Academic Radiology

Ultrasound-guided Therapeutic Injection and Cryoablation of the Medial Plantar Proper Digital Nerve (Joplin's Nerve): Sonographic Findings, Technique, and Clinical Outcomes Publication date: Available online 3 July 2019 Source: Academic Radiology Author(s): Christopher J. Burke, Julien Sanchez, William R. Walter, Luis Beltran, Ronald Adler Rationale and Objectives The medial plantar proper digital nerve, also called Joplin's nerve, arises from the medial plantar nerve, courses along the medial hallux metatarsophalangeal joint, and can be a source of neuropathic pain due to various etiologies, following acute injury including bunion surgery and repetitive microtrauma. We describe our clinical experience with diagnostic ultrasound assessment of Joplin's neuropathy and technique for ultrasound-guided therapeutic intervention including both injection and cryoablation over a 6-year period. Materials and Methods Retrospective review of all diagnostic studies performed for Joplin's neuropathy and therapeutic Joplin's nerve ultrasound-guided injections and cryoablations between 2012 and 2018 was performed. Indications for therapeutic injection and cryoablation, were recorded. Studies were assessed for sonographic abnormalities related to the nerve and perineural soft tissues. Post-treatment outcomes including immediate pain scores, clinical follow-up, and periprocedural complications were documented. Results Twenty-four ultrasound-guided procedures were performed, including 15 perineural injections and nine cryoablations. With respect to sonographic abnormalities, nerve thickening (33%) and perineural hypoechoic scar tissue (27%) were the most common findings. The mean pain severity score prior to the therapeutic injection was 6.4/10 (range 4–10) and 0.25/10 (range 0–2) following the procedure; mean follow-up was 26.2 months (range 3–63 months). All of the cryoablation patients experienced sustained pain relief with a mean length follow-up of 3.75 months (range 0.2–10 months). Conclusion Therapeutic injection of Joplin's nerve is a safe and easily performed procedure under ultrasound guidance, with high rates of immediate symptom improvement. For those experiencing a relapse or recurrent symptoms, cryoablation offers an effective secondary potential treatment option.

To Score or Not to Score—The USMLE Debate Continues Publication date: Available online 2 July 2019 Source: Academic Radiology Author(s): Priscilla J. Slanetz

Discrepancy in Practices Related to the Use of Oral Contrast in Abdominal CT Scan Publication date: July 2019 Source: Academic Radiology, Volume 26, Issue 7 Author(s): Shahmeer Khan, Muhammad Awais, Anwar Ahmed

Counterpoint: Why Some Imposed Structure is a Necessity in Radiology Reporting Publication date: July 2019 Source: Academic Radiology, Volume 26, Issue 7 Author(s): Adam E. Flanders

In Opposition to Standardized Templated Reporting Publication date: July 2019 Source: Academic Radiology, Volume 26, Issue 7 Author(s): David Mark Yousem

Institutional Implementation of a Structured Reporting System: Our Experience with the Brain Tumor Reporting and Data System Publication date: July 2019 Source: Academic Radiology, Volume 26, Issue 7 Author(s): Ashwani Gore, Michael J. Hoch, Hui-Kuo G. Shu, Jeffrey J. Olson, Alfredo D. Voloschin, Brent D. Weinberg Rationale and Objectives Analyze the impact of implementing a structured reporting system for primary brain tumors, the Brain Tumor Reporting and Data System, on attitudes toward radiology reports at a single institution. Materials and Methods Following Institutional Review Board approval, an initial 22 question, 5 point (1—worst to 5—best), survey was sent to faculty members, house staff members, and nonphysician providers at our institution who participate in the direct care of brain tumor patients. Results were used to develop a structured reporting strategy for brain tumors which was implemented across an entire neuroradiology section in a staged approach. Nine months following structured reporting implementation, a follow-up 27 question survey was sent to the same group of providers. Keyword search of radiology reports was used to assess usage of Brain Tumor Reporting and Data System over time. Results Fifty-three brain tumor care providers responded to the initial survey and 38 to the follow-up survey. After implementing BT-RADS, respondents reported improved attitudes across multiple areas including: report consistency (4.3 vs. 3.4; p < 0.001), report ambiguity (4.2 vs. 3.2, p < 0.001), radiologist/physician communication (4.5 vs. 3.8; p < 0.001), facilitation of patient management (4.2 vs. 3.6; p = 0.003), and confidence in reports (4.3 vs. 3.5; p < 0.001). Providers were more satisfied with the BT-RADS structured reporting system (4.3 vs. 3.7; p = 0.04). Use of the reporting template progressively increased with 81% of brain tumor reports dictated using the new template by 9 months. Conclusion Implementing a structured template for brain tumor imaging improves perception of radiology reports among radiologists and referring providers involved in the care of brain tumor patients.

Reliability of MRI-Derived Depth of Invasion of Oral Tongue Cancer Publication date: July 2019 Source: Academic Radiology, Volume 26, Issue 7 Author(s): Ryuji Murakami, Shinya Shiraishi, Ryoji Yoshida, Junki Sakata, Keisuke Yamana, Akiyuki Hirosue, Yoshikazu Uchiyama, Hideki Nakayama, Yasuyuki Yamashita Rationale and Objective To evaluate the inter-rater reliability of the magnetic resonance imaging (MRI)-derived depth of invasion (DOI) and the agreement between MRI and pathological measurements of oral tongue cancer. Materials and Methods The institutional review board approved this retrospective study. The study population consisted of 29 patients with clinical T2N0 oral tongue cancer treated by surgery. Routine pretreatment MRI was performed on a 3T superconducting imager. Two raters with 23 and 18 years of head-and-neck MRI experience, respectively, independently chosen MRI sequences for each patient, then delineate the tumor, and then used three protocols to measure the MRI-derived DOI: the axial reconstructed thickness (method 1), the axial invasive portion (method 2), and the coronal invasive portion (method 3). Then they consensually selected the optimal among the three methods for each patient; it was designated method 4. The Bland-Altman plots, intraclass correlation coefficients (ICCs), and the paired samples test were used. According to the median follow-up of 41 months, the relationship between the MRI-derived DOI and nodal recurrence was also investigated. Results The inter-rater reliability of methods 2 and 4 was excellent (ICC of 0.829 and 0.807, respectively). The correlation between MRI and pathological measurements was good for method 4 (ICC of 0.611), however, all measurements recorded on MRI were 2–3 mm larger than on pathology. No patients whose MRI-derived DOI was less than 5 mm suffered nodal recurrence. Conclusion The MRI-derived DOI was valuable for the preoperative staging. The optimal measurement method should be selected on a case-by-case basis.

Influence of Monoenergetic Images at Different Energy Levels in Dual-Energy Spectral CT on the Accuracy of Computer-Aided Detection for Pulmonary Embolism Publication date: July 2019 Source: Academic Radiology, Volume 26, Issue 7 Author(s): Guangming Ma, Yuequn Dou, Shan Dang, Nan Yu, Yanbing Guo, Chuangbo Yang, Shuanhong Lu, Dong Han, Chenwang Jin Purpose To investigate the influence of monoenergetic images of different energy levels in spectral computed tomography (CT) on the accuracy of computer aided detection (CAD) for pulmonary embolism (PE). Materials and Methods CT images of 20 PE patients who underwent spectral CT pulmonary angiography were retrospectively analyzed. Nine sets of monochromatic images from 40 to 80 keV at 5 keV interval were reconstructed and then independently analyzed for detecting PE using a commercially available CAD software. Two experienced radiologists reviewed all images and recorded the number of emboli manually, which was used as the reference standard. The CAD findings for the number of PE at different energies were compared with the reference standard to determine the number of true positives and false positives with CAD and to calculate the sensitivity and false positive rate at different energies. Result There were 120 true emboli. The total numbers of CAD-detected PE at 40–80 keV were 48, 67, 63, 87, 106, 115, 138, 157, and 226. Images at low energies had low sensitivities and low false positive rates; images at high energies had high sensitivities and high false positive rates. At 60 keV and 65 keV, CAD achieved sensitivity at 81.67% and 84.17%, respectively and false positive rate at 7.55% and 12.17%, respectively to provide the optimum combination of high sensitivity and low false positive rate. Conclusion Monochromatic images of different energies in dual-energy spectral CT affect the accuracy of CAD for PE. The combination of CAD with images at 60–65 keV provides the optimum combination of high sensitivity and low false positive rate in detecting PE.

The Association Between Bronchial Wall CT Attenuation and Spirometry in Patients with Bronchial Asthma Publication date: July 2019 Source: Academic Radiology, Volume 26, Issue 7 Author(s): Shoichiro Matsushita, Tsuneo Yamashiro, Shin Matsuoka, Kunihiro Yagihashi, Yasuo Nakajima Rationale and Objective The purpose of this study was to evaluate the correlation between generation-based bronchial wall attenuation on thin-section computed tomography (CT) scans and airflow limitation in patients with bronchial asthma. Materials and Methods This study included 28 bronchial asthma patients (13 men, 15 women; age range, 23–89 years) who underwent both chest CT and spirometry. On CT, the mean values of peak wall attenuation, wall area percentage, and luminal area were measured in the segmental, subsegmental, and sub-subsegmental bronchi of the right B1 and B10 bronchi. Correlations of the CT measurements with forced expiratory volume in 1 second/forced vital capacity (FEV1/FVC), percent predicted forced expiratory flow at 25%–75% of the FVC (%pred forced expiratory flow25–75), and percent predicted peak flow rate were evaluated with Spearman's rank correlation test. Results The peak wall attenuation of each generation of segmental bronchi significantly correlated with the forced expiratory volume in 1 second/FVC (B1 segmental, ρ = −0.683, p < 0.0001; B1 subsegmental, ρ = −0.875, p < 0.0001; B1 sub-subsegmental, ρ = −0.926, p < 0.0001; B10 segmental, ρ = −0.811, p < 0.0001; B10 subsegmental, ρ = −0.903, p < 0.0001; B10 sub-subsegmental ρ = −0.950, p < 0.0001). Similar correlations were found between the peak wall attenuation and %pred forced expiratory flow 25–75 or percent predicted peak flow rate. Overall, the correlation coefficients were relatively high in the more peripheral bronchial generations. In all measurements, the coefficients of the peak wall attenuations were higher than those of the wall area percentage and luminal area. Conclusion Peak attenuation of the bronchial wall, particularly in the peripheral bronchi, measured on CT is a good biomarker for the severity of bronchial asthma.

A Comparison of Two Hyperpolarized 129Xe MRI Ventilation Quantification Pipelines: The Effect of Signal to Noise Ratio Publication date: July 2019 Source: Academic Radiology, Volume 26, Issue 7 Author(s): Mu He, Wei Zha, Fei Tan, Leith Rankine, Sean Fain, Bastiaan Driehuys Rationale Hyperpolarized 129Xe MRI enables quantitative evaluation of regional ventilation. To this end, multiple classifiers have been proposed to determine ventilation defect percentage (VDP) as well as other cluster populations. However, consensus has not yet been reached regarding which of these methods to deploy for multicenter clinical trials. Here, we compare two published classification techniques–linear-binning and adaptive K-means–to establish their limits of agreement and their robustness against reduced signal-to-noise ratio (SNR). Methods A total of 29 subjects (age: 38.4 ± 19.0 years) were retrospectively identified for inter-method comparison. For each 129Xe ventilation image, 7 images with reduced SNR were generated with equal decrements relative to the native SNR. All 8 sets of images were then analyzed using both methods independently to classify all lung voxels into four clusters: VDP, low-, medium-, and high-ventilation-percentage (LVP, MVP and HVP). For each cluster, the percentage of the lung it comprised was compared between the two methods, as well as how these values persisted as SNR was degraded. Results The limits of agreement for calculating VDP were [+0.2%, +4.0%] with a +1.5% bias for binning relative to K-means. However, the inter-method agreement for the other clusters was moderate, with biases of −5.7%, 8.1%, and −4.0% for LVP, MVP, and HVP, respectively. As SNR decreased below ∼4, both methods began reporting values that deviated substantially from the native image. By requiring VDP to remain within ≤1.8% of that calculated from the native image, the minimum tolerable SNR values were 2.4 ± 1.0 for the linear-binning, and 3.5 ± 1.5 for the K-means. Conclusions Both methods agree well in quantifying VDP, but agreement for LVP and MVP remains variable. We suggest a required SNR threshold be two standard deviations above the minimum value of 3.5 ± 1.5 for robust determination of VDP, suggesting a minimum SNR of 6.6. However, robust quantification of the ventilated clusters required an SNR of 13.4.

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182

6948891480

alsfakia@gmail.com