Retrospective Review Of Imaging Studies Research Articles

Fractura ósea tras un traumatismo menor en la enfermedad de Pyle: un caso poco frecuente en un adulto

Pyle's disease (PD) is a rare autosomal recessive metaphyseal dysplasia with approximately 30 reported cases and has recently gained interest due to its association with specific genes. While most cases are diagnosed in childhood and are asymptomatic, we present the case of a 39-year-old woman who presented to the Emergency Department with left knee pain, patellar fracture, and «Erlenmeyer flask» deformity. Retrospective review of imaging studies and medical history revealed the symmetric and systemic nature of the skeletal disorder, confirming the diagnosis of PD. Familiarity with this disease is crucial for optimal patient management, and the radiologist plays a crucial role in its diagnosis.

Solitary long-bone epiphyseal lesions in children: radiologic-pathological correlation and epidemiology.

Solitary epiphyseal lesions are rare and present with nonspecific imaging features. Knowledge regarding etiologies of pediatric epiphyseal lesions is limited to small studies. The purpose of this study was to determine the relative incidence of pathologies affecting the pediatric epiphysis based on biopsy-proven cases with imaging. We conducted a retrospective review of imaging studies including the terms "biopsy" or "resection" and entities known to affect the epiphysis and cross-referenced these with pathology reports, recording the relevant clinical data. Two radiologists performed comprehensive imaging review and recorded relevant features. Forty-nine children and adolescents met inclusion criteria. The long-bone epiphyseal lesion etiologies included chondroblastoma (n=22, 45%), nonspecific nonmalignant pathology (n=11, 22%), osteomyelitis (n=9, 18%), lymphoma (n=2, 4%) and 1 case of each of aneurysmal bone cyst, chondrosarcoma, enchondroma, hemangioendothelioma, and non-Langerhans cell histiocytosis. Median age was 13.1years old (range 1.5-18.6years). We performed comparative analysis of the two most common lesions in our series, chondroblastoma and osteomyelitis. Chondroblastoma was significantly more likely to be peripherally located (94% vs. 33%, P=0.002) and to demonstrate a discrete T1-weighted hypointense rim (94% vs. 33%, P=0.002); there were no significant differences in enhancement or intrinsic signal properties. Children with chondroblastoma were older (15.1years vs. 7.3years, P=0.001), and chondroblastoma lesions were significantly larger, with mean maximum lesion diameter of 25mm (interquartile range [IQR] 20-30) vs. 12mm (IQR 11-18) (P=0.001) and lesion volumes of 4.4mL (IQR 2.4-7.9) vs. 0.4mL (IQR 0.2-1.4) (P=0.01). This study reports the relative frequency of pathology of pediatric solitary epiphyseal lesions and describes several features that might assist in differentiating between chondroblastoma and osteomyelitis.

Pattern and severity of transverse sinus stenosis in patients with pulsatile tinnitus associated with sigmoid sinus wall anomalies

Describe the location and severity of transverse sinus stenosis (TSS) in a consecutive series of patients with intraoperatively confirmed sigmoid sinus wall abnormalities (SSWA). A retrospective review of imaging studies from patients undergoing sinus wall reconstruction for pulsatile tinnitus associated with SSWA "was performed." Qualitative and quantitative analyses of the TSS, including the side, type, location, extent, and severity, were performed and compared with normal controls and historical controls with idiopathic intracranial hypertension (IIH). Twenty-six of 36 subjects had adequate imaging data. The majority of subjects had some degree of bilateral TSS, and the majority of stenoses involved the distal transverse sinus. Subjects with diverticulum were significantly more likely than those with dehiscence to have ipsilateral distal TSS (16 of 16 vs. 4 of 10, P = 0.009). The mean minimum transverse sinus diameter, stenosis severity grade, and overall posterior venous sinus outflow were significantly worse in the subjects as compared to normal controls (P = 0.002), although not as severe as the comparable values in historical controls with IIH (P < 0.003). Subjects with SSWA have a high incidence of TSS, with patterns differing between those with dehiscence and diverticulum. Severity of TSS and overall posterior fossa venous outflow are worse as compared to normal controls but not as severe as in subjects with IIH. These findings have implications for the pathophysiology and management of SSWA. 4 Laryngoscope, 130:1028-1033, 2020.

Volvulus of the entire small bowel with normal bowel fixation simulating malrotation and midgut volvulus.

Midgut volvulus is a complication of malrotation of bowel and mesenteric malfixation. In contrast, primary volvulus of the small bowel is a distinctly different and rare entity characterized by torsion of the entire small bowel with normal mesenteric fixation. To present the clinical and imaging findings in four infants with primary small bowel volvulus and normal bowel fixation in order to improve awareness of this entity among clinicians and radiologists and to discuss the potential etiologies of this entity to distinguish it from other causes of small bowel volvulus. A retrospective review of imaging studies (two ultrasounds and four upper gastrointestinal series) in four infants (three full-term and one premature) from three institutions with surgically proven volvulus of the entire small bowel and normal bowel fixation were reviewed by three board-certified pediatric radiologists and correlated with clinical and surgical reports when available. The infants presented during the first week to 6 months of life and were acutely ill. The upper gastrointestinal series showed complete duodenal obstruction with beaking in one and partial duodenal obstruction in three. All studies were interpreted as highly suspicious for malrotation and midgut volvulus. Emergent laparotomy demonstrated primary small bowel volvulus with normal mesenteric fixation in all infants. The base of the small bowel mesentery was described by the operating surgeon as smaller than normal in one infant (case 3). There was no mesenteric defect or other abnormality predisposing to volvulus in the other three. In both infants who had abdominal US, a retroperitoneal position of the third portion of the duodenum was demonstrated. All infants survived. One infant required resection of the necrotic small bowel and currently has short gut syndrome, one has malabsorption and two were lost to follow-up. Primary small bowel volvulus with normal fixation is indistinguishable from malrotation with midgut volvulus in the acutely ill infant or child. Radiographic diagnosis can be difficult in patients with intermittent or incomplete small bowel volvulus without malrotation. In these patients, neither an upper gastrointestinal series demonstrating a normal position of the duodenojejunal junction nor the sonographic demonstration of a retromesenteric third portion of the duodenum excludes the diagnosis. In young infants, the clinical and imaging findings may mimic necrotizing enterocolitis. Sonography may be useful to evaluate the bowel for signs of bowel wall compromise or a whirlpool sign.

Imaging features of pancreatic tumors in children: 13-year experience at a pediatric tertiary hospital

Pancreatic tumors are rare in children, resulting in limited information regarding their frequency and imaging appearances. To review all pancreatic tumors seen in children over a decade at a large tertiary pediatric institution and to describe multimodality imaging findings. We conducted a retrospective review of imaging studies performed in children with pancreatic tumors between January 2000 and December 2012, analyzing imaging features on available US, CT and MR examinations. We reviewed patient charts for clinical features, management and final diagnosis. We included 23 children in this study. Of these, 12 had solid and papillary epithelial neoplasms (SPEN), 3 had neuroendocrine tumors, 3 had lymphoma, and 1 each had hemangioendothelioma, benign congenital cysts with adipose tissue, dendritic cell sarcoma, metastatic rhabdomyosarcoma, and lipoma. All children with SPEN were teenage girls. SPEN showed characteristic imaging features including well-defined margins with surrounding capsule, solid-cystic components and hemorrhage. Pancreatic tumors are uncommon in children. SPEN is the most common tumor and is seen predominantly in teenage girls and shows characteristic imaging features.

Durability of branches in branched and fenestrated endografts

Branched and fenestrated repair has been shown to be effective for treatment of complex aortic aneurysms. However, the long-term durability of branches is not well reported. Prospective data collected for all patients enrolled in a physician-sponsored investigational device exemption trial for branched and fenestrated endografts were analyzed. Retrospective review of imaging studies and electronic records was used to supplement the dataset. Incidences of branch stent secondary intervention, stent fracture, migration, branch-related rupture, and death were calculated. A time-to-event analysis was performed for secondary intervention for any branch. Univariable and multivariable analyses were performed to identify related variables. Branch instability, a composite outcome of any branch event, was reported as a function of exponential decay to capture the loss of freedom from complications over time. Between the years 2001 and 2010, 650 patients underwent endovascular aortic repair with branched or fenestrated devices. Over 9 years of follow-up (mean [standard deviation], 3 [2.3] years), secondary procedures were performed for 0.6% of celiac, 4% of superior mesenteric artery (SMA), 6% of right renal artery, and 5% of left renal artery stents. Mean time to reintervention was 237 (354) days. The 30-day, 1-year, and 5-year freedom from branch intervention was 98% (95% confidence interval [CI], 96%-99%), 94% (95% CI, 92%-96%), and 84% (95% CI, 78%-90%), respectively. Death from branch stent complications occurred in three patients, two related to SMA thrombosis and one due to an unstented SMA scallop. Multivariable analysis revealed no factors as independent predictors of need for branch reintervention. Branches, after branched or fenestrated aortic repair, appear to be durable and are rarely the cause of patient death. The absence of long-term data on branch patency in open repair precludes comparison, yet the lower morbidity and mortality risk coupled with longer-term durability data will further alter the balance of repair options.

Use of a quantitative pedicle screw accuracy system to assess new technology: Initial studies on O-arm navigation and its effect on the learning curve of percutaneous pedicle screw insertion

Background A quantitative screw accuracy system is proposed that allows for high-fidelity discrimination between various methods of pedicle screw insertion. Our purpose was to study the utility of a quantitative screw accuracy scoring system to assess new imaging technologies and their effects on the minimally invasive spine learning curve. Methods By use of a hypothetical “perfect screw,” a scoring system is proposed that may be used to compare the position of a small number of screws inserted according to a desired optimal position. This study incorporates a retrospective review of imaging studies for 10 patients who underwent percutaneous pedicle screw placement with either navigation-assisted O-arm imaging or navigation-assisted C-arm imaging. For the learning-curve portion of the study, 2 cadaveric adult torsos were used for instrumentation. Computed tomography imaging studies were used in both studies to assess screw position in the pedicle and vertebral body in relation to an optimal screw by use of a quantitative scoring system to rate accuracy. Results The quantitative scoring system allowed a statistically significant accuracy difference to be ascertained between 2 different technologies using fewer data points than previously published methods. When this screw scoring system is applied to minimally invasive percutaneous pedicle screw insertion, an optimal screw position can be achieved with greater accuracy through navigation-assisted technology (O-arm with computer-assisted navigation). When the O-arm with computer-assisted navigation was used by a novice surgeon learning the technique of percutaneous screw insertion, screws were inserted in a shorter period without loss of accuracy. In contrast, use of the traditional C-arm fluoroscopy leads to a loss of accuracy with faster insertion times. Increased accuracy can be seen clinically when compared with fluoroscopic navigation. Conclusions The use of a quantitative scoring system allows for rapid assessment of screw accuracy. As additional technologies and new teaching techniques for pedicle screw insertion are developed, this scoring system may be useful as an early assessment tool.

Intrahepatic bile duct dilatation after percutaneous radiofrequency ablation for hepatocellular carcinoma: impact on patient's prognosis

Percutaneous radiofrequency ablation (RFA) has been widely accepted as an alternative to surgery for small hepatocellular carcinoma (HCC). In RFA, a portion of liver tissue surrounding tumour is also ablated to achieve a safety margin. The intrahepatic bile duct may be injured and result in chronic bile duct dilatation upstream of the injured site. However, the impact of such an injury on the overall prognosis has been unclear. Patients who showed bile duct dilatation following RFA were identified by a retrospective review of imaging studies. Each dilatation was classified as mild (limited to one hepatic subsegment) or severe (affecting two or more subsegments). The relation between the incidence of intrahepatic bile duct dilatation and HCC recurrence or survival was analysed using proportional hazard models. Among 589 consecutive HCC patients treated with RFA, 70 (11.9%) and 21 (3.6%) patients showed mild and severe bile duct dilatation respectively. Patients with severe dilatation, but not those with mild dilatation, had lower survival and higher HCC recurrence than patients without dilatation. Severe dilatation, but not mild dilatation, was significantly associated with death [hazard ratio (HR) 2.17, P=0.035] and recurrence (HR 2.89, P<0.001). Whereas mild bile duct dilatation after RFA is clinically negligible, bile duct dilatation affecting two or more subsegments should be regarded as a complication that may affect the prognosis and should be observed carefully.

Cerebral Arteriopathy in Children With Neurofibromatosis Type 1

Cerebrovascular abnormalities are serious but underrecognized complications of neurofibromatosis type 1 (NF1). The aim of this study was to investigate the prevalence, clinical presentation, imaging findings, and prognosis of cerebral arteriopathies in childhood NF1. Patients followed at the NF1 clinic at the Hospital for Sick Children, Toronto, Ontario, Canada, between 1990 and 2007 were studied. Patients with confirmed NF1 diagnosis and neuroimaging results were included. All neuroimaging studies were reviewed for the presence of arteriopathy by 2 study pediatric neuroradiologists blinded to clinical information. Clinical records of children with cerebral arteriopathy were reviewed. Among 419 children with confirmed NF1, 266 (63%) received neuroimaging. Among children with neuroimaging results, 17 had cerebral arteriopathy (minimum prevalence rate of 6%). Among the 35 patients who received magnetic resonance angiography (MRA), arteriopathy was more common in patients with NF1 with optic gliomas (11 of 21) compared with those without optic glioma (4 of 14). Forty-seven percent of children developed focal deficits months to years after the diagnosis of the arteriopathy. Follow-up at a mean of 7 years after diagnosis of arteriopathy showed that 35% (6 of 17) had progressive arteriopathy requiring revascularization surgery. Seven patients received aspirin for primary stroke prevention. On retrospective review of imaging studies, a mean delay of 51 months to clinical radiographic reporting of these findings was observed. The prevalence of cerebral arteriopathy in children with NF1 in this study was at least 6% and was associated with young age and optic glioma. Arteriopathy causes stroke with resultant neurologic deficits. Medical and/or surgical interventions may prevent these complications. Therefore, the addition of vascular imaging (MRA/conventional angiography) to brain imaging studies for early detection of arteriopathy should be considered for children with NF1, particularly young patients with optic glioma.

Preoperative Chemotherapy and Split-Course Radiation Therapy for Patients With Localized Soft Tissue Sarcomas: Home Run, Base Hit, or Strike Out?

Kraybill et al report results of Radiation Therapy Oncology Group (RTOG) trial 9514 —a phase II trial of preand postoperative modified mesna, doxorubicin, ifosfamide, and dacarbazine (MAID) chemotherapy combined with preoperative split-course radiation (44 Gy given in two courses interdigitated with MAID cycles) for patients with stage III soft tissue sarcomas (STS) of the extremities and body wall. The authors and the RTOG are to be congratulated for completing the first American cooperative group trial for patients with localized STS in decades. In considering how this report affects the standard of care for patients with STS, however, several issues deserve close attention including patient selection, the toxicities of treatment, the effects of preoperative treatment on the extent of surgery, and the relative contributions of chemotherapy and radiation to the results. The eligibility criteria for RTOG 9514 included high-grade stage III STS of the extremity or body wall 8 cm in diameter. Without question, the study patients were at relatively high risk for systemic relapse, and preor postoperative chemotherapy designed to treat micrometastatic disease was worth considering given that 50% of such patients with large, ostensibly localized, high-grade STS have subclinical metastatic disease at presentation. However, eligibility criteria also included “clinical judgment of R0 surgical intent on completion of neoadjuvant chemotherapy and radiation therapy.” It is not clear exactly what this means. Neither patients nor physicians have the prescience to know who will achieve a sufficient treatment-related response to enable macroscopically and microscopically complete surgical resection (R0 resection), but patients with localized disease considered operable at diagnosis are more likely to be able to undergo limb-sparing R0 resection than are patients with locally advanced disease not immediately operable with commonly utilized limb-sparing approaches. The “R0 surgical intent” criterion therefore raises questions about the patients’ extent of disease. Although many patients enrolled in RTOG 9514 probably had localized disease, it is likely that some participating physicians selected patients for this protocol who had locally advanced disease in the hope that treatment-related response would improve operability. Thus, it would be of great interest to patients and clinicians to know if patients who responded to preoperative therapy had a change in the scope of planned surgery. A significant alteration in the scope of surgery remains an important short-term potential advantage of preoperative chemotherapy or radiation therapy that is independent of the long-term efficacy of such treatment. There is no question that a patient who avoids amputation as a result of a clinically significant chemotherapyand/or radiationrelated response experiences a clinical benefit regardless of whether the therapy impacts overall survival. Thus, an important clinical question that remains is, how often does clinically meaningful down staging occur with preoperative treatment? The issue of clinically meaningful down staging with preoperative treatment was addressed in part in reports from The University of Texas M.D. Anderson Cancer Center (Houston, TX). In 1997, we reported the results of preoperative anthracycline-based chemotherapy in 76 consecutive patients with stage III STS (median tumor size, 10.0 cm). Major radiological responses (confirmed by retrospective review of imaging studies) occurred in 27% of patients, while confirmed radiologic disease progression occurred in 30% of patients. However, this study did not allow us to determine what fraction of responding patients had experienced a primary tumor response significant enough to reduce the scope of planned surgery or what fraction of the 30% of patients who experienced local tumor progression had the scope of planned surgery increased as a consequence of local disease progression during preoperative treatment. This question was addressed in a 2002 report of a nonoverlapping cohort of 65 patients treated with anthracyclineand/or ifosfamide-based preoperative chemotherapy in which we observed a similar 34% response rate and 26% rate of disease progression. In this second report, the impact of preoperative chemotherapy on the scope of anticipated surgery was assessed by a panel of three sarcoma surgeons blinded to the operative treatment rendered and to patient outcome. Preoperative treatment resulted in a decrease in the scope of anticipated surgery in 13% of patients, while 9% had disease progression significant enough to increase the scope of surgery. Apart from this study, the literature evaluating clinically meaningful down staging is limited, and the ambiguity in the eligibility criteria in the report from Kraybill et al does not allow us to shed further light on this important issue. JOURNAL OF CLINICAL ONCOLOGY E D I T O R I A L VOLUME 24 NUMBER 4 FEBRUARY 1 2006

Arachnoid veils and the Chiari I malformation.

The literature contains scant data regarding variations in anatomy at the level of the foramen of Magendie in patients with Chiari I malformation and syringomyelia. Based on their operative experience and hospital data, the authors detailed the incidence of arachnoid veils found in juxtaposition to the foramen of Magendie in patients with hindbrain herniation. Additionally, radiological studies were retrospectively reviewed in cases in which such an anomaly was noted intraoperatively. Of 140 patients with Chiari I malformation who underwent decompressive surgery, an associated syrinx was demonstrated in 80 (57%). The foramen of Magendie was obstructed by an arachnoid veil in 10 (12.5%) of these patients; once the lesion was punctured, the cerebrospinal fluid drained freely from this median aperture. On retrospective review of imaging studies, none of these anomalous structures was evident. In all patients with an arachnoid veil and syringomyelia resolution of syringomyelia was revealed on postoperative imaging. In the absence of a clear pathophysiology of syrinx production, the authors would recommend that patients with syringomyelia and Chiari I malformation undergo duraplasty so that, if present, these veils can be fenestrated.

Solid variant of aneurysmal bone cysts in long tubular bones: giant cell reparative granuloma.

The purpose of this study was to determine the age distribution, location, and imaging features of histologically proven solid variants of aneurysmal bone cysts in long tubular bones. We performed a retrospective review of imaging studies of histologically proven solid aneurysmal bone cysts in long bones between 1961 and 2001. There were 30 cases comprising 29 radiographic, six CT, and eight MR imaging examinations. The lesions were evaluated for bone involved, location within a long bone, matrix, size, soft-tissue mass, and MR imaging characteristics. The imaging findings were correlated with the histologic findings. The patients were 17 females and 13 males ranging in age from 2 to 58 years (mean, 18 years). The bones involved were the femur (n = 10), the ulna (n = 7), the tibia (n = 7), the humerus (n = 2), the radius (n = 2), and the fibula (n = 2). The lesions were five juxtaarticular, 13 metaphyseal, one diametaphyseal, and 11 diaphyseal. The location was eccentric in 20 cases, of which two were intracortical and two periosteal, and central in 10. Lesion size varied between 1 and 7 cm. Thirty-three percent of lesions were nonaneurysmal. Four lesions were mineralized. A soft-tissue mass was present in four cases. Four lesions showed a permeative-lytic pattern simulating a malignant process. Unusual findings included periosteal reaction and development of a solid aneurysmal bone cyst in a preexisting fracture. MR imaging showed solid elements in all cases and pronounced edema in 50% of cases. Solid aneurysmal bone cyst is a reactive nonneoplastic bone lesion with varied imaging characteristics; one third of lesions are nonaneurysmal.

A guide to the evaluation of fourth cranial nerve palsies

PURPOSE To devise a cost-effective guide for the evaluation of fourth nerve palsies (FNP). METHODS A review of the pertinent English language literature was performed to devise a guide for the evaluation (including neuroimaging) of FNP. The authors report a retrospective review of imaging studies performed on 206 patients with FNP. RESULTS The literature was used to develop the imaging guide. In the retrospective chart review of 206 patients from two tertiary care centers, 28 patients (13.6%) underwent a computed tomography scan and/or a magnetic resonance scan. Of these patients, five had associated neurological symptoms (non-isolated), one was traumatic, five were congenital, four were vasculopathic, eleven were non-vasculopathic, and two were progressive. Following the recommendations of the imaging guide, the five isolated congenital FNP and the four isolated vasculopathic FNP would not have undergone neuroimaging studies. The total costs of these neuroimaging studies in these nine patients were 19,000 dollars. Four patients in the retrospective review with associated neurological deficits (non-isolated) should have undergone neuroimaging according to the guide, but did not. CONCLUSIONS Although the evaluation of FNP can be difficult, the decision to order neuroimaging can be improved by using an imaging guide. An imaging guide for the evaluation of FNP may allow more appropriate and cost-effective imaging of these patients. Isolated congenital, old traumatic, or vasculopathic FNP do not require neuroimaging studies. Patients with non-isolated FNP should have directed neuroimaging studies based upon the results of clinical examination.

Histopathologic Diagnosis Made in Lung Tissue Resected From Patients With Severe Emphysema Undergoing Lung Volume Reduction Surgery

This study reports histopathologic findings in a group of emphysema patients who underwent thoracoscopic lung volume reduction surgery (75) or sternotomy (five) with the purpose to induce functional improvement and relief of dyspnea. Immediate outcome and complications were correlated to histologic patterns. Histopathologic material obtained in lung volume reduction surgery in 80 consecutive patients was analyzed. Thirty patients who had other histopathologic diagnoses in addition to emphysema were grouped and compared with 50 patients found to have emphysema exclusively. Postoperative outcome and preoperative lung function variables were compared. All patients had severe obstructive lung disease and significant air trapping preoperatively documented by pulmonary function testing. All had severe exertional dyspnea. All had chest radiographs, CT, and nuclear medicine lung scans consistent only with emphysema. All portions of resected lung tissue were weighed, lung volume was estimated, and routine histopathologic studies were made. Thirty patients (37.5%) had unsuspected findings such as interstitial fibrosis, noncaseating granulomatosis, chronic inflammation, and unsuspected neoplasia (three carcinomas, one carcinoid). Retrospective review of imaging studies in these patients failed to show infiltrative processes. The average lung weight resected in this group was significantly heavier (65+/-18 g) compared with the other group (56+/-13 g), although both had the same estimated lung volume. Average number of days requiring chest tubes and length of hospitalization was also significantly higher (12.8+/-19 vs 6.4+/-5 days with chest tubes and 17.4+/-22 vs 8.5+/-6 days of hospitalization, respectively). None of the preoperative pulmonary function tests variables were different between the two groups. Serious postoperative complications were more frequent in these patients compared with those who showed only emphysema. A significant portion of patients diagnosed as having severe emphysema will have other unsuspected histologic findings. When subjected to lung volume reduction surgery, this subgroup will have more serious complications and longer periods of air leaks, requiring longer hospitalization time. Retrospective review of imaging studies and preoperative pulmonary function tests used to select patients for lung volume reduction failed to identify this subgroup.