The Black Turbinate Sign, A Potential Diagnostic Pitfall: Evaluation of the Normal Enhancement Patterns of the Nasal Turbinates.

BACKGROUND AND PURPOSE: Lack of enhancement of a nasal turbinate on MR imaging, known as the black turbinate, has been reported as a finding highly suggestive of invasive fungal rhinosinusitis in immunocompromised patients. Our purpose was to investigate the normal enhancement pattern of nasal turbinates and to determine whether a black turbinate occurs in patients without invasive fungal rhinosinusitis and, if so, to distinguish differentiating features from pathologic enhancement. MATERIALS AND METHODS: We examined patient medical records and available MR imaging, which included most nasal turbinates in more than 1 sequence. Imaging was performed with contrast, either with or without fat saturation, in patients without invasive fungal rhinosinusitis. All MR images were evaluated for a turbinate enhancement pattern and the presence of nonenhancing areas. RESULTS: After we applied the exclusion criteria, 75 MR images from each group, with and without fat saturation, were included. Overall, the frequency of observed nonenhancing portions of turbinates, ie, black turbinates, was 30%. Most observed black turbinates were located in the posterior portion of inferior turbinates. Tiny areas of nonenhancement within turbinates were also a common finding. CONCLUSIONS: A black turbinate is not uncommon on MR images in immunocompetent patients who have no chance of having invasive fungal rhinosinusitis. Benign turbinate nonenhancement improves over subsequent series, has preserved thin peripheral enhancement, and often has thin internal septa. Knowledge of this normal pattern of nasal turbinate enhancement can aid in the differentiation of the benign black turbinate in immunocompetent patients from the pathologic black turbinate seen in patients with invasive fungal rhinosinusitis.

Dose Reduction While Preserving Diagnostic Quality in Head CT: Advancing the Application of Iterative Reconstruction Using a Live Animal Model.

BACKGROUND AND PURPOSE: Iterative reconstruction has promise in lowering the radiation dose without compromising image quality, but its full potential has not yet been realized. While phantom studies cannot fully approximate the subjective effects on image quality, live animal models afford this assessment. We characterize dose reduction in head CT by applying advanced modeled iterative reconstruction (ADMIRE) in a live ovine model while evaluating preservation of gray-white matter detectability and image texture compared with filtered back-projection. MATERIALS AND METHODS: A live sheep was scanned on a Force CT scanner (Siemens) at 12 dose levels (82-982 effective mAs). Images were reconstructed with filtered back-projection and ADMIRE (strengths, 1-5). A total of 72 combinations (12 doses × 6 reconstructions) were evaluated qualitatively for resemblance to the reference image (highest dose with filtered back-projection) using 2 metrics: detectability of gray-white matter differentiation and noise-versus-smoothness in image texture. Quantitative analysis for noise, SNR, and contrast-to-noise was also performed across all dose-strength combinations. RESULTS: Both qualitative and quantitative results confirm that gray-white matter differentiation suffers at a lower dose but recovers when complemented by higher iterative reconstruction strength, and image texture acquires excessive smoothness with a higher iterative reconstruction strength but recovers when complemented by dose reduction. Image quality equivalent to the reference image is achieved by a 58% dose reduction with ADMIRE-5. CONCLUSIONS: An approximately 60% dose reduction may be possible while preserving diagnostic quality with the appropriate dose-strength combination. This in vivo study can serve as a useful guide for translating the full implementation of iterative reconstruction in clinical practice.

Peeking into the Black Box of Coregistration in Clinical fMRI: Which Registration Methods Are Used and How Well Do They Perform?

BACKGROUND AND PURPOSE: Interpretation of fMRI depends on accurate functional-to-structural alignment. This study explores registration methods used by FDA-approved software for clinical fMRI and aims to answer the following question: What is the degree of misalignment when registration is not performed, and how well do current registration methods perform? MATERIALS AND METHODS: This retrospective study of presurgical fMRI for brain tumors compares nonregistered images and 5 registration cost functions: Hellinger, mutual information, normalized mutual information, correlation ratio, and local Pearson correlation. To adjudicate the accuracy of coregistration, we edge-enhanced echo-planar maps and rated them for alignment with structural anatomy. Lesion-to-activation distances were measured to evaluate the effects of different cost functions. RESULTS: Transformation parameters were congruent among Hellinger, mutual information, normalized mutual information, and the correlation ratio but divergent from the local Pearson correlation. Edge-enhanced images validated the local Pearson correlation as the most accurate. Hellinger worsened misalignment in 59% of cases, primarily exaggerating the inferior translation; no cases were worsened by the local Pearson correlation. Three hundred twenty lesion-to-activation distances from 25 patients were analyzed among nonregistered images, Hellinger, and the local Pearson correlation. ANOVA analysis revealed significant differences in the coronal (P < .001) and sagittal (P = .04) planes. If registration is not performed, 8% of cases may have a >3-mm discrepancy and up to a 5.6-mm lesion-to-activation distance difference. If a poor registration method is used, 23% of cases may have a >3-mm discrepancy and up to a 6.9-mm difference. CONCLUSIONS: The local Pearson correlation is a special-purpose cost function specifically designed for T2*-T1 coregistration and should be more widely incorporated into software tools as a better method for coregistration in clinical fMRI.

The Moving Carotid Artery: A Retrospective Review of the Retropharyngeal Carotid Artery and the Incidence of Positional Changes on Serial Studies.

BACKGROUND AND PURPOSE: Retropharyngeal carotid arteries are a clinically relevant anatomic variant. Prior studies have documented their incidence, but only a single case report has discussed the change in position of the carotid artery to and from a retropharyngeal location. The purpose of this study was to determine the prevalence of retropharyngeal carotid arteries and to evaluate the change in position of retropharyngeal carotid arteries over serial CT examinations of the neck. MATERIALS AND METHODS: A retrospective review of 306 CT examinations of the neck in 144 patients was performed. Patients with previous neck surgery or neck masses displacing the carotid arteries were excluded. The position of each carotid artery was evaluated on each examination. In patients with prior examinations, change or lack of change in position was recorded. The data were reviewed to assess changes in the position of the carotid arteries. RESULTS: Of the 144 patients evaluated, 34 were excluded. The final number of examinations included in the study was 249. Sixty-three of 110 patients had at least 1 comparison study. Twenty-three retropharyngeal carotid arteries were present on the baseline examination in 17 (15.5%) of 110 patients. There was documented change to or from a retropharyngeal position in 4 (6.3%) of 63 patients with comparison studies. CONCLUSIONS: The phenomenon of migration of the carotid arteries to and from a retropharyngeal position with time is confirmed by our study. It is important for physicians to be aware of this phenomenon to avoid potential procedural complications.

Methanol intoxication with putaminal and white matter necrosis: MR and CT findings.

We report a case of methanol intoxication in which the initial CT scans appeared normal. MR at 4 days showed the typical putaminal lesions of methanol intoxication and, in addition, peripheral white matter lesions that spared a thin rim of subcortical white matter. A CT scan at 17 days showed the putaminal and white matter lesions. The white matter lesions correspond well to lesions previously described in pathologic specimens.

The prevalence and CT appearance of the levator claviculae muscle: a normal variant not to be mistaken for an abnormality.

BACKGROUND AND PURPOSE: The levator claviculae muscle is an infrequently recognized variant in humans, occurring in 2% to 3% of the population, and has rarely been reported in the radiologic or anatomic literature. The importance of this muscle to radiologists is in distinguishing it from an abnormality; most commonly, cervical adenopathy. After discovering this muscle on the CT scans of two patients during routine clinical examinations, we conducted a study to determine the prevalence and appearance of the muscle on CT studies. METHODS: We evaluated 300 CT scans that adequately depicted the expected location of the muscle. The most superior level in which the muscle could be identified and the apparent location of insertion on the clavicle were recorded for all subjects in whom the muscle was detected. RESULTS: Seven levator claviculae muscles were identified in six subjects (2%). It was bilateral in one, on the left in four, and on the right in one. It was identified up to the level of the transverse process of C3 in all cases. The insertion was the middle third of the clavicle for two muscles and the lateral third of the clavicle for the remaining five muscles. CONCLUSION: Because the levator claviculae muscle will most likely be encountered during a radiologist's career, it is important to recognize this muscle as a variant and not as an abnormality.

Comparison of dynamic contrast-enhanced gradient-echo and spin-echo sequences in MR of head and neck neoplasms.

PURPOSE: To investigate the utility of dynamic contrast-enhanced gradient-echo MR imaging of head and neck lesions and to compare this technique with the commonly used spin-echo contrast-enhanced fat-saturation technique. METHODS: Twenty-two patients with a total of 23 head and neck neoplasms underwent dynamic gradient-echo and spin-echo MR imaging studies. The spin-echo and dynamic gradient-echo images were compared in each case by consensus of three observers for differences in tumor conspicuity and delineation of margins, particularly with regard to invasion of adjacent structures. When possible, pathologic and/or surgical confirmation of tumor extent was obtained. Relative contrast was also calculated to determine objectively the degree of tumor enhancement with respect to background mucosa. RESULTS: The dynamic gradient-echo images showed better or equal delineation of the tumor margins by subjective observation in all but two cases. Temporally different enhancement patterns were noted for lesions, background mucosa, and adjacent reaction and edema. The dynamic gradient-echo technique provided better relative contrast than the spin-echo technique in 17 (77%) of 22 lesions. CONCLUSION: Dynamic gradient-echo MR imaging is superior to conventional contrast-enhanced spin-echo imaging in delineating the margins and extent of tumor. This technique provided observers with added confidence in their interpretations and suffered from fewer technical limitations.

Intracalvarial cholesterol granulomas--clinicopathologic correlates of three cases.

Cholesterol granulomas (CGs) are tumor-like lesions seldom encountered by neuropathologists. CGs develop in reaction to localized hemorrhage, often occurring in bony sites with possible impaired drainage of blood and blood products. The most common bony location is the petrous apex, although orbital, frontal sinus, and maxillary sinus sites have been reported. We compare and contrast three recent cases seen at our institution that illustrate the spectrum of clinical, radiographic, and pathologic features that can be seen with these mass lesions. One case demonstrated the unique pathological features of Gamma-Gandy body formation, epithelioid histiocytes heavily encrusted with iron pigments, and extensive tophi. The latter most likely represented aggregates of calcium pyrophosphate crystals associated with extensive iron deposition.

The MR imaging appearance of the vascular pedicle nasoseptal flap.

BACKGROUND AND PURPOSE: Recently, surgeons have used an expanded endonasal surgical approach (EENS) to access skull base lesions not previously accessible by minimally invasive techniques. Reconstruction of the large skull base defects created during EENS is necessary to prevent postoperative CSF leaks. A vascular pedicle nasoseptal mucoperiosteal flap based on the nasoseptal artery, (Hadad-Bassagasteguy flap) is becoming a common reconstructive technique. The purpose of this study was to review the expected MR imaging appearance of these flaps and to discuss variations in the appearance that may suggest potential flap failure. MATERIALS AND METHODS: We retrospectively reviewed 10 patients who underwent EENS for resection of sellar lesions with skull base reconstruction by multilayered reconstruction including the Hadad-Bassagasteguy flap. All patients had preoperative, immediate, and delayed postoperative MR imaging scans. Flap features that were evaluated included flap configuration, signal intensity characteristics on T1-weighted and T2-weighted images, enhancement patterns, location, and flap thickness. RESULTS: All patients had detectable postoperative skull base defects. All patients had C-shaped configuration flaps within the operative defect, which were isointense on T1-weighted and T2-weighted images on both immediate and delayed postoperative MR imaging scans. On the immediate scans, 8 of 10 patients had enhancing flaps and 2 of 10 had minimal to no enhancement. There were 9 of 10 patients who had enhancing flaps on delayed scans, and 2 of 10 patients had flaps that increased in enhancing coverage on the delayed scans. CONCLUSIONS: Vascular pedicle nasoseptal flaps have a characteristic MR imaging appearance. It is important for the radiologist to recognize this appearance and to evaluate for variations that may suggest potential flap failure.

Pineocytoma mimicking a pineal cyst on imaging: true diagnostic dilemma or a case of incomplete imaging?

BACKGROUND AND PURPOSE: Pineocytomas have been described as well-circumscribed, homogeneously enhancing masses. However, there is considerable variability in this appearance, and certain pineocytomas may have a predominantly cystic appearance on imaging. This has led some to suggest that differentiation between pineocytomas and pineal cysts may not be possible. We have attempted to determine if cystic pineocytomas could be found in a series of these tumors evaluated by CT and MR imaging. MATERIALS AND METHODS: We searched the radiology literature as well as the medical records from our own institution for pathologically proved pineocytomas with available preoperative imaging or imaging reports, with specific focus on whether postcontrast MR imaging was included. In cases in which images were available, they were evaluated by a Certificate of Added Qualification (CAQ)-certified neuroradiologist and a radiology resident, who attempted to determine if the pineocytomas had any MR imaging characteristics of typical pineal cysts. To be considered a typical pineal cyst, an area of signal-intensity abnormality must be centered on the pineal recess, demonstrating internal homogeneity on T2-weighted imaging, following CSF signal intensity on T1- and T2-weighted images, without any marginal lobularity or nodular contrast enhancement and a wall thickness of <2 mm. In cases in which imaging was not available, radiology reports and/or descriptions provided in the radiology literature were reviewed by a CAQ-certified neuroradiologist. For any lesion described as cystic, we again attempted to elucidate the exact extent of imaging that was performed, note specific lesion characteristics, and determine if the lesion met the criteria described previously. Finally, for tumors in which image size was provided, the mean value of maximal tumor dimension, SD, median, and range were calculated. RESULTS: Forty-four pathologically proved cases of pineocytomas from the radiology literature, as well as 8 pathologically proved cases of pineocytomas from our institution with available imaging studies and/or reports, were reviewed. Of these, 23 were solid masses, and 7 were partially solid and cystic, whereas 14 tumors could not be completely characterized due to incomplete imaging evaluation. Eight were primarily cystic; however, none of these could be confidently characterized as meeting the criteria for a typical cyst. CONCLUSION: In our analysis, no truly cystic pineocytomas were identified.

Incidence and characterization of unifocal mandible fractures on CT.

BACKGROUND AND PURPOSE: Conventional thinking among radiologists is that the mandible acts as a closed "ring" that needs to fracture at 2 points, though the frequency of multiple mandible fractures has been reported to be only as high as 67%. However, many of these studies did not use CT to confirm the presence of suggested fractures and excluded nondisplaced fractures. The purpose of this study was to determine the incidence of unifocal mandibular fractures on the basis of detection with dedicated facial bone CT scans and to characterize these fractures. MATERIALS AND METHODS: We retrospectively reviewed the imaging reports of patients during a 3-year period to identify those who had mandible fractures documented on dedicated facial bone CT scans. The incidence of unifocal fractures was determined, the unifocal fractures were further subcategorized, and any derangements of the temporomandibular joints were also evaluated. RESULTS: One hundred two patients met the inclusion criteria. The incidence of unifocal mandible fractures was 42% (43/102). Three unifocal fracture patterns identified were the following: simple fractures (25/42, 58%), comminuted fractures (11/42, 26%), and fractures associated with condylar subluxations (7/42, 16%). Most fractures had none to mild displacement or distraction. CONCLUSION: Unifocal mandible fractures occur with greater frequency than anticipated by most radiologists. This may be due to the somewhat dynamic nature of the mandibular "ring," which includes the temporomandibular joints, though joint derangements evident on CT occur in the minority of cases.

What's in your mouth? The CT appearance of comestible intraoral foreign bodies.

BACKGROUND AND PURPOSE: Comestible or chewable intraoral foreign bodies (IOFB), such as candies, gum, and chewing tobacco, are seen incidentally on many CT scans of the head and neck. If these foreign bodies are misinterpreted as pathology, patients may be subjected to unnecessary distress or unneeded radiation from additional imaging. The purpose of this study was to characterize the CT appearance of comestible IOFBs and to find characteristics that distinguish them from true pathology. MATERIALS AND METHODS: With institutional review board approval, 30 patients who were already scheduled to undergo CT examinations of the head and neck were enrolled in this study. Nine typical IOFBs with different physical characteristics were selected for inclusion. Each patient placed 1 IOFB in his or her mouth before the initiation of the routine clinical scan. The resulting scans were evaluated by 2 head and neck radiologists. In vivo and ex vivo attenuation measurements were obtained for each IOFB. RESULTS: The attenuation of comestible IOFBs ranged from 184 to 475 Hounsfield units. Large, hard IOFBs were most easily distinguished from mucosal lesions, but might be mistaken for odontogenic or bone tumors. Small, hard IOFBs could be mistaken for calculi, tooth fragments, or enhancing vessels. Soft IOFBs generally had more confusing configurations and more heterogeneous densities and, thus, might be mistaken for enhancing mucosal lesions. Foci of gas were often identified within chewable IOFBs, mimicking an abscess. Because all of the IOFBs had higher densities than soft tissue, they could all be mistaken for calcified, enhancing, or bony lesions. CONCLUSION: Radiologists frequently encounter IOFBs on CT examinations of the head and neck. Familiarity with the expected appearance of these incidental pseudolesions is important to prevent misdiagnosis as a true pathologic process.

A variety of appearances of malignant melanoma in the head: a review.

Imaging is frequently requested to evaluate patients with malignant melanoma for metastases. When melanoma metastasizes to the head, the lesions can have a variety of appearances and can occur in a variety of locations. The usual appearances of malignant melanoma on magnetic resonance images include the melanotic and amelanotic patterns. The melanotic pattern consists of high signal intensity on T1-weighted images and low signal intensity on T2-weighted images. In the amelanotic pattern, the lesion is hypointense or isointense to the cortex on T1-weighted images and hyperintense or isointense to the cortex on T2-weighted images. However, there is frequent deviation from these patterns. Other patterns include small and rapidly growing metastases, miliary metastases, and subependymal metastases. Although the brain is the most common site of metastases to the head from melanoma, melanoma can metastasize to almost any intracranial or extracranial structure. Structures in the head that can be involved by metastases from melanoma include bone, muscle, the nasopharynx and mucosa, the parotid gland, the meninges, the choroid plexus, the internal auditory canal, and the orbit. The radiologist needs to be aware of these varied appearances and the relatively ubiquitous sites of involvement to better detect these lesions.

Computed tomographic scans of minimally displaced type II odontoid fractures.

OBJECTIVE: To determine the computed tomography (CT) appearance of minimally displaced type II odontoid fractures and the optimal protocols to evaluate these fractures by CT. MATERIALS AND METHODS: The CT scans of five patients with minimally displaced type II odontoid fractures and 71 patients without odontoid pathology were reviewed for signs of fracture. A phantom consisting of a cadaver specimen with a type II odontoid fracture was evaluated with several protocols on four CT scanners. The protocols differed in slice thickness and reconstruction algorithm. Helical scanning was also performed, and parasagittal and coronal reformations were created from each image set. MAIN RESULTS: Multiple cortical disruptions longer than 1 mm were demonstrated on the scans of all five patients with type II odontoid fractures. Only three of the 71 patients without odontoid fractures had multiple cortical disruptions, and none were longer than 1 mm. In the phantom study, thinner sections demonstrated cortical disruptions better than thicker sections. Similarly, images reconstructed with a bone reconstruction algorithm demonstrated the cortical disruptions better than images reconstructed with a soft-tissue reconstruction algorithm. Helical scans (1 mm thick) adequately demonstrated the reduced Type II odontoid fracture. Parasagittal and coronal reformations failed to demonstrate a fracture line through the base of the odontoid process on all image sets. CONCLUSIONS: Cortical disruptions greater than 1 mm and multiple cortical disruptions may be the only findings of odontoid fractures and should suggest the diagnosis. Evaluation of potential type II odontoid fractures is improved as CT section thickness is reduced (down to 1 mm) and is also improved by use of a bone reconstruction algorithm. The apparent absence of a fracture line through the base of the odontoid process on parasagittal or coronal reformations does not rule out the diagnosis.

Suprasellar cavernous malformation presenting with extensive subarachnoid hemorrhage.

Cavernous malformations are usually intraparenchymal, extra-axial lesions being uncommon. They have very rarely been reported as the cause of subarachnoid hemorrhage. We present a case of hemorrhage related to a cavernous malformation, unusual in two ways. First, it is rare for an intracranial cavernous malformation to present with massive subarachnoid hemorrhage. Secondly, this cavernous malformation lay in the chiasmatic cistern.