Assessment of tracer delay effect in whole-brain computed tomography perfusion: results for selected regions of interest in middle cerebral artery acute ischemic strokes.

OBJECTIVE: The objective of this study was to compare the variability of computed tomography perfusion (CTP) results in identical data sets of middle cerebral artery (MCA) acute ischemic stroke (AIS) generated by standard singular value decomposition (sSVD) deconvolution and tracer delay-insensitive singular value decomposition (SVD+) algorithm analyses. METHODS: Whole-brain 320-detector-row CTP data sets from 9 unilateral MCA AIS cases and 9 controls were retrospectively analyzed. Computed tomography perfusion values for the combined core/penumbra, contralateral hemispheres and arterial territories were measured and compared with literature values. Simple linear regression models are provided to predict corresponding SVD+ value and sSVD CTP values. RESULTS: In the core/penumbra, sSVD generated lower cerebral blood flow (CBF) values, higher mean transit time (MTT) values, and a broader range of CBF and MTT values as compared with SVD+. Mean transit time value differences between the core/penumbra and contralateral hemispheres were statistically significant using sSVD, whereas those of SVD+ were not. Goodness of fit between algorithms for the core/penumbra was lower for CBF (0.483) and MTT (0.494), as compared with time to peak (0.891) and cerebral blood volume (0.997). CONCLUSIONS: In this study using identical source data for patients with MCA AIS, use of either sSVD or SVD+ analyses created statistically significant differences in the CTP value results. Tracer delay-sensitive and -insensitive algorithms impact CTP results in AIS and controls, highlighting the need to pursue additional studies that assess the variability, accuracy, and clinical implications of CTP results generated when using heterogeneous deconvolution algorithms.

Assessment of the tracer delay effect in whole-brain computed tomography perfusion: results in patients without known neuroanatomic abnormalities.

OBJECTIVE: Whole-brain computed tomography perfusion (CTP) data sets generated by tracer delay-insensitive singular value decomposition plus (SVD+) and standard singular value decomposition (sSVD) deconvolution algorithms were evaluated to quantify relatedness and discrepancies in CTP results. METHODS: Twenty females with symmetrical hemispheric CTP maps indicative of brain tissue without apparent abnormalities were studied. Tissue-specific CTP values were analyzed. RESULTS: Standard SVD values were higher than SVD+ for cerebral blood flow. Other CTP values had minimal differences across brain regions. All simple linear regression models were statistically significant (P < 0.05) except for cerebral blood flow in white matter (P = 0.06). Cerebral blood volume had a good model fit, and mean transit time, a poor fit. CONCLUSIONS: Corresponding fitted CTP values for sSVD and SVD+ based on regression equations for brain-tissue types are presented. Additional research is required to compare SVD+ and sSVD in disease states when significant hemodynamic brain alterations are present.

Developmental venous anomalies: appearance on whole-brain CT digital subtraction angiography and CT perfusion.

INTRODUCTION: Developmental venous anomalies (DVA) consist of dilated intramedullary veins that converge into a large collecting vein. The appearance of these anomalies was evaluated on whole-brain computed tomography (CT) digital subtraction angiography (DSA) and CT perfusion (CTP) studies. METHODS: CT data sets of ten anonymized patients were retrospectively analyzed. Five patients had evidence of DVA and five age- and sex-matched controls were without known neurovascular abnormalities. CT angiograms, CT arterial-venous views, 4-D CT DSA and CTP maps were acquired on a dynamic volume imaging protocol on a 320-detector row CT scanner. Whole-brain CTP parameters were evaluated for cerebral blood flow (CBF), cerebral blood volume (CBV), time to peak (TTP), mean transit time (MTT), and delay. DSA was utilized to visualize DVA anatomy. Radiation dose was recorded from the scanner console. RESULTS: Increased CTP values were present in the DVA relative to the unaffected contralateral hemisphere of 48%, 32%, and 26%; and for the control group with matched hemispheric comparisons of 2%, -10%, and 9% for CBF, CBV, and MTT, respectively. Average effective radiation dose was 4.4 mSv. CONCLUSION: Whole-brain DSA and CTP imaging can demonstrate a characteristic appearance of altered DVA hemodynamic parameters and capture the anomalies in superior cortices of the cerebrum and the cerebellum. Future research may identify the rare subsets of patients at increased risk of adverse outcomes secondary to the altered hemodynamics to facilitate tailored imaging surveillance and application of appropriate preventive therapeutic measures.

Magnetic resonance venography and genetics of a female patient with pelvic venous thrombosis.

A femoral vein thrombosis, originally diagnosed with conventional ultrasound, was fully elucidated and monitored utilizing serial high-resolution magnetic resonance venography in a 19-year-old female with a family history of venous thromboembolism. Genetic testing revealed she was heterozygous for a F5 gene mutation, an abnormality that predisposes carriers to factor V Leiden thrombophilia. An additional risk factor included use of oral contraceptive pills. Subsequent testing of her family uncovered other carriers of the mutation, allowing for the implementation of preventive measures for the entire family. Although magnetic resonance venography has not yet proven to be a cost-effective method for monitoring clot resolution, the case presented here encourages further research on the clinical utility and cost-benefit of utilizing this technology for monitoring venous thrombosis and for clinical management purposes.

Whole-spine dynamic magnetic resonance study of contortionists: anatomy and pathology.

OBJECT: Whole-spine magnetic resonance (MR) images were obtained using a cylindrical 3-T MR imaging system in 5 contortionists to assess the pathological changes possibly associated with the practice of contortion. Whole-spine dynamic MR images were obtained using a 1-T open MR imaging system in 2 of these contortionists with the purpose of defining the range of motion (ROM) achieved during extreme contortion. The range of spinal motion in this unique population was then quantified. METHODS: The study included 5 female contortionists 20-49 years of age. Imaging was performed using open 1-T and cylindrical 3-T high-field MR imaging systems. Data were viewed and analyzed with DICOM-compliant tools. Real-time, dynamic, and standard MR imaging allowed for quantification of the contortionists' ROM. RESULTS: There was a difference of 238 degrees between full spinal extension and full flexion. Three of the 5 contortionists had 4 anterosuperior limbus vertebrae at T-11 and the upper lumbar levels. CONCLUSIONS: Whole-spine dynamic MR imaging is a valuable tool for the evaluation of the extreme ROM in contortionists, allowing for the quantification of extreme mobility. The limbus fractures present in 3 of the 5 contortionists is postulated to be due to avulsion on hyperextension. Future research may open the use of whole-spine dynamic MR imaging into such areas as pain management and traumatic spinal injuries.

Potential use of microarray technology for rapid identification of central nervous system pathogens.

Outbreaks of central nervous system (CNS) diseases result in significant productivity and financial losses, threatening peace and wartime readiness capabilities. To meet this threat, rapid clinical diagnostic tools for detecting and identifying CNS pathogens are needed. Current tools and techniques cannot efficiently deal with CNS pathogen diversity; they cannot provide real-time identification of pathogen serogroups and strains, and they require days, sometimes weeks, for examination of tissue culture. Rapid and precise CNS pathogen diagnostics are needed to provide the opportunity for tailored therapeutic regimens and focused preventive efforts to decrease morbidity and mortality. Such diagnostics are available through genetic and genomic technologies, which have the potential for reducing the time required in serogroup or strain identification from 500+ hours for some viral cultures to less than 3 hours for all pathogens. In the near future, microarray diagnostics and future derivations of these technologies will change the paradigm used for outbreak investigations and will improve health care for all.

Appearance and impact of post-operative intracranial clips and coils on whole-brain CT angiography and perfusion.

BACKGROUND: To evaluate the effect of vascular clips and endovascular coils placed for intracranial aneurysms and arteriovenous malformations on whole-brain computed tomography (CT) angiography and perfusion. METHODS: A 320-detector row dynamic volume CT system imaged 11 patients following surgical placement of vascular clips or endovascular coils. The extent of clip and coil subtraction by automated software was evaluated using CT digital subtraction angiography and CT perfusion. Impact on CT perfusion values by retained intracranial devices was compared to age- and gender-matched controls. RESULTS: Clip and coil subtraction on CT angiography was graded as good in 8 and moderate in 3 cases. A residual neck and additional aneurysm were noted in 1 of 11 patients. Post-procedural axial slice level CT perfusion values decreased in reliability with increasing proximity to the metallic devices secondary to beam hardening. However, the intracranial devices did not affect axial slice level CTP values of cerebral blood volume, cerebral blood flow and mean transit time outside of the level of the device. Time to peak values was globally decreased outside of the immediate vascular intervention region. CONCLUSIONS: Advances in CT technology have provided clinically useful subtraction of intracranial clips and coils. While CT perfusion values were altered in device subtraction areas and within beam hardening artifact areas; they can provide valuable postoperative information on whole-brain hemodynamics. In selected cases, the combination of CT angiography and whole-brain CT perfusion can offer an alternative to conventional angiography that is a more invasive option.

Clinical indications and utilization of 320-detector row CT in 2500 outpatients.

Clinical indications and utilization patterns for 3963 CT scans on 2500 consecutive patents on a 320-detector row CT in an outpatient setting were retrospectively analyzed and compared with previously reported CT studies. The impact of the latest generation CT technology, including whole organ perfusion, on indications and utilization patterns during the study period was also assessed. The top five requested CT scan types were abdomen/pelvis, chest, head, sinuses, and coronary CT angiography. Indication and utilization rates were similar to prior studies for abdomen/pelvis, non-cardiac chest, and head CT scans. Abdominal pain and headaches were the most frequent indications for abdomen/pelvis and head CTs, respectively. The 7.3% cardiac CT scan utilization rate was not comparable to rates of up to 72% in self-referral outpatient settings. Whole organ volume CT imaging was utilized in 100% of coronary CT angiography and 22.7% of head CTs. The 320-row CT had fewer negative head and body CT findings as compared to prior reports. The availability of new technology, such as whole organ dynamic scans, appears to have influenced CT indications, utilization and finding rates with a decrease in negative brain and body results. Comparisons with previous outpatient CT studies were similar for multiple categories with the exception of cardiac CT utilization, which is heavily influenced by self-referral. Further study of outpatient imaging indications and utilization rates from multiple centers may benefit from a standardized categorization to improve understanding of the disparate outpatient imaging environment.

Sagittal whole-spine magnetic resonance imaging in 750 consecutive outpatients: accurate determination of the number of lumbar vertebral bodies.

OBJECT: When the number of lumbar and sacral vertebrae is being assessed, variations from typical lumbosacral anatomy may confuse the practitioner, potentially leading to significant clinical errors. In this study, the authors describe the statistical variation in lumbar spine anatomy in an outpatient imaging setting, evaluate the potential implications for clinical practice based on the variation in the number of lumbar-type vertebrae identified, and recommend a method for rapidly determining the number of lumbar spine vertebral bodies (VBs) in outpatients referred for lumbar spine MR imaging. METHODS: A total of 762 patients (male and female) who presented with low back-related medical conditions underwent whole-spine MR imaging in an outpatient setting. RESULTS: The high-speed whole-spine evaluation was successful for determining the number of lumbar-type VBs in 750 (98%) of 762 consecutive patients. The sagittal whole-spine 3-T MR imaging system images obtained between the beginning of January 2005 and the end of February 2007 were reviewed. The VBs were counted successively from the level of C-2 inferiorly to the intervertebral disc below the most inferior lumbar-type VB. Numbers of disc herniations were also evaluated in the context of the number of VBs. CONCLUSIONS: One in 5 of these outpatients did not have 5 lumbar-type vertebrae: 14.5% had 6; 5.3% had 4; and 1 (0.13%) had the rare finding of 3 lumbar-type vertebrae. Two-thirds of the individuals with 6 lumbar-type vertebrae were male and two-thirds of the individuals with 4 lumbar-type vertebrae were female. Sagittal whole-spine MR imaging can be performed rapidly and efficiently in the majority of patients (98%), and provides improved accuracy for the determination of the number of lumbar-type VBs. A supplementary coronal MR, Ferguson view radiograph or intraoperative fluoroscopic determination for the presence of lumbosacral transitional vertebrae may add additional information when indicated for clinical treatment or surgical planning.

Traumatic brain injury: a review and high-field MRI findings in 100 unarmed combatants using a literature-based checklist approach.

This study reviewed the literature for the extent of neuroimaging findings in boxers, indicative of traumatic brain injury (TBI) as identified in magnetic resonance imaging (MRI). The study then utilized a systematic checklist approach to assess 100 unselected consecutive 1.5- and 3.0-Tesla MRI examinations of professional unarmed combatants to determine the extent of identifiable TBI findings. The percentage of positive findings and the localization of lesions were quantified using the checklist that included the MRI findings previously reported in the medical literature. Seventy-six percent of the unarmed combatants had at least one finding that may be associated with TBI: 59% hippocampal atrophy, 43% cavum septum pellucidum, 32% dilated perivascular spaces, 29% diffuse axonal injury, 24% cerebral atrophy, 19% increased lateral ventricular size, 14% pituitary gland atrophy, 5% arachnoid cysts, and 2% had contusions. Statistical relationships were found between number of bouts and lateral ventricular size (tau-b = 0.149, p = 0.0489), with years of fighting correlating with the presence of dilated perivascular spaces (tau-b = 0.167, p = 0.0388) and diffuse axonal injury (tau-b = 0.287, p = 0.0013) findings. The improved resolution and increased signal-to-noise ratio on 1.5- and 3.0-Tesla high-field MRI systems defines the range of pathological variations that may occur in professional unarmed combatants. Additionally, the use of a systematic checklist approach insures evaluation for all possible TBI-related abnormalities. This knowledge can be used to anticipate the regions of potential brain pathology for radiologists and emergency medicine physicians, and provides important information for evaluating unarmed combatants relative to their safety and long-term neurocognitive outcome.

Application of broad-spectrum, sequence-based pathogen identification in an urban population.

A broad spectrum detection platform that provides sequence level resolution of target regions would have a significant impact in public health, case management, and means of expanding our understanding of the etiology of diseases. A previously developed respiratory pathogen microarray (RPM v.1) demonstrated the capability of this platform for this purpose. This newly developed RPM v.1 was used to analyze 424 well-characterized nasal wash specimens from patients presenting with febrile respiratory illness in the Washington, D. C. metropolitan region. For each specimen, the RPM v.1 results were compared against composite reference assay (viral and bacterial culture and, where appropriate, RT-PCR/PCR) results. Across this panel, the RPM assay showed >or=98% overall agreement for all the organisms detected compared with reference methods. Additionally, the RPM v.1 results provide sequence information which allowed phylogenetic classification of circulating influenza A viruses in approximately 250 clinical specimens, and allowed monitoring the genetic variation as well as antigenic variability prediction. Multiple pathogens (2-4) were detected in 58 specimens (13.7%) with notably increased abundances of respiratory colonizers (esp. S. pneumoniae) during viral infection. This first-ever comparison of a broad-spectrum viral and bacterial identification technology of this type against a large battery of conventional "gold standard" assays confirms the utility of the approach for both medical surveillance and investigations of complex etiologies of illness caused by respiratory co-infections.

Broad-spectrum respiratory tract pathogen identification using resequencing DNA microarrays.

The exponential growth of pathogen nucleic acid sequences available in public domain databases has invited their direct use in pathogen detection, identification, and surveillance strategies. DNA microarray technology has offered the potential for the direct DNA sequence analysis of a broad spectrum of pathogens of interest. However, to achieve the practical attainment of this potential, numerous technical issues, especially nucleic acid amplification, probe specificity, and interpretation strategies of sequence detection, need to be addressed. In this report, we demonstrate an approach that combines the use of a custom-designed Affymetrix resequencing Respiratory Pathogen Microarray (RPM v.1) with methods for microbial nucleic acid enrichment, random nucleic acid amplification, and automated sequence similarity searching for broad-spectrum respiratory pathogen surveillance. Successful proof-of-concept experiments, utilizing clinical samples obtained from patients presenting adenovirus or influenza virus-induced febrile respiratory illness (FRI), demonstrate the ability of this approach for correct species- and strain-level identification with unambiguous statistical interpretation at clinically relevant sensitivity levels. Our results underscore the feasibility of using this approach to expedite the early surveillance of diseases, and provide new information on the incidence of multiple pathogens.