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OBJECTIVE: This study aimed to prospectively assess outcomes for surgical autologous fat transfer (AFT) applied for traumatic and postsurgical craniofacial deformities. The minimally invasive nature of AFT has potential for reduced risk and superior outcomes compared with current reconstructive options. BACKGROUND: Craniofacial deformities have functional and psychosocial sequelae and can profoundly affect quality of life. Traditional reconstructive options are invasive, invasive, complex, and often lack precision in outcomes. Although AFT is safe, effective, and minimally invasive, only anecdotal evidence exists for reconstruction of craniofacial deformities. METHODS: In this Institutional Review Board-approved prospective cohort study, 20 subjects underwent AFT (average volume: 23.9â±â13.2âmL). Volume retention over time was determined using high-resolution computed tomography. Flow cytometry was used to assess cellular subpopulations and viability in the stromal vascular fraction. Quality of life assessments were performed. After the completion of 9-month follow-up, 5 subjects were enrolled for a second treatment. RESULTS: No serious adverse events occurred. Volume retention averaged 63â±â17% at 9 months. Three-month retention strongly predicted 9-month retention (r=0.996, P < 0.0001). There was no correlation between the total volume injected and retention. Patients undergoing a second procedure had similar volume retention as the first (P = 0.05). Age, sex, body mass index, and stromal vascular fraction cellular composition did not impact retention. Surprisingly, former smokers had greater volume retention at 9 months compared with nonsmokers (74.4% vs 56.2%, P = 0.009). Satisfaction with physical appearance (P = 0.002), social relationships (P = 0.02), and social functioning quality of life (P = 0.05) improved from baseline to 9 months. CONCLUSIONS: For craniofacial defects, AFT is less invasive and safer than traditional reconstructive options. It is effective, predictable, and reaches volume stability at 3 months. Patient-reported outcomes demonstrate a positive life-changing impact.
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Tecido Adiposo/transplante , Anormalidades Craniofaciais/cirurgia , Medidas de Resultados Relatados pelo Paciente , Procedimentos de Cirurgia Plástica/métodos , Qualidade de Vida , Adulto , Anormalidades Craniofaciais/diagnóstico , Feminino , Seguimentos , Sobrevivência de Enxerto , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Tomografia Computadorizada por Raios X , Transplante Autólogo , Adulto JovemRESUMO
OBJECTIVES: The use of cone-beam computed tomography (CBCT) is well-established in clinical practice. This study seeks to categorize and quantify the incidental finding (IF) rate on CBCT in patients with cleft lip and palate (CLP) prior to orthodontic or surgical treatment. METHODS: This is systematic retrospective review of head and neck CBCTs in patients with nonsyndromic CLP taken between 2012 and 2019 at a single tertiary referral center. All assessments were performed independently by 4 observers (a head and neck radiologist and 3 orthodontists, including 2 fellowship-trained cleft-craniofacial orthodontists ). The images were divided into 9 anatomical areas and screened using serial axial slices and 3D reconstructions. The absolute number of IFs was reported for each area and statistical analysis was performed. RESULTS: Incidental findings were found in 106 (95.5%) of the 111 patients. The most common sites were the maxilla (87.4%, principally dental anomalies), paranasal sinuses (46.8%, principally inflammatory opacification), and inner ear cavities (18.9%, principally inflammatory opacification). Eleven patients had skull malformations. Thirty-three patients had IFs in 1 anatomical area, 49 patients in 2 anatomical areas, 19 patients in 3 areas, and 5 patients presented with IFs in 4 of the 9 anatomical areas. DISCUSSION: In patients with CLP, IFs on CBCT exam were present in the majority of cases. Most patients with IFs had them in multiple anatomical areas of the head and neck. The maxillary dental-alveolar complex was the most common area. Inflammatory changes in the inner ear cavities and paranasal sinuses were also common; however, cervical spine and skull abnormalities were also identified. Clinicians caring for patients with CLP should be aware of IFs, which may warrant further investigation and treatment.
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Fenda Labial , Fissura Palatina , Tomografia Computadorizada de Feixe Cônico , Humanos , Achados Incidentais , Estudos RetrospectivosRESUMO
OBJECTIVE: Advances in 3-dimensional (3D) printing technology permit the rapid creation of detailed anatomical models. Integration of this technology into neurosurgical practice is still in its nascence, however. One potential application is to create models depicting neurosurgical pathology. The goal of this study was to assess the clinical value of patient-specific 3D printed models for neurosurgical planning and education. METHODS: The authors created life-sized, patient-specific models for 4 preoperative cases. Three of the cases involved adults (2 patients with petroclival meningioma and 1 with trigeminal neuralgia) and the remaining case involved a pediatric patient with craniopharyngioma. Models were derived from routine clinical imaging sequences and manufactured using commercially available software and hardware. RESULTS: Life-sized, 3D printed models depicting bony, vascular, and neural pathology relevant to each case were successfully manufactured. A variety of commercially available software and hardware were used to create and print each model from radiological sequences. The models for the adult cases were printed in separate pieces, which had to be painted by hand, and could be disassembled for detailed study, while the model for the pediatric case was printed as a single piece in separate-colored resins and could not be disassembled for study. Two of the models were used for patient education, and all were used for presurgical planning by the surgeon. CONCLUSIONS: Patient-specific 3D printed models are useful to neurosurgical practice. They may be used as a visualization aid for surgeons and patients, or for education of trainees.
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Imageamento Tridimensional/métodos , Modelos Anatômicos , Neurocirurgia/educação , Medicina de Precisão/métodos , Cuidados Pré-Operatórios/métodos , Impressão Tridimensional , Adenocarcinoma , Idoso , Pré-Escolar , Angiografia por Tomografia Computadorizada , Fossa Craniana Posterior/diagnóstico por imagem , Craniofaringioma/diagnóstico por imagem , Craniofaringioma/cirurgia , Feminino , Humanos , Imageamento por Ressonância Magnética , Masculino , Neoplasias Meníngeas/diagnóstico por imagem , Neoplasias Meníngeas/cirurgia , Meningioma/diagnóstico por imagem , Meningioma/cirurgia , Pessoa de Meia-Idade , Segunda Neoplasia Primária/diagnóstico por imagem , Segunda Neoplasia Primária/cirurgia , Neuroimagem , Neoplasias Hipofisárias/diagnóstico por imagem , Neoplasias Hipofisárias/cirurgia , Neoplasias da Próstata , Neuralgia do Trigêmeo/diagnóstico por imagem , Neuralgia do Trigêmeo/etiologia , Neuralgia do Trigêmeo/cirurgiaRESUMO
Although spontaneous regression of herniated disk material has been reported in the lumbar and cervical spine, reports of complete spontaneous regression of calcified thoracic disk herniations are exceedingly rare. In symptomatic patients, surgery is typically the treatment of choice; however, conservative therapy with surveillance may allow time for spontaneous resolution and potentially avoid high-risk surgery. We report a 40-year-old woman with complete spontaneous resolution of a large calcified thoracic disk extrusion with conservative management over an 8-month period.
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Calcinose/diagnóstico por imagem , Deslocamento do Disco Intervertebral/diagnóstico por imagem , Vértebras Torácicas , Adulto , Vértebras Cervicais , Tratamento Conservador/métodos , Feminino , Humanos , Disco Intervertebral/diagnóstico por imagem , Deslocamento do Disco Intervertebral/terapia , Imageamento por Ressonância Magnética , Remissão Espontânea , Compressão da Medula Espinal/diagnóstico por imagem , Compressão da Medula Espinal/etiologiaRESUMO
OBJECTIVE: The purpose of our study was to determine the diagnostic and therapeutic yield of the head and abdomen portions of PET/CT scans of patients with head and neck squamous cell cancer (HNSCC) to determine whether these areas should be routinely included with PET/CT of the neck and chest. MATERIALS AND METHODS: Patients with pathologically proven HNSCC who underwent full-body PET/CT were evaluated for metastases to the head, chest, and abdomen. Medical records were reviewed to determine whether the head and abdominal findings changed the clinical management, beyond the findings in the neck and chest. RESULTS: Five hundred ninety-eight patients who underwent 1625 PET/CT scans were included. All studies included the head, neck, and chest. For 542 of 598 patients (91%), the PET/CT scans included the abdomen. Two of 598 patients (0.3%) had distant calvarial metastases. Neither of the calvarial metastases changed patient management. Twelve of 542 patients (2.2%) had abdominal metastases. For 10 of 542 patients (1.8%), the abdominal findings changed patient management. Thoracic metastases were found in 82 of 598 patients (13.7%). The total rate of distant metastases to the head and abdomen in patients with thoracic metastatic disease was 12.2% (10/82), whereas in patients without thoracic metastases, it was 0.8% (4/460). CONCLUSION: Routine extension of PET/CT scans to include the head and abdomen in patients with HNSCC is not indicated. For patients without evidence of thoracic metastases, routine PET/CT examinations should include the neck and chest only.
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Neoplasias Abdominais/diagnóstico por imagem , Neoplasias Abdominais/secundário , Carcinoma de Células Escamosas/diagnóstico por imagem , Neoplasias de Cabeça e Pescoço/diagnóstico por imagem , Tomografia por Emissão de Pósitrons combinada à Tomografia Computadorizada/estatística & dados numéricos , Neoplasias Cranianas/dietoterapia , Neoplasias Cranianas/secundário , Neoplasias Abdominais/epidemiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Carcinoma de Células Escamosas/epidemiologia , Fluordesoxiglucose F18 , Neoplasias de Cabeça e Pescoço/epidemiologia , Humanos , Pessoa de Meia-Idade , Pennsylvania/epidemiologia , Prevalência , Compostos Radiofarmacêuticos , Reprodutibilidade dos Testes , Fatores de Risco , Sensibilidade e Especificidade , Neoplasias Cranianas/epidemiologia , Carcinoma de Células Escamosas de Cabeça e PescoçoRESUMO
PURPOSE: The purpose of this study was to determine whether Meniere's disease (MD) produces endolymphatic cavity size changes that are detectable using unenhanced high-resolution T2-weighted MRI. MATERIALS & METHODS: This retrospective case-control study included patients with documented MD who had a high-resolution T2-weighted or steady-state free procession MRI of the temporal bones within one month of diagnosis, between 2002 and 2015. Patients were compared to age- and sex- matched controls. Cross sectional area, length, and width of the vestibule and utricle were measured in both ears along with the width of the basal turn of the cochlea and its endolymphatic space. Absolute measurements and ratios of endolymph to perilymph were compared between affected, contralateral, and control ears using analysis of variance and post-hoc pairwise comparisons. RESULTS: Eighty-five case-control pairs were enrolled. Mean utricle areas for affected, contralateral, and control ears were 0.038cm2, 0.037cm2, and 0.033cm2. Mean area ratios for affected, contralateral, and control ears were 0.32, 0.32, and 0.29. There was a statistically significant difference between groups for these two variables; post-hoc comparisons revealed no difference between affected and contralateral ears in Meniere's patients, while ears in control patients were different from the ears of patients with MD. All other measurements failed to show significant differences. CONCLUSIONS: Enlargement of the endolymphatic cavity can be detected using non-contrast T2-weighted MRI. MRI, using existing protocols, can be a useful diagnostic tool for the evaluation of MD, and intratympanic or delayed intravenous contrast may be unnecessary for this diagnosis.
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Imageamento por Ressonância Magnética , Doença de Meniere/diagnóstico por imagem , Adulto , Idoso , Cóclea/diagnóstico por imagem , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Curva ROC , Estudos Retrospectivos , Vestíbulo do Labirinto/diagnóstico por imagemRESUMO
OBJECTIVE: Trigeminal neuralgia is a debilitating facial pain disorder, frequently caused by vascular compression of the trigeminal nerve. Vascular compression that results in trigeminal neuralgia occurs along the cisternal segment of the nerve. CONCLUSION: Imaging combined with clinical information is critical to correctly identify patients who are candidates for microvascular decompression. The purpose of this article is to review trigeminal nerve anatomy and to provide strategies for radiologists to recognize important MRI findings in patients with trigeminal neuralgia.
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Imageamento por Ressonância Magnética , Síndromes de Compressão Nervosa/etiologia , Nervo Trigêmeo/anatomia & histologia , Neuralgia do Trigêmeo/diagnóstico , Doenças Vasculares/complicações , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Síndromes de Compressão Nervosa/cirurgia , Nervo Trigêmeo/patologia , Nervo Trigêmeo/cirurgia , Neuralgia do Trigêmeo/etiologia , Neuralgia do Trigêmeo/cirurgia , Doenças Vasculares/cirurgiaRESUMO
OBJECTIVE: Headaches due to CSF leak are a well-described complication of dural puncture. It is uncertain how long patients should be observed after dural puncture to reduce the risk of headache. Most of the literature has focused on dural punctures performed without fluoroscopic guidance. The purpose of this study was to determine the incidence of complications from fluoroscopically guided dural punctures, with attention to predictive factors such as the length of bed rest after the procedure. MATERIALS AND METHODS: We retrospectively reviewed 2141 fluoroscopically guided dural punctures performed over a 5-year period by a single radiology practitioner assistant. All patients were contacted 48-72 hours after the procedure to assess for complications. Complications were categorized according to whether the patient reported having severe headache (requiring epidural blood patch for treatment), any headache, or any complaint. Using a multivariate logistic regression model, we assessed several possible predictors of complication: patient age, patient sex, needle caliber, puncture site, distance driven after recovery, length of postprocedural bed rest, contrast concentration, and contrast volume. RESULTS: In all, 0.8% of patients reported having a severe headache, 2.2% reported having any headache, and 2.6% reported having any complaint. In the multivariate analysis, age and sex were predictive of complication rates (with younger women having higher rates), but the other variables were not predictive. In particular, length of postprocedural bed rest showed statistical equivalence. CONCLUSION: Fluoroscopically guided dural punctures result in few complications compared with lumbar punctures performed without fluoroscopic guidance. Postprocedural bed rest greater than 2 hours does not reduce complication rates for fluoroscopically guided lumbar punctures.
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Cefaleia/epidemiologia , Mielografia/métodos , Complicações Pós-Operatórias/epidemiologia , Radiografia Intervencionista , Punção Espinal , Adolescente , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Repouso em Cama , Meios de Contraste , Feminino , Fluoroscopia , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Agulhas , Estudos Retrospectivos , Fatores de Risco , Fatores Sexuais , ViagemRESUMO
PURPOSE: Given the problems of overuse of medical technology and the current burden of health care cost in the United States, it is important to establish clear imaging guidelines to diagnose conditions such as juvenile ossifying fibroma (JOF). This study compared the efficacy of computed tomography (CT) and magnetic resonance imaging (MRI) in the evaluation of JOF and thus could aid establishing such guidelines. MATERIALS AND METHODS: Radiologic criteria were established by 2 radiologists to compare the efficacy of CT and MRI in the evaluation of JOF. The following parameters were compared: presence of a well-defined corticated border, presence of a well-delineated internal calcified component, fluid-to-fluid levels, and anatomic extent of the lesion. Six patients diagnosed with JOF of the craniofacial bones from 2002 to 2013 had preoperative CT and MRI studies available for review. RESULTS: After review of CT and MRI images, fluid-to-fluid levels and anatomic extent of the lesions were comparable on CT and MRI. However, the corticated borders and the internal calcified component were better defined on CT images, which also enabled for distinction between the 2 subtypes of JOF. No MRI characteristics were identified that allowed for this distinction. CONCLUSION: Based on these findings, CT is an adequate and preferable imaging modality in the evaluation of JOF.
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Fibroma Ossificante/diagnóstico , Imageamento por Ressonância Magnética/métodos , Neoplasias Cranianas/diagnóstico , Tomografia Computadorizada por Raios X/métodos , Adolescente , Adulto , Calcinose/diagnóstico , Calcinose/diagnóstico por imagem , Criança , Pré-Escolar , Meios de Contraste , Feminino , Fibroma Ossificante/diagnóstico por imagem , Humanos , Processamento de Imagem Assistida por Computador/métodos , Masculino , Estudos Retrospectivos , Neoplasias Cranianas/diagnóstico por imagemRESUMO
We present the first report of a case of hemifacial spasm caused by an anomalous, enlarged branch of the ascending pharyngeal artery and treated with microvascular decompression. Clinicians must appreciate unusual causes of hemifacial spasm so that patients are not denied a curative operation due to atypical radiographic findings.
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Hemifacial spasm (HFS) is a condition that may severely reduce patients' quality of life. We sought to determine the sensitivity and specificity of thin-slice T2 magnetic resonance imaging (MRI) for detecting vascular compression in HFS patients. Prospective information was collected on 28 patients with HFS who presented to our center between March 2011 and March 2012 with thin-slice T2 MR imaging. The sensitivity and specificity for differentiating patients from controls were calculated. Sensitivities were 78.6% and 92.9% for the blinded radiologists and 75% for the partially blinded neurosurgeon. Specificities were 42.9% and 28.6% for the blinded radiologists and 75% for the partially blinded neurosurgeon. Magnetic resonance imaging of the facial nerve can guide clinicians in selecting patients who are good surgical candidates. Thin-slice T2 MRI should be viewed as supportive rather than diagnostic.
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Espasmo Hemifacial/patologia , Imageamento por Ressonância Magnética , Microvasos/patologia , Estudos de Casos e Controles , Transtornos Cerebrovasculares/etiologia , Transtornos Cerebrovasculares/patologia , Nervo Facial/patologia , Feminino , Espasmo Hemifacial/cirurgia , Humanos , Processamento de Imagem Assistida por Computador , Masculino , Cirurgia de Descompressão Microvascular/métodos , Pessoa de Meia-Idade , Sensibilidade e EspecificidadeRESUMO
BACKGROUND AND OBJECTIVES: Classical trigeminal neuralgia (cTN) is a painful disease. Microvascular decompression (MVD) provides immediate and durable relief in many patients. A variety of positive and negative prognostic biomarkers for MVD have been identified. The sagittal angle of the trigeminal nerve at the porus trigeminus (SATNaPT) is an MRI biomarker that can identify a subset of patients with cTN whose trigeminal nerve anatomy is different from normal controls. The purpose of this case-control study was to determine whether an abnormally hyperacute SATNaPT is a negative prognostic biomarker in patients with cTN undergoing MVD. METHODS: Preoperative MRIs from 300 patients with cTN who underwent MVD were analyzed to identify patients with a hyperacute SATNaPT (defined as less than 3 SDs below the mean). The rate of surgical success (pain-free after at least 12 months) was compared between patients with a hyperacute SATNaPT and all other patients. RESULTS: Patients without a hyperacute SATNaPT had an 82% likelihood of surgical success, whereas patients with a hyperacute SATNaPT had a 58% likelihood of surgical success ( P < .05). Patients with a hyperacute SATNaPT who also had no evidence of vascular compression on preoperative MRI had an even lower likelihood of success (29%, P < .05). CONCLUSION: In patients with cTN being considered for MVD, a hyperacute SATNaPT is a negative prognostic biomarker that predicts a higher likelihood of surgical failure. Patients with a hyperacute SATNaPT, particularly those without MRI evidence of vascular compression, may benefit from other surgical treatments or a modification of MVD to adequately address the underlying cause of cTN.
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Cirurgia de Descompressão Microvascular , Neuralgia do Trigêmeo , Humanos , Neuralgia do Trigêmeo/diagnóstico por imagem , Neuralgia do Trigêmeo/cirurgia , Neuralgia do Trigêmeo/etiologia , Cirurgia de Descompressão Microvascular/efeitos adversos , Estudos de Casos e Controles , Nervo Trigêmeo/diagnóstico por imagem , Nervo Trigêmeo/cirurgia , Resultado do Tratamento , Biomarcadores , Estudos RetrospectivosRESUMO
In this article, we review the normal embryology of the thyroid gland, categorize the ways in which this embryology can fail, and describe how those failures manifest clinically and radiologically. Finally, we describe a new manifestation of abnormal thyroid embryology. Laryngoscope, 134:995-997, 2024.
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Doenças da Glândula Tireoide , Glândula Tireoide , Humanos , Glândula Tireoide/embriologiaRESUMO
This article reviews the system of facial buttresses and discusses the role of diagnostic imaging in the evaluation of the patient with maxillofacial trauma.
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Traumatismos Maxilofaciais , Fraturas Cranianas , Humanos , Traumatismos Maxilofaciais/diagnóstico por imagem , Face , Diagnóstico por ImagemRESUMO
OBJECTIVE: The purpose of this research is to more precisely quantify the positivity rate for conventional radiographs (CR) of the orbit performed for the purpose of pre-MR screening in patients at risk of having a radio-opaque orbital foreign body (ROFB). METHODS: By review of electronic medical records, we identified 47,237 patients who had undergone orbital CR for clearance of ROFB prior to MRI. The reports from these examinations were manually reviewed, and the examinations with positive findings were re-interpreted by a CAQ-certified head and neck radiologist. The rate of ROFB found in these examinations was reported and compared to historical estimates in the literature. RESULTS: 328 of the 47,237 examinations (0.69 %) were originally interpreted as positive for ROFB. Upon re-review, only 39 of the 47,237 examinations (0.083 %, 95 % CI 0.06 %-0.11 %) contained ROFB that were in locations that posed a risk to ocular or vascular structures or were in an equivocal location. Almost all of the patients with false-positive initial interpretations had been denied MRI. DISCUSSION: The rate of ROFB discovered on clearance CR of the orbits prior to MRI is far less than previously estimated in the radiology literature. More conservative guidelines for MR clearance may be useful to reduce costs, mitigate imaging delays, and avoid unnecessary denial of imaging.
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Corpos Estranhos no Olho , Doenças Orbitárias , Humanos , Corpos Estranhos no Olho/diagnóstico por imagem , Corpos Estranhos no Olho/etiologia , Metais , Radiografia , Imageamento por Ressonância Magnética , Órbita/diagnóstico por imagemRESUMO
OBJECTIVES: Implantable hypoglossal nerve stimulation (HNS) therapy is an evolving therapeutic alternative for patients with refractory obstructive sleep apnea (OSA). The muscular anatomy of this region has implications for surgical access through this zone as well as positioning and anchoring of hardware in this area. The purpose of this study was to radiologically describe the topography of the mylohyoid muscle and adjacent structures across a wide age spectrum. METHODS: We retrospectively evaluated computed tomography scans of the neck in 102 patients who were imaged for reasons unrelated to the floor of mouth or submental space. Patients with prior surgery or pathology in the area of interest were excluded. Fourteen relevant muscle measurements were made on a midline sagittal image and a coronal image positioned at the midpoint between the hyoid bone and the mandible. RESULTS: We included 49 men and 53 women with an average age of 44 years (range 19-70). The average mylohyoid length was 42 mm; the average distance between the anterior digastric bellies was 17 mm. The average angle of the central mylohyoid was 174° in the sagittal plane and 164° in the coronal plane. Several measurements were significantly correlated with patient age, including the angle measurements and the distance between the digastric muscles. Aberrant digastric anatomy was common. CONCLUSIONS: The mylohyoid muscle has multiple radiologically distinct segments with predictable curvatures. An understanding of submental muscular anatomy, along with its variability between patients, may be beneficial to the development of bilateral implantable neurostimulation technology for the treatment of refractory OSA. LEVEL OF EVIDENCE: N/A Laryngoscope, 134:2970-2975, 2024.
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Músculos do Pescoço , Humanos , Masculino , Adulto , Pessoa de Meia-Idade , Idoso , Idoso de 80 Anos ou mais , Músculos do Pescoço/anatomia & histologia , Músculos do Pescoço/diagnóstico por imagem , Estudos Retrospectivos , Tomografia Computadorizada por Raios XRESUMO
Our rationale was to review the imaging options for patients with primary hyperparathyroidism and to advocate for judicious use of 4-dimensional (4D) SPECT/CT to visualize diseased parathyroid glands in patients with complex medical profiles or in whom other imaging modalities fail. We review the advantages and disadvantages of traditional imaging modalities used in preoperative assessment of patients with primary hyperparathyroidism: ultrasound, SPECT, and 4D CT. We describe a scheme for optimizing and individualizing preoperative imaging of patients with hyperfunctioning parathyroid glands using traditional modalities in tandem with 4D SPECT/CT. Using the input from radiologists, endocrinologists, and surgeons, we apply patient criteria such as large body habitus, concomitant multiglandular disease, multinodular thyroid disease, confusing previous imaging, and unsuccessful previous surgery to create an imaging paradigm that uses 4D SPECT/CT yet is cost-effective, accurate, and limits extraneous radiation exposure. 4D SPECT/CT capitalizes on the strengths of SPECT and 4D CT and addresses limitations that exist when these modalities are used in isolation. In select patients with complicated clinical parameters, preoperative imaging with 4D SPECT/CT can improve accuracy yet remain cost-effective.