Initial MR Research Articles

Imaging Metal-on-Metal Hip Replacements: the Norwich Experience

BackgroundAdverse reaction to metal debris is a relatively recently described and often a silent complication of metal-on-metal (MOM) total hip replacements (THR). The Norfolk & Norwich University Hospital has been performing metal artefact reduction (MARS) MRI for 8 years in a variety of different types of MOM THR.Questions/purposesThe aims of this review are to describe the experience of using MARS MRI in Norwich and to compare our experience with that published by other groups.MethodsA MEDLINE keyword search was performed for studies including MRI in MOM THR. Relevant publications were reviewed and compared with published data from the Norfolk & Norwich University Hospital. The similarities and differences between these data were compared and possible explanations for these discussed.ResultsMARS MRI appears to be the most useful tool for diagnosing, staging and monitoring adverse reactions to metal debris (ARMD). There appears to be no clinically useful association between clinical and serological markers of disease and the severity of MR findings. Although severe early ARMD is associated with significant morbidity, mild disease is often stable for years. If patients with normal initial MR examinations develop ARMD, this usually occurs 7 years. A 1-year interval between MRI examinations is reasonable in asymptomatic patients.ConclusionsThere is a general international consensus that ARMD is prevalent in symptomatic and asymptomatic patients with MOM THR and that while appearances vary with the type of prosthesis, there are characteristic features that make MARS MRI essential for diagnosis, staging and surveillance of the disease.Electronic supplementary materialThe online version of this article (doi:10.1007/s11420-013-9357-5) contains supplementary material, which is available to authorized users.

Abstract TP164: Significance of the Thrombus Component as a Predictor for Malignant Middle Cerebral Artery Infarction

Background and Purpose— Malignant middle cerebral artery (MCA) infarction is one of the most devastating forms of ischemic stroke, and identification of predictors of a malignant course of the MCA or internal carotid artery (ICA) infarction is exceedingly important. Here, we investigated whether thrombus component defined with MR imaging could predict malignant changes in the acute stage of the cerebral infarction. Methods— We retrospectively analyzed 468 consecutive patients with cerebral infarction in our institute from 2007 to 2011. In all the patients, initial MR imaging including T2 star (T2*), diffusion weighted imaging (DWI), fluid-attenuated inversion recovery (FLAIR) and MR angiography were performed and susceptibility vessel sign (SVS) on T2* was evaluated in relation to the brain swelling on CT 24 hours after the initial imaging. Correlation of the thrombus component between MRI and CT was also evaluated. Results— One hundred and twelve patients showed MCA main trunk or carotid T occlusion. Among them, 38 patients were t-PA failed or did not undergo endovascular treatment. Twenty eight patients had ICA occlusion and 10 patients had MCA main trunk occlusion. SVS was apparent in 17 (45%) patients, and there was no significant difference between SVS positive and SVS negative group in age (75.6 vs. 72.3 years old), time to arrival (84.4 vs. 106.9 min) and NIH stroke scale (19.5 vs. 18.7). On the other hand, DWI area was significantly larger in SVS positive group (189.3 vs. 107.6 ml). DWI area was also significantly correlated with brain swelling 24 hour later regardless of SVS. Most SVS positive patients showed MCA dense sign on CT performed 24 hours later (85.7% vs. 29.4%). Conclusions— Susceptibility vessel sign on MRI, which suggests RBC rich thrombus, indicates early maturation of the infarct in the MCA area, but could not predict following malignant change.

Renal Cell Carcinoma Initially Presenting as an Arteriovenous Malformation: A Case Presentation and a Review of the Literature

We describe a case of a patient who presented with hematuria and was diagnosed with a renal arteriovenous malformation (AVM). Transcatheter arterial embolization subsequently was performed on this lesion multiple times. Follow-up imaging demonstrated that the AVM was masking an underlying, rapidly growing renal cell carcinoma (RCC). We describe the pathological and radiographic characteristics of AVMs and RCC. We describe the strengths and weaknesses of computed tomography (CT) and magnetic resonance imaging (MRI) to detect and characterize RCC and AVM. We recommend initial and follow-up MR imaging in patients with an AVM to establish a baseline, monitor treatment response, and survey lesions for underlying and obscured malignancy.

Multifocal and Multicentric Glioblastoma with Leptomeningeal Gliomatosis: A Case Report and Review of the Literature

Glioblastoma (GBM) rarely presents as an infratentorial tumor in adults. The authors present a case of concomitant supratentorial and infratentorial GBM in an adult. A 72-year-old man presented with headache, nausea, vomiting, and lightheadedness. Initial MR images revealed enhancing masses in the right cerebellum and right posterior periventricular region. The patient underwent a suboccipital craniotomy and resection of the cerebellar lesion. Final histopathology was consistent with glioblastoma. The patient went on to receive standard radiation treatment for GBM with concurrent and adjuvant temozolomide. However, the patient experienced clinical deterioration within a few days after starting radiotherapy. He and his family decided to forego treatment and pursue palliative care. The patient expired three months after the initial diagnosis. Autopsy findings supported the diagnosis of GBM with leptomeningeal gliomatosis and involvement of the cerebrum, cerebellum, and spinal cord. The authors review the literature and propose that the pathogenesis of multiple and multicentric GBM may involve neural stem cells within the subventricular zone or could result from tumor dissemination along established CNS routes, such as white matter tracts and CSF pathways.

Effect of Low-and High-Dose Atorvastatin on Carotid Artery Distensibility Using Carotid Magnetic Resonance Imaging ^|^mdash;A Post-Hoc Sub Group Analysis of ATHEROMA (Atorvastatin Therapy: Effects on Reduction of Macrophage Activity) Study

To assess the effect of low-(10 mg) or high-(80 mg) dose atorvastatin on carotid artery distensibility in patients with asymptomatic carotid artery disease using carotid magnetic resonance imaging. Eighteen patients underwent initial 2-dimensional ECG gated-phase contrast carotid MR imaging and off-line applanation tonometry for distensibility assessment before randomisation to receive low- or high-dose statins and this was repeated at 12 weeks. Phase and magnitude images from the 2-D phase contrast acquisitions were used for quantification of distensibility and compliance coefficients and were compared between the low- and high-dose statin groups. Both groups were comparable with regards to their demographics, co-morbidities and baseline cholesterol levels. After 12 weeks of high-dose statin administration, a significant decrease in LDL (p=0.003) and CRP (p=0.03) was observed. At 12 weeks, the distensibility coefficient of the common and internal carotid artery was found to be significantly higher (with respect to baseline) in the high-dose group (p=0.004 and p=0.007, respectively). The compliance coefficient was likewise found to be raised in the high-dose group when compared with the low-dose group [common carotid (p=0.002), internal carotid (p=0.009)]. High-dose atorvastatin tends to reduce carotid arterial stiffness, as suggested by increased distensibility and compliance coefficients; however, these results need validation through large-scale trials to fully establish their possible use in clinical practice.

Susac's syndrome

A 34-year-old right-handed woman, with frequent episodic headaches, typical of migraine with visual aura, presented in December 2010. Two months later, she reported episodes of transient numbness over the left...

Clinical application and diagnostic value of non-invasive spinal angiography in spinal vascular malformations

Objective To explore the value of CT spinal angiography with 256 MSCT and fast dynamic contrast-enhanced 3D MR angiography (CE-MRA) at 3.0 T in the diagnosis of spinal vascular malformations by comparing with results of DSA and operation.Methods Seventeen patients suspected of spinal vascular diseases by initial MR and clinical manifestations all underwent CT spinal angiography.Of them,10 patients underwent MRA,15 patients underwent DSA within 3-5 days,and 8 patients finally underwent surgical treatment.Results CTA examination clearly showed the abnormal vascular lesions in 16 of 17 cases,including 7 cases with the diagnosis of spinal dural arteriovenous fistula,7 cases of perimedullary arteriovenous fistula,and 2 cases of spinal arteriovenous malformations. The results were consistent with the diagnosis of DSA or surgery.One case was poorly diagnosed.The feeding vessels were correctly determined in 12 cases,and the level of fistulas were correctly displayed in 12 cases.The level of fistulas and feeding vessels were accurately showed in 7 of 10 cases with MRA,while the other 3 cases exhibited normal with DSA.Conclusions Spinal angiography with 256 MSCT and CE-MRA at 3.0 T can clearly show the extent of spinal vascular malformations,feeding arteries and fistula location.They are safe,noninvasive,convinient and can shorten the time of DSA diagnosis and treatment.They play an important role in diagnosis and treatment of spinal vascular malformations and postoperative follow-up. Key words: Spinal cord vascular diseases; Magnetic resonance imagiag; Tomography, X-ray computed; Angiography,digital subtraction

Optimizing MR Imaging Detection of Type 2 Focal Cortical Dysplasia: Best Criteria for Clinical Practice

Type 2 FCD is one of the main causes of drug-resistant partial epilepsy. Its detection by MR imaging has greatly improved surgical outcomes, but it often remains overlooked. Our objective was to determine the prevalence of typical MR imaging criteria for type 2 FCD, to provide a precise MR imaging pattern, and to optimize its detection. We retrospectively reviewed 1.5T MR imaging of 71 consecutive patients with histologically proved type 2 FCD. The protocol included millimetric 3D T1-weighted, 2D coronal and axial T2-weighted, and 2D or 3D FLAIR images. Two experienced neuroradiologists looked for 6 criteria: cortex thickening, cortical and subcortical signal changes, blurring of the GWM interface, the "transmantle" sign, and gyral abnormalities. The frequency of each sign and their combination were assessed. We compared the delay between epilepsy onset and surgery, taking into account the time of type 2 FCD detection by MR imaging. Only 42 patients (59%) had positive MR imaging findings. In this group, a combination of at least 3 criteria was always found. Subcortical signal changes were constant. Three characteristic signs (cortical thickening, GWM blurring, and transmantle sign) were combined in 64% of patients, indicating that MR imaging can be highly suggestive. However, typical features of type 2 FCD were overlooked on initial imaging in 40% of patients, contributing to a delay in referral for surgical consideration (17 versus 11.5 years when initial MR imaging findings were positive). A combination of 3 major MR imaging signs allows type 2 FCD to be recognized in clinical practice, thereby enabling early identification of candidates for surgery.

Is Antiplatelet Treatment Effective on the Progression of White Matter Hyperintensity? - 5 Year Follow Up, Propensity Score Adjusted, Observational Study (P04.203)

Objective: We performed this study to assess the effects of antiplatelet treatment on the progression of white matter change. Background White matter hyperintensity on MRI is commonly observed in asymptomatic elderly, and chronic ischemic insult is one of the postulated mechanisms. However, there is no consensus on the treatment of these patients, including the usage of antiplatelet. Design/Methods: From 2003 to 2005, subjects who performed brain MRI for health check up and showed mild white matter change only without any significant lesion on were selected, and follow up MRI were performed in 2010. During this period, patients were prescribed either antiplatelet or not according to the attending physician9s preference. White matter hyperintensity volume in FLAIR was blindly assessed by one investigator using 3D slicer imaging analysis software. For statistical comparison, propensity score weighting method was used. Results: Among 192 screened patients, 93 patients were followed and analyzed. The average interval between initial and follow up MR was 5.2 years. Male was 33 and mean age at the time of initial MR was 60.6 years old. Among them, 54 patients were taking antiplatelet during follow up period. Between the antiplatelet group and control, there was no difference in demographic and risk factor profiles except hypertension, which was more prevalent in those taking antiplatelet (38.9 vs. 15.4%, P=0.002). Compared to the control, the antiplatelet group also showed more severe baseline white matter lesion volume (1953 vs. 3963 mm3, P=0.002) and more progression of white matter change (1010 vs. 2944 mm3, P=0.001). When we adjusted the variables using inverse probability treatment weighting method, there was no difference between the two groups. Conclusions: Subjects with large white matter lesion volume on MRI were more likely to take antiplatelet, but there was no effect of antiplatelet on the progression of white matter hyperintensity. Disclosure: Dr. Rha has nothing to disclose. Dr. Park has nothing to disclose. Dr. Park has nothing to disclose. Dr. Yoo has nothing to disclose.

7T clinical cardiovascular MR imaging: initial experience

Initial 7T Clinical Cardiovascular MR imaging results are presented. Although there are many basic problems that have to be resolved, 7T cardiovascular MRI has high potential for advanced imaging. Clinical practice has to prove what the specific advantages are of high-field cardiovascular MR imaging.

Ventriculus Terminalis in Adults: Unusual Magnetic Resonance Imaging Features and Review of the Literature

ObjectiveThe ventriculus terminalis (VT) in adults is a rare pathology. We report various MR imaging features of the adult VT.Materials and MethodsTen patients were included in this retrospective review.. All patients had undergone magnetic resonance (MR imaging with a surface coil that used two different 1.5T MR systems. All patients had undergone initial and follow-up MR imaging with contrast enhancement using gadopentate dimeglumine. Three patients underwent additional MR imaging using the echocardiogram-gated spatial modulation of magnetization (SPAMM) technique. If a shift in tagging band during the systolic phase was less than half of the band space, it was defined as a "non-pulsatile fluid". Two neuroradiologists independently reviewed these images, while clinical symptoms and outcomes were statistically analyzed between the treated and non-treated group.ResultsAll cases presented an intramedullary cystic lesion in the conus medullaris and showed the same signal intensity as CSF. Three VTs had intracystic septation and cord edema, which were pathologically confirmed after surgery; two of these were associated with kyphotic deformity and spinal arteriovenous malformation. SPAMM-MRI of 3 patients demonstrated non-pulsatile fluid motion within the VT. In the treated group, clinical symptoms improved better than the non-treated group.ConclusionThe adult VT shows some unusual imaging features, including septation, cord edema, and coexistence of a spinal AVM, as well as the typical findings. Surgical maneuvers may be considered as a treatment option in adult VT with progressive neurological symptoms.

C1–2 instability from os odontoideum mimicking intramedullary spinal cord tumor

Os odontoideum is a common cause of atlantoaxial instability in the pediatric population. The authors present the cases of 2 patients whose initial clinical presentation and MR imaging findings were suggestive of an intramedullary neoplasm, but whose ultimate diagnosis was determined to be cervical spine instability and cord injury due to os odontoideum.

Is bone scintigraphy necessary in the initial surgical staging of chondrosarcoma of bone?

To assess the value of whole-body bone scintigraphy in the initial surgical staging of chondrosarcoma of bone. A retrospective review was conducted of the bone scintigraphy reports of a large series of patients with peripheral or central chondrosarcoma of bone treated in a specialist orthopaedic oncology unit over a 13-year period. Abnormal findings were correlated against other imaging, histological grade and the impact on surgical staging. A total of 195 chondrosarcomas were identified in 188 patients. In 120 (63.8%) patients the reports of bone scintigraphy noted increased activity at the site of one or more chondrosarcomas. In one patient the tumour was outside the field-of-view of the scan, and in the remaining 67 (35.6%) cases, there was increased activity at the site of the chondrosarcoma and further abnormal activity in other areas of the skeleton. Causes of these additional areas of activity included degenerative joint disease, Paget's disease and in one case a previously undiagnosed melanoma metastasis. No cases of skeletal metastases from the chondrosarcoma were found in this series. Multifocal chondrosarcomas were identified in three cases. In two it was considered that all the tumours would have been adequately revealed on the initial MR imaging staging studies. In only the third multifocal case was an unsuspected, further presumed low-grade, central chondrosarcoma identified in the opposite asymptomatic femur. Although this case revealed an unexpected finding the impact on surgical staging was limited as it was decided to employ a watch-and-wait policy for this tumour. There is little role for the routine use of whole-body bone scintigraphy in the initial surgical staging in patients with chondrosarcoma of bone irrespective of the histological grade.

Nodular enhancement within the internal auditory canal following retrosigmoid vestibular schwannoma resection: a unique radiological pattern

The authors describe the unique occurrence of nodular enhancement within the fundus of the internal auditory canal (IAC) lateral to the preoperative radiological tumor margin following gross-total vestibular schwannoma (VS) resection. The nature of the study was a retrospective chart review of records. The authors reviewed the cases of all patients who underwent microsurgical resection of a VS between January 2000 and January 2010 at a single tertiary referral center. Patients with incomplete resection, neurofibromatosis Type 2, and those with fewer than 2 postoperative MR images available for review were excluded. Postsurgical patients with IAC enhancement located lateral to the preoperative imaging-delineated tumor margin were identified. Lesion morphology was characterized on serial MR imaging studies. Clinical follow-up and outcomes were recorded. Over the past decade, 350 patients underwent microsurgical VS resection. Of these, 16 patients met study criteria and were found to have postsurgical enhancement in the distal aspect of the IAC lateral to the imaging limits of the preoperative tumor margin on the first postoperative MR imaging study (37.5% women, median age 45 years). Initial MR imaging was performed at a mean of 3.1 months following surgery, and the mean radiological follow-up duration was 39.8 months (range 16.4-101.9 months). None of the 16 patients developed recurrence during the follow-up course. In contrast to previous publications that have reported a high rate of recurrence in cases involving nodular enhancement within the original tumor bed, postoperative enhancement in the IAC lateral to the original tumor margin appears to carry much less risk for tumor recurrence. These findings may be helpful when counseling patients on the recommended frequency of postoperative follow-up imaging.

SU‐C‐BRB‐06: High‐Precision Volume‐Staged Treatments with Stereotactic Radiosurgery

Purpose: The purpose of the study was to develop a procedure using selective region mutual information image registration and anatomic landmarks transformation to improve the treatment accuracy of volume‐staged Gamma Knife (GK) radiosurgery for large arteriovenous malformations (AVMs). Methods: The procedure was implemented via Leksell Gamma Plan (LGP version 9.0) and an in‐house point registration program for multiple session staged GK treatments. A requirement of such treatments was to match the partial‐volume dose distribution of a previously delivered treatment with the current treatment. In our procedure, MR images of the current treatment plan were first imported and co‐registered with the initial reference MR studies via selective region mutual information algorithm in LGP. Then the current MR studies were re‐imported and defined for its stereotactic frame. Based on these two MR studies (one registered and one defined), four or more anatomic landmarks surrounding the target region were selected, and then a rigid‐body transformation matrix was calculated from these points to map the original treatment plan onto the current treatment plan for the existing frame coordinate system. We analyzed the accuracy of such procedures performed for a group of 12 patients with 14 staged treatments at our institution since 2007. Results: The average discrepancy in the landmark vector distance between the original treatment plan and the transformed treatment plan was 0.25±0.09 mm. This value was 3–4 times smaller than previously published results. Additional studies on the accuracy of mutual information registration of MR‐MR images of the same objects/patients on our LGP system yielded a mean standard deviation of 0.16±0.07 mm, where the largest deviation was generally observed along the image scanning direction Conclusions: Volume‐staged GK treatments can be delivered to the same level of accuracy as single fraction GK treatments.

Changes in susceptibility signs on serial T2*-weighted single-shot echo-planar gradient-echo images in acute embolic infarction: comparison with recanalization status on 3D time-of-flight magnetic resonance angiography

The present study compares changes in susceptibility signs on follow-up single-shot echo-planar gradient-echo T2*-weighted images (GRE-EPI) with vascular status on follow-up magnetic resonance angiography (MRA) in acute embolic infarction. Twenty consecutive patients with acute embolic infarction repeatedly underwent MR imaging including GRE-EPI and MRA using a 1.5-T MR superconducting system. All patients underwent initial MR examination within 24h of onset and follow-up MR imaging within 1month after onset. Changes in susceptibility signs on follow-up GRE-EPI were compatible with vascular status on follow-up MRA in 19 of the 20 patients. Susceptibility signs disappeared with complete recanalization in 13 patients, migrated with partial recanalization in 3, did not change together with the absence of recanalization in 2, and became extended together with the absence of recanalization in 1. Cerebral hemorrhage obscured susceptibility signs in the one remaining patient. Susceptibility signs on follow-up GRE-EPI can reflect changes in an acute embolus, such as recanalization or migration, in this study. Serial GRE-EPI in acute embolism complements the diagnostic certainty of MRA by directly detecting an embolus as a susceptibility sign.

Spontaneous radiographic resolution and subsequent redemonstration of an untreated glioblastoma

The authors present the first case of spontaneous radiographic resolution and subsequent redemonstration of Gd enhancement of an untreated glioblastoma. They also review the literature on MR imaging enhancement patterns of high-grade gliomas and speculate that this phenomenon could be attributed to the dynamic biology of glioblastomas but could also represent pseudoregression following successful control of seizure activity. A 57-year-old woman presented with left-sided paresthesias and numbness. Initial Gd-enhanced MR images exhibited T2 and FLAIR signal changes in the right insular region without mass effect or contrast enhancement. Electroencephalography revealed intermittent sharp wave activity in this area. Antiepileptic medication was started, and the patient's symptoms resolved. Follow-up MR imaging 6 weeks later revealed enlargement of the lesion and contrast enhancement in the superior temporal gyrus. Consequently, the patient was scheduled for a brain biopsy. However, surgical planning MR images obtained on the day of surgery 4 weeks later showed that the enhancement had spontaneously resolved, and so the operation was cancelled. Repeat MR imaging performed 2 weeks later as a result of increased seizure frequency redemonstrated contrast enhancement. The patient then underwent a craniotomy, and final histopathology was consistent with glioblastoma.

Patients with Chiari malformation Type I presenting with acute neurological deficits: case series

Object A subset of patients with Chiari malformation Type I (CM-I) presented with acute onset of a neurological deficit. In this study the authors summarize their experience with these patients' clinical presentation, imaging results, timing of surgery, and outcome following decompression. Methods The authors reviewed clinical records, imaging studies, and operative notes from all patients undergoing posterior fossa decompression for CM-I at St. Louis Children's Hospital from 1990 to 2008. Of the 189 patients who underwent surgery, 6 were identified with the acute onset of a neurological deficit at presentation. Results All 6 children (age range 3–14 years, 3 boys and 3 girls) had either syringomyelia (5 patients) or T2 signal changes in the spinal cord (1 patient) and CM-I on initial MR imaging. Three patients presented after minor trauma (1 with paraparesis, 2 with sensory deficits). Three patients presented without a clear history of trauma (1 with abrupt onset of spontaneous dysphagia and ataxia, 2 with sensory deficits). Decompression was performed at a mean 7.7 ± 4.9 days after symptom onset (7.0 ± 1.6 days after neurosurgical evaluation). In 1 patient, symptoms had resolved by the time of surgery; in the remainder of the patients, clear improvements were noted within 2 weeks of surgery, with complete resolution of symptoms by 12 months postoperatively. Follow-up MR images were obtained in 4 patients, demonstrating improvement in the extent of the syrinx in each patient. Conclusions Children with CM-I and syringomyelia can develop acute spinal cord or bulbar deficits with relatively minor head or neck injuries. The prognosis for symptomatic improvement in the observed deficit is good, with each patient in our series showing resolution of deficits over time. However, based on this relatively limited experience, the authors suggest that patients who present with an acute neurological deficit and are found to have CM-I be managed with early posterior fossa decompression. Patients with CM-I and syringomyelia may be at higher risk of acute neurological deficit than those without a syrinx.

MR Imaging-Guided Intravenous Thrombolysis in Posterior Cerebral Artery Stroke

PCA stroke was under-represented in or excluded from the clinical trials examining thrombolysis based on the PWI-DWI mismatch concept. We present 6 patients with PCA stroke treated with thrombolysis in an extended time window by using MR imaging criteria. Symptoms included aphasia, sensorimotor hemiparesis, hemineglect, and homonymous hemianopia. Initial MR imaging demonstrated circumscribed ischemic lesions in the thalamus or hippocampus; MR angiography showed PCA occlusion with corresponding hypoperfusion. Follow-up MR imaging showed partial/complete recanalization in 4 patients with minor infarction growth, while in 1 patient, PCA occlusion persisted, resulting in a large PCA infarction. Three patients improved within 2 hours; at discharge, homonymous hemianopia had resolved in 3 patients. At 3-month follow-up, 4 patients had an mRS score of 0 or 1. These results support the approach to treat patients with PCA stroke with thrombolysis based on the mismatch concept. Because rehabilitation options for hemianopia are limited, thrombolysis may enhance the chance of a favorable outcome.

Can Whole-Body MRI Secure the Diagnosis of Suspected Infant Abuse?

Source: Perez-Rossello JM, Connoly S, Newton A, et al. Wholebody MRI in suspected infant abuse. AJR. 2010; 195(3): 744– 750; doi: 10.2214/AJR.09.3364Investigators from Children’s Hospital of Boston assessed the utility of whole-body MRI as compared to skeletal survey (SS) for finding skeletal and soft tissue injuries in infants with suspected physical abuse. They retrospectively analyzed imaging studies performed in 21 infants who met entry criteria from March 2003 to October 2005 and who underwent whole-body 1.5 Tesla magnetic resonance imaging (MR) within 5 days of the SS. Sixteen infants also had a follow-up SS; the combined findings of both surveys were referred to as the “summary skeletal survey.”Fifty-two body areas were analyzed on the MR and SS. Each examination type was reviewed for mean total number of injuries. Coronal and sagittal MR images were obtained using STIR sequences. Slice thicknesses were 3 to 5 mm. SS were performed using departmental protocol and the recommendations of the American College of Radiology. A pediatric radiologist monitored the SS studies and requested additional views, if necessary. MR images were reviewed independently by two board-certified pediatric radiologists who were aware of the history but were blinded to the SS findings. Bones, soft tissues, and solid organs were studied for abnormality. A third radiologist, blinded to the MR findings, studied the SS radiographs. The cervical spine was not evaluated as the whole-body examination began at the shoulder.Overall concordance rate was 95% for pre-MR SS versus follow-up SS, 87% for initial SS versus MR, and 89% for summary SS versus MR. There was no statistical difference between the average of 4.7 areas of abnormality seen on MR and the 5.4 fractures seen on the SS. Of the total of 167 fractures in the 21 children, 40.7% were seen by SS only, 31.7% by MR alone and 27.5% by both techniques. MR had a high specificity (95%) but a low sensitivity (40%). Radiography (24 of 37) was superior to MR (2 of 37) in finding metaphyseal corner fractures. MR sensitivity to this classic finding in child abuse was only 31%. MR was superior to SS for soft tissue injuries. Soft tissue injuries included 84 instances of muscle edema and 54 of subcutaneous edema, as well as 15 joint effusions, 12 pleural effusions, 3 intra-abdominal free fluid, 1 liver laceration, and 1 ligamentous injury of the spine.The authors emphasize the limited ability of MR to detect metaphyseal corner fractures and rib fractures, the most specific fractures for nonaccidental trauma and responsible for 90% of noncranial skeletal injuries in infant abuse fatalities. The authors conclude that MR cannot replace, but may complement, the SS.Dr Cohen has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.The best imaging for the infant with suspected physical abuse continues to be “old-fashioned” skeletal radiographs. Since Caffey’s landmark article1 in 1946 describing the imaging findings of the battered child, consistently achieving the goal of early diagnosis has been a major challenge. The medical, social, and legal consequences of missed diagnosis are of obvious major importance. The current study showed that 7 of 21 cases of child abuse would not have been diagnosed by MR alone. The absence of ionizing radiation makes MR an appealing imaging option. However, despite the accompanying radiation exposure, the pediatrician should not be dissuaded from ordering SS, which provide far superior identification of classic child abuse findings like metaphyseal corner fractures and rib fractures and which provide better information on the ages of the injuries.2 This study also demonstrates the superior ability of MR to pick up soft tissue injuries which can obscure fractures on SS and require follow-up. Scintigraphy may play a complementary role.Notably, some fractures were not identified on either study. Clinicians should use their judgment based on history, physical, and radiologic findings to identify and manage possible cases of physical abuse. When child abuse is suspected, an open dialogue between pediatricians and their radiologic colleagues is vital.