encountered. The four remaining cases had a provisional diagnosis of acoustic schwannoma and were scheduled for follow-up imaging and clinical review. Analysis of whether contrast material would have been administered to the appropriate patients (ie, those with disease of the cerebellopontine angle and/or internal auditory canal) according to CISS MR imaging findings revealed a sensitivity of 100% and a specificity of 98% for observer 1 and a sensitivity of 94% and a specificity of 94% for observer 2. CONCLUSION: CISS-3DFT MR imaging, in this patient population, provided high sensitivity and specificity in detecting lesions of the cerebellopontine angle and internal auditory canal; however, further experience is required before a definitive statement regarding the suitability of this technique as a screening procedure can be made. When contrast material cannot be administered, CISS MR imaging may be considered an adequate examination for the evaluation of possible acoustic schwannoma.

Magnetic resonance angiography findings in the early post-carotid endarterectomy period.

This preliminary study was designed to investigate the ability of multiple axial volume three-dimensional fourier transform (3DFT) time-of-flight (TOF) magnetic resonance angiography (MRA) to depict the carotid bifurcation in the early post-carotid endarterectomy period. Five patients underwent intra-operative digital subtraction angiography (DSA) and carotid MRA within 5 days of carotid endarterectomy. An axial volume fast imaging in steady-state precession (FISP) gradient-echo 3DFT TOF carotid MRA technique in this limited series appeared to display accurately the surgically significant abnormalities at the carotid bifurcation after endarterectomy. However, in normal or near-normal intra-operative DSA studies, overestimation of internal carotid artery stenoses was encountered. Postoperative MRA demonstrates potential as a useful non-invasive investigation after carotid endarterectomy but should be interpreted with caution until larger studies become available.