Clinical Radiology - Articles in Press

Decontamination of transvaginal ultrasound probes: Review of national practice and need for national guidelines - Corrected Proof

R.A. Gray, P.L. Williams, P.A. Dubbins, P.J. Jenks — 2012-05-17

Aim: To determine the national practice of transvaginal ultrasound (TVUS) probe decontamination in English hospitals and to develop recommendations for guidance.Materials and methods: A literature review was undertaken to clarify best practice and evaluate methods of decontamination of TVUS probes. A questionnaire was developed to ascertain TVUS probe decontamination programmes in current use within English hospitals. This was sent to ultrasound leads of 100 English hospitals; 68 hospitals responded.Results: There is a wide variation in TVUS probe decontamination across English hospitals. Although the majority of respondents (87%, 59/68) reported having clear and practical written guidelines for TVUS decontamination, the frequency, methods, and types of decontamination solutions utilized were widely variable and none meet the standards required to achieve high-level disinfection.Conclusion: While the decontamination of other endoluminal medical devices (e.g., flexible endoscopes) is well defined and regulated, the decontamination of TVUS probes has no such guidance. There appears to be incomplete understanding of the level of risk posed by TVUS probes, and in some cases, this has resulted in highly questionable practices regarding TVUS hygiene. There is an urgent need to develop evidence-based national guidance for TVUS probe decontamination.

Delayed response assessment with FDG-PET-CT following (chemo)radiotherapy for locally advanced head and neck squamous cell carcinoma - Corrected Proof

2012-05-17

Aims: To analyse the diagnostic accuracy of delayed response assessment 2-[18F]-fluoro-2-deoxy-d-glucose (FDG) positron-emission tomography–computed tomography (PET-CT) following (chemo)radiation for locally advanced head and neck squamous cell carcinoma (HNSCC).Material and methods: Forty-four consecutive patients who underwent a baseline and response assessment using FDG PET-CT for HNSCC following (chemo)radiation between August 2008 and April 2011 were identified retrospectively. Clinicopathological findings and serial clinical follow-up provided the reference standard.Results: Median follow-up was 14 months (range 5–43 months). Response assessment FDG PET-CT was performed at 16.8 weeks (inter-quartile range 15.8–18.6 weeks). Thirty-one out of 44 (70%) response assessment examinations showed a complete metabolic response. Seven out of 40 (18%) assessable primary tumours were positive. Eight out of 41 (20%) patients with pre-treatment nodal disease had equivocal or positive FDG uptake at response assessment. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for primary disease and nodal disease were 100, 89, 43, 100, and 100%, and 92, 63, and 100%, respectively. Seven patients had residual FDG-negative soft tissue detectable on the unenhanced CT component of the response assessment images; all remained disease free after clinical observation. Distant metastases were detected on response assessment FDG PET-CT in four out of the 44 patients (10%).Conclusion: The diagnostic accuracy of response assessment with FDG PET-CT performed at approximately 16 weeks post-(chemo)radiotherapy is good. The very high NPV of a complete metabolic response can be used to guide management decisions. Although the PPV is limited for local residual disease, FDG PET-CT is a powerful screening tool for the detection of interim metastatic disease.

An exploratory study into the role of dynamic contrast-enhanced (DCE) MRI metrics as predictors of response in head and neck cancers - Corrected Proof

S. Agrawal, R. Awasthi, A. Singh, M. Haris, R.K. Gupta, R.K.S. Rathore — 2012-05-17

Aim: To assess the efficacy of dynamic contrast-enhanced magnetic resonance imaging (DCE MRI) in prediction of the response to treatment in patients with head and neck cancers (HNCs).Methods and materials: Twenty-one patients with advanced HNC, suitable for concurrent chemoradiotherapy underwent DCE MRI, for the quantification of blood flow (BF) and volume (BV). All the patients received radical doses of conventionally fractionated radiotherapy up to a dose of 70 Gy along with concurrent weekly cisplatin.Results: The values of BV and BF were higher in complete responders as compared to partial responders at primary as well as nodes. Both BF and BV were found to be significantly higher in patients with high T-stage as compared to patients with lower T-stage.Conclusions: DCE metrics can be used as a predictor of response to treatment in locally advanced HNCs after validation of these observations in a larger number of patients.

Differences in left and right carotid intima-media thickness - Corrected Proof

T. Kawada — 2012-05-17

Sir — I read with interest the paper by Luo et al. recently published in the Journal. It focused on the differences between left and right carotid intima–media thickness (CIMT) and the impact on associated factors. The authors speculated the reason for the anatomical difference, which would cause superior hydrostatic pressure in the left CIMT and dynamic pressure in right CIMT. They quoted several references describing the left–right difference as a causal factor in the development of atherosclerotic plaque or hormonal difference. They mentioned the need for further study to provide an adequate explanation for the left–right difference. On this point, Plichart et al. reported that carotid plaques, but not CIMT measured at a plaque-free site, were independent predictors of coronary heart disease or risk prediction in older adults with no separate consideration of CIMT.

Percutaneous drainage as a novel approach for the treatment of Brodie's abscess - Corrected Proof

K. Tan, P. Yoong, T.J. Marshall, C. Martin — 2012-05-16

Brodie's abscess is an insidious, localized, subacute osteomyelitis, typically caused by Staphylococcus aureus. Typically seen in the metaphyses of long bones in a young male patient, the diagnosis is frequently challenging. There are often mild clinical symptoms and radiographic features are frequently similar to primary bone tumours such as osteoid osteoma.

Post-mortem skeletal surveys in suspected non-accidental injury - Corrected Proof

Y. Hughes-Roberts, O.J. Arthurs, H. Moss, P.A.K. Set — 2012-05-14

Aim: To evaluate potential differences between live (LSS) and post-mortem skeletal surveys (PMSS) in cases of non-accidental injury (NAI).Materials and methods: All skeletal surveys (SS) performed for suspected NAI over a 5 year period were retrospectively reviewed. Demographic details, injuries obtained, artefacts, and radiographic difficulties encountered during LSS and PMSS were recorded.Results: Of 195 surveys performed, there were significantly fewer positive PMSS (11/128; 8.6%) than LSS (16/67; 23.8%), but no difference between the actual injuries encountered. Of those who had a positive SS, dead children were significantly younger (mean age 2.6 ± 3.4 months old) than live children (7.8 ± 6.9 months old; p < 0.05). Thirty-six percent of all contemporary digital radiographs contained artefacts, particularly in PMSS (599/1504; 39.8%) compared to LSS (269/904: 29.7%; p < 0.001), which were mostly patient identification labels (55.1 versus 21.6%; p < 0.001). PMSS demonstrated death-related radiographic complications in 10.6% of cases.Conclusion: Radiographic imaging in deceased children is not easy, and yields significant artefacts, which may hamper image interpretation. A technique for obtaining multiple views of a limb in fixed flexion deformity to maximize the diagnostic potential is described. Careful consideration of these factors would maximize the diagnostic yield in this unique patient population.

Discontinuity of the incudo-stapedial joint within a fully aerated middle ear and mastoid on computed tomography: A clinico-radiological study of its aetiology and clinical consequence - Corrected Proof

S.E.J. Connor, I. Pai, D. Jiang, A.J.D. Spiers, A. Fitzgerald-O'Connor — 2012-05-14

Aim: To investigate the aetiology and clinical consequences of incudo-stapedial (IS) discontinuity when it is demonstrated on computed tomography (CT) within a fully aerated middle ear and mastoid.Methods and materials: Patients with CT evidence of IS discontinuity within a fully aerated middle ear and mastoid were prospectively identified. Clinical history, otoscopic findings, audiometry, and CT data were evaluated. Predefined criteria were used to determine the likely aetiology of IS discontinuity, whether it was diagnosed prior to the CT study, and the clinical consequences in terms of degree of conductive hearing loss and requirement for surgical correction. The range of CT appearances was evaluated.Results: The IS discontinuity in 34/36 ears was felt to be due to incus erosion secondary to chronic otitis, on the basis of clinical history and otoscopic findings. The IS discontinuity was rarely evident prior to CT with long-process deficiency being identified in only 5/36 cases. The mean air bone gap was only 22.5 dB. The ossicular defect was surgically addressed in only four cases. The incus deficiency was confined to the lower-third on CT in 19/36 cases.Conclusion: When IS discontinuity is demonstrated within a fully aerated middle ear and mastoid, the most likely aetiology is of acquired incus erosion due to chronic otitis media. The IS discontinuity on CT is usually not evident otoscopically. It usually results in only mild conductive hearing loss and the ossicular discontinuity was rarely surgically addressed in the present series.

Complications after percutaneous placement of totally implantable venous access ports in the forearm - Corrected Proof

J.P. Goltz, B. Petritsch, A. Thurner, D. Hahn, R. Kickuth — 2012-05-14

This article focuses on radiological imaging of complications after interventional percutaneous insertion of totally implantable venous access ports (TIVAPs) which were placed in the forearm. Thus far most reviews have dealt with pectorally-placed TIVAPs. Compared with the pectoral approach, implantation in the forearm has been associated with certain complications owing to a longer route of the port catheter within a smaller vein, and owing to the route across the elbow joint, resulting in higher rates of catheter-associated thrombosis and possible mechanical complications. The purpose of this review is to describe the complications after implantation of TIVAPs in the forearm, and to make radiologists familiar with the key findings of the complications during radiological imaging, including colour-coded and compression Duplex ultrasound, computed tomography, and digital subtraction venography.

Replacement tunnelled dialysis catheters for haemodialysis access: Same site, new site, or exchange — A multivariate analysis and risk score - Corrected Proof

C.R. Tapping, P.M. Scott, R. Lakshminarayan, D.F. Ettles, G.J. Robinson — 2012-05-07

Aim: To identify variables related to complications following tunnelled dialysis catheter (TDC) replacement and stratifying the risk to reduce morbidity in patients with end-stage renal disease.Materials and methods: One hundred and forty TDCs (Split Cath, medCOMP) were replaced in 140 patients over a 5 year period. Multiple variables were retrospectively collected and analysed to stratify the risk and to predict patients who were more likely to suffer from complications. Multivariate regression analysis was used to identify variables predictive of complications.Results: There were six immediate complications, 42 early complications, and 37 late complications. Multivariate analysis revealed that variables significantly associated to complications were: female sex (p = 0.003; OR 2.9); previous TDC in the same anatomical position in the past (p = 0.014; OR 4.1); catheter exchange (p = 0.038; OR 3.8); haemoglobin <11 g/dl (p = 0.033; OR 3.6); albumin <30 g/l (p = 0.007; OR 4.4); prothrombin time >15 s (p = 0.002; OR 4.1); and C-reactive protein >50 mg/l (p = 0.007; OR 4.6). A high-risk score, which used the values from the multivariate analysis, predicted 100% of the immediate complications, 95% of the early complications, and 68% of the late complications.Conclusion: Patients can now be scored prior to TDC replacement. A patient with a high-risk score can be optimized to reduce the chance of complications. Further prospective studies to confirm that rotating the site of TDC reduces complications are warranted as this has implications for current guidelines.

The role of interventional radiology and imaging in pancreatic islet cell transplantation - Corrected Proof

2012-05-03

Pancreatic islet cell transplantation (PICT) is a novel treatment for patients with insulin-dependent diabetes who have inadequate glycaemic control or hypoglycaemic unawareness, and who suffer from the microvascular/macrovascular complications of diabetes despite aggressive medical management. Islet transplantation primarily aims to improve the quality of life for type 1 diabetic patients by achieving insulin independence, preventing hypoglycaemic episodes, and reversing hypoglycaemic unawareness. The islet cells for transplantation are extracted and purified from the pancreas of brain-stem dead, heart-beating donors. They are infused into the recipient's portal vein, where they engraft into the liver to release insulin in order to restore euglycaemia. Initial strategies using surgical access to the portal vein have been superseded by percutaneous access using interventional radiology techniques, which are relatively straightforward to perform. It is important to be vigilant during the procedure in order to prevent major complications, such as haemorrhage, which can be potentially life-threatening. In this article we review the history of islet cell transplantation, present an illustrated review of our experience with islet cell transplantation by describing the role of imaging and interventional radiology, and discuss current research into imaging techniques for monitoring graft function.

Peritumoural steatosis in metastatic “non-functioning” neuroendocrine tumour of the pancreas - Corrected Proof

P. Borghei, Z. Pan, Lincoln L. Berland — 2012-05-03

We report a case of peritumoural steatosis surrounding a solitary hepatic metastasis from a primary “non-functioning” neuroendocrine tumour of the pancreas. To the authors' knowledge, this is the first case to be reported of peritumoural steatosis around a metastasis from such a lesion. The metastasis was confined to the central portion without extension into the adjacent hepatic steatosis.

Intravenous contrast medium administration at 128 multidetector row CT pulmonary angiography: Bolus tracking versus test bolus and the implications for diagnostic quality and effective dose - Corrected Proof

J.C.L. Rodrigues, H. Mathias, I.S. Negus, N.E. Manghat, M.C.K. Hamilton — 2012-04-23

Aim: To investigate the effects of a test bolus protocol contrast medium administration on diagnostic image quality in computed tomography pulmonary angiography (CTPA).Materials and methods: Fifty patients referred for exclusion of pulmonary embolism underwent CTPA using a test bolus protocol CTPA at 120 kVp and were compared with 50 patients undergoing CTPA using a standard bolus-tracking protocol at 120 kVp, via assessment of attenuation, signal-to-noise ratio (SNR), and contrast-to-noise ratio (CNR) seen in the pulmonary arteries (PAs). An additional group of 10 non-obese patients who underwent CTPA using a test bolus protocol performed at 100 kVp were also analysed. Mean effective dose was calculated from the dose–length product, using standard conversion factors.Results: The test bolus protocol showed significantly higher attenuation, SNR, and CNR in the pulmonary vasculature down to the segmental level compared to bolus-tracking CTPA (p < 0.0001). There was no significant difference in effective dose between the test bolus and bolus tracking cohorts. The additional group of test bolus CTPA examinations performed at 100 kVp had a significantly reduced effective dose in comparison to both test bolus CTPA at 120 kVp and bolus-tracking CTPA at 120 kVp (p < 0.005) yet maintained mean PA attenuation to segmental level significantly better than bolus-tracking CTPA performed at 120 kVp and comparable to the test bolus cohort performed at 120 kVp.Conclusion: Test bolus contrast administration should be used as an optimal protocol. Performing test bolus CTPA at 100 kVp, as opposed to 120 kVp, significantly reduces dose without compromising PA attenuation in non-obese subjects.

Diagnostic and radiological management of cystic pancreatic lesions: Important features for radiologists - Corrected Proof

B. Buerke, D. Domagk, W. Heindel, J. Wessling — 2012-04-20

Cystic pancreatic neoplasms are often an incidental finding, the frequency of which is increasing. The understanding of such lesions has increased in recent years, but the numerous types of lesions involved can hinder differential diagnosis. They include, in particular, intraductal papillary mucinous neoplasms (IPMN), serous cystic neoplasms (SCN), and mucinous cystic neoplasms (MCN). Knowledge of their histological and radiological structure, as well as distribution in terms of localization, age, and sex, helps to differentiate such tumours from common pancreatic pseudocysts. Several types of cystic pancreatic neoplasms can undergo malignant transformation and, therefore, require differentiated radiological management. This review aims to develop a broader understanding of the pathological and radiological characteristics of cystic pancreatic neoplasms, and provide a guideline for everyday practice based on current concepts in the radiological management of the given lesions.

CT imaging of primary pleuropulmonary synovial sarcoma - Corrected Proof

W.-D. Zhang, Y.-B. Guan, Y.-F. Chen, C.-X. Li — 2012-04-19

Aim: To evaluate the computed tomography (CT) imaging findings of primary pleuropulmonary synovial sarcoma.Materials and methods: Five cases of synovial sarcoma confirmed by histopathology and cytogenetic study were retrospectively analysed. All patients had undergone chest radiography and unenhanced and contrast-enhanced CT examinations, and three had also undergone multiphase CT enhancement examinations. Image characteristics, including shape, size, margin, and attenuation of each lesion before and after contrast enhancement, were analysed.Results: The chest radiographs of the five patients showed well-defined or partly well-defined masses, which were homogeneous and without associated calcification or lymphadenopathy. Pneumothorax was present in one patient. The unenhanced CT images showed well-defined, heterogeneous masses with patchy low density in all five patients. The contrast-enhanced CT images showed heterogeneous enhancement in all cases, three of which demonstrated cystic and necrotic areas. The tumour showed no prolonged or delayed enhancement in three cases using multiphase CT. There were small pleural effusions in four cases. No calcification was observed in any of the cases. There was no evidence of hilar or mediastinal lymphadenopathy.Conclusions: In these five patients, primary pleuropulmonary synovial sarcoma presented as a well-defined mass with patchy low density and heterogeneous enhancement, with no evidence of regional lymphadenopathy. It should be included in the differential diagnosis of regional tumours.

Distal ureteral seeding metastasis of collecting duct carcinoma manifesting as deep vein thrombosis - Corrected Proof

G.E. Yang, J.W. Seo, J.H. Park — 2012-04-19

Renal collecting duct carcinoma (CDC), also known as Bellini's duct carcinoma, is a rare type of renal cell carcinoma (RCC), accounting for 0.4–1.8% of all RCCs. CDC tends to be a very aggressive disease, so accompanying metastatic disease is present at initial presentation in most reported cases. The prognosis of CDC is therefore poor, with approximately 70% of patients dying of disease progression within 2 years after diagnosis. Several cases of CDC have been reported with extensive multi-organ metastasis including the lung, liver, spleen, bone marrow, adrenal gland, para-aortic lymph node, and proximal ureter, resulting in complex presentation.

Diffusion-weighted MRI of adult male pelvic cancers - Corrected Proof

K.S. Lim, C.H. Tan — 2012-04-13

Magnetic resonance imaging (MRI), with its superior soft-tissue delineation, plays a pivotal role in the staging and surveillance of cancers affecting adult males, in particular, rectal, urinary bladder, and prostate cancers. There has been much recent interest in the complementary roles of diffusion-weighted imaging (DWI) for imaging of pelvic cancers. DWI measures the diffusivity of water molecules in biological tissue. Cancer, with its high cellular density and nuclear:cytoplasmic ratio, and extracellular disorganization, typically shows significant restricted diffusivity compared with surrounding normal tissue. In theory, diffusivity of water molecules may vary according to degree of tumour aggressiveness and changes in cell density and extracellular fluid content after treatment. Information regarding these variations may be used to study the histological grades of cancers and their response to treatment. In this article, we present the currently available evidence on the potential roles of DWI for the assessment of pelvic cancers in men, and demonstrate with imaging examples how this knowledge may be applied to daily clinical practice.

The “safe” triangle, contrast material, and particulate steroids in lumbar transforaminal injections: What are the right things to do? - Corrected Proof

J.D. Hilton, R. Eddy, D. Connell — 2012-04-09

Lumbar transforaminal steroid injections (LTFI) for radicular back pain are generally safe and well tolerated. In the United States alone, Medicare data indicate that over 1 million LTFI are carried out every year (). In the last decade, a cluster of case reports from the US, England, and France, describing 15 patients, have highlighted the rare complication of spinal cord infarction related to LFTI. Although the exact incidence of this complication is unknown, the risk of spinal cord infarction from a LTFI is likely to be less than one per million per year. The rarity of the event makes it difficult to determine the precise cause of this complication and measures to avoid it. This uncertainty has not prevented the publication of strongly worded opinions on the value of the “safe triangle”, the requirement for contrast medium injection, and the possible danger of particulate steroids. The present analysis leads us to very different conclusions.

StarClose arterial closure after conversion from retrograde to antegrade access - Corrected Proof

C.R. Tapping, S. Dixon, M.W. Little, M.J. Bratby, S. Anthony, R. Uberoi — 2012-04-09

Arterial closure devices (ACDs) were introduced in the 1990s with the advantage that patients were able to ambulate almost immediately after the procedure. The overall procedure time can be reduced and also patient satisfaction and acceptance has been shown to be greater. The StarClose device (Abbott Vascular Devices, Redwood City, CA, USA) has been shown to be efficient with a high level of clinical and technical success. Antegrade and retrograde punctures have been successfully sealed with the StarClose vascular device. However, a higher rate of puncture site minor complications has been associated with antegrade access.

Central skull base osteomyelitis as a complication of necrotizing otitis externa: Imaging findings, complications, and challenges of diagnosis - Corrected Proof

A. Adams, C. Offiah — 2012-04-09

Central skull base osteomyelitis is a rare, life-threatening complication of necrotizing or “malignant” otitis externa (NOE), which results in destruction of the skull base. The imaging appearances can be misinterpreted as malignancy but consideration of this diagnosis, both radiologically and clinically, is imperative to avoid the need for biopsy. The aim of this review is to highlight the pertinent imaging findings on computed tomography and magnetic resonance imaging as well as the potential complications of this condition.

Adrenal neoplasms - Corrected Proof

G. Low, H. Dhliwayo, D.J. Lomas — 2012-04-09

Adenoma, myelolipoma, phaeochromocytoma, metastases, adrenocortical carcinoma, neuroblastoma, and lymphoma account for the majority of adrenal neoplasms that are encountered in clinical practice. A variety of imaging methods are available for evaluating adrenal lesions including ultrasound, computed tomography (CT), magnetic resonance imaging (MRI), and nuclear medicine techniques such as meta-iodobenzylguanidine (MIBG) scintigraphy and positron-emission tomography (PET). Lipid-sensitive imaging techniques such as unenhanced CT and chemical shift MRI enable detection and characterization of lipid-rich adenomas based on an unenhanced CT attenuation of ≤10 HU and signal loss on opposed-phase compared to in-phase T1-weighted images, respectively. In indeterminate cases, an adrenal CT washout study may differentiate adenomas (both lipid-rich and lipid-poor) from other adrenal neoplasms based on an absolute percentage washout of >60% and/or a relative percentage washout of >40%. This is based on the principle that adenomas show rapid contrast washout while most other adrenal neoplasms including malignant tumours show slow contrast washout instead. 18F-2-fluoro-2-deoxy-d-glucose–PET (18FDG-PET) imaging may differentiate benign from malignant adrenal neoplasms by demonstrating high tracer uptake in malignant neoplasms based on the increased glucose utilization and metabolic activity found in most of these malignancies. In this review, the multi-modality imaging appearances of adrenal neoplasms are discussed and illustrated. Key imaging findings that facilitate lesion characterization and differentiation are emphasized. Awareness of these imaging findings is essential for improving diagnostic confidence and for reducing misinterpretation errors.

Differentiation between tuberculosis and lymphoma in mediastinal lymph nodes: Evaluation with contrast-enhanced MDCT - Corrected Proof

S.-S. Tang, Z.-G. Yang, W. Deng, H. Shao, J. Chen, L.-Y. Wen — 2012-04-09

Aim: To determine the specific imaging criteria on contrast-enhanced multidetector computed tomography (MDCT) for differentiating between tuberculosis and lymphoma in mediastinal lymph nodes.Materials and methods: The anatomical distribution and enhancement patterns of mediastinal lymph nodes on contrast-enhanced MDCT were reviewed in 37 patients with tuberculosis and 54 patients with lymphoma. Of the patients with lymphoma, 18 had Hodgkin's disease and 36 had non-Hodgkin's lymphoma.Results: Region 10R was involved more often in tuberculosis than in Hodgkin's disease and non-Hodgkin's lymphoma. Region 6 had a higher tendency to be affected in Hodgkin's disease and non-Hodgkin's lymphoma compared with tuberculosis. Tuberculosis showed peripheral enhancement in 78% of cases, frequently with a multilocular appearance, compared to Hodgkin's disease and non-Hodgkin's lymphoma, which showed peripheral enhancement in only 6 and 3% of cases, respectively. Homogeneous enhancement was more commonly seen in lymphoma (83% for Hodgkin's disease, and 83% for non-Hodgkin's lymphoma) than in tuberculosis (8%). In the determination of tuberculosis, results showed that when a peripheral enhancement pattern was seen, sensitivity was 78%, specificity was 96%, and accuracy was 89%. In the determination of lymphoma, results showed that when a homogeneous enhancement pattern was seen, sensitivity was 83%, specificity was 92%, and accuracy was 87%.Conclusion: The findings of the present study indicate that specific anatomical distribution and enhancement patterns of lymphadenopathy shown on contrast-enhanced MDCT can be useful in differentiating tuberculosis from lymphoma of mediastinal lymph nodes.

Assessing reader performance in radiology, an imperfect science: Lessons from breast screening - Corrected Proof

B.P. Soh, W. Lee, P.L. Kench, W.M. Reed, M.F. McEntee, A. Poulos, P.C. Brennan — 2012-04-09

The purpose of this article is to review the limitations associated with current methods of assessing reader accuracy in mammography screening programmes. Clinical audit is commonly used as a quality-assurance tool to monitor the performance of screen readers; however, a number of the metrics employed, such as recall rate as a surrogate for specificity, do not always accurately measure the intended clinical feature. Alternatively, standardized screening test sets, which benefit from ease of application, immediacy of results, and quicker assessment of quality improvement plans, suffer from experimental confounders, thus questioning the relevance of these laboratory-type screening test sets to clinical performance. Four key factors that impact on the external validity of screening test sets were identified: the nature and extent of scrutiny of one's action, the artificiality of the environment, the over-simplification of responses, and prevalence of abnormality. The impact of these factors on radiological and other contexts is discussed, and although it is important to acknowledge the benefit of standardized screening test sets, issues relating to the relevance of test sets to clinical activities remain. The degree of correlation between performance based on real-life clinical audit and performances at screen read test sets must be better understood and specific causal agents for any lack of correlation identified.

MRI findings of isoniazid-induced central nervous system toxicity in a child - Corrected Proof

Z.I. Hasiloglu, S. Albayram, M. Asik, O. Kilic, O. Unver, H.E. Erdemli, N. Kocer — 2012-04-06

Isoniazid (INH) is frequently used for the treatment of latent or active tuberculosis (TB) in adults and children. However, there are side effects of this treatment, such as hepatitis, peripheral and central neurotoxicity, lupus-like syndrome, and hypersensivity reactions. Central nervous system (CNS) toxicity is a rare but serious complication and its imaging findings are not well known.

Ovarian vein thrombosis - Corrected Proof

P. Sharma, S. Abdi — 2012-04-05

Ovarian vein thrombosis is a well-known but rare entity, which can occur during the post-partum period. This condition has also been associated with inflammatory and malignant processes within the pelvis. Untreated, complications of ovarian vein thrombosis can be significant due to the associated sepsis and risk of pulmonary embolism. Diagnosis can be made with confidence using ultrasound, computed tomography or magnetic resonance imaging. Treatment of ovarian vein thrombosis is particularly important in the post-partum patients, with anticoagulation therapy being the current recommendation.

Current and potential renal applications of contrast-enhanced ultrasound - Corrected Proof

C. McArthur, G.M. Baxter — 2012-04-05

The combination of microbubble technology and complementary ultrasound techniques has resulted in the development of contrast-enhanced ultrasound (CEUS) and, although initial clinical applications largely focussed on the liver, these are now becoming more diverse. With regard to the kidney, it is a safe, well-tolerated, and reproducible technique, and in selected cases, can obviate the need for computed tomography or magnetic resonance imaging. A clear advantage is the absence of nephrotoxicity. With respect to the current and potential renal applications, it is a useful technique in the evaluation of pseudotumours, acute pyelonephritis, renal tumours, cystic lesions, vascular insults, and renal transplantation. It may also be of value for monitoring the kidney following anti-angiogenic treatment or nephron-sparing interventional techniques for renal tumours. Assessment of microvascular perfusion using time–intensity curves is also likely to have further far-reaching applications in the kidney as well as other organs.

Provision of out-of-hours interventional radiology services in Scotland - Corrected Proof

I.A. Zealley, T.J. Gordon, I. Robertson, J.G. Moss, I.N. Gillespie — 2012-04-05

Aim: To evaluate the availability of out-of-hours (OOH) interventional radiology (IR) services in Scotland and discuss implications for service redesign.Materials and methods: Data were gathered via a survey conducted by telephone/e-mail interview. The setting was hospitals in Scotland with acute medical and/or surgical beds. The interviewees were consultant interventional radiologists representing each of the 14 geographical Health Boards in Scotland.Results: Three of the 14 geographical Health Boards provided a formal, prospectively planned OOH IR service in at least one hospital. Fourteen of the 34 acute hospitals provided an in-hours IR service, which includes endovascular haemorrhage control. Eight of the 34 acute hospitals had formal, prospectively planned on-call IR arrangements, 12 had an ad-hoc service, and 20 transferred patients to other facilities. Thirty-eight of the 223 consultant radiologists in Scotland were able to perform endovascular haemorrhage control procedures: only 18 of these 38 (47%) were included in on-call rotas. A further 42 radiologists were able to perform nephrostomy and a further 61 were able to perform abscess drainage. Eighty-two radiologists did not perform any interventional procedures.Conclusions: The provision of OOH IR services in Scotland is limited and available resources, both skills and equipment, are being underutilized. These data will be used to inform a process of OOH IR service redesign in Scotland.

Scrotal calcification in a symptomatic paediatric population: Prevalence, location, and appearance in a cohort of 516 patients - Corrected Proof

A. Deganello, D. Svasti-Salee, P. Allen, J.L. Clarke, M.E.K. Sellars, P.S. Sidhu — 2012-04-05

Aim: To describe the prevalence of all forms of scrotal calcification within a symptomatic paediatric population and to compare this with previous reported data in paediatric and adult populations.Materials and methods: A retrospective analysis of testicular ultrasound examinations performed in a single institution over a 55 month period. All examinations were performed by experienced operators using high-frequency linear array transducers. Types of scrotal calcification and position were recorded with all available images analysed by experienced radiologists.Results: A total 516 male patients under the age of 19 years (mean age 10.5 years) were included. The prevalence of testicular microlithiasis (TM) was 8.7% and the prevalence of non-TM macrocalcification was 0.4%. 2.3% of the patients had scrotal pearls and 0.2% had epididymal calcification recorded. No other form of calcification was identified. A single patient had a co-existing testicular tumour and TM at examination.Conclusion: The prevalence of TM in the symptomatic paediatric population is greater than that reported in the symptomatic adult population, whereas the prevalence of intra-testicular macrocalcification is lower. It is speculated that TM and macrocalcification represent different pathways for the possible risk of testicular tumour development.

Re: Small bowel MRI imaging in the DGH — Are you doing it yet? - Corrected Proof

G. Bhatnagar, M. Puckett — 2012-03-22

Sir — We read the article by Lee-Elliott and Ayer with great interest. Torbay hospital has been performing small bowel MRI since 2009. Although there is a great deal within the article with which we agree, there are some key differences in our practice that we would like to highlight to the authors and the readers.

Differentiating mass-forming intrahepatic cholangiocarcinoma from atypical hepatocellular carcinoma using gadoxetic acid-enhanced MRI - Corrected Proof

Y.S. Chong, Y.K. Kim, M.W. Lee, S.H. Kim, W.J. Lee, H.C. Rhim, S.J. Lee — 2012-03-19

Aim: To examine the differential features of mass-forming intrahepatic cholangiocarcinoma (ICC) from atypical hypovascular hepatocellular carcinoma (HCC) on gadoxetic acid-enhanced magnetic resonance imaging (MRI).Materials and methods: The institutional review board approved this retrospective study and waived informed patient consent. Seventy patients with pathologically proven ICCs (35) and hypovascular atypical HCCs (35) who had undergone preoperative gadoxetic acid-enhanced MRI were enrolled in this study. Images were analysed for the shape of the lesions and presence of hyperintensity on the T1-weighted image (T1WI) and hypo- or hyperintense areas on the T2-weighted image (T2WI). In addition, images were analysed for the presence of linear hyperintensity or multifocal, tiny, hyperintense foci on T2WI and the presence of rim enhancement during early dynamic phases and a central enhancement with a hypointense rim (target appearance) on the 10 and 20 min hepatobiliary phase images. The significance of these findings was determined by the X2 test.Results: Univariate analysis revealed that the following significant parameters favour ICC or hypovascular HCC; the presence of T2 hypo- and hyperintense areas and target appearance on the 10 min hepatobiliary phase images favour ICC, and the presence of T2 linear hyperintensity and T2 multifocal hyperintense foci favour hypovascular HCC (p < 0.05). Multivariate analysis revealed that only target appearance on the 10 min hepatobiliary phase was predictive of ICC (p = 0.002) as 30 ICCs (85.7%) showed this feature. However, the target appearance was also observed in all six scirrhous HCCs.Conclusion: A target appearance on the 10 min hepatobiliary phase images is the best predictor for identifying mass-forming ICC at gadoxetic acid-enhanced MRI.

Radiological features of Gorham’s disease - Corrected Proof

R. Kotecha, L. Mascarenhas, H.A. Jackson, R. Venkatramani — 2012-03-19

Aim: To describe the key findings on plain radiography, computed tomography (CT), and magnetic resonance imaging (MRI) of Gorham’s disease.Materials and methods: Eight children diagnosed with Gorham’s disease between 1999 and 2009 were included. All imaging studies performed on each patient were reviewed with special attention to the extent of bone, soft tissue, and visceral involvement.Results: All patients had bone lesions at diagnosis, most commonly in the vertebrae. CT showed generalized osteopenia, multiple lytic lesions, and heterogeneous bone density. MRI demonstrated altered signal intensity in bone marrow that was hyperintense on T1 imaging. Seven patients had soft-tissue lymphangiomatous lesions adjacent to identified osseous lesions. Four patients had chylous pleural effusions: three with bilateral and one with unilateral involvement. The spleen was involved in six patients.Conclusion: Splenic lesions and soft-tissue involvement are common in patients with Gorham’s disease. The presence of extra-osseous lesions along with characteristic bone lesions on plain radiography may be pathognomonic of Gorham’s disease.

Re: The radiology report — Are we getting the message across? - Corrected Proof

S. Chhatani, A. Sahu, P. Sankaye — 2012-02-29

Sir — We read with interest the article from Wallis and McCoubrie in the Journal. As trainees in the Southwest Peninsula Radiology Programme, we would like to put forward a trainee’s perspective of radiology reporting.

Re: The radiology report — Are we getting the message across? - Corrected Proof

D. Allen — 2012-02-20

Sir — I read the above article with great interest. I thought it was excellent and the content will be extremely useful to me in the work that I do — namely running a postgraduate certificate pathway for CT Head Reporting Radiographers. The authors mentioned in passing that “reporting radiographers and sonographers also receive little, if any, formal training in reporting technique and style”. Oddly, in our experience, the exact opposite is the case. Simply because radiographers have a different medical background from radiologists and lack the developed medico-legal and professional support structure that doctors enjoy, we are obliged to pay close scrutiny to exactly what we write in our reports. This practice is taught formally in the university setting, and developed in practice through the completion of a portfolio of reports, written in close working relationship with a radiological mentor. It is perhaps indicative of our different professional circumstances that radiographers have had to adopt such a meticulous approach from the outset, and it is reassuring to know that we are in agreement with radiologists on the need for clarity and good communication.

Re: The radiology report — Are we getting the message across? - Corrected Proof

L.D. Wheeler — 2012-02-20

Sir — I enjoyed the article by Wallis and McCoubrie on the radiology report and support their suggestion of giving clinicians what they want in the way they want to hear it. What they want is the ‘truth’, but what we have from cross-sectional imaging is shades of grey obtained by utilizing certain physical properties of matter manipulated by a complex mathematical algorithm. This version of the ‘truth’ hence has intrinsic uncertainty, and I would argue that the ubiquitous ‘hedge’ within the report rightly reflects that. Add in often limited or inaccurate clinical information and the widespread use of ‘hedge’ vocabulary, as listed by the authors, can be explained and embraced. It is well recognized that many radiological errors are due to errors in interpretation rather than in perception, and an educated and well-explained hedge may serve the clinician (and patient) better than over-committing. I do not accept that a 10% error rate is a reasonable price to pay for a statement of certainty.

The presence of radiological features on chest radiographs: How well do clinicians agree? - Corrected Proof

2012-02-17

Aim: To compare levels of agreement amongst paediatric clinicians with those amongst consultant paediatric radiologists when interpreting chest radiographs (CXRs).Materials and methods: Four paediatric radiologists used picture archiving and communication system (PACS) workstations to evaluate the presence of five radiological features of infection, independently in each of 30 CXRs. The radiographs were obtained over 1 year (2008) from children with fever and signs of respiratory distress, aged 6 months to <16 years. The same CXRs were interpreted a second time by the paediatric radiologists and by 21 clinicians with varying experience levels, using the Web 1000 viewing system and a projector. Intra- and interobserver agreement within groups, split by grade and specialty, were analysed using free-marginal multi-rater kappa.Results: Normal CXRs were identified consistently amongst all 25 participants. The four paediatric radiologists showed high levels of intraobserver agreement between methods (kappa scores between 0.53 and 1.00) and interobserver agreement for each method (kappa scores between 0.67 and 0.96 for PACS assessment). The 21 clinicians showed varying levels of agreement from 0.21 to 0.89.Conclusion: Paediatric radiologists showed high levels of agreement for all features. In general, the clinicians had lower levels of agreement than the radiologists. This study highlights the need for improved training in interpreting CXRs for clinicians and the timely reporting of CXRs by radiologists to allow appropriate patient management.

Susceptibility weighted imaging of the neonatal brain - Corrected Proof

2012-02-16

Susceptibility weighted imaging (SWI) is a well-established magnetic resonance technique, which is highly sensitive for blood, iron, and calcium depositions in the brain and has been implemented in the routine clinical use in both children and neonates. SWI in neonates might provide valuable additional diagnostic and prognostic information for a wide spectrum of neonatal neurological disorders. To date, there are few articles available on the application of SWI in neonatal neurological disorders. The purpose of this article is to illustrate and describe the characteristic SWI findings in various typical neonatal neurological disorders.

Imaging and management of complications of open surgical repair of abdominal aortic aneurysms - Corrected Proof

M. Nayeemuddin, A.D. Pherwani, J.R. Asquith — 2012-02-16

Open repair is still considered the reference standard for long-term repair of abdominal aortic aneurysms (AAA). In contrast to endovascular aneurysm repair (EVAR), patients with open surgical repair of AAA are not routinely followed up with imaging. Although complications following EVAR are widely recognized and routinely identified on follow-up imaging, complications also do occur following open surgical repair. With frequent use of multi-slice computed tomography (CT) angiography (CTA) in vascular patients, there is now improved recognition of the potential complications following open surgical repair. Many of these complications are increasingly being managed using endovascular techniques. The aim of this review is to illustrate a variety of potential complications that may occur following open surgical repair and to demonstrate their management using both surgical and endovascular techniques.

Additional diffusion-weighted imaging in the detection of new, very small hepatocellular carcinoma lesions after interventional therapy compared with conventional 3 T MRI alone - Corrected Proof

2012-02-16

Aim: To evaluate the added value of diffusion-weighted imaging (DWI) combined with conventional magnetic resonance imaging (MRI) in the detection of new, very small hepatocellular carcinoma lesions (≤1 cm) in patients with hepatocellular carcinoma following interventional therapy compared to conventional MRI alone.Materials and methods: After interventional therapy, 45 patients with hepatocellular carcinoma underwent conventional MRI and DWI with a b-value of 0 and 700 s/mm2. Twenty-one new, small hepatocellular carcinoma lesions were confirmed in 16 patients at follow-up MRI. Two observers independently retrospectively analysed the two imaging sets in random order. The diagnostic performance using each imaging set was evaluated by received operating characteristic curve analysis.Results: Twenty-one new, very small hepatocellular carcinoma lesions found in 16 patients was confirmed as the final result. The area under the receiver operating characteristic curve of the DWI/conventional MRI combination (observer 1, 0.952; observer 2, 0.976) and conventional MRI images alone (observer 1, 0.905; observer 2, 0.905) were statistically significant. The kappa value of the DWI/conventional MRI combination was 0.884, and that of conventional MRI was 0.722. Among the 21 lesions, 100% (21/21) of the lesions were both recognized by two independent reviewers on DWI, while only 76% (16/21) and 71% (15/21) of the lesions were regarded as very small hepatocellular carcinomas on conventional MRI.Conclusion: Due to the higher detection rate of new subcentimetre lesions in hepatocellular carcinoma patients following interventional therapy, DWI could be considered complementary to conventional MRI in the diagnosis of hepatocellular carcinoma.

The value of low-dose prospective ECG-gated dual-source CT angiography in the diagnosis of coarctation of the aorta in infants and children - Corrected Proof

P. Nie, X. Wang, Z. Cheng, Y. Duan, X. Ji, J. Chen, H. Zhang — 2012-02-16

Aim: To investigate the value of prospective electrocardiogram (ECG)-gated dual-source computed tomography (DSCT) in the diagnosis of coarctation of the aorta (CoA).Materials and methods: Seventeen patients clinically suspected of having CoA underwent prospective ECG-gated DSCT angiography and transthoracic echocardiography (TTE). Surgery was performed in all patients. The diagnostic accuracy of DSCT angiography and TTE was compared with the surgical findings as the reference standard. Image quality was evaluated using a five-point scale. Effective radiation dose was calculated from the dose–length product (DLP).Results: CoA was diagnosed in 17 patients by DSCT angiography and in 16 patients by TTE. A total of 46 separate cardiovascular abnormalities were confirmed by surgical findings. The diagnostic accuracy of DSCT angiography and TTE was 96.32% and 97.06%, respectively. There was no significant difference in the diagnostic accuracy between DSCT angiography and TTE (χ2 = 0, p > 0.05). The mean score of image quality was 4.2 ± 0.8. The mean effective dose was 0.69 ± 0.09 mSv.Conclusion: Prospective ECG-gated DSCT with a low radiation dose is a valuable technique in the diagnosis of CoA in infants and children.

CT and MRI findings of sphenoid sinus internal carotid artery pseudoaneurysm: An important and challenging differential diagnosis for a skull base mass - Corrected Proof

R.R. Saket, S.W. Hetts, J.K. Tatum, C.M. Glastonbury — 2012-02-16

Intrasphenoid internal carotid artery (ICA) pseudoaneurysm can present as and mimic a sinonasal mass. The purpose of this review is to describe the computed tomography (CT) and magnetic resonance imaging (MRI) features that should prompt the radiologist to consider this lesion in the differential diagnosis of a skull base mass. Specifically, when a sphenoid mass appears hyperdense, expansile, and destructive on CT and has mixed T1 signal and/or flow-related artefacts on MRI, the differential diagnosis should include a pseudoaneurysm. Vascular imaging is warranted to confirm the diagnosis.

Quantitative assessment of first-pass perfusion using a low-dose method at multidetector CT in oesophageal squamous cell carcinoma: Correlation with VEGF expression - Corrected Proof

T.-w. Chen, Z.-g. Yang, H.-j. Chen, Y. Li, S.-s. Tang, J. Yao, Z.-h. Dong, D. He — 2012-02-16

Aim: To investigate the correlation between vascular endothelial cell growth factor (VEGF) expression and first-pass perfusion parameters at multidetector computed tomography (MDCT) using a low-dose technique, and to determine how to discriminate VEGF positivity from VEGF negativity by perfusion CT in oesophageal squamous cell carcinomas.Materials and methods: Thirty-two patients with oesophageal squamous cell carcinomas underwent first-pass perfusion with 64-section MDCT at 50 mAs. Perfusion parameters, including perfusion, peak enhanced density (PED), time to peak (TTP), and blood volume (BV), were measured. Postoperative specimens were assessed for VEGF expression. Correlation tests were performed to determine the associations between each CT perfusion parameter and VEGF expression. The cut-off values of perfusion parameters were obtained statistically to discriminate VEGF positivity from VEGF negativity.Results: Mean perfusion, PED, TTP, and BV were 38.47 ± 30.26 ml/min/ml, 24.68 ± 9.65 HU, 28.35 ± 9.03 s, and 11.82 ± 6.06 ml/100 g, respectively. PED or BV were significantly higher in the VEGF-positive group than in the VEGF-negative group (all p < 0.05), but no significant difference in perfusion or TTP was found between the VEGF-positive and VEGF-negative groups (all p > 0.05). In VEGF positivity, PED and BV were correlated with VEGF expression (r = 0.576 and 0.765, respectively; all p < 0.05), whereas perfusion and TTP were not (r = 0.361 and 0.239, respectively; all p > 0.05). A threshold of BV (10.23 ml/100 g) achieved a sensitivity of 94.4%, and a specificity of 92.9% for discriminating VEGF positivity from VEGF negativity.Conclusion: BV could reflect tumour VEGF expression, and could be an indicator for evaluating angiogenesis in oesophageal tumours.

Apparent diffusion coefficient values of necrotic and solid portion of lymph nodes: Differential diagnostic value in cervical lymphadenopathy - Corrected Proof

Y. Zhang, J. Chen, J. Shen, J. Zhong, R. Ye, B. Liang — 2012-02-10

Aim: To evaluate whether the analysis of the apparent diffusion coefficient (ADC) values of the necrotic and solid portions of lymph nodes aids differentiation between the causes of cervical lymphadenopathy.Materials and methods: Thirty-six patients with cervical lymph node metastasis from head and neck squamous cell carcinomas (SCC), 19 patients with lymphoma, and 23 patients with tuberculous lymphadenitis underwent conventional magnetic resonance imaging (MRI) and diffusion-weighted imaging (DWI). The ADC values of necrotic and solid portions of lymph nodes were measured and compared. Receiver operating characteristic (ROC) analysis was employed to investigate whether ADC values could help to discriminate between the causes of cervical lymphadenopathy, and to obtain the optimal ADC threshold values.Results: The mean ADC values of the solid portions of metastatic nodes, lymphomatous nodes, and tuberculous nodes were (0.93±0.16)×10−3mm2/s, (0.64±0.13)×10−3mm2/s and (1.01±0.11)×10−3mm2/s, respectively (p<0.01). The mean ADC values of necrosis of metastatic and tuberculous nodes were (2.02±0.36)×10−3mm2/s and (1.25±0.15)×10−3mm2/s (p<0.01). By using the ADC value of the solid portion, the optimal ADC threshold values for distinguishing between metastasis and lymphoma, between metastasis and tuberculosis, and between lymphoma and tuberculosis were 0.77×10−3, 0.98×10−3 and 0.81×10−3mm2/s, respectively, and the sensitivities and specificities were 83 and 89%, 70 and 68%, 93 and 100%, respectively. By using ADC values of necrosis, the optimal ADC threshold value for distinguishing between metastasis and tuberculosis was 1.59×10−3mm2/s, and the sensitivity and specificity were 88 and 100%, respectively.Conclusion: The ADC values both of the necrotic and solid portions of the lymph nodes are useful in differentiation between the causes of cervical lymphadenopathy. The ADC value of necrosis is especially helpful in discriminating metastasis from tuberculosis.

Quantitative assessment of pure aortic valve regurgitation with dual-source CT - Corrected Proof

Z. Li, L. Huang, X. Chen, C. Xia, Y. Yuan, T. Shuai — 2012-02-10

Aim: To assess the severity of pure aortic regurgitation by measuring regurgitation volumes (RV) and fractions (RF) with dual-source computed tomography (DSCT) as compared to magnetic resonance imaging (MRI) and echocardiography.Materials and methods: Thirty-eight patients (15 men, 23 women; mean age 46±11 years) with isolated aortic valve regurgitation underwent retrospectively electrocardiogram (ECG)-gated DSCT, echocardiography, and MRI. Stroke volumes of the left and right ventricles were measured at DSCT and MRI. Thus, RVs and RFs were calculated and compared. The agreement between DSCT and MRI was tested by intraclass correlation coefficient and Bland–Altman analyses. Spearman’s rank order correlation and weighted κ tests were used for testing correlations of AR severity between DSCT results and corresponding echocardiographic grades.Results: The RV and RF measured by DSCT were not significantly different from those measured using MRI (p=0.71 and 0.79). DSCT correlated well with MRI for the measurement of RV (rI=0.86, p<0.001) and calculation of the RF (rI =0.90, p<0.001). Good agreement between the techniques was obtained by using Bland–Altman analyses. The severity of regurgitation estimated by echocardiography correlated well with DSCT (rs=0.95, p<0.001) and MRI (rs=0.95, p<0.001). Inter-technique agreement between DSCT and two-dimensional transthoracic echocardiography (2DTTE) regarding the grading of the severity of AR was excellent (κ=0.90), and good agreement was also obtained between MRI and 2DTTE assessments of the severity of AR (κ=0.87).Conclusion: DSCT using a volume approach can be used to quantitatively determine the severity of pure aortic regurgitation when compared with MRI and echocardiography.

In vivo proton MRS of normal pancreas metabolites during breath-holding and free-breathing - Corrected Proof

A. Bainbridge, S. Punwani — 2012-02-10

Magnetic resonance spectroscopy (MRS) is an important clinical tool for many applications, delivering information complementary to that obtained via imaging. However, many radiologists are unfamiliar with MRS and its potential to augment imaging. MRS already has an established clinical role for tissue characterization; for example, prostate cancer can be diagnosed with more confidence where an elevation of cell membrane metabolites is demonstrated.

In vivo proton MRS of normal pancreas metabolites during breath-holding and free-breathing - Corrected Proof

T.-H. Su, E.-H. Jin, H. Shen, Y. Zhang, W. He — 2012-02-10

Aim: To characterize normal pancreas metabolites using in vivo proton magnetic resonance spectroscopy (1H MRS) at 3T under conditions of breath-holding and free-breathing.Materials and methods: The pancreases of 32 healthy volunteers were examined using 1H MRS during breath-holding and free-breathing acquisitions in a single-voxel point-resolved selective spectroscopy sequence (PRESS) technique using a 3T MRI system. Resonances were compared between paired spectra of the two breathing modes. Furthermore, correlations between lipid (Lip) content and age, body-mass index (BMI), as well as choline (Cho) peak visibility of the normal pancreas were analysed during breath-holding.Results: Twenty-nine pairs of spectra were successfully obtained showing three major resonances, Lip, Cho, cholesterol and the unsaturated parts of the olefinic region of fatty acids (Chol+Unsat). Breath-hold spectra were generally better, with higher signal-to-noise ratios (SNR; Z=–2.646, p=0.008) and Cho peak visible status (Z=–2.449, p=0.014). Correlations were significant between spectra acquired by the two breathing modes, especially for Lip height, Lip area, and the area of other peaks at 1.9–4.1ppm. However, the Lip resonance was significantly different between the spectra of the two breathing modes (p<0.05). In the breath-holding spectra, there were significant positive correlations between Lip peak height, area, and age (r=0.491 and 0.521, p=0.007 and 0.004), but not between Lip peak area and BMI. There was no statistical difference in Cho resonances between males and females. The Lip peak height and area were significantly higher in the Cho peak invisible group than in the Cho peak visible group (t=2.661 and 2.353, p=0.030 and 0.043).Conclusion: In vivo 1H MRS of the normal pancreas at 3T is technically feasible and can characterize several metabolites. 1H MRS during breath-holding acquisition is superior to that during free-breathing acquisition.

The utility of cardiac CT beyond the assessment of suspected coronary artery disease - Corrected Proof

N. Kakouros, J. Giles, N.B. Crundwell, E.T.M. McWilliams — 2012-02-10

Extensive work has been done over recent years to improve the spatial and temporal resolution of electrocardiogram (ECG)-gated cardiac computed tomography (CT). Advances in both hardware and software analysis have enabled the development of non-invasive coronary angiography. However, these high-quality examinations lend themselves to multiple additional applications beyond coronary angiography. In this review, we illustrate and discuss some established and some emerging applications of ECG-gated cardiac CT beyond the assessment of suspected coronary disease, particularly in light of recent recommendations on the appropriate use of this technology.

Shoulder arthroplasty. Part 2: Normal and abnormal radiographic findings - Corrected Proof

B.D. Sheridan, N. Ahearn, A. Tasker, C. Wakeley, P. Sarangi — 2012-02-10

Frequently, the decision made by general practitioners or musculoskeletal triage assessment services to refer patients for specialist review is initiated by a radiological report. Following shoulder arthroplasty it is important to ensure that any patient with asymptomatic evidence of a failing prosthesis is referred for review so that revision surgery can be contemplated and planned before the situation becomes unsalvageable. The first paper in this series described the various types of shoulder arthroplasty and indications for each. This follow-up paper will concentrate on their modes of failure and the associated radiographic features, and is aimed at radiology trainees and non-musculoskeletal specialist radiologists.

Accuracy of brain imaging in the diagnosis of idiopathic intracranial hypertension - Corrected Proof

2012-02-10

Aim: To investigate the accuracy of individual and combinations of signs on brain magnetic resonance imaging (MRI) and magnetic resonance venography (MRV) in the diagnosis of idiopathic intracranial hypertension (IIH).Materials and methods: This study was approved by the institutional research ethics board without informed consent. Forty-three patients and 43 control subjects were retrospectively identified. Each patient and control had undergone brain MRI and MRV. Images were anonymized and reviewed by three neuroradiologists, blinded to clinical data, for the presence or absence of findings associated with IIH. The severity of stenosis in each transverse sinus was graded and summed to generate a combined stenosis score (CSS). The sensitivity, specificity, and likelihood ratios (LR) were calculated for individual and combinations of signs.Results: Partially empty sella (specificity 95.3%, p < 0.0001), flattening of the posterior globes (specificity 100%, p < 0.0001), and CSS <4 (specificity 100%, p < 0.0001) were highly specific for IIH. The presence of one sign, or any combination, significantly increased the odds of a diagnosis of IIH (LR+ 18.5 to 46, p < 0.0001). Their absence, however, did not rule out IIH.Conclusions: Brain MRI with venography significantly increased the diagnostic certainty for IIH if there was no evidence of a mass, hydrocephalus, or sinus thrombosis and one of the following signs was present: flattening of the posterior globes, partially empty sella, CSS <4. However, absence of these signs did not exclude a diagnosis of IIH.

Complaint and litigation in breast imaging – Realities, myths and strategies - Corrected Proof

I.D. Lyburn — 2012-02-06

In most aspects of clinical medicine, the role of imaging and image-guided intervention is increasing. There is an increasing impact of the initial assessment in many clinical scenarios and the subsequent follow-up, assessment of response to treatment, and surveillance. In evaluating breast disease, or potential breast disease, imaging has played a central role for decades and as it strongly features “in the frontline” there is a perception that breast imaging is a “high-risk” specialty relative to others with regard to medico-legal issues. Purushothaman et al. provide an interesting overview of a 10 year period of medico-legal breast cases involving imaging in the UK. In this series, imaging personnel are deemed to be at fault and the cause of substandard care in 60% cases. In spite of this figure, however, a very small number of cases (2%) in the UK go to court, as in order for successful litigation resultant harm from the error must be proven. Purushothaman et al. discuss the different categories of error that may occur in radiological evaluation of the breast and present ways in which many of the errors could be prevented, thus reducing risk of complaint and possible harm.

Value of subtraction MRI in assessing treatment response following image-guided loco-regional therapies for hepatocellular carcinoma - Corrected Proof

S.D. Winters, S. Jackson, G.A. Armstrong, I.W. Birchall, K.H.Y. Lee, G. Low — 2012-02-02

Aim: To compare contrast-enhanced subtraction magnetic resonance imaging (MRI) with contrast-enhanced standard MRI in assessing treatment response following loco-regional therapies for hepatocellular carcinoma (HCC).Method and materials: Institutional review board approval was obtained and informed consent was waived for this retrospective study. All patients were analysed from our institution’s liver tumour database that had loco-regional HCC therapy and the following: (1) a contrast-enhanced MRI ≤6 weeks post-treatment, (2) an unenhanced T1-weighted high-signal treatment zone (TZ) ≥1 cm, (3) follow-up contrast-enhanced MRI performed ≥6 months post-treatment. Randomized standard and subtraction TZ datasets were independently assessed by three blinded radiology readers for either complete treatment necrosis or residual disease. The standard of reference (SOR) comprised a consensus read by two radiologists with knowledge of the follow-up MRI and all available clinical data. Statistical analyses were performed using receiver operating characteristics (ROC), t-test, and kappa statistic.Results: Twenty-six patients (19 male and seven female patients; mean age 60 years, standard deviation 10.9 years, range 46–88 years) had a total of 45 corresponding HCCs and TZs. For ROC, the area under the curve (AUC) was 0.93 (subtraction protocol) versus 0.90 (standard protocol; p = 0.49). For the t-test, the mean reader confidence level was 4.4, 3.6, and 4.4 (subtraction protocol) versus 3, 3, and 3.7 (standard protocol; p ≤ 0.011). The kappa statistic for reader-to-SOR agreement was 0.83, 0.63, and 0.71 (subtraction protocol) versus 0.51, 0.36, and 0.64 (standard protocol).Conclusion: Subtraction MRI significantly improves the reader confidence level in the assessment of treatment response following loco-regional therapies for HCC.

Shoulder arthroplasty. Part 1: Prosthesis terminology and classification - Corrected Proof

B.D. Sheridan, N. Ahearn, A. Tasker, C. Wakeley, P. Sarangi — 2012-02-02

Shoulder arthroplasty is the third most common joint replacement procedure in the UK, and there are a number of different implant options available to surgeons to treat a variety of shoulder disorders. With an increasing burden placed on clinical follow-up, more patients are remaining under the care of their general practitioners and musculoskeletal triage assessment services and are not necessarily being seen by specialists. Referrals to orthopaedic specialists are therefore often prompted by radiological reports describing evidence of implant failure. This article is the first of two reviews on shoulder arthroplasty, concentrating on implant features and the indications for their use. The second article will address the modes of failure of shoulder arthroplasty and describe the relevant associated radiological features.