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Caracciolo JT, Ali S, Chang CY, Degnan AJ, Flemming DJ, Henderson ER, Kransdorf MJ, Letson GD, Madewell JE, Murphey MD. Bone Tumor Risk Stratification and Management System: A Consensus Guideline from the ACR Bone Reporting and Data System Committee. J Am Coll Radiol 2023; 20:1044-1058. [PMID: 37855758 DOI: 10.1016/j.jacr.2023.07.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 06/21/2023] [Accepted: 07/05/2023] [Indexed: 10/20/2023]
Abstract
The assessment and subsequent management of a potentially neoplastic bone lesion seen at diagnostic radiography is often complicated by diagnostic uncertainty and inconsistent management recommendations. Appropriate clinical management should be directed by risk of malignancy. Herein, the ACR-sponsored Bone Reporting and Data System (Bone-RADS) Committee, consisting of academic leaders in the fields of musculoskeletal oncology imaging and orthopedic oncology, presents the novel Bone-RADS scoring system to aid in risk assignment and provide risk-aligned management suggestions. When viewed in the proper clinical context, a newly identified bone lesion can be risk stratified as having very low, low, intermediate, or high risk of malignancy. Radiographic features predictive of risk are reviewed include margination, pattern of periosteal reaction, depth of endosteal erosion, pathological fracture, and extra-osseous soft tissue mass. Other radiographic features predictive of histopathology are also briefly discussed. To apply the Bone-RADS scoring system to a potentially neoplastic bone lesion, radiographic features predictive of risk are each given a point value. Point values are summed to yield a point total, which can be translated to a Bone-RADS score (1-4) with corresponding risk assignment (very low, low, intermediate, high). For each score, evidence-based and best practice consensus management suggestions are outlined. Examples of each Bone-RADS scores are presented, and a standardized diagnostic radiography report template is provided.
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Affiliation(s)
- Jamie T Caracciolo
- Senior Member and Professor, Diagnostic Imaging, Section Head, Musculoskeletal Imaging, Moffitt Cancer Center, Tampa, Florida.
| | - Sayed Ali
- Professor of Radiology, Section Chief of Musculoskeletal Radiology, Temple University Hospital, Philadelphia, Pennsylvania
| | - Connie Y Chang
- Associate Professor of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Andrew J Degnan
- Radiologist, Section Chief of Pediatric Radiology, Abington Hospital-Jefferson Health, UPMC Children's Hospital of Pittsburgh, Abington, Pennsylvania
| | - Donald J Flemming
- Professor of Radiology and Orthopaedics and Diagnostic Radiology Residency Program Director, Department of Radiology, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - Eric R Henderson
- Associate Professor of Orthopaedic Surgery Adjunct Associate Professor of Engineering, Norris Cotton Cancer Center, Dartmouth-Hitchcock Health, Lebanon, New Hampshire
| | | | - George Douglas Letson
- Physician in Chief of the Moffitt Medical Group, Moffitt Cancer Center, Tampa, Florida
| | - John E Madewell
- Professor and Chair ad interim Musculoskeletal Imaging, MD Anderson Cancer Center, Houston, Texas
| | - Mark D Murphey
- Physician-in-Chief, American Institute for Radiologic Pathology, Silver Spring, Maryland
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Serai SD, Panganiban J, Dhyani M, Degnan AJ, Anupindi SA. Imaging Modalities in Pediatric NAFLD. Clin Liver Dis (Hoboken) 2021; 17:200-208. [PMID: 33868666 PMCID: PMC8043697 DOI: 10.1002/cld.994] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 06/05/2020] [Accepted: 06/12/2020] [Indexed: 02/04/2023] Open
Affiliation(s)
- Suraj D. Serai
- Department of RadiologyThe Children’s Hospital of PhiladelphiaPhiladelphiaPA,Perelman School of Medicine at the University of PennsylvaniaPhiladelphiaPA
| | - Jennifer Panganiban
- Department of Gastroenterology, Hepatology and NutritionThe Children's Hospital of PhiladelphiaPhiladelphiaPA
| | - Manish Dhyani
- Department of RadiologyLahey Hospital and Medical CenterBurlingtonMA
| | - Andrew J. Degnan
- Department of RadiologyThe Children’s Hospital of PhiladelphiaPhiladelphiaPA
| | - Sudha A. Anupindi
- Department of RadiologyThe Children’s Hospital of PhiladelphiaPhiladelphiaPA,Perelman School of Medicine at the University of PennsylvaniaPhiladelphiaPA
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Degnan AJ, Jelinek JS, Murphey MD. Lipoblastoma: computed tomographic and magnetic resonance imaging features correlate with tumor behavior and pathology. Pediatr Radiol 2021; 51:614-621. [PMID: 33151344 DOI: 10.1007/s00247-020-04882-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 08/02/2020] [Accepted: 10/08/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND Lipoblastoma is a rare benign neoplasm of immature fat cells in children. Imaging appearances are frequently complex, sometimes simulating liposarcoma. OBJECTIVE To characterize features of lipoblastoma on MRI and CT in comparison with recurrence risk. MATERIALS AND METHODS We identified cases via retrospective review of histopathology-proven lipoblastoma cases in a large referral database and a pediatric medical center. Two radiologists scored CT and MRI on the basis of lesion features. RESULTS We included a total of 56 children (32 boys and 24 girls) with a mean age of 2.6 years (range 0.1-13 years). Extremity lesions were most common (27%), followed by neck (19%), gluteal region (18%), chest (14%) and mesentery (14%). Children most commonly presented with painless masses (73%), followed by dyspnea (9%), distension (9%) and pain (7%). Non-adipose soft-tissue components were identified on CT and MRI in 78% of cases. Significant (moderate or marked) septations were noted in 59% and enhancement in 35%. Compartmental invasion was present in 43% of cases. Of paraspinal cases, 38% involved the neural foramina or central canal. Lesion complexity did not significantly correlate with age. Recurrence was observed in 9% of cases and was significantly correlated with compartmental invasion (correlation: 0.303, P=0.009) and septation complexity (correlation: 0.227, P=0.038) on initial imaging. CONCLUSION Although lipoblastoma is a fat-containing entity, many lesions demonstrate marked complexity and local infiltration that resemble liposarcoma, which is exceedingly rare in younger children. Compartmental invasion and thicker septations appear to confer greater risk of recurrence following resection.
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Affiliation(s)
- Andrew J Degnan
- American Institute for Radiologic Pathology, Silver Spring, MD, USA. .,Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA. .,Department of Radiology, Abington Hospital Jefferson Health, Abington, PA, USA.
| | - James S Jelinek
- Department of Radiology, MedStar Washington Hospital Center, Washington, DC, USA
| | - Mark D Murphey
- American Institute for Radiologic Pathology, Silver Spring, MD, USA.,Uniformed Services University of the Health Sciences, Bethesda, MD, USA.,Department of Radiology, Walter Reed National Military Medical Center, Bethesda, MD, USA
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Shi Z, Li J, Zhao M, Zhang X, Degnan AJ, Mossa-Basha M, Saloner D, Lu J, Liu Q, Zhu C. Progression of Plaque Burden of Intracranial Atherosclerotic Plaque Predicts Recurrent Stroke/Transient Ischemic Attack: A Pilot Follow-Up Study Using Higher-Resolution MRI. J Magn Reson Imaging 2021; 54:560-570. [PMID: 33600033 PMCID: PMC8359205 DOI: 10.1002/jmri.27561] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 01/29/2021] [Accepted: 02/01/2021] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Patients with intracranial atherosclerotic disease (ICAD) have a high frequency of stroke recurrence. However, there has been little investigation into the prognostic value of higher-resolution magnetic resonance imaging (HR-MRI). PURPOSE To investigate the use of intracranial atherosclerotic plaques features in predicting risk of recurrent cerebrovascular ischemic events using HR-MRI. STUDY TYPE Prospective. POPULATION Fifty-eight patients with acute/subacute stroke (N = 46) or transient ischemic attack (N = 12). FIELD STRENGTH/SEQUENCE A 3.0 T, 3D time-of-flight gradient echo sequence and T1- and T2-weighted fast spin echo sequences with 0.31 x 0.39 mm2 in-plane resolution, twice (with >3 months between scans) following the initial event. ASSESSMENT Patients were also followed clinically for recurrent ischemic events for up to 48 months or until a subsequent event occurred. The degree of stenosis, plaque burden (PB), minimal lumen area (MLA), and contrast enhancement ratio were assessed at each scanning session and the percentage change of each over time was calculated. STATISTICAL TESTS Univariable and multivariable Cox regression analyses were used to calculate the hazard ratio (HR) and 95% confidence interval (CI) for predicting recurrent events. RESULTS The mean time interval between baseline and follow-up MRI scans was 6.2 ± 4.1 months. After the second MRI scan, 20.7% of patients (N = 12) had experienced ipsilateral recurrent TIA/stroke within 10.9 ± 9.2 months. Univariable analyses showed that baseline triglyceride, percentage change of PB, and progression of PB were significantly associated with recurrent events (all P < 0.05). Multivariable Cox regression indicated that progression of PB (HR, 6.293; 95% CI, 1.620-24.444; P < 0.05) was a significant independent imaging feature for recurrent ischemic events. DATA CONCLUSION Progression of PB was independently associated with recurrent ischemic cerebrovascular events. HR-MRI may help risk stratification of patients at risk of recurrent stroke. LEVEL OF EVIDENCE 2 TECHNICAL EFFICACY: Stage 4.
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Affiliation(s)
- Zhang Shi
- Department of Radiology, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Jing Li
- Department of Radiology, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Ming Zhao
- Department of Neurology, Changhai Hospital, Naval Medical University, Shanghai, China.,The 983th Hospital of Joint Logistics Support Forces of Chinese PLA, Tianjin, China
| | - Xuefeng Zhang
- Department of Radiology, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Andrew J Degnan
- Department of Radiology, Abington Hospital - Jefferson Health, Philadelphia, Pennsylvania, USA.,Department of Radiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Mahmud Mossa-Basha
- Department of Radiology, University of Washington, Seattle, Washington, USA
| | - David Saloner
- Department of Radiology and Biomedical Imaging, UCSF, San Francisco, California, USA
| | - Jianping Lu
- Department of Radiology, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Qi Liu
- Department of Radiology, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Chengcheng Zhu
- Department of Radiology, University of Washington, Seattle, Washington, USA.,Department of Radiology and Biomedical Imaging, UCSF, San Francisco, California, USA
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Larsen EP, Hailu T, Sheldon L, Ginader A, Bodo N, Dewane D, Degnan AJ, Finley J, Sze RW. Optimizing Radiology Reading Room Design: The Eudaimonia Radiology Machine. J Am Coll Radiol 2021; 18:108-120. [PMID: 33065075 PMCID: PMC7553105 DOI: 10.1016/j.jacr.2020.09.041] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 09/09/2020] [Accepted: 09/10/2020] [Indexed: 11/25/2022]
Abstract
Physical and mental stressors on radiologists can result in burnout. Although current efforts seek to target the issues of burnout and stress for radiologists, the impact of their physical workspace is often overlooked. By combining evidence-based design, human factors, and the architectural concept of the Eudaimonia Machine, we have developed a redesign of the radiology reading room that aims to create an optimal workspace for the radiologist. Informed by classical principles of well-being and contemporary work theory, Eudaimonia integrates concerns for individual wellness and efficiency to create an environment that fosters productivity. This layout arranges a work environment into purposeful spaces, each hosting tasks of varying degrees of intensity. The improved design addresses the radiologist's work requirements while also alleviating cognitive and physical stress, fatigue, and burnout. This new layout organizes the reading room into separate areas, each with a distinct purpose intended to support the range of radiologists' work, from consultation with other health care providers to reading images without interruption. The scientific principles that undergird evidence-based design and human factors considerations ensure that the Eudaimonia Radiology Machine is best suited to support the work of the radiologists and the entire radiology department.
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Affiliation(s)
- Ethan P Larsen
- Department of Radiology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Center for Healthcare Quality and Analytics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.
| | - Tigist Hailu
- Department of Radiology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Lydia Sheldon
- Department of Radiology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Abigail Ginader
- Department of Radiology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Nicole Bodo
- Department of Radiology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | - Andrew J Degnan
- Department of Radiology, Abington Hospital-Jefferson Health, Abington, Pennsylvania
| | - John Finley
- Facilities Project Management and Construction, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Raymond W Sze
- Associate Radiologist in Chief, Department of Radiology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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Sotardi ST, Degnan AJ, Liu CA, Mecca PL, Serai SD, Smock RD, Victoria T, White AM. Establishing a magnetic resonance safety program. Pediatr Radiol 2021; 51:709-715. [PMID: 33871724 PMCID: PMC8054505 DOI: 10.1007/s00247-020-04910-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 09/03/2020] [Accepted: 11/09/2020] [Indexed: 11/24/2022]
Abstract
Establishing a magnetic resonance (MR) safety program is crucial to ensuring the safe MR imaging of pediatric patients. The organizational structure includes a core safety council and broader safety committee comprising all key stakeholders. These groups work in synchrony to establish a strong culture of safety; create and maintain policies and procedures; implement device regulations for entry into the MR setting; construct MR safety zones; address intraoperative MR concerns; guarantee safe scanning parameters, including complying with specific absorption rate limitations; adhere to national regulatory body guidelines; and ensure appropriate communication among all parties in the MR environment. Perspectives on the duties of the safety council members provide important insight into the organization of program oversite. Ultimately, the collective dedication and vigilance of all MR staff are crucial to the success of a safety program.
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Affiliation(s)
- Susan T. Sotardi
- Department of Radiology, Children’s Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA 19104 USA
| | - Andrew J. Degnan
- Department of Radiology, Children’s Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA 19104 USA
| | - Chang Amber Liu
- Department of Anesthesiology, Massachusetts General Hospital, Boston, MA USA
| | - Patricia L. Mecca
- Department of Radiology, Children’s Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA 19104 USA
| | - Suraj D. Serai
- Department of Radiology, Children’s Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA 19104 USA
| | - R. Daniel Smock
- Department of Radiology, Children’s Mercy Hospital, Kansas City, MO USA
| | - Teresa Victoria
- Department of Radiology, Children’s Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA 19104 USA
| | - Ammie M. White
- Department of Radiology, Children’s Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA 19104 USA
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7
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Ficicioglu C, Matalon DR, Luongo N, Menello C, Kornafel T, Degnan AJ. Diagnostic journey and impact of enzyme replacement therapy for mucopolysaccharidosis IVA: a sibling control study. Orphanet J Rare Dis 2020; 15:336. [PMID: 33256811 PMCID: PMC7706253 DOI: 10.1186/s13023-020-01618-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 11/16/2020] [Indexed: 12/13/2022] Open
Abstract
Background Mucopolysaccharidosis (MPS) IVA, also known as Morquio A syndrome, is a rare autosomal recessive lysosomal storage disorder caused by a deficiency in the enzyme N-acetylgalactosamine-6-sulfatase. Early recognition, diagnosis, and treatment of this progressive, multisystem disease by enzyme replacement therapy (ERT) can lead to improved outcomes and reduced mortality. Methods This report documents the diagnostic journey and treatment with ERT of three siblings with MPS IVA. Clinical outcome measures included growth, endurance, imaging, cardiac, respiratory, ophthalmology, and laboratory evaluations. Results Three siblings, diagnosed at 14.7, 10.1, and 3.2 years of age, demonstrated clinical improvement with weekly infusions of 2.0 mg/kg elosulfase alfa (Vimizim®, BioMarin Pharmaceutical, Novato, CA, USA). Patient 1 (oldest sibling) and Patient 2 (middle sibling) experienced a diagnostic delay of 8 years 7 months and 4 years after symptom onset, respectively. All three patients demonstrated improvements in growth, 6-min walk distance, joint range of motion, and respiratory function after 30 months of ERT. The treatment was well tolerated without any adverse events. Conclusions This case series highlights the importance of early recognition of the clinical and imaging findings that are initially subtle in MPS IVA. Early treatment with ERT is necessary to slow irreversible disease progression and improve patient outcomes. The oldest sibling experienced improvements in mobility despite severe symptoms resulting from a late diagnosis. When evaluating patients with skeletal anomalies, imaging multiple body regions is recommended. When findings such as anterior beaking of vertebrae or bilateral femoral head dysplasia are present, MPS IVA should be included in the differential diagnosis. Newborn screening must be considered for early detection, accurate diagnosis, and initiation of treatment to reduce morbidity.
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Affiliation(s)
- Can Ficicioglu
- Division of Human Genetics/Metabolism, Lysosomal Storage Diseases Program, The Children's Hospital of Philadelphia, Perelman School of Medicine, The University of Pennsylvania, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA.
| | - Dena R Matalon
- Stanford University, Lucile Packard Children's Hospital, Palo Alto, CA, USA
| | - Nicole Luongo
- Division of Human Genetics/Metabolism, Lysosomal Storage Diseases Program, The Children's Hospital of Philadelphia, Perelman School of Medicine, The University of Pennsylvania, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA
| | - Caitlin Menello
- Division of Human Genetics/Metabolism, Lysosomal Storage Diseases Program, The Children's Hospital of Philadelphia, Perelman School of Medicine, The University of Pennsylvania, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA
| | - Tracy Kornafel
- Division of Human Genetics/Metabolism, Lysosomal Storage Diseases Program, The Children's Hospital of Philadelphia, Perelman School of Medicine, The University of Pennsylvania, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA
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El-Ali AM, Coblentz A, Degnan AJ. Solitary long-bone epiphyseal lesions in children: radiologic-pathological correlation and epidemiology. Pediatr Radiol 2020; 50:1724-1734. [PMID: 32638051 DOI: 10.1007/s00247-020-04752-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 04/23/2020] [Accepted: 06/02/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Solitary epiphyseal lesions are rare and present with nonspecific imaging features. Knowledge regarding etiologies of pediatric epiphyseal lesions is limited to small studies. OBJECTIVE The purpose of this study was to determine the relative incidence of pathologies affecting the pediatric epiphysis based on biopsy-proven cases with imaging. MATERIALS AND METHODS We conducted a retrospective review of imaging studies including the terms "biopsy" or "resection" and entities known to affect the epiphysis and cross-referenced these with pathology reports, recording the relevant clinical data. Two radiologists performed comprehensive imaging review and recorded relevant features. RESULTS Forty-nine children and adolescents met inclusion criteria. The long-bone epiphyseal lesion etiologies included chondroblastoma (n=22, 45%), nonspecific nonmalignant pathology (n=11, 22%), osteomyelitis (n=9, 18%), lymphoma (n=2, 4%) and 1 case of each of aneurysmal bone cyst, chondrosarcoma, enchondroma, hemangioendothelioma, and non-Langerhans cell histiocytosis. Median age was 13.1 years old (range 1.5-18.6 years). We performed comparative analysis of the two most common lesions in our series, chondroblastoma and osteomyelitis. Chondroblastoma was significantly more likely to be peripherally located (94% vs. 33%, P=0.002) and to demonstrate a discrete T1-weighted hypointense rim (94% vs. 33%, P=0.002); there were no significant differences in enhancement or intrinsic signal properties. Children with chondroblastoma were older (15.1 years vs. 7.3 years, P=0.001), and chondroblastoma lesions were significantly larger, with mean maximum lesion diameter of 25 mm (interquartile range [IQR] 20-30) vs. 12 mm (IQR 11-18) (P=0.001) and lesion volumes of 4.4 mL (IQR 2.4-7.9) vs. 0.4 mL (IQR 0.2-1.4) (P=0.01). CONCLUSION This study reports the relative frequency of pathology of pediatric solitary epiphyseal lesions and describes several features that might assist in differentiating between chondroblastoma and osteomyelitis.
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Affiliation(s)
- Alexander M El-Ali
- Department of Pediatric Radiology, The Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA.
| | - Ailish Coblentz
- Department of Pediatric Radiology, The Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA.,Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, ON, Canada
| | - Andrew J Degnan
- Department of Pediatric Radiology, The Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA.,American Institute for Radiologic Pathology, Silver Spring, MD, USA
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9
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Zhang J, Ding S, Zhao H, Sun B, Li X, Zhou Y, Wan J, Degnan AJ, Xu J, Zhu C. Evaluation of chronic carotid artery occlusion by non-contrast 3D-MERGE MR vessel wall imaging: comparison with 3D-TOF-MRA, contrast-enhanced MRA, and DSA. Eur Radiol 2020; 30:5805-5814. [PMID: 32529567 DOI: 10.1007/s00330-020-06989-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 04/17/2020] [Accepted: 05/27/2020] [Indexed: 12/24/2022]
Abstract
OBJECTIVES To analyze the accuracy of a non-contrast MR vessel wall imaging technique, three-dimensional motion-sensitized driven equilibrium prepared rapid gradient echo (3D-MERGE) for diagnosing chronic carotid artery occlusion (CCAO) characteristics compared with 3D time-of-flight (TOF) MRA, and contrast-enhanced MRA (CE-MRA), using digital subtraction angiography (DSA) as a reference standard. METHODS Subjects diagnosed with possible CCAO by ultrasound were retrospectively analyzed. Patients underwent 3.0-T MR imaging with 3D-MERGE, 3D-TOF-MRA, and CE-MRA followed by DSA within 1 week. Diagnostic accuracy of occlusion, occlusion site, and proximal stump condition were assessed independently on 3 MRI sequences and DSA. Agreement of the above indicators was evaluated in reference to DSA. RESULTS One hundred twenty-four patients with 129 suspected CCAO (5 with bilateral occlusions) met the inclusion criteria for our study. 3D-MERGE demonstrated a sensitivity, specificity, and accuracy of 97.0%, 86.7%, and 94.6%, respectively, with excellent agreement (Cohen's κ = 0.85; 95% CI, 0.71, 0.94) for diagnosing CCAO in reference to DSA. 3D-MERGE was superior in diagnosing CCAO compared with 3D-TOF-MRA (Cohen's κ = 0.61; 95% CI, 0.42, 0.77) and similar to CE-MRA (Cohen's κ = 0.93; 95% CI, 0.86, 1.00). 3D-MERGE also had excellent agreement compared with DSA for assessing occlusion sites (Cohen's κ = 0.85; 95% CI, 0.71, 0.97) and stump condition (Cohen's κ = 0.83; 95% CI, 0.71, 0.94). Moreover, 3D-MERGE provided additional information regarding the occluded segment, such as distal lumen collapse and vessel wall lesion components. CONCLUSION 3D-MERGE can reliably assess chronic carotid occlusive characteristics and has the ability to identify other vessel wall features of the occluded segment. This non-contrast MR vessel wall imaging technique is promising for assessment of CCAO. KEY POINTS • Excellent agreement was found between 3D-MERGE and DSA for assessing chronic carotid artery occlusion, occlusion site, and proximal stump condition. • 3D-MERGE was shown to be a more accurate and efficient tool than 3D-TOF-MRA to detect the characteristics of the occluded segment. • 3D-MERGE provides not only luminal images for characterizing the proximal characteristics of occlusion but also vessel wall images for assessing the distal lumen and morphology of occlusion segment, which might help clinicians to optimize the treatment strategy for patients with chronic carotid artery occlusion.
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Affiliation(s)
- Jin Zhang
- Department of Radiology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Shenghao Ding
- Department of Neurosurgery, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Huilin Zhao
- Department of Radiology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China.
| | - Beibei Sun
- Department of Radiology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Xiao Li
- Department of Radiology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Yan Zhou
- Department of Radiology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Jieqing Wan
- Department of Neurosurgery, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Andrew J Degnan
- Department of Radiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.,American Institute for Radiologic Pathology, Silver Spring, MD, USA.,Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jianrong Xu
- Department of Radiology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China.
| | - Chengcheng Zhu
- Department of Radiology, University of Washington, Seattle, WA, USA
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Degnan AJ, Ho-Fung VM, Wang DJ, Ficicioglu C, Jaramillo D. Gaucher disease status and treatment assessment: pilot study using magnetic resonance spectroscopy bone marrow fat fractions in pediatric patients. Clin Imaging 2020; 63:1-6. [PMID: 32120306 DOI: 10.1016/j.clinimag.2020.02.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 02/10/2020] [Accepted: 02/20/2020] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To assess magnetic resonance spectroscopy (MRS) bone marrow fat fractions' ability to discern between untreated Gaucher disease patients and healthy controls based on assessment of bone marrow infiltration and evaluate response to enzyme replacement therapy (ERT) on serial imaging. METHODS This retrospective case-controlled study compared conventional MRI and bone marrow MRS findings in six pediatric and young adult Gaucher disease patients with age- and sex-matched controls, examining femoral neck and lumbar spine bone marrow fat fractions and bone marrow burden (BMB) scores. Separate analysis of six patients with serial imaging on ERT was performed with analysis of fat fractions, BMB scores, organ volumes, and serum chitotriosidase. RESULTS Untreated patients had significantly lower femoral and lumbar spine fat fractions than controls (0.32 versus 0.67, p = 0.041 and 0.17 versus 0.34, p = 0.041, respectively). Total BMB scores were significantly higher in patients (8.0 versus 3.5, p = 0.015). In patients on ERT with average follow-up of 3.5 years, femoral neck fat fraction was the sole significant predictor of treatment duration (R square: 0.804, p < 0.001) when adjusted for age. Femoral neck fat fraction also correlated with lumbar spine fat fraction, liver volume and chitotriosidase (p < 0.05). MRS test-retest reliability was excellent (Pearson correlations: 0.96, 0.99; p-values <0.001). BMB inter-rater reliability was good overall with an intra-class correlation coefficient of 0.79 for total score, although lumbar spine score reliability was poor at 0.45. CONCLUSION MRS-derived bone marrow fat fractions appear capable of detecting Gaucher disease severity and monitoring treatment-related changes as a predictor of ERT duration in pediatric and young adult patients.
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Affiliation(s)
- Andrew J Degnan
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA 19104, USA; Department of Radiology, Perelman School of Medicine at the University of Pennsylvania, 3400 Civic Center Blvd., Philadelphia, PA 19104, USA.
| | - Victor M Ho-Fung
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA 19104, USA; Department of Radiology, Perelman School of Medicine at the University of Pennsylvania, 3400 Civic Center Blvd., Philadelphia, PA 19104, USA.
| | - Dah-Jyuu Wang
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA 19104, USA.
| | - Can Ficicioglu
- Division of Human Genetics, The Children's Hospital of Philadelphia, Colket Translational Research Building, 3501 Civic Center Blvd, Floor 9, Philadelphia, PA 19104, USA; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, 3400 Civic Center Blvd., Philadelphia, PA 19104, USA.
| | - Diego Jaramillo
- Department of Radiology, Columbia University Medical Center, 622 West 168th Street, PH1-301, New York, NY 10032, USA.
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11
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Otero HJ, Degnan AJ, Kadom N, Neumann PJ, Lavelle TA. Cost-Effectiveness Analysis in Pediatric Imaging: The Evidence (or Lack Thereof) Thus Far. J Am Coll Radiol 2019; 17:452-461. [PMID: 31790678 DOI: 10.1016/j.jacr.2019.10.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2019] [Revised: 10/07/2019] [Accepted: 10/07/2019] [Indexed: 01/03/2023]
Abstract
OBJECTIVE To systematically review all published cost-effectiveness analyses (CEAs) of imaging technologies in children. METHODS We identified all CEAs involving fetal and pediatric imaging included in a publicly available repository of CEAs published since 1976. Information on publication characteristics, methods, costs, quality of life weights, and incremental cost-effectiveness ratios (ICERs) was recorded for each article. RESULTS Of 480 diagnostic CEAs, only 10 focused on fetal and pediatric imaging. The 10 studies reported 43 quality of life weights based on previously published adult data (n = 20, 46.5%); pregnant women perspective (n = 11, 25.6%), and treating physician perspective (n = 12, 27.9%). None of the studies elicited quality of life weights from children nor took into consideration the postnatal impact of disease on family's quality of life. All studies used a health care payer perspective without incorporating patients' incurred cost such as loss wages or travel related cost. Of 37 ICERs, 7 (18.9%) were cost saving and 6 (16.2%) were more expensive and less effective. The remaining ICERs ranged from $1,400 per quality-adjusted life-year (MRI versus ultrasound in newborns with moderate risk of occult spinal dysraphism) to $10,000,000 per quality-adjusted life-year (CT versus no imaging in children at low risk for craniosynostosis). CONCLUSION There is a striking paucity of cost-effectiveness studies evaluating imaging technologies in children. Existing studies do not incorporate the patient and family perspectives regarding utilities (eg, impact of child's disease on families' quality of life) or cost (eg, loss wages, travel, time off). Future studies should elicit and incorporate the impact of disease on families to better reflect real-world scenarios.
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Affiliation(s)
- Hansel J Otero
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.
| | - Andrew J Degnan
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Nadja Kadom
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia; Department of Radiology, Children's Healthcare of Atlanta (Egleston), Atlanta, Georgia
| | - Peter J Neumann
- Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts
| | - Tara A Lavelle
- Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts
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12
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Saade-Lemus S, Degnan AJ, Acord MR, Srinivasan AS, Reid JR, Servaes SE, States LJ, Anupindi SA. Whole-body magnetic resonance imaging of pediatric cancer predisposition syndromes: special considerations, challenges and perspective. Pediatr Radiol 2019; 49:1506-1515. [PMID: 31620850 DOI: 10.1007/s00247-019-04431-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 04/16/2019] [Accepted: 05/15/2019] [Indexed: 02/06/2023]
Abstract
Cancer predisposition syndromes increase the incidence of tumors during childhood and are associated with significant morbidity and mortality. Imaging is paramount for ensuring early detection of neoplasms, impacting therapeutic interventions and potentially improving outcome. While conventional imaging techniques involve considerable exposure to ionizing radiation, whole-body MRI is a radiation-free modality that allows continuous imaging of the entire body and has increasingly gained relevance in the surveillance, diagnosis, staging and monitoring of pediatric patients with cancer predisposition syndromes. Nevertheless, widespread implementation of whole-body MRI faces several challenges as a screening tool. Some of these challenges include developing clinical indications, variability in protocol specifications, image interpretation as well as coding and billing practices. These factors impact disease management, patient and family experience and research collaborations. In this discussion we review the aforementioned special considerations and the potential direction that might help overcome these challenges and promote more widespread use of whole-body MRI in children with cancer predisposition syndromes.
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Affiliation(s)
- Sandra Saade-Lemus
- Department of Radiology, The Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA.
| | - Andrew J Degnan
- Department of Radiology, The Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA
| | - Michael R Acord
- Department of Radiology, The Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA
| | - Abhay S Srinivasan
- Department of Radiology, The Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA
| | - Janet R Reid
- Department of Radiology, The Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA
| | - Sabah E Servaes
- Department of Radiology, The Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA
| | - Lisa J States
- Department of Radiology, The Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA
| | - Sudha A Anupindi
- Department of Radiology, The Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA
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13
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Degnan AJ, Fox WW, Zhang H, Saul D. Partial liquid ventilation for bronchopulmonary dysplasia: Visualizing ventilation patterns on chest radiographs. Pediatr Neonatol 2019; 60:587-588. [PMID: 30448214 DOI: 10.1016/j.pedneo.2018.10.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Revised: 08/09/2018] [Accepted: 10/25/2018] [Indexed: 12/01/2022] Open
Affiliation(s)
- Andrew J Degnan
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
| | - William W Fox
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA; Division of Neonatology and Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Huayan Zhang
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA; Division of Neonatology and Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - David Saul
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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Degnan AJ, Ho-Fung VM, Ahrens-Nicklas RC, Barrera CA, Serai SD, Wang DJ, Ficicioglu C. Imaging of non-neuronopathic Gaucher disease: recent advances in quantitative imaging and comprehensive assessment of disease involvement. Insights Imaging 2019; 10:70. [PMID: 31289964 PMCID: PMC6616606 DOI: 10.1186/s13244-019-0743-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Accepted: 04/29/2019] [Indexed: 12/17/2022] Open
Abstract
Gaucher disease is an inherited metabolic disorder resulting in deficiency of lysosomal enzyme β-glucocerebrosidase causing the accumulation of abnormal macrophages (“Gaucher cells”) within multiple organs, most conspicuously affecting the liver, spleen, and bone marrow. As the most common glycolipid metabolism disorder, it is important for radiologists encountering these patients to be familiar with advances in imaging of organ and bone marrow involvement and understand the role of imaging in clinical decision-making. The recent advent of commercially available, reliable, and reproducible quantitative MRI acquisitions to measure fat fractions prompts revisiting the role of quantitative assessment of bone marrow involvement. This manuscript reviews the diverse imaging manifestations of Gaucher disease and discusses more optimal quantitative approaches to ascertain solid organ and bone marrow involvement with an emphasis on future applications of other quantitative methods including elastography.
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Affiliation(s)
- Andrew J Degnan
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA. .,Department of Radiology, Perelman School of Medicine at the University of Pennsylvania, 3400 Civic Center Blvd., Philadelphia, PA, 19104, USA.
| | - Victor M Ho-Fung
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA.,Department of Radiology, Perelman School of Medicine at the University of Pennsylvania, 3400 Civic Center Blvd., Philadelphia, PA, 19104, USA
| | - Rebecca C Ahrens-Nicklas
- Division of Human Genetics, The Children's Hospital of Philadelphia, Colket Translational Research Building, 3501 Civic Center Blvd, Floor 9, Philadelphia, PA, 19104, USA.,Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, 3400 Civic Center Blvd., Philadelphia, PA, 19104, USA
| | - Christian A Barrera
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA
| | - Suraj D Serai
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA
| | - Dah-Jyuu Wang
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA
| | - Can Ficicioglu
- Division of Human Genetics, The Children's Hospital of Philadelphia, Colket Translational Research Building, 3501 Civic Center Blvd, Floor 9, Philadelphia, PA, 19104, USA.,Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, 3400 Civic Center Blvd., Philadelphia, PA, 19104, USA
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15
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Degnan AJ, Ghobadi EH, Hardy P, Krupinski E, Scali EP, Stratchko L, Ulano A, Walker E, Wasnik AP, Auffermann WF. Perceptual and Interpretive Error in Diagnostic Radiology-Causes and Potential Solutions. Acad Radiol 2019; 26:833-845. [PMID: 30559033 DOI: 10.1016/j.acra.2018.11.006] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2018] [Revised: 11/19/2018] [Accepted: 11/21/2018] [Indexed: 12/13/2022]
Abstract
Interpretation of increasingly complex imaging studies involves multiple intricate tasks requiring visual evaluation, cognitive processing, and decision-making. At each stage of this process, there are opportunities for error due to human factors including perceptual and ergonomic conditions. Investigation into the root causes of interpretive error in radiology first began over a century ago. In more recent work, there has been increasing recognition of the limits of human image perception and other human factors and greater acknowledgement of the role of the radiologist's environment in increasing the risk of error. This article reviews the state of research on perceptual and interpretive error in radiology. This article focuses on avenues for further error examination, and strategies for mitigating these errors are discussed. The relationship between artificial intelligence and interpretive error is also considered.
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Affiliation(s)
- Andrew J Degnan
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Emily H Ghobadi
- Department of Radiology, Northwestern Memorial Hospital, Chicago, Illinois
| | - Peter Hardy
- Department of Radiology, University of Kentucky Medical Center, Lexington, Kentucky
| | - Elizabeth Krupinski
- Department of Radiology & Imaging Sciences, Emory University Hospital, Atlanta, Georgia
| | - Elena P Scali
- Department of Radiology, University of British Columbia, Vancouver, BC Canada
| | - Lindsay Stratchko
- Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Adam Ulano
- Department of Radiology, University of Vermont Medical Center, The Robert Larner, M.D. College of Medicine at the University of Vermont, Burlington, Vermont
| | - Eric Walker
- Department of Radiology, Penn State Health, Milton S. Hershey Medical Center & Penn State College of Medicine, H066, Hershey, Pennsylvania; Department of Radiology and Nuclear Medicine, Uniformed University of the Health Sciences, Bethesda, Maryland
| | - Ashish P Wasnik
- Department of Radiology, University of Michigan Health System-Michigan Medicine, University Hospital B1D502D, Ann Arbor, Michigan
| | - William F Auffermann
- Department of Radiology and Imaging Sciences, University of Utah School of Medicine, 30 North 1900 East, Rm # 1A71, Salt Lake City, UT 84132, USA.
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Zhu C, Wang X, Eisenmenger L, Tian B, Liu Q, Degnan AJ, Hess C, Saloner D, Lu J. Surveillance of Unruptured Intracranial Saccular Aneurysms Using Noncontrast 3D-Black-Blood MRI: Comparison of 3D-TOF and Contrast-Enhanced MRA with 3D-DSA. AJNR Am J Neuroradiol 2019; 40:960-966. [PMID: 31122914 DOI: 10.3174/ajnr.a6080] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Accepted: 04/15/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND PURPOSE Patients with unruptured intracranial aneurysms routinely undergo surveillance imaging to monitor growth. Angiography is the criterion standard for aneurysm diagnosis, but it is invasive. This study aimed to evaluate the accuracy and reproducibility of a 3D noncontrast black-blood MR imaging technique for unruptured intracranial aneurysm measurement in comparison with 3D-TOF and contrast-enhanced MRA, using 3D rotational angiography as a reference standard. MATERIALS AND METHODS Sixty-four patients (57.3 ± 10.9 years of age, 41 women) with 68 saccular unruptured intracranial aneurysms were recruited. Patients underwent 3T MR imaging with 3D-TOF-MRA, 3D black-blood MR imaging, and contrast-enhanced MRA, and they underwent 3D rotational angiography within 2 weeks. The neck, width, and height of the unruptured intracranial aneurysms were measured by 2 radiologists independently on 3D rotational angiography and 3 MR imaging sequences. The accuracy and reproducibility were evaluated by Bland-Altman plots, the coefficient of variance, and the intraclass correlation coefficient. RESULTS 3D black-blood MR imaging demonstrates the best agreement with DSA, with the smallest limits of agreement and measurement error (coefficients of variance range, 5.87%-7.04%). 3D-TOF-MRA had the largest limits of agreement and measurement error (coefficients of variance range, 12.73%-15.78%). The average coefficient of variance was 6.26% for 3D black-blood MR imaging, 7.03% for contrast-enhanced MRA, and 15.54% for TOF-MRA. No bias was found among 3 MR imaging sequences compared with 3D rotational angiography. All 3 MR imaging sequences had excellent interreader agreement (intraclass correlation coefficient, >0.95). 3D black-blood MR imaging performed the best for patients with intraluminal thrombus (n = 10). CONCLUSIONS 3D black-blood MR imaging achieves better accuracy for aneurysm size measurements compared with 3D-TOF, using 3D rotational angiography as a criterion standard. This noncontrast technique is promising for surveillance of unruptured intracranial aneurysms.
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Affiliation(s)
- C Zhu
- From the Department of Radiology and Biomedical Imaging (C.Z., L.E., C.H., D.S.), University of California, San Francisco, San Francisco, California
| | - X Wang
- Department of Radiology (X.W., B.T., Q.L., J.L.), Changhai Hospital, Shanghai, China.,Department of Radiology (X.W.), General Hospital of Northern Military Command, Liaoning, China
| | - L Eisenmenger
- From the Department of Radiology and Biomedical Imaging (C.Z., L.E., C.H., D.S.), University of California, San Francisco, San Francisco, California
| | - B Tian
- Department of Radiology (X.W., B.T., Q.L., J.L.), Changhai Hospital, Shanghai, China
| | - Q Liu
- Department of Radiology (X.W., B.T., Q.L., J.L.), Changhai Hospital, Shanghai, China
| | - A J Degnan
- Department of Radiology (A.J.D.), Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - C Hess
- From the Department of Radiology and Biomedical Imaging (C.Z., L.E., C.H., D.S.), University of California, San Francisco, San Francisco, California
| | - D Saloner
- From the Department of Radiology and Biomedical Imaging (C.Z., L.E., C.H., D.S.), University of California, San Francisco, San Francisco, California
| | - J Lu
- Department of Radiology (X.W., B.T., Q.L., J.L.), Changhai Hospital, Shanghai, China
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17
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Degnan AJ, Zhu X, Flowers C, Fox WW, Zhang H, Saul D. Imaging Assessment of Partial Liquid Ventilation in Bronchopulmonary Dysplasia. Curr Probl Diagn Radiol 2019; 48:247-250. [DOI: 10.1067/j.cpradiol.2018.12.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Revised: 11/15/2018] [Accepted: 12/05/2018] [Indexed: 11/22/2022]
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18
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Degnan AJ, Alson MD, Duszak R. Variability in billing practices for whole-body magnetic resonance imaging. Pediatr Radiol 2019; 49:153. [PMID: 30194459 DOI: 10.1007/s00247-018-4255-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Accepted: 08/30/2018] [Indexed: 11/30/2022]
Affiliation(s)
- Andrew J Degnan
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd.,, Philadelphia, PA, 19104, USA. .,Department of Radiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
| | | | - Richard Duszak
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, USA
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19
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Degnan AJ, Yi PH, Kim N, Swietlik J, Huh E, Nguyen JC. Diagnostic and Interventional Imaging Services are Significant Sources of Medicare Revenue for Highly Reimbursed Nonradiologist Providers. Curr Probl Diagn Radiol 2018; 49:17-22. [PMID: 30466795 DOI: 10.1067/j.cpradiol.2018.10.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 10/28/2018] [Accepted: 10/29/2018] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Nonradiologist providers increasingly perform diagnostic imaging examinations and imaging-guided interventions traditionally performed by radiologists, which have raised concerns regarding appropriate utilization and self-referral. The purpose of this study was to assess the contribution of imaging studies to Medicare reimbursements for highly compensated nonradiologist providers in specialties often performing imaging studies. METHODS The Medicare Provider Utilization and Payment Database was queried for provider information regarding overall reimbursement for providers in anesthesiology, cardiology, emergency medicine, neurology, obstetrics and gynecology, orthopedic surgery, neurology, and vascular surgery. Information regarding imaging studies reported and payment amounts were extracted for the 25 highest-reimbursed providers. Data were analyzed for relative contribution of imaging payments to overall medical Medicare payments. RESULTS Significant differences between numbers of imaging studies, types of imaging, and payment amounts were noted based on provider specialty (p < 0.001). Highest-reimbursed cardiologists received the greatest percentage of Medicare payments from imaging (18.3%) followed by vascular surgery (11.6%), obstetrics and gynecology (10.9%), orthopedic surgery (9.6%), emergency medicine (8.7%), neurology (7.8%), and anesthesiology (3.2%) providers. Mean imaging payments amongst highly reimbursed nonradiologists were greatest for cardiology ($578,265), vascular surgery ($363,912), and orthopedic surgery ($113,634). Amongst highly reimbursed specialists, most common nonradiologist imaging payments were from ultrasound (45%) and cardiac nuclear medicine studies (40%). CONCLUSIONS Nonradiologist performed imaging payments comprised substantial proportions of overall Medicare reimbursement for highly reimbursed physicians in several specialties, especially cardiology, vascular surgery, and orthopedic surgery. Further investigation is needed to better understand the wider economic implications of nonradiologist imaging study performance and self-referral beyond the Medicare population.
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Affiliation(s)
- Andrew J Degnan
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA.; Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA.
| | - Paul H Yi
- The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Nathan Kim
- Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - John Swietlik
- Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Eric Huh
- The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jie C Nguyen
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA.; Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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Zhu C, Tian X, Degnan AJ, Lu J, Liu Q. Reply. AJNR Am J Neuroradiol 2018; 40:E2. [PMID: 30442701 DOI: 10.3174/ajnr.a5895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- C Zhu
- Department of Radiology and Biomedical Imaging University of California, San Francisco San Francisco, California
| | - X Tian
- Department of Radiology Changhai Hospital Shanghai, China
| | - A J Degnan
- Department of Radiology Children's Hospital of Philadelphia Philadelphia, Pennsylvania
| | - J Lu
- Department of Radiology Changhai Hospital Shanghai, China
| | - Q Liu
- Department of Radiology Changhai Hospital Shanghai, China
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Chung CY, Alson MD, Duszak R, Degnan AJ. From imaging to reimbursement: what the pediatric radiologist needs to know about health care payers, documentation, coding and billing. Pediatr Radiol 2018; 48:904-914. [PMID: 29552707 DOI: 10.1007/s00247-018-4104-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2017] [Revised: 01/15/2018] [Accepted: 02/20/2018] [Indexed: 10/17/2022]
Abstract
Medical coding and billing processes in the United States are complex, cumbersome and poorly understood by radiologists. Despite the direct implications of radiology documentation on reimbursement, trainees and practicing radiologists typically receive limited relevant training. This article summarizes the payer structure including the state-based Children's Health Insurance Programs, discusses the essential processes by which radiologists request and receive reimbursement, details the mechanisms of coding diagnoses using International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes and imaging services using Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) codes, and explores reimbursement and coding-related issues specific to pediatric radiology. Appropriate documentation, informed by knowledge of coding, billing and reimbursement fundamentals, facilitates appropriate payment for clinically relevant services provided by pediatric radiologists.
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Affiliation(s)
- Chul Y Chung
- Department of Radiology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | | | - Richard Duszak
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Andrew J Degnan
- Department of Radiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA. .,Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA.
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Abstract
The aim of this study was to compare image quality of low tube voltage cerebral computed tomography angiography (CTA) reconstructed with knowledge-based iterative model reconstruction (IMR), filtered back projection (FBP), and hybrid iterative reconstruction (HIR).A total of 101 patients with suspected cerebrovascular diseases were enrolled and randomized into 2 groups, 100 kVp tube voltage (n = 53) and reduced tube voltage (80 kVp) (n = 48). Computed tomography data were reconstructed with IMR, FBP, and HIR algorithms. The image noise, vascular attenuation, signal-to-noise ratio (SNR), and contrast-to-noise ratio (CNR) were measured and calculated. Two blinded radiologists independently evaluated image quality based on diagnostic confidence on a 3-point scale. Quantitative and qualitative assessments were compared between different groups and reconstruction subgroups.Vascular attenuation was higher in the reduced tube voltage group than in 100-kVp tube voltage group, but showed no significant difference within each group. In both groups, the image noise, vascular SNR, and CNR were significantly improved by IMR as compared with FBP and HIR. Inter-group comparison indicated that IMR with reduced tube voltage showed better image quality with lower image noise and higher vascular SNR and CNR than FBP and HIR at 100 kVp, but slightly inferior to IMR at 100 kVp. IMR also yields the best qualitative image quality, and improves the diagnostic confidence of atherosclerosis and aneurysm. Compared with the standard 120-kVp protocol (1.86mSv), the radiation doses of 100 kVp (1.13mSv) and 80 kVp (0.56mSv) were 39% and 70% less, respectively.The quantitative and qualitative image quality obtained by IMR was superior to that obtained by FBP and HIR for low tube voltage cerebral CTA.
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Affiliation(s)
- Xinrui Wang
- From the Department of Radiology, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Chengcheng Zhu
- From the Department of Radiology and Biomedical Imaging, UCSF, San Francisco, CA
| | - Jing Li
- From the Department of Radiology, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Andrew J. Degnan
- From the Department of Radiology, University of Pittsburgh, Pittsburgh, PA
| | - Tao Jiang
- From the Department of Radiology, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Jianping Lu
- From the Department of Radiology, Changhai Hospital, Second Military Medical University, Shanghai, China
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Zhu C, Tian X, Degnan AJ, Shi Z, Zhang X, Chen L, Teng Z, Saloner D, Lu J, Liu Q. Clinical Significance of Intraplaque Hemorrhage in Low- and High-Grade Basilar Artery Stenosis on High-Resolution MRI. AJNR Am J Neuroradiol 2018; 39:1286-1292. [PMID: 29794236 DOI: 10.3174/ajnr.a5676] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 03/29/2018] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Intraplaque hemorrhage within intracranial atherosclerotic plaques identified by high-resolution MR imaging has been studied as a potential marker of stroke risk. However, previous studies only examined intracranial arteries with high-grade stenosis (degree of stenosis, >50%). This study aimed to ascertain the clinical relevance of intraplaque hemorrhage in patients with low- and high-grade stenotic basilar artery plaques. MATERIALS AND METHODS Patients with basilar artery stenosis (n = 126; mean age, 62 ± 10 years; 66 symptomatic and 60 asymptomatic) underwent high-resolution MR imaging. The relationship between imaging findings (intraplaque hemorrhage, contrast enhancement, degree of stenosis, minimal lumen area, and plaque burden) and symptoms was analyzed. RESULTS Intraplaque hemorrhage was identified in 22 patients (17.5%), including 21 (31.8%) symptomatic patients and 1 (1.7%) asymptomatic patient. Multivariate analysis showed that intraplaque hemorrhage was the strongest independent marker of symptomatic status (odds ratio, 27.5; 95% CI, 3.4-221.5; P = .002). Contrast enhancement was also independently associated with symptomatic status (odds ratio, 9.9; 95% CI, 1.5-23.6; P = .016). Stenosis, minimal lumen area, and plaque burden were not correlated with symptoms (P > .05). Intraplaque hemorrhage was present in both low- and high-grade stenotic basilar arteries (11.3% versus 16.3%, P = .63). Diagnostic performance values of intraplaque hemorrhage for patients with acute/subacute symptomatic stroke were the following: specificity, 98.3%; sensitivity, 31.8%; positive predictive value, 95.5%; and negative predictive value, 56.7%. CONCLUSIONS Intraplaque hemorrhage is present in both low- and high-grade stenotic basilar artery plaques and is independently associated with symptomatic stroke status. Intraplaque hemorrhage may identify high-risk plaque and provide new insight into the management of patient with stroke without significant stenosis.
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Affiliation(s)
- C Zhu
- From the Department of Radiology and Biomedical Imaging (C.Z., D.S.), University of California, San Francisco, San Francisco, California
| | - X Tian
- Department of Radiology (X.T., Z.S., X.Z., L.C., J.L., Q.L.), Changhai Hospital, Shanghai, China
| | - A J Degnan
- Department of Radiology (A.J.D.), Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Z Shi
- Department of Radiology (X.T., Z.S., X.Z., L.C., J.L., Q.L.), Changhai Hospital, Shanghai, China
| | - X Zhang
- Department of Radiology (X.T., Z.S., X.Z., L.C., J.L., Q.L.), Changhai Hospital, Shanghai, China
| | - L Chen
- Department of Radiology (X.T., Z.S., X.Z., L.C., J.L., Q.L.), Changhai Hospital, Shanghai, China
| | - Z Teng
- Department of Radiology (Z.T.), University of Cambridge, Cambridge, UK
| | - D Saloner
- From the Department of Radiology and Biomedical Imaging (C.Z., D.S.), University of California, San Francisco, San Francisco, California
| | - J Lu
- Department of Radiology (X.T., Z.S., X.Z., L.C., J.L., Q.L.), Changhai Hospital, Shanghai, China
| | - Q Liu
- Department of Radiology (X.T., Z.S., X.Z., L.C., J.L., Q.L.), Changhai Hospital, Shanghai, China
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Shi Z, Zhu C, Degnan AJ, Tian X, Li J, Chen L, Zhang X, Peng W, Chen C, Lu J, Jiang T, Saloner D, Liu Q. Identification of high-risk plaque features in intracranial atherosclerosis: initial experience using a radiomic approach. Eur Radiol 2018; 28:3912-3921. [PMID: 29633002 PMCID: PMC6081255 DOI: 10.1007/s00330-018-5395-1] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Revised: 02/15/2018] [Accepted: 02/20/2018] [Indexed: 01/15/2023]
Abstract
OBJECTIVES To evaluate a quantitative radiomic approach based on high-resolution magnetic resonance imaging (HR-MRI) to differentiate acute/sub-acute symptomatic basilar artery plaque from asymptomatic plaque. METHODS Ninety-six patients with basilar artery stenosis underwent HR-MRI between January 2014 and December 2016. Patients were scanned with T1- and T2-weighted imaging, as well as T1 imaging following gadolinium-contrast injection (CE-T1). The stenosis value, plaque area/burden, lumen area, minimal luminal area (MLA), intraplaque haemorrhage (IPH), contrast enhancement ratio and 94 quantitative radiomic features were extracted and compared between acute/sub-acute and asymptomatic patients. Multi-variate logistic analysis and a random forest model were used to evaluate the diagnostic performance. RESULTS IPH, MLA and enhancement ratio were independently associated with acute/subacute symptoms. Radiomic features in T1 and CE-T1 images were associated with acute/subacute symptoms, but the features from T2 images were not. The combined IPH, MLA and enhancement ratio had an area under the curve (AUC) of 0.833 for identifying acute/sub-acute symptomatic plaques, and the combined T1 and CE-T1 radiomic approach had a significantly higher AUC of 0.936 (p = 0.01). Combining all features achieved an AUC of 0.974 and accuracy of 90.5%. CONCLUSIONS Radiomic analysis of plaque texture on HR-MRI accurately distinguished between acutely symptomatic and asymptomatic basilar plaques. KEY POINTS • High-resolution magnetic resonance imaging can assess basilar artery atherosclerotic plaque. • Radiomic features in T1 and CE-T1 images are associated with acute symptoms. • Radiomic analysis can accurately distinguish between acute symptomatic and asymptomatic plaque. • The highest accuracy may be achieved by combining radiomic and conventional features.
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Affiliation(s)
- Zhang Shi
- Department of Radiology, Changhai Hospital, Second Military Medical University, Shanghai, 200433, China
| | - Chengcheng Zhu
- Department of Radiology and Biomedical Imaging, UCSF, San Francisco, CA, USA
| | - Andrew J Degnan
- Department of Radiology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Xia Tian
- Department of Radiology, Changhai Hospital, Second Military Medical University, Shanghai, 200433, China
| | - Jing Li
- Department of Radiology, Changhai Hospital, Second Military Medical University, Shanghai, 200433, China
| | - Luguang Chen
- Department of Radiology, Changhai Hospital, Second Military Medical University, Shanghai, 200433, China
| | - Xuefeng Zhang
- Department of Radiology, Changhai Hospital, Second Military Medical University, Shanghai, 200433, China
| | - Wenjia Peng
- Department of Radiology, Changhai Hospital, Second Military Medical University, Shanghai, 200433, China
| | - Chao Chen
- Department of Radiology, Changhai Hospital, Second Military Medical University, Shanghai, 200433, China
| | - Jianping Lu
- Department of Radiology, Changhai Hospital, Second Military Medical University, Shanghai, 200433, China
| | - Tao Jiang
- Department of Radiology, Changhai Hospital, Second Military Medical University, Shanghai, 200433, China
| | - David Saloner
- Department of Radiology and Biomedical Imaging, UCSF, San Francisco, CA, USA
| | - Qi Liu
- Department of Radiology, Changhai Hospital, Second Military Medical University, Shanghai, 200433, China.
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Degnan AJ, Hemingway J, Hughes DR. Medicare Utilization of Vertebral Augmentation 2001 to 2014: Effects of Randomized Clinical Trials and Guidelines on Vertebroplasty and Kyphoplasty. J Am Coll Radiol 2018; 14:1001-1006. [PMID: 28778222 DOI: 10.1016/j.jacr.2017.04.026] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Revised: 04/19/2017] [Accepted: 04/19/2017] [Indexed: 12/21/2022]
Abstract
PURPOSE Vertebral fractures have a substantial impact on the health and quality of life of elderly individuals as one of the most common complications of osteoporosis. Vertebral augmentation procedures including vertebroplasty and kyphoplasty have been supported as means of reducing pain and mitigating disability associated with these fractures. However, use of vertebroplasty is debated, with negative randomized controlled trials published in 2009 and divergent clinical guidelines. The effect of changing evidence and guidelines on different practitioners' utilization of both kyphoplasty and vertebroplasty in the years after these developments and publication of data supporting their use is poorly understood. METHODS Using national aggregate Medicare claims data from 2002 through 2014, vertebroplasty and kyphoplasty procedures were identified by provider type. Changes in utilization by procedure type and provider were studied. RESULTS Total vertebroplasty billing increased 101.6% from 2001 (18,911) through 2008 (38,123). Total kyphoplasty billing frequency increased 17.2% from 2006 (54,329) through 2008 (63,684). Vertebroplasty billing decreased 60.9% from 2008 through 2014 to its lowest value (14,898). Kyphoplasty billing decreased 8.4% from 2008 (63,684) through 2010 (58,346), but then increased 7.6% from 2010 to 2013 (62,804). CONCLUSIONS Vertebroplasty billing decreased substantially beginning in 2009 and continued to decrease through 2014 despite publication of more favorable studies in 2010 to 2012, suggesting studies published in 2009 and AAOS guidelines in 2010 may have had a persistent negative effect. Kyphoplasty did not decrease as substantially and increased in more recent years, suggesting a clinical practice response to favorable studies published during this period.
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Affiliation(s)
- Andrew J Degnan
- Department of Radiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
| | | | - Danny R Hughes
- Harvey L. Neiman Health Policy Institute, Reston, Virginia; Department of Health Administration and Policy, George Mason University, Fairfax, Virginia
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26
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Degnan AJ, Kietz DA, Grudziak JS, Shah A. Bilateral absence of the cruciate ligaments with meniscal dysplasia: Unexpected diagnosis in a child with juvenile idiopathic arthritis. Clin Imaging 2018; 49:193-197. [PMID: 29635139 DOI: 10.1016/j.clinimag.2018.03.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Revised: 03/21/2018] [Accepted: 03/23/2018] [Indexed: 01/17/2023]
Abstract
Bilateral agenesis of the cruciate ligaments is a rare congenital anomaly. We report a unique case of a young girl who had congenital short femur and diagnosed with polyarticular juvenile idiopathic arthritis (JIA) and later discovered to have congenital absence of both anterior and posterior cruciate ligaments and meniscal dysplasia in both the knees when MRI was performed at 11 years of age. The MRI was performed to evaluate knee laxity and persistent symptoms despite medical management and multiple steroid injections for arthritis treatment. This patient is one of the youngest with congenital absence of both the cruciate ligaments to be treated with ACL reconstruction. We highlight the unique radiographic imaging manifestations of congenital cruciate ligament agenesis and emphasize the role of MRI to confirm and depict additional intraarticular abnormalities.
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Affiliation(s)
- Andrew J Degnan
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Daniel A Kietz
- Department of Rheumatology, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, United States
| | - Jan S Grudziak
- Division of Orthopedics, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, United States
| | - Amisha Shah
- Department of Radiology, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, United States.
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27
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Degnan AJ, Tocchio S, Kurtom W, Tadros SS. Pediatric neuroendocrine carcinoid tumors: Management, pathology, and imaging findings in a pediatric referral center. Pediatr Blood Cancer 2017; 64. [PMID: 28205418 DOI: 10.1002/pbc.26477] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Revised: 12/20/2016] [Accepted: 01/10/2017] [Indexed: 12/24/2022]
Abstract
BACKGROUND While neuroendocrine (carcinoid) tumors are increasingly recognized in the adult population, they are often not suspected in children. PROCEDURE Retrospective review of all well-differentiated neuroendocrine (carcinoid) tumors was performed based on pathology reports from a quaternary pediatric medical center between January 2003 and June 2016. Clinical presentations, treatment approaches, imaging findings, and outcomes were reviewed and analyzed. RESULTS A total of 45 cases of pathology-proven carcinoid tumor were reported with an average age of 14.1 years (range: 7-21 years, SD: 2.8 years). Of these cases, 80% (36) were appendiceal, 11% (5) bronchial, 2% (1) colonic, 2% (1) gastric, 2% (1) enteric, and 2% (1) testicular. Metastases were observed in one (3%) appendiceal, one (100%) enteric, and two (40%) bronchial cases. No recurrence was demonstrated in any appendiceal carcinoid cases. Recurrence was seen in one of three extra-appendiceal gastrointestinal tumors. Tumor site and size significantly correlated with metastases and recurrence. CONCLUSIONS Contrary to recent epidemiological investigations in adults, appendiceal carcinoid tumors remain the most common site for pediatric carcinoid tumors. Appendiceal carcinoid tumors exhibited benign clinical courses without recurrence during short-term follow-up. Extra-appendiceal gastrointestinal carcinoid tumors exhibited much more aggressive behavior with greater metastases and recurrence. Bronchial carcinoid tumors demonstrated good clinical response to resection even in cases with mediastinal lymph node involvement. While increased use of urine 5-HIAA levels and somatostatin receptor-specific imaging might improve detection and guide management of extra-appendiceal carcinoid tumors, longer-term follow-up is needed.
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Affiliation(s)
- Andrew J Degnan
- Department of Radiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.,Department of Pediatric Radiology, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania.,Department of Radiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Shannon Tocchio
- Department of Pediatric Radiology, University of Virginia, Charlottesville, Virginia
| | - Waleed Kurtom
- Division of Neonatology, Department of Pediatrics, University of Miami, Miami, Florida
| | - Sameh S Tadros
- Department of Radiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.,Department of Pediatric Radiology, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania.,Department of Radiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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Degnan AJ, Chung CY, Shah AJ. Quantitative diffusion-weighted magnetic resonance imaging assessment of chemotherapy treatment response of pediatric osteosarcoma and Ewing sarcoma malignant bone tumors. Clin Imaging 2017; 47:9-13. [PMID: 28806574 DOI: 10.1016/j.clinimag.2017.08.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Revised: 06/28/2017] [Accepted: 08/04/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Assessment of tumor response to chemotherapy is essential in managing malignant pediatric bone tumors prior to resection. SUBJECTS AND METHODS Pre-chemotherapy and post-chemotherapy osteosarcoma and Ewing sarcoma cases (n=18) were analyzed with apparent diffusion coefficient (ADC) values measured by two readers. RESULTS Treated tumors demonstrated significantly greater ADC values compared to untreated tumors (p<0.001). Intraclass correlation coefficients ranged between 0.858 and 0.935. No significant tumor volume differences were observed. Regression analysis demonstrated average ADC as the best predictor of treatment. CONCLUSIONS Our study suggests that ADC values may be useful for evaluating chemotherapeutic response of malignant pediatric bone tumors.
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Affiliation(s)
- Andrew J Degnan
- Department of Radiology, University of Pittsburgh Medical Center, Pittsburgh, PA, United States; Department of Pediatric Radiology, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, United States; Department of Radiology, The Children's Hospital of Philadelphia, Philadelphia, PA, United States.
| | - Chul Y Chung
- Department of Radiology, University of Pittsburgh Medical Center, Pittsburgh, PA, United States; Department of Pediatric Radiology, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, United States.
| | - Amisha J Shah
- Department of Radiology, University of Pittsburgh Medical Center, Pittsburgh, PA, United States; Department of Pediatric Radiology, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, United States.
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29
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Jiang Y, Peng W, Tian B, Zhu C, Chen L, Wang X, Liu Q, Wang Y, Xiang Z, Degnan AJ, Teng Z, Saloner D, Lu J. Identification and Quantitative Assessment of Different Components of Intracranial Atherosclerotic Plaque by Ex Vivo 3T High-Resolution Multicontrast MRI. AJNR Am J Neuroradiol 2017; 38:1716-1722. [PMID: 28684455 DOI: 10.3174/ajnr.a5266] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Accepted: 04/23/2017] [Indexed: 01/30/2023]
Abstract
BACKGROUND AND PURPOSE High-resolution 3T MR imaging can visualize intracranial atherosclerotic plaque. However, histologic validation is still lacking. This study aimed to evaluate the ability of 3T MR imaging to identify and quantitatively assess intracranial atherosclerotic plaque components ex vivo with histologic validation. MATERIALS AND METHODS Fifty-three intracranial arterial specimens with atherosclerotic plaques from 20 cadavers were imaged by 3T MR imaging with T1, T2, and proton-density-weighted FSE and STIR sequences. The signal characteristics and areas of fibrous cap, lipid core, calcification, fibrous tissue, and healthy vessel wall were recorded on MR images and compared with histology. Fibrous cap thickness and maximum wall thickness were also quantified. The percentage of areas of the main plaque components, the ratio of fibrous cap thickness to maximum wall thickness, and plaque burden were calculated and compared. RESULTS The signal intensity of the lipid core was significantly lower than that of the fibrous cap on T2-weighted, proton-density, and STIR sequences (P < .01) and was comparable on T1-weighted sequences (P = 1.00). Optimal contrast between the lipid core and fibrous cap was found on T2-weighted images. Plaque component mean percentages were comparable between MR imaging and histology: fibrous component (81.86% ± 10.59% versus 81.87% ± 11.59%, P = .999), lipid core (19.51% ± 10.76% versus 19.86% ± 11.56%, P = .863), and fibrous cap (31.10% ± 11.28% versus 30.83% ± 8.51%, P = .463). However, MR imaging overestimated mean calcification (9.68% ± 5.21% versus 8.83% ± 5.67%, P = .030) and plaque burden (65.18% ± 9.01% versus 52.71% ± 14.58%, P < .001). CONCLUSIONS Ex vivo 3T MR imaging can accurately identify and quantitatively assess intracranial atherosclerotic plaque components, providing a direct reference for in vivo intracranial plaque imaging.
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Affiliation(s)
- Y Jiang
- From the Department of Radiology (Y.J.), Wuhan General Hospital of the People's Liberation Army, Wuhan, China.,Departments of Radiology (Y.J., W.P., B.T., L.C., X.W., Q.L., J.L.)
| | - W Peng
- Departments of Radiology (Y.J., W.P., B.T., L.C., X.W., Q.L., J.L.)
| | - B Tian
- Departments of Radiology (Y.J., W.P., B.T., L.C., X.W., Q.L., J.L.)
| | - C Zhu
- Department of Radiology and Biomedical Imaging (C.Z., D.S.), University of California, San Francisco, San Francisco, California
| | - L Chen
- Departments of Radiology (Y.J., W.P., B.T., L.C., X.W., Q.L., J.L.)
| | - X Wang
- Departments of Radiology (Y.J., W.P., B.T., L.C., X.W., Q.L., J.L.)
| | - Q Liu
- Departments of Radiology (Y.J., W.P., B.T., L.C., X.W., Q.L., J.L.)
| | - Y Wang
- Pathology (Y.W., Z.X.), Changhai Hospital, Shanghai, China
| | - Z Xiang
- Pathology (Y.W., Z.X.), Changhai Hospital, Shanghai, China
| | - A J Degnan
- Department of Radiology (A.J.D.), University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Z Teng
- Department of Radiology (Z.T.), University of Cambridge, Cambridge, UK
| | - D Saloner
- Department of Radiology and Biomedical Imaging (C.Z., D.S.), University of California, San Francisco, San Francisco, California
| | - J Lu
- Departments of Radiology (Y.J., W.P., B.T., L.C., X.W., Q.L., J.L.)
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Degnan AJ, Lee KKW, Minervini MI, Borhani AA. Metastatic extrapleural malignant solitary fibrous tumor presenting with hypoglycemia (Doege-Potter syndrome). Radiol Case Rep 2016; 12:113-119. [PMID: 28228892 PMCID: PMC5310265 DOI: 10.1016/j.radcr.2016.10.014] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2016] [Accepted: 10/23/2016] [Indexed: 11/29/2022] Open
Abstract
We report a rare case of metastatic malignant solitary fibrous tumor (SFT) that presented with hypoglycemia because of insulin growth factor-2 production. Initial workup included computed tomography imaging that revealed a large, partially necrotic liver mass, a hypervascular pancreatic head lesion, and 2 renal lesions. Following hepatic resection, pancreatic head resection and nephrectomy, all these lesions demonstrated pathological findings that were consistent with SFT. The patient also had a history of an intracranial mass that had been previously resected and treated with gamma knife therapy at an outside institution, which was found to also be SFT. Six months after initial pancreatic head resection, the patient developed a new lesion involving the pancreatic tail that was found to represent recurrent metastatic SFT. This case emphasizes the highly aggressive nature of extrapleural SFT, while rare, and the role of imaging in follow-up for disease recurrence.
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Affiliation(s)
- Andrew J Degnan
- Department of Radiology, University of Pittsburgh Medical Center, 200 Lothrop Street, Suite, Pittsburgh, PA 15213, USA
| | - Kenneth K W Lee
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Marta I Minervini
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Amir A Borhani
- Department of Radiology, University of Pittsburgh Medical Center, 200 Lothrop Street, Suite, Pittsburgh, PA 15213, USA
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Jiang Y, Zhu C, Peng W, Degnan AJ, Chen L, Wang X, Liu Q, Wang Y, Xiang Z, Teng Z, Saloner D, Lu J. Ex-vivo imaging and plaque type classification of intracranial atherosclerotic plaque using high resolution MRI. Atherosclerosis 2016; 249:10-6. [PMID: 27062404 DOI: 10.1016/j.atherosclerosis.2016.03.033] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2015] [Revised: 03/23/2016] [Accepted: 03/24/2016] [Indexed: 10/22/2022]
Abstract
BACKGROUND AND AIMS Recent development of high resolution MRI techniques have enabled imaging of intracranial atherosclerotic plaque in vivo. However, identifying plaque composition remains challenging given the small size and the lack of histological validation. This study aims to quantify the relaxation times of intracranial plaque components ex vivo at 3 T and to determine whether multi-contrast MRI could classify intracranial plaque according to the American Heart Association classification with histological validation. METHODS A total of 53 intracranial arteries with atherosclerotic plaques from 20 cadavers (11 male, age 73.8 ± 10.9) were excised. Quantitative T1/T2/T2* mapping sequences and multi-contrast fast-spin echo sequences (T1, T2, proton-density weighted and short time inversion recovery) were acquired. Plaque components including: fibrous cap, lipid core, fibrous tissue, calcification, and healthy wall were segmented on histology, and their relaxation times were derived from quantitative images. Two radiologists independently classified plaque type blinded to the histology results. RESULTS Relaxation times of plaque components are distinct and different. T2 and T2* values of lipid core are lower than fibrous cap (p = 0.026 & p < 0.0001), but are comparable with fibrous tissue and healthy wall (p = 0.76 & p = 0.42). MRI reliably classified plaque type compared with histology (κ = 0.69) with an overall accuracy of 80.7%. The sensitivity and specificity using MRI to identify fibro-lipid atheroma (type IV-V) was 94.8% and 77.1%, respectively. Inter-observer agreement was excellent (κ = 0.77). CONCLUSION Intracranial plaque components have distinct and different relaxation times at 3 T. High-resolution MRI is able to characterize intracranial plaque composition and classify plaque types ex vivo at 3 T.
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Affiliation(s)
| | - Chengcheng Zhu
- Department of Radiology and Biomedical Imaging, UCSF, San Francisco, CA, USA.
| | - Wenjia Peng
- Department of Radiology, Changhai Hospital, Shanghai, China
| | - Andrew J Degnan
- Department of Radiology, University of Pittsburgh, Pittsburgh, USA
| | - Luguang Chen
- Department of Radiology, Changhai Hospital, Shanghai, China
| | - Xinrui Wang
- Department of Radiology, Changhai Hospital, Shanghai, China
| | - Qi Liu
- Department of Radiology, Changhai Hospital, Shanghai, China
| | - Yang Wang
- Department of Pathology, Changhai Hospital, Shanghai, China
| | - Zhenzhen Xiang
- Department of Pathology, Changhai Hospital, Shanghai, China
| | - Zhongzhao Teng
- Department of Radiology, University of Cambridge, Cambridge, UK
| | - David Saloner
- Department of Radiology and Biomedical Imaging, UCSF, San Francisco, CA, USA
| | - Jianping Lu
- Department of Radiology, Changhai Hospital, Shanghai, China.
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33
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Degnan AJ, Wisnowski JL, Choi S, Ceschin R, Bhushan C, Leahy RM, Corby P, Schmithorst VJ, Panigrahy A. Altered Structural and Functional Connectivity in Late Preterm Preadolescence: An Anatomic Seed-Based Study of Resting State Networks Related to the Posteromedial and Lateral Parietal Cortex. PLoS One 2015; 10:e0130686. [PMID: 26098888 PMCID: PMC4476681 DOI: 10.1371/journal.pone.0130686] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2014] [Accepted: 05/22/2015] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE Late preterm birth confers increased risk of developmental delay, academic difficulties and social deficits. The late third trimester may represent a critical period of development of neural networks including the default mode network (DMN), which is essential to normal cognition. Our objective is to identify functional and structural connectivity differences in the posteromedial cortex related to late preterm birth. METHODS Thirty-eight preadolescents (ages 9-13; 19 born in the late preterm period (≥32 weeks gestational age) and 19 at term) without access to advanced neonatal care were recruited from a low socioeconomic status community in Brazil. Participants underwent neurocognitive testing, 3-dimensional T1-weighted imaging, diffusion-weighted imaging and resting state functional MRI (RS-fMRI). Seed-based probabilistic diffusion tractography and RS-fMRI analyses were performed using unilateral seeds within the posterior DMN (posterior cingulate cortex, precuneus) and lateral parietal DMN (superior marginal and angular gyri). RESULTS Late preterm children demonstrated increased functional connectivity within the posterior default mode networks and increased anti-correlation with the central-executive network when seeded from the posteromedial cortex (PMC). Key differences were demonstrated between PMC components with increased anti-correlation with the salience network seen only with posterior cingulate cortex seeding but not with precuneus seeding. Probabilistic tractography showed increased streamlines within the right inferior longitudinal fasciculus and inferior fronto-occipital fasciculus within late preterm children while decreased intrahemispheric streamlines were also observed. No significant differences in neurocognitive testing were demonstrated between groups. CONCLUSION Late preterm preadolescence is associated with altered functional connectivity from the PMC and lateral parietal cortex to known distributed functional cortical networks despite no significant executive neurocognitive differences. Selective increased structural connectivity was observed in the setting of decreased posterior interhemispheric connections. Future work is needed to determine if these findings represent a compensatory adaptation employing alternate neural circuitry or could reflect subtle pathology resulting in emotional processing deficits not seen with neurocognitive testing.
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Affiliation(s)
- Andrew J. Degnan
- Department of Pediatric Radiology, Children's Hospital of Pittsburgh of UPMC, 4401 Penn Avenue, Floor 2, Pittsburgh, PA, 15224, United States of America
- Department of Radiology, University of Pittsburgh Medical Center (UPMC), 3950 Presby South Tower, 200 Lothrop Street, Pittsburgh, PA 15213, United States of America
| | - Jessica L. Wisnowski
- Department of Pediatric Radiology, Children's Hospital of Pittsburgh of UPMC, 4401 Penn Avenue, Floor 2, Pittsburgh, PA, 15224, United States of America
- Brain and Creativity Institute, University of Southern California, 3620A McClintock Avenue, Los Angeles, CA 90089, United States of America
- Department of Radiology, Children’s Hospital Los Angeles, Los Angeles, CA 90027, United States of America
| | - SoYoung Choi
- Brain and Creativity Institute, University of Southern California, 3620A McClintock Avenue, Los Angeles, CA 90089, United States of America
| | - Rafael Ceschin
- Department of Pediatric Radiology, Children's Hospital of Pittsburgh of UPMC, 4401 Penn Avenue, Floor 2, Pittsburgh, PA, 15224, United States of America
- Department of Biomedical Informatics, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Chitresh Bhushan
- Signal and Image Processing Institute, University of Southern California, Los Angeles, CA 90089, United States of America
| | - Richard M. Leahy
- Signal and Image Processing Institute, University of Southern California, Los Angeles, CA 90089, United States of America
| | - Patricia Corby
- Twins Institute for Genetics Research, Montes Claros, Minas Gerais 39400–115, Brazil
- New York University Bluestone Center for Clinical Research, 421 1st Ave, New York, NY 10010, United States of America
| | - Vincent J. Schmithorst
- Department of Pediatric Radiology, Children's Hospital of Pittsburgh of UPMC, 4401 Penn Avenue, Floor 2, Pittsburgh, PA, 15224, United States of America
| | - Ashok Panigrahy
- Department of Pediatric Radiology, Children's Hospital of Pittsburgh of UPMC, 4401 Penn Avenue, Floor 2, Pittsburgh, PA, 15224, United States of America
- Brain and Creativity Institute, University of Southern California, 3620A McClintock Avenue, Los Angeles, CA 90089, United States of America
- Department of Radiology, Children’s Hospital Los Angeles, Los Angeles, CA 90027, United States of America
- Department of Biomedical Informatics, University of Pittsburgh, Pittsburgh, PA, United States of America
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Degnan AJ, Maldjian C, Pantanowitz L, Kofler JK. Rare case of a radiographically occult sacral lesion detected on MRI presenting with intractable back pain. BJR Case Rep 2015; 1:20150002. [PMID: 30363177 PMCID: PMC6159129 DOI: 10.1259/bjrcr.20150002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2014] [Revised: 04/28/2015] [Accepted: 05/04/2015] [Indexed: 11/05/2022] Open
Abstract
We report the imaging findings and histopathology of a rare case of sacral hibernoma in a female presenting with right buttock pain while sitting. The lesion was occult on radiographs and CT scan. A small, rounded right S2 lesion was hypointense on T1 weighted images and hyperintense on short tau inversion-recovery images. It demonstrated homogeneous contrast enhancement. The lesion was biopsied, and histopathology revealed an intraosseous hibernoma composed of brown fat cells. Intraosseous hibernomas are rare and demonstrate non-specific imaging findings requiring biopsy for diagnosis, although most hibernomas are incidental and asymptomatic. Initial treatment with microwave ablation and cementoplasty improved the patient’s symptoms temporarily but cementoplasty caused radicular symptoms, and eventually, cement removal, bone curettage, grafting and sacral nerve root decompression were required for symptom remission.
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Affiliation(s)
| | - C Maldjian
- University of Pittsburgh, Pittsburgh, PA, USA
| | - L Pantanowitz
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - J K Kofler
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Degnan AJ, Maldjian C, Adam RJ, Harner CD. Passive Posterior Tibial Subluxation on Routine Knee MRI as a Secondary Sign of PCL Tear. Radiol Res Pract 2014; 2014:715439. [PMID: 25587446 PMCID: PMC4283255 DOI: 10.1155/2014/715439] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2014] [Accepted: 12/05/2014] [Indexed: 11/17/2022] Open
Abstract
The posterior drawer test is an accurate clinical test to diagnose posterior cruciate ligament (PCL), indicating laxity of the PCL that allows posterior tibial translation. This study aimed to determine whether posterior tibial translation relative to the femur on routine MRI could serve as an additional sign of PCL tear. Routine knee MRI in eleven patients (7 males, 4 females) with arthroscopically confirmed isolated PCL tears were reviewed independently by two musculoskeletal radiologists. Measurements of tibial translation were made in the medial and lateral compartments of patients and controls (10 males, 12 females) without clinical or MRI evidence of ligament injury. Significant medial compartment posterior tibial translation was present in patients with PCL tear compared to controls (+2.93 mm versus +0.03 mm, P = 0.002) with excellent interobserver agreement (intraclass correlation coefficient (ICC) = 0.94). No significant difference in lateral compartment tibial translation was observed (+0.17 mm versus -0.57 mm, P = 0.366) despite excellent interobserver agreement (ICC = 0.96). Posterior tibial translation in the midmedial compartment may be a secondary sign of isolated PCL tear on routine knee MRI with passive extension without manipulation or weight bearing. Additional work in a larger cohort may better address the accuracy of this finding.
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Affiliation(s)
- Andrew J. Degnan
- Department of Radiology, University of Pittsburgh Medical Center, 3950 Presby South Tower, 200 Lothrop Street, Pittsburgh, PA 15213, USA
- University of Pittsburgh, Pittsburgh, PA 15260, USA
| | | | - Richard J. Adam
- Department of Radiology, University of Pittsburgh Medical Center, 3950 Presby South Tower, 200 Lothrop Street, Pittsburgh, PA 15213, USA
| | - Christopher D. Harner
- Department of Orthopedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
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Degnan AJ, Ceschin R, Lee V, Schmithorst VJ, Blüml S, Panigrahy A. Early metabolic development of posteromedial cortex and thalamus in humans analyzed via in vivo quantitative magnetic resonance spectroscopy. J Comp Neurol 2014; 522:3717-32. [PMID: 24888973 DOI: 10.1002/cne.23634] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2013] [Revised: 05/25/2014] [Accepted: 05/27/2014] [Indexed: 12/27/2022]
Abstract
The posteromedial cortex (PMC) including the posterior cingulate, retrosplenial cortex, and medial parietal cortex/precuneus is an epicenter of cortical interactions in a wide spectrum of neural activity. Anatomic connections between PMC and thalamic components have been established in animal studies, but similar studies do not exist for the fetal and neonatal period. Magnetic resonance spectroscopy (MRS) allows for noninvasive measurement of metabolites in early development. Using single-voxel 3-T MRS, healthy term neonates (n = 31, mean postconception age 41.5 weeks ± 3.8 weeks) were compared with control children (n = 23, mean age 9.4 years ± 5.1 years) and young adults (n = 10, mean age 24.1 years ± 2.6 years). LCModel-based calculations compared metabolites within medial parietal gray matter (colocalizing to the PMC), posterior thalamus, and parietal white matter voxels. Common metabolic changes existed for neuronal-axonal maturation and structural markers in the PMC, thalamus, and parietal white matter with increasing NAA and glutamate and decreasing myoinositol and choline with age. Key differences in creatine and glucose metabolism were noted in the PMC, in contrast to the thalamic and parietal white matter locations, suggesting a unique role of energy metabolism. Significant parallel metabolite developmental changes of multiple other metabolites including aspartate, glutamine, and glutathione with age were present between PMC and parietal white matter but not between PMC and thalamus. These findings offer insight into the metabolic architecture of the interface between structural and functional topology of brain networks. Further investigation unifying metabolic changes with functional and anatomic pathways may further enhance the understanding of the PMC in posterior default mode network development.
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Affiliation(s)
- Andrew J Degnan
- Department of Pediatric Radiology, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania, 15224; Department of Radiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, 15213
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Degnan AJ, Samtani R, Paudel K, Levy LM. Neuroimaging of epilepsy: a review of MRI findings in uncommon etiologies and atypical presentations of seizures. Future Neurology 2014. [DOI: 10.2217/fnl.14.32] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
ABSTRACT: Imaging patients with seizures presents a challenge to both clinician and radiologist, especially when symptoms or EEG features are atypical, not conforming to established epilepsy syndromes or EEG patterns. Appropriate, directed use of MRI enhances the detection of underlying epileptogenic foci and can evaluate both common and unusual etiologies. This review examines imaging evaluation of epilepsies due to uncommon presentations of common conditions, unusual conditions and atypical seizure presentations. Understanding these uncommon presentations of seizures ensures optimal clinical management and can guide appropriate intervention. Advances in newer imaging methods including diffusion tensor imaging, functional connectivity MRI, magnetic source imaging and magnetic resonance spectroscopic imaging can further increase sensitivity to detect subtle structural abnormalities causing epilepsy and can also be used to plan more successful epilepsy surgery.
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Affiliation(s)
- Andrew J Degnan
- Department of Radiology, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
| | - Rajeev Samtani
- Department of Radiology, George Washington University Medical Center, Washington, DC 20037, USA
| | - Kalyan Paudel
- Department of Radiology, George Washington University Medical Center, Washington, DC 20037, USA
| | - Lucien M Levy
- Department of Radiology, George Washington University Medical Center, Washington, DC 20037, USA
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Gruner P, Vo A, Argyelan M, Ikuta T, Degnan AJ, John M, Peters BD, Malhotra AK, Uluğ AM, Szeszko PR. Independent component analysis of resting state activity in pediatric obsessive-compulsive disorder. Hum Brain Mapp 2014; 35:5306-15. [PMID: 24867148 DOI: 10.1002/hbm.22551] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2013] [Revised: 04/11/2014] [Accepted: 05/06/2014] [Indexed: 01/31/2023] Open
Abstract
Obsessive-compulsive disorder (OCD) is an often severely disabling illness with onset generally in childhood or adolescence. Little is known, however, regarding the pattern of brain resting state activity in OCD early in the course of illness. We therefore examined differences in brain resting state activity in patients with pediatric OCD compared with healthy volunteers and their clinical correlates. Twenty-three pediatric OCD patients and 23 healthy volunteers (age range 9-17), matched for sex, age, handedness, and IQ completed a resting state functional magnetic resonance imaging exam at 3T. Patients completed the Children's Yale Brown Obsessive Scale. Data were decomposed into 36 functional networks using spatial group independent component analysis (ICA) and logistic regression was used to identify the components that yielded maximum group separation. Using ICA we identified three components that maximally separated the groups: a middle frontal/dorsal anterior cingulate network, an anterior/posterior cingulate network, and a visual network yielding an overall group classification of 76.1% (sensitivity = 78.3% and specificity = 73.9%). Independent component expression scores were significantly higher in patients compared with healthy volunteers in the middle frontal/dorsal anterior cingulate and the anterior/posterior cingulate networks, but lower in patients within the visual network. Higher expression scores in the anterior/posterior cingulate network correlated with greater severity of compulsions among patients. These findings implicate resting state fMRI abnormalities within the cingulate cortex and related control regions in the pathogenesis and phenomenology of OCD early in the course of the disorder and prior to extensive pharmacologic intervention.
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Affiliation(s)
- Patricia Gruner
- Department of Psychiatry, Yale University School of Medicine, Connecticut Mental Health Center, New Haven, Connecticut
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Abstract
Alzheimer disease prevails as a major cause of disability in the elderly population and ranks as the most common form of dementia that affects 1 of 8 individuals older than 65 years of age. Most AD cases are late in onset and are probably influenced by both genetic and environmental factors. Apart from age, the risk factors include family history; brain injury, both traumatic and vascular; and metabolic diseases, such as diabetes, hypercholesterolemia, and obesity. Based on twin studies, inheritance plays a role in approximately 80% of cases (familial and sporadic).
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Affiliation(s)
- A T Rao
- From the George Washington University Medical Center (A.T.R., L.M.L.), Washington, DC
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Abstract
Most dementias begin insidiously, developing slowly and generally occurring in the elderly age group. The so-called rapidly progressive dementias constitute a different, diverse collection of conditions, many of which are reversible or treatable. For this reason, prompt identification and assessment of acute and subacute forms of dementia are critical to effective treatment. Numerous other entities within this category of presenile rapid-onset dementias are untreatable such as the prion-related diseases. Neuroimaging aids in the diagnosis and evaluation of many of these rapidly progressive dementias, which include myriad conditions ranging from variations of more common neurodegenerative dementias, such as Alzheimer disease, dementia with Lewy bodies, and frontotemporal dementia; infectious-related dementias such as acquired immune deficiency syndrome dementia; autoimmune and malignancy-related conditions; to toxic and metabolic forms of encephalopathy. This first of a 2-part review will specifically address the ability of MR imaging and ancillary neuroimaging strategies to support the diagnostic evaluation of rapidly progressive dementias due to neurodegenerative causes.
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Affiliation(s)
- A J Degnan
- From the University of Pittsburgh Medical Center (A.J.D.), Pittsburgh, Pennsylvania
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Affiliation(s)
- A J Degnan
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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Degnan AJ, Levy LM. Imaging of the 6-OPRI mutation prion disease: an entity distinct from typical Creutzfeldt-Jakob disease? AJNR Am J Neuroradiol 2013; 34:1731-2. [PMID: 23538413 DOI: 10.3174/ajnr.a3490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Degnan AJ, Levy LM. Neuroimaging of rapidly progressive dementias, part 2: prion, inflammatory, neoplastic, and other etiologies. AJNR Am J Neuroradiol 2013; 35:424-31. [PMID: 23413251 DOI: 10.3174/ajnr.a3455] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Most dementias begin insidiously, developing slowly and generally occurring in the elderly age group. The so-called rapidly progressive dementias constitute a different, diverse collection of conditions, many of which are reversible or treatable. For this reason, accurate identification and assessment of acute and subacute forms of dementia are critical to effective treatment; neuroimaging aids greatly in narrowing the diagnosis of these conditions. This second installment of a 2-part review of rapidly progressive dementias examines the use of imaging in an assortment of other etiologies in the differential diagnosis, from prion disease and neoplastic-related conditions to rare metabolic and other conditions such as Wernicke encephalopathy. In these clinical conditions, MR imaging has the potential to narrow this broad differential diagnosis and, at times, can definitively aid in the diagnosis of certain conditions on the basis of typical imaging patterns.
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Affiliation(s)
- A J Degnan
- From the University of Pittsburgh Medical Center (A.J.D.), Pittsburgh, Pennsylvania
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Abstract
SUMMARY GABA serves as a major neurotransmitter of the brain and functions mainly to inhibit neural excitatory activity. Disruption of the GABAergic processes appears to occur in various neurologic and psychiatric conditions, including epilepsy, mood disorders, motor disorders such as focal dystonia and stiff-person syndrome, sleep disorders, neuroplasticity, and drug and alcohol dependence. These concentration differences may be ascertained by using MR spectroscopy to provide information on the concentration of different metabolites. This review briefly discusses advances in MR spectroscopy methods and explores the application of this technique to detect changes in GABA due to disease processes and medication-induced effects.
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Affiliation(s)
- L M Levy
- Department of Radiology, George Washington University Medical Center, Washington, DC 20037, USA.
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Degnan AJ, Patterson AJ, Tang TY, Howarth SPS, Gillard JH. Evaluation of ultrasmall superparamagnetic iron oxide-enhanced MRI of carotid atherosclerosis to assess risk of cerebrovascular and cardiovascular events: follow-up of the ATHEROMA trial. Cerebrovasc Dis 2012; 34:169-73. [PMID: 22922841 DOI: 10.1159/000339984] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2012] [Accepted: 06/04/2012] [Indexed: 11/19/2022] Open
Affiliation(s)
- Andrew J Degnan
- University Department of Radiology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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Teng Z, He J, Degnan AJ, Chen S, Sadat U, Bahaei NS, Rudd JHF, Gillard JH. Critical mechanical conditions around neovessels in carotid atherosclerotic plaque may promote intraplaque hemorrhage. Atherosclerosis 2012; 223:321-6. [PMID: 22762729 PMCID: PMC3437553 DOI: 10.1016/j.atherosclerosis.2012.06.015] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2012] [Revised: 06/01/2012] [Accepted: 06/11/2012] [Indexed: 12/02/2022]
Abstract
Objective Intraplaque hemorrhage is an increasingly recognized contributor to plaque instability. Neovascularization of plaque is believed to facilitate the entry of inflammatory and red blood cells (RBC). Under physiological conditions, neovessels are subject to mechanical loading from the deformation of atherosclerotic plaque by blood pressure and flow. Local mechanical environments around neovessels and their relevant pathophysiologic significance have not yet been examined. Methods and results Four carotid plaque samples removed at endarcterectomy were collected for histopathological examination. Neovessels and other components were manually segmented to build numerical models for mechanical analysis. Each component was assumed to be non-linear isotropic, piecewise homogeneous and incompressible. The results indicated that local maximum principal stress and stretch and their variations during one cardiac cycle were greatest around neovessels. Neovessels surrounded by RBC underwent a much larger stretch during systole than those without RBCs present nearby (median [inter quartile range]; 1.089 [1.056, 1.131] vs. 1.034 [1.020, 1.067]; p < 0.0001) and much larger stress (5.3 kPa [3.4, 8.3] vs. 3.1 kPa [1.6, 5.5]; p < 0.0001) and stretch (0.0282 [0.0190, 0.0427] vs. 0.0087 [0.0045, 0.0185]; p < 0.0001) variations during the cardiac cycle. Conclusions Local critical mechanical conditions may lead to the rupture of neovessels resulting in the formation and expansion of intraplaque hemorrhage.
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Affiliation(s)
- Zhongzhao Teng
- University Department of Radiology, University of Cambridge, UK.
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Patterson AJ, Degnan AJ, Walsh SR, Eltayeb M, Scout EF, Clarke JMF, Wilson YG, Tang TY. Efficacy of VBHOM to Predict Outcome Following Major Lower Limb Amputation. Vasc Endovascular Surg 2012; 46:369-73. [DOI: 10.1177/1538574412445600] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Purpose: This study tests an existing Vascular Biochemistry and Haematology Outcome Model (VBHOM) on independent data and presents further refinements to the model. Methods: Data from 306 patients who underwent lower limb amputation over a 4-year period were collated. Urea, creatinine, sodium, potassium, hemoglobin, white cell count, albumin, age, gender, mode-of-admission, and short-term mortality events were extracted from the database. This study tests an existing model and trains a new model for predicting mortality using forward stepwise logistic regression. Results: The existing model suggests a significant lack of fit (c-index = 0.665, P = .04). For the exception of gender and mode-of-admission, all predictor variables had significant univariate associations with short-term mortality ( P < .05). The refined model included age, sodium, potassium, creatinine, and albumin and had good discriminatory power (c-index = 0.8, no evidence of lack of fit, P = .616). Conclusions: Our simplified model had good predictive ability and suggests redundancy in input variables used by the existing models.
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Affiliation(s)
- Andrew J. Patterson
- MRIS Unit & University Department of Radiology, Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge, UK
| | - Andrew J. Degnan
- MRIS Unit & University Department of Radiology, Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge, UK
| | - Stewart R. Walsh
- Graduate Entry Medical School, University of Limerick, Mid-Western Regional Hospital, Limerick, Ireland
| | - Mohammed Eltayeb
- Norfolk & Norwich Vascular Unit, Norfolk & Norwich University Hospital, Colney Lane, Norwich, UK
| | - Earl F. Scout
- Norfolk & Norwich Vascular Unit, Norfolk & Norwich University Hospital, Colney Lane, Norwich, UK
| | - James M. F. Clarke
- Norfolk & Norwich Vascular Unit, Norfolk & Norwich University Hospital, Colney Lane, Norwich, UK
| | - Yvonne G. Wilson
- Norfolk & Norwich Vascular Unit, Norfolk & Norwich University Hospital, Colney Lane, Norwich, UK
| | - Tjun Y. Tang
- Department of Vascular Surgery, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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Degnan AJ, Young VEL, Gillard JH. Advances in noninvasive imaging for evaluating clinical risk and guiding therapy in carotid atherosclerosis. Expert Rev Cardiovasc Ther 2012; 10:37-53. [PMID: 22149525 DOI: 10.1586/erc.11.168] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Managing asymptomatic carotid atherosclerosis with a view to preventing ischemic stroke is a challenging task. As the annual risk of stroke in untreated asymptomatic patients on average is less than the risk of surgical intervention, the key question is how to identify those asymptomatic individuals whose risk of stroke is elevated and who would benefit from surgery, while sparing low-risk asymptomatic patients from the risks of surgical intervention. The advent of a multitude of noninvasive carotid imaging techniques offers an opportunity to improve risk stratification in patients and to monitor the response to medical therapies; assessing efficacy at individual and population levels. As part of this, plaque measurement techniques (using ultrasound, computed tomography or MRI) may be employed in monitoring plaque/component regression and progression. Novel imaging applications targeted to plaque characteristics, inflammation and neovascularization, including contrast-enhanced ultrasound and MRI, dynamic contrast-enhanced MRI, and fluorodeoxyglucose-PET, are also being explored. Ultimately, noninvasive imaging and other advances in risk stratification aim to improve and individualize the management of patients with carotid atherosclerosis.
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Affiliation(s)
- Andrew J Degnan
- University Department of Radiology, Addenbrooke's Hospital, Box 218, Hills Road, Cambridge, Cambridgeshire, CB2 2QQ, UK
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Degnan AJ, Young VE, Tang TY, Gill AB, Graves MJ, Gillard JH, Patterson AJ. Ex vivo study of carotid endarterectomy specimens: quantitative relaxation times within atherosclerotic plaque tissues. Magn Reson Imaging 2012; 30:1017-21. [PMID: 22503089 DOI: 10.1016/j.mri.2012.02.018] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2011] [Revised: 01/10/2012] [Accepted: 02/17/2012] [Indexed: 10/28/2022]
Abstract
PURPOSE Previous studies reporting relaxation times within atherosclerotic plaque have typically used dedicated small-bore high-field systems and small sample sizes. This study reports quantitative T(1), T(2) and T(2) relaxation times within plaque tissue at 1.5 T using spatially co-matched histology to determine tissue constituents. METHODS Ten carotid endarterectomy specimens were removed from patients with advanced atherosclerosis. Imaging was performed on a 1.5-T whole-body scanner using a custom built 10-mm diameter receive-only solenoid coil. A protocol was defined to allow subsequent computation of T(1), T(2) and T(2) relaxation times using multi-flip angle spoiled gradient echo, multi-echo fast spin echo and multi-echo gradient echo sequences, respectively. The specimens were subsequently processed for histology and individually sectioned into 2-mm blocks to allow subsequent co-registration. Each imaging sequence was imported into in-house software and displayed alongside the digitized histology sections. Regions of interest were defined to demarcate fibrous cap, connective tissue and lipid/necrotic core at matched slice-locations. Relaxation times were calculated using Levenberg-Marquardt's least squares curve fitting algorithm. A linear-mixed effect model was applied to account for multiple measurements from the same patient and establish if there was a statistically significant difference between the plaque tissue constituents. RESULTS T(2) and T(2) relaxation times were statistically different between all plaque tissues (P=.026 and P=.002 respectively) [T(2): lipid/necrotic core was lower 47 ± 13.7 ms than connective tissue (67 ± 22.5 ms) and fibrous cap (60 ± 13.2 ms); T(2): fibrous cap was higher (48 ± 15.5 ms) than connective tissue (19 ± 10.6 ms) and lipid/necrotic core (24 ± 8.2 ms)]. T(1) relaxation times were not significantly different (P=.287) [T(1): Fibrous cap: 933 ± 271.9 ms; connective tissue (1002 ± 272.9 ms) and lipid/necrotic core (1044 ± 304.0 ms)]. We were unable to demarcate hemorrhage and calcium following histology processing. CONCLUSIONS This study demonstrates that there is a significant difference between qT(2) and qT(2) in plaque tissues types. Derivation of quantitative relaxation times shows promise for determining plaque tissue constituents.
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Affiliation(s)
- Andrew J Degnan
- Department of Radiology, Cambridge University Hospital NHS Foundation Trust, Cambridge, CB2 0QQ
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Passi N, Degnan AJ, Levy LM. MR imaging of papilledema and visual pathways: effects of increased intracranial pressure and pathophysiologic mechanisms. AJNR Am J Neuroradiol 2012; 34:919-24. [PMID: 22422187 DOI: 10.3174/ajnr.a3022] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Papilledema, defined as swelling of the optic disc, frequently occurs in the setting of increased ICP and in a variety of medical conditions, including pseudotumor cerebri, sinus thrombosis, intracerebral hemorrhage, frontal lobe neoplasms, and Chiari malformation. Noninvasive imaging of the ON is possible by using MR imaging, with a variety of findings occurring in the setting of papilledema, including flattening of the posterior sclera, protrusion of the optic disc, widening of the ONS, and tortuosity of the ON. Early recognition of papilledema and elevated ICP is of paramount importance for ensuring restoration of vision. Newer advanced MR imaging techniques such as fMRI and DTI may prove useful in the future to assess the potential effects of papilledema on retinal and visual pathway integrity.
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Affiliation(s)
- N Passi
- Department of Radiology, George Washington University Hospital, Washington, DC 20037, USA
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