Detection of the Stellate and Thoracic Sympathetic Chain Ganglia with High-Resolution 3D-CISS MR Imaging

BACKGROUND AND PURPOSE

Despite the importance of the sympathetic nervous system in homeostasis and its putative role in various disease states, little is known regarding our ability to image the sympathetic chain and sympathetic chain ganglia, perhaps owing to their small size. In this retrospective study, we sought to evaluate the normal anatomy of the sympathetic chain ganglia and assess the detectability of the sympathetic chain and sympathetic chain ganglia on high-resolution 3D-CISS images.

MATERIALS AND METHODS

This study included 29 patients who underwent 3D-CISS MR imaging of the thoracic spine for reasons unrelated to abnormalities of the sympathetic nervous system. Patients with a prior spinal operation or visible spinal pathology were excluded. The sympathetic chain ganglia were evaluated using noncontrast 3D-CISS MR imaging. Statistical analyses included t tests and measures of central tendency. The Cohen κ statistic was calculated to evaluate interrater reliability.

RESULTS

The stellate ganglion and thoracic chain ganglia were identified in all subjects except at the T10-T11 and T11-T12 levels. The stellate ganglion was found inferomedial to the subclavian artery and anterior and inferior to the transverse process of C7 in all subjects. Thoracic sympathetic chain ganglia were identified ventral to the costovertebral junction in all subjects from T2 to T10. There was strong interobserver agreement for the detection of the sympathetic chain ganglia with κ > 0.80. The size, shape, and location of these structures corresponded with gross anatomic and surgical observations.

CONCLUSIONS

The thoracic sympathetic chain ganglia can be identified on precontrast 3D-CISS MR imaging. This technique may aid in the initial evaluation of stellate ganglion and/or sympathetic chain ganglia size and signal change for comparison in future studies.

Reporting of Resting-State Functional Magnetic Resonance Imaging Preprocessing Methodologies

There has been a rapid increase in resting-state functional magnetic resonance imaging (rs-fMRI) literature in the past few years. We aim to highlight the variability in the current reporting practices of rs-fMRI acquisition and preprocessing parameters. The PubMed database was searched for the selection of appropriate articles in the rs-fMRI literature and the most recent 100 articles were selected based on our criteria. These articles were evaluated based on a checklist for reporting of certain preprocessing steps. All of the studies reported the temporal resolution for the scan and the software used for the analysis. Less than half of the studies reported physiologic monitoring, despiking, global signal regression, framewise displacement, and volume censoring. A majority of the studies mentioned the scanning duration, eye status, and smoothing kernel. Overall, we demonstrate the wide variability in reporting of preprocessing methods in rs-fMRI studies. Although there might be potential variability in reporting across studies due to individual requirements for a study, we suggest the need for standardizing reporting guidelines to ensure reproducibility.

Obesity and Ethnicity: Obstructive Sleep Apnea Risk Factors Poorly Represented in Sleep Apnea Screening Questionnaires

BACKGROUND: The gold standard for the diagnosis of pediatric obstructive sleep apnea (OSA) is polysomnography, a resource-intensive tool that is not easily accessible. It has been shown thatquestionnaires cannot accurately diagnose OSA in children. However,questionnaires are often used as screening tools for OSA to help clinicians prioritize objective sleep testing in sleep laboratories. Although many tools exist to screen for OSA, there is significant variability in the elements they take into consideration.

OBJECTIVES: To identify all questionnaires that screen for OSA in children and to review and contrast items within these questionnaires.

DESIGN/METHODS: We conducted a review of the literature to identify all questionnaires for pediatric OSA. We searched PubMed (keywords: sleep disordered breathing, OSA, sleep apnea and risk factor) and the health and psychosocial instruments (HaPi) database. We also checked reference lists of all included articles. Questionnaires were included in the analysis if their primary goal was to identify or screen for pediatric OSA in children 0-18 years old. We described the questionnaires qualitatively by identifying all items within each questionnaire, including demographics, risk factors, signs, symptoms, and outcomes.

RESULTS: The search yielded 476 articles. After reviewing titles and abstracts, 130 articles were included of which 60 articles were deemed relevant for final analysis based on predetermined inclusion criteria. Forty-two questionnaires were identified. Thirty-two questionnaires containing 48 different items were included in the analysis. Items most commonly included in questionnaires were: snoring (78%), observed apnea (78%) and daytime sleepiness (75%). Other clinically relevant items, such as ethnicity (6%), and body mass index (31%), were not consistently included. Thirty-one questionnaires used quantitative scores to identify OSA. One questionnaire derived a formula to identify OSA, in which certain items (risk factors) were assigned relative weights. Moreover, most questionnaires sought to predict the diagnosis of OSA without emphasis on OSA severity.

CONCLUSION: There are currently several questionnaires that aim to screen children for OSA. However, these questionnaires rarely include known OSA risk factors such as ethnicityand obesityand are not able to screen for OSA severity.

Ectopic craniopharyngioma of the fourth ventricle in a patient with Gardner syndrome

Ectopic craniopharyngioma is uncommon and a craniopharyngioma confined purely within the fourth ventricle is extremely rare. We report a craniopharyngioma of the fourth ventricle in a 20-year-old man with Gardner syndrome. Imaging characteristics of craniopharyngiomas and fourth ventricle lesions are discussed with a review of the literature regarding the pathogenesis of craniopharyngiomas and the possible association with Gardner syndrome.

Reevaluating the Utility of Maxillary Sinus Opacification as a Screening Tool for Facial Bone Fracture a Decade After Its Original Analysis

In 1997, Lambert and colleagues demonstrated that the absence of sinus fluid on head CT essentially excludes a fracture involving the sinus walls. Our purpose is to reevaluate this association utilizing the current standard of imaging technology. With improved image resolution, we aim to reassess whether the sensitivity and specificity of the “clear sinus sign” are improved or worsened. Furthermore, the current standard of care is to obtain a CT of the facial bones along with a head CT when facial trauma is suspected, so we also analyzed the association of the "clear sinus sign" with nasal bone and mandible fractures. We identified 629 facial bone CT scans performed on adult patients in the emergency department between July 2012 and May 2013. They were retrospectively analyzed by three reviewers for the presence of facial bone fracture and/or fluid opacification of at least one paranasal sinus (as defined by either complete sinus opacification or an air-fluid level - circumferential mucosal thickening was considered the absence of fluid). We found that sinus opacification was 98.8% specific for facial bone fracture but only 44.7% sensitive. However, for complex facial fractures, such as zygomaticomaxillary complex, orbital, and sinus fractures, the lack of sinus fluid is significantly more sensitive at 91%. Therefore, our results for complex facial fractures are congruent with those of the previous studies conducted by Lambert, et al. and Lewandowski, et al. However, we also demonstrate that sinus opacification is not specific for nasal bone or mandibular fractures.  

Mesenchymal stem cell (MSC) viability on PVA and PCL polymer coated hydroxyapatite scaffolds derived from cuttlefish

In the present study, cuttlefish bones are used to prepare highly porous hydroxyapatite (HA) scaffolds via hydrothermal treatment at 200 °C.

The present and future disease burden of hepatitis C virus infections with today's treatment paradigm - volume 3

The total number, morbidity and mortality attributed to viraemic hepatitis C virus (HCV) infections change over time making it difficult to compare reported estimates from different years. Models were developed for 15 countries to quantify and characterize the viraemic population and forecast the changes in the infected population and the corresponding disease burden from 2014 to 2030. With the exception of Iceland, Iran, Latvia and Pakistan, the total number of viraemic HCV infections is expected to decline from 2014 to 2030, but the associated morbidity and mortality are expected to increase in all countries except for Japan and South Korea. In the latter two countries, mortality due to an ageing population will drive down prevalence, morbidity and mortality. On the other hand, both countries have already experienced a rapid increase in HCV-related mortality and morbidity. HCV-related morbidity and mortality are projected to increase between 2014 and 2030 in all other countries as result of an ageing HCV-infected population. Thus, although the total number of HCV countries is expected to decline in most countries studied, the associated disease burden is expected to increase. The current treatment paradigm is inadequate if large reductions in HCV-related morbidity and mortality are to be achieved.

Strategies to manage hepatitis C virus infection disease burden - volume 3

The hepatitis C virus (HCV) epidemic was forecasted through 2030 for 15 countries in Europe, the Middle East and Asia, and the relative impact of two scenarios was considered: increased treatment efficacy while holding the annual number of treated patients constant and increased treatment efficacy and an increased annual number of treated patients. Increasing levels of diagnosis and treatment, in combination with improved treatment efficacy, were critical for achieving substantial reductions in disease burden. A 90% reduction in total HCV infections within 15 years is feasible in most countries studied, but it required a coordinated effort to introduce harm reduction programmes to reduce new infections, screening to identify those already infected and treatment with high cure rate therapies. This suggests that increased capacity for screening and treatment will be critical in many countries. Birth cohort screening is a helpful tool for maximizing resources. Among European countries, the majority of patients were born between 1940 and 1985. A wider range of birth cohorts was seen in the Middle East and Asia (between 1925 and 1995).

Historical epidemiology of hepatitis C virus (HCV) in select countries - volume 3

Detailed, country-specific epidemiological data are needed to characterize the burden of chronic hepatitis C virus (HCV) infection around the world. With new treatment options available, policy makers and public health officials must reconsider national strategies for infection control. In this study of 15 countries, published and unpublished data on HCV prevalence, viraemia, genotype, age and gender distribution, liver transplants and diagnosis and treatment rates were gathered from the literature and validated by expert consensus in each country. Viraemic prevalence in this study ranged from 0.2% in Iran and Lebanon to 4.2% in Pakistan. The largest viraemic populations were in Pakistan (7 001 000 cases) and Indonesia (3 187 000 cases). Injection drug use (IDU) and a historically unsafe blood supply were major risk factors in most countries. Diagnosis, treatment and liver transplant rates varied widely between countries. However, comparison across countries was difficult as the number of cases changes over time. Access to reliable data on measures such as these is critical for the development of future strategies to manage the disease burden.

Quantitative Imaging Analysis of FDG PET/CT Imaging for Detection of Central Neurolymphomatosis in a Case of Recurrent Diffuse B-Cell Lymphoma

Neurolymphomatosis (NL) is a rare disease characterized by malignant lymphocytes infiltrating various structures of the nervous system. It typically manifests as a neuropathy involving the peripheral nerves, nerve roots, plexuses, or cranial nerves. It often presents as a complication of lymphoma, but it can be the presenting feature of recurrent lymphoma. It is essential to identify and initiate treatment early with chemotherapy and/or radiation therapy in all cases of nodal or visceral (including neural) involvement with lymphoma. There are various diagnostic tests that can be used for its detection, such as cerebrospinal spinal fluid (CSF) cytology, electromyography (EMG), magnetic resonance imaging (MRI), and positron-emission tomography/computed tomography (PET/CT). FDG-PET/CT is the standard of care in lymphoma staging, restaging, and therapy response assessment, but has an inherent limitation in the detection of disease involvement in the central nervous system. While that is mostly true for visual assessment, there are quantitative methods to measure variation in the metabolic activity in the brain, which in turn helps detect the occurrence of neurolymphomatosis.

Improving postoperative pain management in subpectoral tissue expander implant reconstruction of the breast using an elastomeric pump

INTRODUCTION

Postoperative pain after breast surgery is one of the major factors contributing to delay in mobilisation and prolonged hospital stay. A retrospective analysis was performed of patients undergoing skin sparing mastectomy and insertion of a subpectoral implant. The aim was to determine whether the use of an elastomeric local anaesthetic pump improved pain control and length of stay.

METHODS

Twenty-five consecutive patients undergoing the above procedure were sited with an elastomeric local anaesthetic infusion pump intraoperatively, in addition to standard regular and pro re nata analgesia. The control group comprised 25 patients undergoing the same procedure in the same year who received standard analgesia alone. Visual analogue scale scores were recorded for the duration of inpatient stay, as was any further analgesic requirement.

RESULTS

The median age was 51 years (range: 26-75 years) in the intervention group and 50 years (range: 28-70 years) in the control group. The mean visual analogue scale score was 0.28 (standard deviation [SD]: 0.61) at 24 hours for the intervention group and 1.84 (SD: 0.37) for the control group (p<0.0001). The mean length of stay was 1.8 days (SD: 0.71 days) for the intervention group and 2.28 days (SD: 0.94 days) for the control group (p=0.15). There were no complications involving catheter placement, leakage or toxicity relating to use of the local anaesthetic.

CONCLUSIONS

There was significantly reduced pain with the use of the local anaesthetic infusion pump. The elastomeric pump is a step towards enhanced patient recovery after breast surgery in the case of skin sparing mastectomy and subpectoral tissue expander reconstruction.

Characteristic CT Findings After Percutaneous Cryoablation Treatment of Malignant Lung Nodules

Assess computed tomography (CT) imaging characteristics after percutaneous cryotherapy for lung cancer.A retrospective IRB-approved analysis of 40 patients who underwent nonsurgical treatment for primary stage 1 lung cancer performed from January 2007 to March 2011 was included in this study. All procedures were performed using general anesthesia and CT guidance. Follow-up imaging with CT of the chest was obtained at 1 month, 3 months, 6 months, and 12 months postprocedure to evaluate the ablated lung nodule. Nodule surface area, density (in Hounsfield units), and presence or absence of cavitations were recorded. In addition, the degree of nodule enhancement was also recorded. Patients who were unable to obtain the aforementioned follow-up were excluded from the study.Thirty-six patients underwent percutaneous cryoablation with men to women ratio of 75% with mean age for men 74.6 and mean age for women 74.3 years of age. The average nodule surface area preablation and postcryoablation at 1-, 3-, 6-, and 12-month follow-ups were 2.99, 7.86, 3.89, 3.18 and 3.07[REPLACEMENT CHARACTER]cm, respectively. The average precontrast nodule density before cryoablation was 8.9 and average precontrast nodule density postprocedure at 1, 3, 6, and 12 months follow-ups were 8.5, -5.9, -9.4, and -3.8 HU, respectively. There is increased attenuation of lung nodules over time with an average postcontrast enhancement of 11.4, 18.5, 16.1, and 25.7 HU at the aforementioned time intervals. Cavitations occurred in the cryoablation zone in 53% (19/36) of patients. 80.6% (29/36) of the cavitations in the cryoablation zone resolved within 12 months. Four patients (11%) had recurrence of tumor at the site of cryoablation and none of the patients had satellite or distant metastasis.Our study shows that patients who underwent cryotherapy for lung nodules treatment had characteristic changes on follow-up CT including. The surface area of the nodule increases at the 1-month follow-up with subsequent gradual decrease in the surface area. Decreased nodule density (Hounsfield units) at each interval follow-up is associated with complete ablation of the lung cancer whereas increasing nodule density was suggestive of recurrence. Cavity formation within the region of the ablated nodule, most of which typically resolved within the first 3 to 6 months. Nodule enhancement is difficult to assess because of the limited data sets that are available.

An Unusual MRI Appearance of Osseous Metastases

Bone metastases can present in a wide variety of appearances across all imaging modalities. We present a unique appearance of a distal femoral metastasis in a patient who initially complained of knee pain. The radiographic and CT findings were initially suspicious for calcium pyrophosphate deposition (CPPD) arthropathy; however, an MRI demonstrated multiple lesions with a lamellated appearance confirmed on biopsy to be metastatic disease. This unusual lamellated appearance has not been previously described. We present this case to help distinguish this entity radiographically and better classify this finding as a manifestation of metastatic disease.

Isolated right pulmonary artery agenesis with agenesis of right upper lobe and bronchiectasis of right lower lobe with anomalous arterial supply from celiac axis with normal venous drainage

Isolated unilateral absence of pulmonary artery (UAPA) is a rare congenital anomaly. When detected in infancy, the condition is commonly associated with cardiovascular defects which are more frequently associated with left pulmonary artery agenesis. Patients with isolated right pulmonary artery agenesis survive into adulthood with minimal or no symptoms and are diagnosed incidentally on the chest radiographs. We report a case of a 19-year-old female patient who presented to us with recurrent haemoptysis. She was symptomatic since the age of four years. We report the rare occurrence of UAPA on right side, agenesis of right upper lobe and bronchiectasis of right lower lobe with anomalous arterial supply of right lung from coeliac axis in this patient.