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Background and purpose: The magnetic resonance imaging in multiple sclerosis consensus guidelines currently mandate three sagittal non-contrast enhanced sequences of T2-weighted fast spin echo, proton density-weighted fast spin echo and short tau inversion recovery; however, these particular three sequences have not previously been compared at 3T. This study compared T2-weighted fast spin echo, proton density-weighted fast spin echo, short tau inversion recovery as well as the double inversion recovery sequence for the sagittal detection of multiple sclerosis lesions in the cervical spinal cord at 3T. Method(s): Nineteen multiple sclerosis patients underwent magnetic resonance imaging with 3T sagittal T2-weighted fast spin echo, proton density-weighted fast spin echo, short tau inversion recovery and double inversion recovery between November 2012 and April 2013. Two neuroradiologists independently reviewed the images, and the number of lesions detected on each sequence was recorded. Lesion conspicuity was quantitatively assessed with the lesion-to-cord-contrast ratio and lesion contrast-to-noise ratio. The Wilcoxon signed rank test was performed for statistical analysis. Result(s): Proton density-weighted fast spin echo and short tau inversion recovery detected 32% more lesions compared to T2-weighted fast spin echo, and 37% more lesions compared to double inversion recovery. The lesion-to-cord-contrast ratio was highest in short tau inversion recovery, while the lesion contrast-to-noise ratio was highest for proton density-weighted fast spin echo. Conclusion(s): This study provides the necessary evidentiary support at 3T for the magnetic resonance imaging in multiple sclerosis spinal magnetic resonance imaging protocol consensus guidelines. At 3T sagittal proton density-weighted fast spin echo and short tau inversion recovery sequences allowed improved detection of cervical spinal cord multiple sclerosis lesions, compared to T2-weighted fast spin echo and three-di

Errors in diagnostic radiology are not infrequent. Patient harm related to these errors is however less common and may be avoided via various preventative mechanisms within the medical system including, but not limited to, multidisciplinary meetings, second opinions, subspecialty expertise and clinician experience. Failure at a number of points in the system is often required to result in patient harm. Radiologists, and in particular departmental leaders, should proactively address the known underlying root causes of diagnostic errors and cognitive biases, ensure systems are in place to promptly discover and control unmitigated root causes as they arise and ensure an unbiased 'blameless' or 'just' culture of error investigation and proces sing including the implementation of non-punitive peer feedback and peer learning. This article provides an overview of errors in diagnostic radiology including the causes and potential ramifications and how we might reduce their frequency and impact.Copyright © 2021 The Royal Australian and New Zealand College of Radiologists

Background and purpose: The magnetic resonance imaging in multiple sclerosis consensus guidelines currently mandate three sagittal non-contrast enhanced sequences of T2-weighted fast spin echo, proton density-weighted fast spin echo and short tau inversion recovery; however, these particular three sequences have not previously been compared at 3T. This study compared T2-weighted fast spin echo, proton density-weighted fast spin echo, short tau inversion recovery as well as the double inversion recovery sequence for the sagittal detection of multiple sclerosis lesions in the cervical spinal cord at 3T. Method(s): Nineteen multiple sclerosis patients underwent magnetic resonance imaging with 3T sagittal T2-weighted fast spin echo, proton density-weighted fast spin echo, short tau inversion recovery and double inversion recovery between November 2012 and April 2013. Two neuroradiologists independently reviewed the images, and the number of lesions detected on each sequence was recorded. Lesion conspicuity was quantitatively assessed with the lesion-to-cord-contrast ratio and lesion contrast-to-noise ratio. The Wilcoxon signed rank test was performed for statistical analysis. Result(s): Proton density-weighted fast spin echo and short tau inversion recovery detected 32% more lesions compared to T2-weighted fast spin echo, and 37% more lesions compared to double inversion recovery. The lesion-to-cord-contrast ratio was highest in short tau inversion recovery, while the lesion contrast-to-noise ratio was highest for proton density-weighted fast spin echo. Conclusion(s): This study provides the necessary evidentiary support at 3T for the magnetic resonance imaging in multiple sclerosis spinal magnetic resonance imaging protocol consensus guidelines. At 3T sagittal proton density-weighted fast spin echo and short tau inversion recovery sequences allowed improved detection of cervical spinal cord multiple sclerosis lesions, compared to T2-weighted fast spin echo and three-di

Errors in diagnostic radiology are not infrequent. Patient harm related to these errors is however less common and may be avoided via various preventative mechanisms within the medical system including, but not limited to, multidisciplinary meetings, second opinions, subspecialty expertise and clinician experience. Failure at a number of points in the system is often required to result in patient harm. Radiologists, and in particular departmental leaders, should proactively address the known underlying root causes of diagnostic errors and cognitive biases, ensure systems are in place to promptly discover and control unmitigated root causes as they arise and ensure an unbiased 'blameless' or 'just' culture of error investigation and proces sing including the implementation of non-punitive peer feedback and peer learning. This article provides an overview of errors in diagnostic radiology including the causes and potential ramifications and how we might reduce their frequency and impact.Copyright © 2021 The Royal Australian and New Zealand College of Radiologists

BACKGROUND: The lifetime prevalence of depression in people with multiple sclerosis (MS) is approximately 50% compared with around 15% in the general population. There is a relationship between depression and quality of life in people with MS and evidence that depression may contribute to disease progression. METHODS: This cross-sectional pilot study assessed the association between depression and regional brain atrophy, including amygdala and hippocampal volume. Forty-nine participants with MS recruited through a hospital MS clinic were administered the Center for Epidemiological Studies Depression Scale Revised (CESD-R) to investigate whether higher endorsements on the items depressive affect and interpersonal symptoms were associated with volumetric magnetic resonance imaging measurements of hippocampal and amygdala atrophy. RESULTS: Regression analysis revealed an association between depression-related interpersonal symptoms and right amygdala volume. No association was found between depression and hippocampal volume. CONCLUSIONS: These results provide preliminary support for a unilateral, biologically based relationship between the right amygdala and characteristic interpersonal depressive symptoms expressed by people with MS and add to the growing body of literature implicating regional brain atrophy in MS-associated depression. Given that the interpersonal subcomponent of the CESD-R measures social functioning, and the neural networks in the amygdala are known to be implicated in processing social stimuli, this research suggests that targeted diagnosis and treatments for depression in people with MS may be particularly beneficial. Further confirmatory research of this relationship is required.

Background: Australian and USA guidelines recommend routine brain imaging, either computed tomography (CT) or magnetic resonance imaging (MRI), to exclude structural lesions in presentations for first-episode psychosis. Objective(s): This review examines the evidence for the appropriateness and clinical utility of using CT or MRI to exclude structural lesions in presentations of first-episode psychosis. Method(s): A systematic review of studies reporting diagnostic outcomes of screening with CT or MRI in patients with psychosis. Finding(s): There were 16 suitable studies published between 1988 and 2017 with the majority examining the outcomes of screening with CT. Most were observational studies with retrospective design. The majority found that while structural abnormalities were a common finding, these findings rarely required clinical intervention and were very rarely the cause of the psychotic symptoms. Only 2 of the 16 studies concluded that brain imaging should be routinely ordered in first-episode psychosis. Conclusion(s): There is insufficient evidence to suggest that brain imaging should be routinely ordered for patients presenting with first-episode psychosis without associated neurological or cognitive impairment. National guidelines should reflect evidence-based data.

Background: Australian and US guidelines recommend routine brain imaging, either computed tomography or magnetic resonance imaging, to exclude structural lesions in presentations for first-episode psychosis. The aim of this review was to examine the evidence for the appropriateness and clinical utility of this recommendation by assessing the frequency of abnormal radiological findings in computed tomography and magnetic resonance imaging scans among patients with first-episode psychosis. Method(s): PubMed and Embase database were searched from inception to April 2018 using appropriate MeSH or Emtree terms. Studies were included in the review if they reported data on computed tomography or magnetic resonance imaging scan findings of individuals with first-episode psychosis. No restriction on the geographical location of the study or the age of participants was applied. We calculated the percentage of abnormal radiological findings in each study, separately by the two diagnostic methods. Result(s): There were 16 suitable studies published between 1988 and 2017, reporting data on an overall 2312 patients with first-episode psychosis. Most were observational studies with a retrospective design and the majority examined patients with computed tomography. While structural abnormalities were a relatively common finding, these rarely required clinical intervention (range across studies: 0-60.7%; median: 3.5%) and were very rarely the cause of the psychotic symptoms (range: 0-3.3%; median: 0%). Only 2 of the 16 studies concluded that brain imaging should be routinely ordered in first-episode psychosis. Conclusion(s): There is insufficient evidence to suggest that brain imaging should be routinely ordered for patients presenting with first-episode psychosis without associated neurological or cognitive impairment. The appropriate screening procedure for structural brain lesions is conventional history-taking, mental status and neurological examination. If intracranial patholog

The potential of antidepressant medication to have a neuroprotective effect for people with multiple sclerosis (MS) has received increased interest in recent years. The possibility of antidepressants, particularly fluoxetine, for potential repurposing to treat primary progressive and secondary progressive MS is of interest as a result of the relative lack of disease-modifying medications for these subtypes. A number of animal studies have found positive results for a neuroprotective effect of antidepressant use in MS, with human studies showing mixed results. These human studies all have a significant limitation: they exclude people with moderate to severe depressive symptoms, a core symptom of MS beyond that of reactive depression. It is likely that reregulation of the common mechanisms in depression and MS, such as inflammation, serotonin, norepinephrine, glutamate and brain-derived neurotropic factor disruption, and hypothalamic-pituitary-thalamic axis dysregulation, are important to the neuroprotective value of antidepressant medication. Given that MS is known for its heterogeneity, the question might be less about whether antidepressant medication provides neuroprotective benefits to people with multiple sclerosis but for whom they provide benefits and whether we are designing studies that will detect a benefit. To answer these questions, studies must include people with MS and depressive symptoms as well as people with relapsing remitting and chronic subtypes.Copyright © 2019, American Psychiatric Association. All rights reserved.

Background: Australian and US guidelines recommend routine brain imaging, either computed tomography or magnetic resonance imaging, to exclude structural lesions in presentations for first-episode psychosis. The aim of this review was to examine the evidence for the appropriateness and clinical utility of this recommendation by assessing the frequency of abnormal radiological findings in computed tomography and magnetic resonance imaging scans among patients with first-episode psychosis. Method(s): PubMed and Embase database were searched from inception to April 2018 using appropriate MeSH or Emtree terms. Studies were included in the review if they reported data on computed tomography or magnetic resonance imaging scan findings of individuals with first-episode psychosis. No restriction on the geographical location of the study or the age of participants was applied. We calculated the percentage of abnormal radiological findings in each study, separately by the two diagnostic methods. Result(s): There were 16 suitable studies published between 1988 and 2017, reporting data on an overall 2312 patients with first-episode psychosis. Most were observational studies with a retrospective design and the majority examined patients with computed tomography. While structural abnormalities were a relatively common finding, these rarely required clinical intervention (range across studies: 0-60.7%; median: 3.5%) and were very rarely the cause of the psychotic symptoms (range: 0-3.3%; median: 0%). Only 2 of the 16 studies concluded that brain imaging should be routinely ordered in first-episode psychosis. Conclusion(s): There is insufficient evidence to suggest that brain imaging should be routinely ordered for patients presenting with first-episode psychosis without associated neurological or cognitive impairment. The appropriate screening procedure for structural brain lesions is conventional history-taking, mental status and neurological examination. If intracranial patholog

Background: Australian and USA guidelines recommend routine brain imaging, either computed tomography (CT) or magnetic resonance imaging (MRI), to exclude structural lesions in presentations for first-episode psychosis. Objective(s): This review examines the evidence for the appropriateness and clinical utility of using CT or MRI to exclude structural lesions in presentations of first-episode psychosis. Method(s): A systematic review of studies reporting diagnostic outcomes of screening with CT or MRI in patients with psychosis. Finding(s): There were 16 suitable studies published between 1988 and 2017 with the majority examining the outcomes of screening with CT. Most were observational studies with retrospective design. The majority found that while structural abnormalities were a common finding, these findings rarely required clinical intervention and were very rarely the cause of the psychotic symptoms. Only 2 of the 16 studies concluded that brain imaging should be routinely ordered in first-episode psychosis. Conclusion(s): There is insufficient evidence to suggest that brain imaging should be routinely ordered for patients presenting with first-episode psychosis without associated neurological or cognitive impairment. National guidelines should reflect evidence-based data.

The potential of antidepressant medication to have a neuroprotective effect for people with multiple sclerosis (MS) has received increased interest in recent years. The possibility of antidepressants, particularly fluoxetine, for potential repurposing to treat primary progressive and secondary progressive MS is of interest as a result of the relative lack of disease-modifying medications for these subtypes. A number of animal studies have found positive results for a neuroprotective effect of antidepressant use in MS, with human studies showing mixed results. These human studies all have a significant limitation: they exclude people with moderate to severe depressive symptoms, a core symptom of MS beyond that of reactive depression. It is likely that reregulation of the common mechanisms in depression and MS, such as inflammation, serotonin, norepinephrine, glutamate and brain-derived neurotropic factor disruption, and hypothalamic-pituitary-thalamic axis dysregulation, are important to the neuroprotective value of antidepressant medication. Given that MS is known for its heterogeneity, the question might be less about whether antidepressant medication provides neuroprotective benefits to people with multiple sclerosis but for whom they provide benefits and whether we are designing studies that will detect a benefit. To answer these questions, studies must include people with MS and depressive symptoms as well as people with relapsing remitting and chronic subtypes.Copyright © 2019, American Psychiatric Association. All rights reserved.

Glioblastomas with a substantial proportion of noncontrast-enhancing tumour (nCET) have a variety of imaging appearances. We aimed to determine whether glioblastomas demonstrating a substantial proportion (>33%) of nCET can be sub-classified by different morphologic pattern of nCET. We then assessed whether this improves the ability of MRI to predict isocitrate dehydrogenase-1 (IDH1) mutation status and whether this has prognostic significance independent of IDH1 mutation status. Pre-operative MRIs of patients with a new diagnosis of glioblastoma were reviewed. Tumours with >33% nCET were sub-classified by the dominant morphologic pattern of nCET: mass-like expansion, white matter dissemination, grey matter dissemination or a combination. IDH1 mutation status (by immunohistochemistry) and survival were compared for each pattern. 153 patients met the inclusion criteria, of whom 34 patients demonstrated >33% nCET. 10 patients had a significant mass-like component, either as the dominant pattern (n = 4) or as part of a mixed pattern (n = 6). The 10 patients with a significant mass-like component had longer survival than those without (median 387 days, compared to 241 days), though this was not statistically significant (p = 0.242). Three patients had R132H-IDH1 mutations and >33% nCET, and all three had a mass-like component. Using the presence of a mass-like component of nCET for predicting IDH1 mutation status improved the positive predictive value, specificity and overall accuracy of MRI. Classification of nCET by morphologic pattern improves the ability of MRI to predict IDH1 mutations and may provide useful prognostic information.Copyright © 2017 Elsevier Ltd

Glioblastomas with a substantial proportion of noncontrast-enhancing tumour (nCET) have a variety of imaging appearances. We aimed to determine whether glioblastomas demonstrating a substantial proportion (>33%) of nCET can be sub-classified by different morphologic pattern of nCET. We then assessed whether this improves the ability of MRI to predict isocitrate dehydrogenase-1 (IDH1) mutation status and whether this has prognostic significance independent of IDH1 mutation status. Pre-operative MRIs of patients with a new diagnosis of glioblastoma were reviewed. Tumours with >33% nCET were sub-classified by the dominant morphologic pattern of nCET: mass-like expansion, white matter dissemination, grey matter dissemination or a combination. IDH1 mutation status (by immunohistochemistry) and survival were compared for each pattern. 153 patients met the inclusion criteria, of whom 34 patients demonstrated >33% nCET. 10 patients had a significant mass-like component, either as the dominant pattern (n = 4) or as part of a mixed pattern (n = 6). The 10 patients with a significant mass-like component had longer survival than those without (median 387 days, compared to 241 days), though this was not statistically significant (p = 0.242). Three patients had R132H-IDH1 mutations and >33% nCET, and all three had a mass-like component. Using the presence of a mass-like component of nCET for predicting IDH1 mutation status improved the positive predictive value, specificity and overall accuracy of MRI. Classification of nCET by morphologic pattern improves the ability of MRI to predict IDH1 mutations and may provide useful prognostic information.Copyright © 2017 Elsevier Ltd

Isocitrate dehydrogenase 1 (IDH1) mutations in gliomas have been associated with a frontal lobe location and a greater proportion of noncontrast-enhancing tumour (nCET). The purpose of our study was to validate the utility of MRI imaging features in predicting IDH1 mutations in glioblastomas. Pre-operative MRIs of new glioblastoma patients, consisting of at least FLAIR and T1-weighted post-contrast sequences, were reviewed by a neuroradiologist based primarily on the VASARI feature set. IDH1 mutation testing was performed on all patients using immunohistochemistry. 153 patients met the inclusion criteria, of whom five had IDH1 mutations (3.3%). A frontal lobe location had equivalent frequency in both the IDH1-mutated and IDH1-wildtype cohorts (p = 1.000). Three (60%) of the IDH1-mutated tumours had >33% nCET, compared to 21% of IDH1-wildtype (p = 0.073). 12 tumours had a frontal lobe epicentre and >33% nCET, all being IDH1-wildtype. All five IDH1-mutated tumours had either a frontal lobe epicentre or >33% nCET, but none had both these features. Our results question the strength of the association between frontal lobe glioblastomas with substantial nCET and IDH1 mutations, as these features are also relatively frequent in IDH1-wildtype tumours, which are much more common. MRI is thus more useful for ruling out an IDH1 mutation rather than strongly suggesting its presence: if a particular glioblastoma does not have a frontal lobe epicentre and has less than 33% nCET, it can be predicted to be IDH1-wildtype with a high degree of confidence.Copyright © 2017 Elsevier Ltd

Magnetic resonance (MR) diffusion-weighted imaging (DWI) and perfusion-weighted imaging (PWI) offer unique insight into acute ischemic stroke pathophysiology. These techniques may offer the ability to apply pathophysiology to accurately individualize acute stroke reperfusion treatment, including extending the opportunity of reperfusion treatment to well beyond the current time-based treatment windows. This review examines the use of DWI and PWI in the major stroke trials, their current clinical utility, and potential limitations for reperfusion treatment selection. DWI and PWI continue to be investigated in ongoing randomized controlled trials, and continued research into these techniques will help achieve the goal of tissue-based decision making and individualized acute stroke treatment.Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.

Isocitrate dehydrogenase 1 (IDH1) mutations in gliomas have been associated with a frontal lobe location and a greater proportion of noncontrast-enhancing tumour (nCET). The purpose of our study was to validate the utility of MRI imaging features in predicting IDH1 mutations in glioblastomas. Pre-operative MRIs of new glioblastoma patients, consisting of at least FLAIR and T1-weighted post-contrast sequences, were reviewed by a neuroradiologist based primarily on the VASARI feature set. IDH1 mutation testing was performed on all patients using immunohistochemistry. 153 patients met the inclusion criteria, of whom five had IDH1 mutations (3.3%). A frontal lobe location had equivalent frequency in both the IDH1-mutated and IDH1-wildtype cohorts (p = 1.000). Three (60%) of the IDH1-mutated tumours had >33% nCET, compared to 21% of IDH1-wildtype (p = 0.073). 12 tumours had a frontal lobe epicentre and >33% nCET, all being IDH1-wildtype. All five IDH1-mutated tumours had either a frontal lobe epicentre or >33% nCET, but none had both these features. Our results question the strength of the association between frontal lobe glioblastomas with substantial nCET and IDH1 mutations, as these features are also relatively frequent in IDH1-wildtype tumours, which are much more common. MRI is thus more useful for ruling out an IDH1 mutation rather than strongly suggesting its presence: if a particular glioblastoma does not have a frontal lobe epicentre and has less than 33% nCET, it can be predicted to be IDH1-wildtype with a high degree of confidence.Copyright © 2017 Elsevier Ltd

Magnetic resonance (MR) diffusion-weighted imaging (DWI) and perfusion-weighted imaging (PWI) offer unique insight into acute ischemic stroke pathophysiology. These techniques may offer the ability to apply pathophysiology to accurately individualize acute stroke reperfusion treatment, including extending the opportunity of reperfusion treatment to well beyond the current time-based treatment windows. This review examines the use of DWI and PWI in the major stroke trials, their current clinical utility, and potential limitations for reperfusion treatment selection. DWI and PWI continue to be investigated in ongoing randomized controlled trials, and continued research into these techniques will help achieve the goal of tissue-based decision making and individualized acute stroke treatment.Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.

BACKGROUND: Voice change is one of the earliest features of Parkinson's disease. However, quantitative studies of vocal fold dynamics which are needed to provide insight into disease biology, aid diagnosis, or track progression, are few. METHODS: We therefore quantified arytenoid cartilage movements and glottic area during repeated phonation in 15 patients with Parkinson's disease (symptom duration < 6 years) and 19 controls, with 320-slice computerised tomography (CT). We related these measures to perceptual voice evaluations and spirometry. We hypothesised that Parkinson's disease patients have a smaller inter-arytenoid distance, a preserved or larger glottic area because vocal cord bowing has previously been reported, less variability in loudness, more voice dysdiadochokinesis and breathiness and a shortened phonation time because of arytenoid hypokinesis relative to glottic area. RESULTS: Inter-arytenoid distance in Parkinson's disease patients was moderately smaller (Mdn = 0.106, IQR = 0.091-0.116) than in controls (Mdn = 0.132, IQR = 0.116-0.166) (W = 212, P = 0.015, r = -0.42), normalised for anatomical and other inter-subject variance, analysed with two-tailed Wilcoxon's rank sum test. This finding was confirmed in a linear mixed model analysis-Parkinson's disease significantly predicted a reduction in the dependent variable, inter-arytenoid distance (b = -0.87, SEb = 0.39, 95% CI [-1.66, -0.08], t(31) = -2.24, P = 0.032). There was no difference in glottic area. On perceptual voice evaluation, patients had more breathiness and dysdiadochokinesis, a shorter maximum phonation time, and less variability in loudness than controls. There was no difference in spirometry after adjustment for smoking history. CONCLUSIONS: As predicted, vocal fold adduction movements are reduced in Parkinson's disease on repeated phonation but glottic area is maintained. Some perceptual characteristics of Parkinsonian speech reflect these changes. We are the first to use 320-slice C

Glioblastoma usually presents on imaging as a single peripherally enhancing lesion, but multiple enhancing lesions can occur, termed multifocal if there is a connection between enhancing lesions, or multicentric when no communication is demonstrated. We aim to determine the incidence and prognostic implications of multifocal and multicentric glioblastoma in the era of modern MRI, focusing on the added benefit of T2-weighted fluid-attenuated inversion recovery (FLAIR) imaging. Patients with a new diagnosis of glioblastoma were identified. Preoperative MRI were reviewed to determine whether more than one distinct enhancing lesion was present, and whether there was communication between lesions. The findings were compared against survival data. More than one discrete contrast-enhancing lesion was present in 51 of the 151 patients (34%). Communication between lesions was identified in 47 of these, most commonly direct parenchymal spread (41 patients). The patients with multiple lesions had worse survival (median 176 days, compared to 346 days), but this difference was not statistically significant (p = 0.253). These tumours more frequently involved deep structures (p < 0.001) and the posterior fossa (p = 0.045), both of which were associated with worse survival. The presence of multiple enhancing foci in glioblastoma is common, occurring in about one-third of patients, and the majority have multifocal disease. The FLAIR sequence is the crucial sequence for demonstrating a communication between lesions. The worse survival of these patients is, at least in large part related to more extensive tumour dissemination and more frequent involvement of key structures, rather than multiplicity per se.Copyright © 2016 Elsevier Ltd

Introduction The presence of non-enhancing cortical signal abnormality is useful for differentiating between glioblastoma and metastatic disease, but its significance has not been studied. We aimed to determine the incidence and prognostic implications of non-enhancing cortical signal abnormality in glioblastomas. Methods Patients with a new diagnosis of glioblastoma between September 2007 and December 2010 were identified. Only patients with at least fluid-attenuated inversion recovery (FLAIR) and post-contrast T1-weighted sequences were included. Pre-operative MRIs were reviewed together by two readers to determine whether there was evidence of non-enhancing cortical signal abnormality, based primarily on the FLAIR sequence. The results were compared with patient survival using both univariate and multivariate analysis. Results One hundred fifty-one patients met the inclusion criteria. Seventy-seven patients (51%) had evidence of non-enhancing cortical signal abnormality. On both univariate and multivariate analysis, there was overall no significant difference in survival between patients with non-enhancing cortical signal abnormality and those without. Peripheral enhancing lesions (51 patients) were generally associated with the longest survival, but subgroup analysis suggested that non-enhancing signal abnormality was associated with worse survival in these patients (P = 0.004), conveying an intermediate prognosis. Conclusions Non-enhancing cortical signal abnormality is a common feature of glioblastomas, occurring in about half of cases. It does not affect survival overall, but appears to be associated with worse survival in the setting of a peripherally located enhancing lesion. This has the potential to alter surgical management.Copyright © 2015 The Royal Australian and New Zealand College of Radiologists.

Glioblastoma usually presents on imaging as a single peripherally enhancing lesion, but multiple enhancing lesions can occur, termed multifocal if there is a connection between enhancing lesions, or multicentric when no communication is demonstrated. We aim to determine the incidence and prognostic implications of multifocal and multicentric glioblastoma in the era of modern MRI, focusing on the added benefit of T2-weighted fluid-attenuated inversion recovery (FLAIR) imaging. Patients with a new diagnosis of glioblastoma were identified. Preoperative MRI were reviewed to determine whether more than one distinct enhancing lesion was present, and whether there was communication between lesions. The findings were compared against survival data. More than one discrete contrast-enhancing lesion was present in 51 of the 151 patients (34%). Communication between lesions was identified in 47 of these, most commonly direct parenchymal spread (41 patients). The patients with multiple lesions had worse survival (median 176 days, compared to 346 days), but this difference was not statistically significant (p = 0.253). These tumours more frequently involved deep structures (p < 0.001) and the posterior fossa (p = 0.045), both of which were associated with worse survival. The presence of multiple enhancing foci in glioblastoma is common, occurring in about one-third of patients, and the majority have multifocal disease. The FLAIR sequence is the crucial sequence for demonstrating a communication between lesions. The worse survival of these patients is, at least in large part related to more extensive tumour dissemination and more frequent involvement of key structures, rather than multiplicity per se.Copyright © 2016 Elsevier Ltd

Introduction The presence of non-enhancing cortical signal abnormality is useful for differentiating between glioblastoma and metastatic disease, but its significance has not been studied. We aimed to determine the incidence and prognostic implications of non-enhancing cortical signal abnormality in glioblastomas. Methods Patients with a new diagnosis of glioblastoma between September 2007 and December 2010 were identified. Only patients with at least fluid-attenuated inversion recovery (FLAIR) and post-contrast T1-weighted sequences were included. Pre-operative MRIs were reviewed together by two readers to determine whether there was evidence of non-enhancing cortical signal abnormality, based primarily on the FLAIR sequence. The results were compared with patient survival using both univariate and multivariate analysis. Results One hundred fifty-one patients met the inclusion criteria. Seventy-seven patients (51%) had evidence of non-enhancing cortical signal abnormality. On both univariate and multivariate analysis, there was overall no significant difference in survival between patients with non-enhancing cortical signal abnormality and those without. Peripheral enhancing lesions (51 patients) were generally associated with the longest survival, but subgroup analysis suggested that non-enhancing signal abnormality was associated with worse survival in these patients (P = 0.004), conveying an intermediate prognosis. Conclusions Non-enhancing cortical signal abnormality is a common feature of glioblastomas, occurring in about half of cases. It does not affect survival overall, but appears to be associated with worse survival in the setting of a peripherally located enhancing lesion. This has the potential to alter surgical management.Copyright © 2015 The Royal Australian and New Zealand College of Radiologists.

PURPOSE: Double inversion recovery (DIR) brain imaging at 3T has greater diagnostic value in detection of multiple sclerosis (MS) lesions compared to T2-weighted turbo spin-echo (T2-TSE) imaging. Our aim was to compare cervical cord MS lesion detection using 3T sagittal DIR imaging to the sagittal T2-TSE, proton density (PD) and short-tau inversion recovery (STIR) magnetic resonance (MR) sequences recommended by the Consortium of MS Centers. MATERIALS AND METHODS: We prospectively enrolled patients with MS and imaged the cervical cord with 3T sagittal DIR, sagittal and axial T2-TSE, sagittal PD, sagittal STIR and axial multi-echo recombined gradient echo (MERGE) MRI sequences. Two neuroradiologists blinded to clinical and demographic data reviewed the MR images. A definite MS lesion was defined by either detection on 2 sagittal sequences, or if seen on 1 sagittal sequence alone, then by detection of the same lesion by axial T2-TSE or axial MERGE MR imaging. The cervical cord was divided into 13 segments - C1, C1/2, C2, C2/3, C3, C3/4, C4, C4/5, C5, C5/6, C6, C6/7, and C7. For each MR sequence, we analysed the total number of involved cord segments and compared the normalised lesion-to-cord contrast ratio (LCCR) and the contrast-to-noise ratio (CNR). The Wilcoxon signed-rank test was used for statistical correlation. RESULT(S): Nineteen patients (13 females) with mean age of 47 years (range 23-74 years) were included. Eighty percent had definite cervical cord MS lesions. DIR cervical cord imaging detected definite MS lesions in 48 cervical cord segments. PD detected the greatest number of involved cord segments (n=75), significantly greater than DIR (p=0.0005) and T2-TSE (p=0.01), but similar to STIR (p=0.17). STIR and T2-TSE also detected a significantly greater number of involved cord segments than DIR (STIR, n=67;p=0.01 and T2, n=61;p=0.01). The LCCR was highest for STIR; significantly greater than DIR (p=0.0009). The CNR was highest for PD; significantly greater

PURPOSE: To determine the incidence and prognostic implications of non-enhancing cortical FLAIR (fluid attenuated inversion recovery) hyperintensity in histologically-proven glioblastomas. MATERIALS AND METHODS: Institutional Human Research Ethics Committee approval was obtained. Patients with a new diagnosis of glioblastoma between September 2007 and December 2010 were identified. Only patients with at least FLAIR and post-contrast T1-weighted sequences were included. Pre-operative Magnetic Resonance Imaging studies were reviewed together by two readers to determine whether there was evidence of non-enhancing cortical signal abnormality, based primarily on the FLAIR sequence. It was graded as either 'negative', 'minor' (a thin rim around enhancing tumour) or 'more extensive'. Patient survival was then compared between groups, correcting for age, sex, performance status, axial measurements of the largest enhancing lesion and location (deep, periventricular or peripheral). RESULT(S): 151 patients met the inclusion criteria. 77 patients (51%) had evidence of non-enhancing cortical signal abnormality - minor in 37 of these patients (median survival 220 days) and more extensive in 40 (median survival 310 days). The 74 patients without non-enhancing cortical signal abnormality had a median survival of 261 days. On multivariate analysis, there was no significant difference in survival between the three groups (p=0.109 comparing 'negative' and 'minor'; p=0.399 comparing 'negative' and 'more extensive'). The only significant differences in survival were when assessing only patients with peripherally-located enhancing lesions, when the presence of non-enhancing cortical signal abnormality was associated with worse survival (hazard ratio=3.4, p=0.003 for 'minor'; HR=2.3, p=0.038 for 'more extensive'). CONCLUSION(S): Non-enhancing cortical signal abnormality is common in glioblastoma, occurring in about half of cases. In general, its presence does not alter survival, and facto

PURPOSE: To determine the incidence and significance of multiple enhancing lesions in histologically-proven glioblastomas. MATERIALS AND METHODS: Institutional Human Research Ethics Committee approval was obtained. Patients with a new diagnosis of glioblastoma between September 2007 and December 2010 were identified. Pre-operative Magnetic Resonance Imaging (MRI) studies were reviewed to determine whether or not there was more than one enhancing lesion and, if present, whether there was evidence on imaging of a communication between lesions (multifocal) or not (multicentric). The presence of a communication was predominantly determined using the fluid attenuated inversion recovery (FLAIR) sequence. Patient survival was then compared between groups, correcting for age, sex, performance status, axial measurements of the largest enhancing lesion and location (deep, periventricular or peripheral). RESULT(S): 55 of 167 patients (33%) had more than one discrete enhancing lesion. In the majority (49 of 55, or 89%), there was evidence of a communication between all lesions, ie. a multifocal glioblastoma. The communication was parenchymal (along white and/or grey matter, including the corpus callosum) in 45 of these, subependymal in three cases and leptomeningeal in one case. There was no convincing imaging communication in six patients, consistent with a multicentric glioblastoma. Patients demonstrating multiple enhancing lesions had a median survival of 183 days, compared to 304 days for patients without multiple lesions. There was no difference in survival on multivariate analysis, however (p=0.747). A deep location was predictive of worse survival (p<0.001 compared to a peripheral location; p=0.008 compared to a periventricular location), and was more common in patients with multiple lesions (35 of 55, or 64%) compared to those without (38 of 112, or 34%). CONCLUSION(S): The presence of multiple enhancing lesions in glioblastoma is relatively common, occurring in about o

Purpose: The new Philips Allura Clarity upgrade allows Xray reduction during image acquisition by automatic motion compensation, temporal and spatial noise reduction and image enhancement. Our aim was to quantify the radiation dose reduction achieved after installation of the Philips Allura Clarity platform compared to the Philips Allura Xper platform. Method(s): Polymethylmethacrylate (PMMA) phantoms of 4 different thickness (15, 18, 20 and 23 cm) were used to simulate patient head attenuation. A direct dosimeter was used to measure Air Kerma rates (AKR) during fluoroscopy and cerebral digital subtraction angiography (DSA) on the Philips Allura Xper platform, and then again after the Philips Allura Clarity upgrade. The measurements conformed to the International Electrotechnical Commission (IEC) standards i.e. no table top, X-ray beam focus to PMMA entrance distance of 62.5 cm, source to image distance of 105 cm and dosimeter placement at the PMMA entrance. Result(s): The pre and post Philips Allura Clarity upgrade fluoroscopy AKRs for 15, 18, 20 and 23 cm phantoms were 0.09 to 0.08, 0.15 to 0.12, 0.20 to 0.19, 0.32 to 0.23 mGy/s respectively. Mean dose reduction was 17% (range 9-30%). In DSA the pre and post upgrade AKRs for 15, 18, 20 and 23 cm phantoms were 3.08 to 0.23, 6.04 to 0.58, 9.57 to 0.89, 14.68 to 1.74 mGy/frame respectively. Mean dose reduction was 90% (range 88-92%). Conclusion(s): This study confirms significant radiation dose reduction, particularly during DSA, after installation of the Philips AlluraClarity imaging platform.

PURPOSE: To determine the incidence of additional lesions consistent with low grade glioma in patients with a new diagnosis of glioblastoma, with subsequent imaging follow-up. MATERIALS AND METHODS: Institutional Human Research Ethics Committee approval was obtained. Patients with a new diagnosis of glioblastoma between September 2007 and December 2010 were identified. Only patients with at least FLAIR (fluid attenuated inversion recovery) and post-contrast sequences were included. Pre-operative Magnetic Resonance Imaging (MRI) studies were reviewed together by two readers to determine whether there were lesions with imaging appearances consisting with a low grade glioma separate from the dominant tumour (ie. multicentric lesions on imaging). This was based primarily on the FLAIR sequence, with the diagnosis being made on the presence of cortical signal hyperintensity and mass effect, without post-contrast enhancement. RESULT(S): 9 of 151 patients (6%) had lesions consistent on imaging with a low grade glioma separate from the dominant tumour. Their median survival was 183 days, compared to 264 days for patients without this feature. This worse survival was statistically significant on multivariate analysis (p=0.024). There was a high incidence of multiple enhancing lesions separate from the focus of low grade tumour, occurring in 5 of these 9 patients. Excluding studies performed immediately post-operatively, follow-up MRIs were performed in three patients. In all three, these additional areas of tumour developed enhancement and evidence of necrosis within one year, and became confluent on FLAIR with the dominant lesion. In a fourth patient, a further separate lesion had developed evidence of necrosis in the 22-day interval between the full diagnostic study and the limited postcontrast study performed for stereotaxis. CONCLUSION(S): The presence of a low grade glioma separate from the dominant lesion is an uncommon finding in glioblastoma, but likely to be useful i

Background: It has been described that lacunar infarct is characterized by its smallish size (15-20 mm) in the axial plane. However, the size of the basal ganglia artery responsible for this type of infarct is uncertain. Detection of small arterial occlusion is not possible with current angiography, hindering correlation of arterial occlusion with subcortical infarct size. Recently, investigators have published microangiographic templates of arteries supplying the basal ganglia. These templates display first-order (proximal) to third-order (distal) branching of these arteries and can help with estimating the likely site of arterial disease in subcortical infarcts. We correlated the dimensions of subcortical infarcts with the order of arterial branching described in a microangiographic template. Such data may provide further clues about the type of arteries associated with subcortical infarcts and assist in refining the concept of lacunar infarction. Method(s): Patients with subcortical infarcts on MR imaging (MRI) admitted to our institution between 2009 and 2011 were included in the study. Infarcts were manually segmented and registered to a standard brain template. These segmented infarcts were scaled and overlapped with published microangiographic templates, and used by 6 raters who independently estimated the branching order of arterial disease that might result in these infarcts. We used regression analysis to relate these ratings to infarct dimensions. Result(s): Among 777 patients, there were 33 (58% male) patients with subcortical infarcts. The mean age was 63.1 +/- 15.1 years. Infarct dimensions for the groups were as follows: group 1 (first-order branch): height 37.6 +/- 7.4 mm, horizontal width 21.2 +/- 11.6 mm, anterior-posterior length 36.8 +/- 20.1 mm; group 2 (second-order branch): height 25.2 +/- 7.9 mm, horizontal width 16.6 +/- 22.8 mm, anterior-posterior length 16.1 +/- 8.0 mm; group 3 (third-order branch): height 11.6 +/- 5.7 mm, axial width 5.3

PURPOSE: Double inversion recovery (DIR) brain imaging at 3T has greater diagnostic value in detection of multiple sclerosis (MS) lesions compared to T2-weighted turbo spin-echo (T2-TSE) imaging. Our aim was to compare cervical cord MS lesion detection using 3T sagittal DIR imaging to the sagittal T2-TSE, proton density (PD) and short-tau inversion recovery (STIR) magnetic resonance (MR) sequences recommended by the Consortium of MS Centers. MATERIALS AND METHODS: We prospectively enrolled patients with MS and imaged the cervical cord with 3T sagittal DIR, sagittal and axial T2-TSE, sagittal PD, sagittal STIR and axial multi-echo recombined gradient echo (MERGE) MRI sequences. Two neuroradiologists blinded to clinical and demographic data reviewed the MR images. A definite MS lesion was defined by either detection on 2 sagittal sequences, or if seen on 1 sagittal sequence alone, then by detection of the same lesion by axial T2-TSE or axial MERGE MR imaging. The cervical cord was divided into 13 segments - C1, C1/2, C2, C2/3, C3, C3/4, C4, C4/5, C5, C5/6, C6, C6/7, and C7. For each MR sequence, we analysed the total number of involved cord segments and compared the normalised lesion-to-cord contrast ratio (LCCR) and the contrast-to-noise ratio (CNR). The Wilcoxon signed-rank test was used for statistical correlation. RESULT(S): Nineteen patients (13 females) with mean age of 47 years (range 23-74 years) were included. Eighty percent had definite cervical cord MS lesions. DIR cervical cord imaging detected definite MS lesions in 48 cervical cord segments. PD detected the greatest number of involved cord segments (n=75), significantly greater than DIR (p=0.0005) and T2-TSE (p=0.01), but similar to STIR (p=0.17). STIR and T2-TSE also detected a significantly greater number of involved cord segments than DIR (STIR, n=67;p=0.01 and T2, n=61;p=0.01). The LCCR was highest for STIR; significantly greater than DIR (p=0.0009). The CNR was highest for PD; significantly greater

PURPOSE: To determine the incidence and prognostic implications of non-enhancing cortical FLAIR (fluid attenuated inversion recovery) hyperintensity in histologically-proven glioblastomas. MATERIALS AND METHODS: Institutional Human Research Ethics Committee approval was obtained. Patients with a new diagnosis of glioblastoma between September 2007 and December 2010 were identified. Only patients with at least FLAIR and post-contrast T1-weighted sequences were included. Pre-operative Magnetic Resonance Imaging studies were reviewed together by two readers to determine whether there was evidence of non-enhancing cortical signal abnormality, based primarily on the FLAIR sequence. It was graded as either 'negative', 'minor' (a thin rim around enhancing tumour) or 'more extensive'. Patient survival was then compared between groups, correcting for age, sex, performance status, axial measurements of the largest enhancing lesion and location (deep, periventricular or peripheral). RESULT(S): 151 patients met the inclusion criteria. 77 patients (51%) had evidence of non-enhancing cortical signal abnormality - minor in 37 of these patients (median survival 220 days) and more extensive in 40 (median survival 310 days). The 74 patients without non-enhancing cortical signal abnormality had a median survival of 261 days. On multivariate analysis, there was no significant difference in survival between the three groups (p=0.109 comparing 'negative' and 'minor'; p=0.399 comparing 'negative' and 'more extensive'). The only significant differences in survival were when assessing only patients with peripherally-located enhancing lesions, when the presence of non-enhancing cortical signal abnormality was associated with worse survival (hazard ratio=3.4, p=0.003 for 'minor'; HR=2.3, p=0.038 for 'more extensive'). CONCLUSION(S): Non-enhancing cortical signal abnormality is common in glioblastoma, occurring in about half of cases. In general, its presence does not alter survival, and facto

PURPOSE: To determine the incidence and significance of multiple enhancing lesions in histologically-proven glioblastomas. MATERIALS AND METHODS: Institutional Human Research Ethics Committee approval was obtained. Patients with a new diagnosis of glioblastoma between September 2007 and December 2010 were identified. Pre-operative Magnetic Resonance Imaging (MRI) studies were reviewed to determine whether or not there was more than one enhancing lesion and, if present, whether there was evidence on imaging of a communication between lesions (multifocal) or not (multicentric). The presence of a communication was predominantly determined using the fluid attenuated inversion recovery (FLAIR) sequence. Patient survival was then compared between groups, correcting for age, sex, performance status, axial measurements of the largest enhancing lesion and location (deep, periventricular or peripheral). RESULT(S): 55 of 167 patients (33%) had more than one discrete enhancing lesion. In the majority (49 of 55, or 89%), there was evidence of a communication between all lesions, ie. a multifocal glioblastoma. The communication was parenchymal (along white and/or grey matter, including the corpus callosum) in 45 of these, subependymal in three cases and leptomeningeal in one case. There was no convincing imaging communication in six patients, consistent with a multicentric glioblastoma. Patients demonstrating multiple enhancing lesions had a median survival of 183 days, compared to 304 days for patients without multiple lesions. There was no difference in survival on multivariate analysis, however (p=0.747). A deep location was predictive of worse survival (p<0.001 compared to a peripheral location; p=0.008 compared to a periventricular location), and was more common in patients with multiple lesions (35 of 55, or 64%) compared to those without (38 of 112, or 34%). CONCLUSION(S): The presence of multiple enhancing lesions in glioblastoma is relatively common, occurring in about o

PURPOSE: To determine the incidence of additional lesions consistent with low grade glioma in patients with a new diagnosis of glioblastoma, with subsequent imaging follow-up. MATERIALS AND METHODS: Institutional Human Research Ethics Committee approval was obtained. Patients with a new diagnosis of glioblastoma between September 2007 and December 2010 were identified. Only patients with at least FLAIR (fluid attenuated inversion recovery) and post-contrast sequences were included. Pre-operative Magnetic Resonance Imaging (MRI) studies were reviewed together by two readers to determine whether there were lesions with imaging appearances consisting with a low grade glioma separate from the dominant tumour (ie. multicentric lesions on imaging). This was based primarily on the FLAIR sequence, with the diagnosis being made on the presence of cortical signal hyperintensity and mass effect, without post-contrast enhancement. RESULT(S): 9 of 151 patients (6%) had lesions consistent on imaging with a low grade glioma separate from the dominant tumour. Their median survival was 183 days, compared to 264 days for patients without this feature. This worse survival was statistically significant on multivariate analysis (p=0.024). There was a high incidence of multiple enhancing lesions separate from the focus of low grade tumour, occurring in 5 of these 9 patients. Excluding studies performed immediately post-operatively, follow-up MRIs were performed in three patients. In all three, these additional areas of tumour developed enhancement and evidence of necrosis within one year, and became confluent on FLAIR with the dominant lesion. In a fourth patient, a further separate lesion had developed evidence of necrosis in the 22-day interval between the full diagnostic study and the limited postcontrast study performed for stereotaxis. CONCLUSION(S): The presence of a low grade glioma separate from the dominant lesion is an uncommon finding in glioblastoma, but likely to be useful i

Purpose: The new Philips Allura Clarity upgrade allows Xray reduction during image acquisition by automatic motion compensation, temporal and spatial noise reduction and image enhancement. Our aim was to quantify the radiation dose reduction achieved after installation of the Philips Allura Clarity platform compared to the Philips Allura Xper platform. Method(s): Polymethylmethacrylate (PMMA) phantoms of 4 different thickness (15, 18, 20 and 23 cm) were used to simulate patient head attenuation. A direct dosimeter was used to measure Air Kerma rates (AKR) during fluoroscopy and cerebral digital subtraction angiography (DSA) on the Philips Allura Xper platform, and then again after the Philips Allura Clarity upgrade. The measurements conformed to the International Electrotechnical Commission (IEC) standards i.e. no table top, X-ray beam focus to PMMA entrance distance of 62.5 cm, source to image distance of 105 cm and dosimeter placement at the PMMA entrance. Result(s): The pre and post Philips Allura Clarity upgrade fluoroscopy AKRs for 15, 18, 20 and 23 cm phantoms were 0.09 to 0.08, 0.15 to 0.12, 0.20 to 0.19, 0.32 to 0.23 mGy/s respectively. Mean dose reduction was 17% (range 9-30%). In DSA the pre and post upgrade AKRs for 15, 18, 20 and 23 cm phantoms were 3.08 to 0.23, 6.04 to 0.58, 9.57 to 0.89, 14.68 to 1.74 mGy/frame respectively. Mean dose reduction was 90% (range 88-92%). Conclusion(s): This study confirms significant radiation dose reduction, particularly during DSA, after installation of the Philips AlluraClarity imaging platform.

Background: It has been described that lacunar infarct is characterized by its smallish size (15-20 mm) in the axial plane. However, the size of the basal ganglia artery responsible for this type of infarct is uncertain. Detection of small arterial occlusion is not possible with current angiography, hindering correlation of arterial occlusion with subcortical infarct size. Recently, investigators have published microangiographic templates of arteries supplying the basal ganglia. These templates display first-order (proximal) to third-order (distal) branching of these arteries and can help with estimating the likely site of arterial disease in subcortical infarcts. We correlated the dimensions of subcortical infarcts with the order of arterial branching described in a microangiographic template. Such data may provide further clues about the type of arteries associated with subcortical infarcts and assist in refining the concept of lacunar infarction. Method(s): Patients with subcortical infarcts on MR imaging (MRI) admitted to our institution between 2009 and 2011 were included in the study. Infarcts were manually segmented and registered to a standard brain template. These segmented infarcts were scaled and overlapped with published microangiographic templates, and used by 6 raters who independently estimated the branching order of arterial disease that might result in these infarcts. We used regression analysis to relate these ratings to infarct dimensions. Result(s): Among 777 patients, there were 33 (58% male) patients with subcortical infarcts. The mean age was 63.1 +/- 15.1 years. Infarct dimensions for the groups were as follows: group 1 (first-order branch): height 37.6 +/- 7.4 mm, horizontal width 21.2 +/- 11.6 mm, anterior-posterior length 36.8 +/- 20.1 mm; group 2 (second-order branch): height 25.2 +/- 7.9 mm, horizontal width 16.6 +/- 22.8 mm, anterior-posterior length 16.1 +/- 8.0 mm; group 3 (third-order branch): height 11.6 +/- 5.7 mm, axial width 5.3

Purpose: Current MRI guidelines from the Consortium of Multiple Sclerosis Centers recommend the use of both T2 and proton density (PD) weighted sequences in the assessment of multiple sclerosis (MS) spinal cord lesions. However, there is a paucity of literature comparing the utility of these two sequences for spinal cord lesion detection. We sought to compare cervical cord MS lesion detection and conspicuity on sagittal 1.5T PD and T2 weighted MRI. Methods and Materials: Nineteen patients with MS or clinically isolated syndromes were included in this retrospective analysis. All patients were examined with sagittal PD and T2 cervical cord imaging on a 1.5T Siemens Magnetom Avanto MRI scanner with a 4-channel neck matrix coil. Two neuroradiologists identified MS lesions, with consensus agreement for single viewer lesions. Regions of interest were obtained within lesions using the software program, Osirix v3.0.2. Quantitative analysis comparing the normalised lesion-to-cord contrast ratio (LCCR) and the signal-to-noise ratio (SNR) for each sequence was performed using the Wilcoxon rank-sum test, where P < 0.05 was considered statistically significant. Result(s): Fifteen patients were found to have cervical cord lesions - 20 lesions were identified on T2 and 34 lesions on PD weighted imaging. Twenty-two lesions seen on PD imaging were not seen on T2 imaging, and eight lesions seen on T2 imaging were not seen on PD imaging. PD and T2 weighted imaging were comparable for both the LCCR (PD 0.25 +/- 0.02 vs. T2 0.30 +/- 0.03, P = 0.24) and SNR (PD 50.87 +/- 3.80 vs. T2 50.82 +/- 4.50, P = 0.85). Conclusion(s): Although MS lesion conspicuity is similar with both T2 and PD weighted cervical cord MRI, several MS lesions detected on PD weighted imaging were not seen on T2 imaging. For cervical cord MS lesion detection, PD weighted imaging may be superior than T2 weighted imaging.

Background The ischemic penumbra defines the cerebral tissue which can be salvaged with prompt reperfusion. This is defined by thresholded volumes of perfusion defect based on magnetic resonance image (MRI) or computer tomography (CT) perfusion. This volume based approach excludes consideration of regional difference such as variation in vascular supply relating to the degree of leptomeningeal anastomoses. Hence a voxel based method may help to clarify tissue fate in different brain regions. We hypothesis that the likelihood of tissue infarction differs depend on the brain region. Method Ischemic stroke patients presented within 4.5 hours of onset, received tissue plasminogen activator (tpa) with middle cerebral artery (MCA) occlusion on CT angiography and had CT perfusion (64 multirow scan) were recruited. Ischemic penumbra was defined as region of perfusion defect (Tmax > 2 seconds) not overlapped by the infarct core (cerebral blood volume > 2.5 seconds). Final infarct was assessed by MRI beyond 3 months from onset. Positive likelihood ratio for infarction (PLR) was generated at a voxel level, taking into account the relationship between the finding of penumbra and infarct at a given voxel. We defined voxels with PLR between 5-10 as providing useful clinical information with regards to risk of infarction; and voxels PLR > 10 as highly likely to progress to infarction. Result 19 patients were studied with median age of 66 years (10 males). The regions within the penumbra supplied by the deep MCA compartment (striatocapsular and internal watershed regions) had PLR values > 10 while the more superficial compartment has PLR range of 1.3-5.0. The posterior temporoparietal region had PLR < 2. Conclusion The deep compartment of the MCA territory has very high PLR and is most likely to progress to infarction despite receiving tpa. A likelihood ratio approach may help to refine the zone least likely to infarct, the penumbra and the infarct core on CT perfusion imaging.

PURPOSE Double inversion recovery (DIR) has been shown to be more sensitive than T2 turbo spin echo (TSE) and FLAIR for detection of multiple sclerosis (MS) lesions in the brain. However DIR sensitivity in the cervical cord remains unexplored. The cervical cord to C6 is routinely included as part of brain DIR imaging. We hypothesised that detection of cervical cord lesions on brain DIR may mitigate the need for dedicated cervical cord T2/PD imaging. The aim of the study was to compare cervical cord MS lesion detection and conspicuity on sagittal 1.5 T DIR brain to PD TSE and T2 TSE cervical cord imaging. METHODS 40 patients being treated or investigated for MS over a six-month period with brain and cervical cord MRI were included in this retrospective analysis. Sagittal DIR, PD TSE and T2 TSE images were acquired on a 1.5 T Siemens Magnetom Avanto MRI scanner. A head and neck matrix coil combination was utilised for brain DIR, which included the cervical cord to C6. A 4-channel neck matrix coil was employed for PD TSE and T2 TSE sequences. Two neuroradiologists identified MS lesions, with consensus agreement for single viewer lesions. Regions of interest were obtained within lesions using Osirix v3.0.2. Quantitative analysis comparing the normalised lesion-to-cord contrast ratio (LCCR) and the signal-to-noise ratio (SNR) for each sequence was performed using sample T-tests, where P>0.05 was considered statistically significant. RESULTS 81 cervical cord lesions were detected in 19 patients - 25 on DIR, 25 on T2 TSE and 31 on PD TSE. Five patients with positive T2 TSE scans had negative DIR imaging. Compared to PD and T2, DIR had greater LCCR (DIR 1.51+/-0.09 vs. PD TSE 0.26+/-0.02, P<0.0001; DIR vs. T2 TSE 0.30+/-0.03, P<0.0001), and higher SNR (DIR 126.90+/-5.94 vs. PD TSE 52.63+/-4.00, P<0.0001; DIR vs. T2 TSE 53.02+/-4.99, P<0.0001). CONCLUSIONS DIR detected lesions demonstrate superior contrast resolution and SNR compared to T2 TSE and PD TSE imaging. However mul

Background: CT Coronary Angiography provides accurate noninvasive evaluation of coronary arteries but also images lung parenchyma and other mediastinal structures. Little is known about the range and incidence of non-cardiac findings in the Australian population and while CT screening has been shown to reduce mortality in high risk individuals the significance of identified pulmonary nodules in this mixed risk population is unknown. A lack of data regarding the malignant potential of these incidentally identified nodules makes evaluation of the relative risk/benefit of both initial imaging of the lung and subsequent surveillance scanning is difficult. Method(s): A retrospective analysis was performed on reports of all cardiac CT scans done in the calendar year 2012. Descriptive data was collected including baseline patient characteristics, type of nodule and smoking history, as well as whether a full field or restricted field view was performed. Surveillance radiological data and pathology was collected on a sub-group of the population. Result(s): 2500 Cardiac CT scans analysed with 48% females. Reports analysed for presence of lung nodules and type of nodule with most common nodule granuloma. Total lung nodules 14% (355) with follow up recommended by specialist radiologists; significant variation from recommendation in practice was noted. 39% of population positive for smoking exposure placing them in high risk population. No episodes of malignancy within follow up CT scans with the majority of nodules being stable over the follow up period. Majority of nodules were <4mm making up 60% of the total nodules described, 4-8mm 20% nodules of described nodules, >8mm making up 12% of nodules. Pulmonary Cysts represented 4% of nodules. Subpleural nodules described separately and making up a minority of nodules. Conclusion(s): Cardiac CTs are an increasingly common modality used to evaluate coronary artery disease. Pulmonary nodules are a common finding with a prevalence in

Background Therapeutic neurointerventional (NI) procedures have become a significant source of radiation exposure during the treatment of cerebrovascular disease. While there are well-established radiation dose reference levels (DRLs) for diagnostic imaging, no similar NI DRLs are available. We analyzed the patient radiation dose for therapeutic NI procedures at a tertiary teaching hospital, with an aim to develop local DRLs that could form the foundation for developing national NI radiation safety guidelines. Method Retrospective analysis of radiation dose area product (DAP) in Gy. Cm2 for consecutive patients undergoing therapeutic NI procedures between July 2011 and April 2014 was performed. NI procedures were categorized into arteriovenous malformation (AVM) embolization, cerebral aneurysm embolization (primarily coiling vs balloon/stent assisted) and cerebral vasospasm procedures. Median and inter-quartile radiation dose levels were calculated for each NI category. The 75th percentile was deemed to be the local DRL. Wilcoxon signed-rank test was performed for statistical correlation. Results A total of 303 NI procedures were included. Patients undergoing AVM embolization received a significantly higher radiation dose (n = 44; median 338 Gy. Cm2 [IQR 225-528 Gy. Cm2]) than patients undergoing cerebral aneurysm embolization (n = 188; median 211 Gy. Cm2 [IQR 130-328 Gy. Cm2]; p = 0.003). Patients treated with primary coiling received a significantly lower radiation dose (n = 96; median 170 Gy. Cm2 [IQR 125-282 Gy. Cm2]) than patients undergoing stent/balloon assisted aneurysm embolization (n = 92; median 241 Gy. Cm2 [IQR 145-369 Gy. Cm2]); p = 0.0002). Patients undergoing cerebral vasospasm procedures (n = 71) received median 161 Gy. Cm2 [IQR 106-219 Gy. Cm2] of radiation. Conclusion Therapeutic NI procedures are a significant source of radiation exposure, particularly for AVM embolization. Proposed NI radiation DRLs based on the 75th percentile for DAP were 528 G

A 40-year-old male patient had his right femoral vein catheterised following admission with altered conscious state from polypharmacy overdose. The procedure was documented as successful and uncomplicated. A postprocedural chest radiograph demonstrated a linear metallic opacity projecting over the superior vena cava and inferior vena cava (SVC and IVC, respectively), with superior and inferior ends not visualised. This did not alert the attending radiologist and intensivist who might have assumed such a metallic object to be external to the patient. Only the central line was removed prior to patient discharge 2 days later. The patient died 2 years later from unrelated streptococcal pneumonia complicated by septicaemia and multiorgan failure. The postmortem discovered a central venous guidewire in the IVC across the right atrium into SVC. Copyright 2014 BMJ Publishing Group. All rights reserved.

A 40-year-old male patient had his right femoral vein catheterised following admission with altered conscious state from polypharmacy overdose. The procedure was documented as successful and uncomplicated. A postprocedural chest radiograph demonstrated a linear metallic opacity projecting over the superior vena cava and inferior vena cava (SVC and IVC, respectively), with superior and inferior ends not visualised. This did not alert the attending radiologist and intensivist who might have assumed such a metallic object to be external to the patient. Only the central line was removed prior to patient discharge 2 days later. The patient died 2 years later from unrelated streptococcal pneumonia complicated by septicaemia and multiorgan failure. The postmortem discovered a central venous guidewire in the IVC across the right atrium into SVC. Copyright 2014 BMJ Publishing Group. All rights reserved.

Background The ischemic penumbra defines the cerebral tissue which can be salvaged with prompt reperfusion. This is defined by thresholded volumes of perfusion defect based on magnetic resonance image (MRI) or computer tomography (CT) perfusion. This volume based approach excludes consideration of regional difference such as variation in vascular supply relating to the degree of leptomeningeal anastomoses. Hence a voxel based method may help to clarify tissue fate in different brain regions. We hypothesis that the likelihood of tissue infarction differs depend on the brain region. Method Ischemic stroke patients presented within 4.5 hours of onset, received tissue plasminogen activator (tpa) with middle cerebral artery (MCA) occlusion on CT angiography and had CT perfusion (64 multirow scan) were recruited. Ischemic penumbra was defined as region of perfusion defect (Tmax > 2 seconds) not overlapped by the infarct core (cerebral blood volume > 2.5 seconds). Final infarct was assessed by MRI beyond 3 months from onset. Positive likelihood ratio for infarction (PLR) was generated at a voxel level, taking into account the relationship between the finding of penumbra and infarct at a given voxel. We defined voxels with PLR between 5-10 as providing useful clinical information with regards to risk of infarction; and voxels PLR > 10 as highly likely to progress to infarction. Result 19 patients were studied with median age of 66 years (10 males). The regions within the penumbra supplied by the deep MCA compartment (striatocapsular and internal watershed regions) had PLR values > 10 while the more superficial compartment has PLR range of 1.3-5.0. The posterior temporoparietal region had PLR < 2. Conclusion The deep compartment of the MCA territory has very high PLR and is most likely to progress to infarction despite receiving tpa. A likelihood ratio approach may help to refine the zone least likely to infarct, the penumbra and the infarct core on CT perfusion imaging.

Purpose: Current MRI guidelines from the Consortium of Multiple Sclerosis Centers recommend the use of both T2 and proton density (PD) weighted sequences in the assessment of multiple sclerosis (MS) spinal cord lesions. However, there is a paucity of literature comparing the utility of these two sequences for spinal cord lesion detection. We sought to compare cervical cord MS lesion detection and conspicuity on sagittal 1.5T PD and T2 weighted MRI. Methods and Materials: Nineteen patients with MS or clinically isolated syndromes were included in this retrospective analysis. All patients were examined with sagittal PD and T2 cervical cord imaging on a 1.5T Siemens Magnetom Avanto MRI scanner with a 4-channel neck matrix coil. Two neuroradiologists identified MS lesions, with consensus agreement for single viewer lesions. Regions of interest were obtained within lesions using the software program, Osirix v3.0.2. Quantitative analysis comparing the normalised lesion-to-cord contrast ratio (LCCR) and the signal-to-noise ratio (SNR) for each sequence was performed using the Wilcoxon rank-sum test, where P < 0.05 was considered statistically significant. Result(s): Fifteen patients were found to have cervical cord lesions - 20 lesions were identified on T2 and 34 lesions on PD weighted imaging. Twenty-two lesions seen on PD imaging were not seen on T2 imaging, and eight lesions seen on T2 imaging were not seen on PD imaging. PD and T2 weighted imaging were comparable for both the LCCR (PD 0.25 +/- 0.02 vs. T2 0.30 +/- 0.03, P = 0.24) and SNR (PD 50.87 +/- 3.80 vs. T2 50.82 +/- 4.50, P = 0.85). Conclusion(s): Although MS lesion conspicuity is similar with both T2 and PD weighted cervical cord MRI, several MS lesions detected on PD weighted imaging were not seen on T2 imaging. For cervical cord MS lesion detection, PD weighted imaging may be superior than T2 weighted imaging.

PURPOSE Double inversion recovery (DIR) has been shown to be more sensitive than T2 turbo spin echo (TSE) and FLAIR for detection of multiple sclerosis (MS) lesions in the brain. However DIR sensitivity in the cervical cord remains unexplored. The cervical cord to C6 is routinely included as part of brain DIR imaging. We hypothesised that detection of cervical cord lesions on brain DIR may mitigate the need for dedicated cervical cord T2/PD imaging. The aim of the study was to compare cervical cord MS lesion detection and conspicuity on sagittal 1.5 T DIR brain to PD TSE and T2 TSE cervical cord imaging. METHODS 40 patients being treated or investigated for MS over a six-month period with brain and cervical cord MRI were included in this retrospective analysis. Sagittal DIR, PD TSE and T2 TSE images were acquired on a 1.5 T Siemens Magnetom Avanto MRI scanner. A head and neck matrix coil combination was utilised for brain DIR, which included the cervical cord to C6. A 4-channel neck matrix coil was employed for PD TSE and T2 TSE sequences. Two neuroradiologists identified MS lesions, with consensus agreement for single viewer lesions. Regions of interest were obtained within lesions using Osirix v3.0.2. Quantitative analysis comparing the normalised lesion-to-cord contrast ratio (LCCR) and the signal-to-noise ratio (SNR) for each sequence was performed using sample T-tests, where P>0.05 was considered statistically significant. RESULTS 81 cervical cord lesions were detected in 19 patients - 25 on DIR, 25 on T2 TSE and 31 on PD TSE. Five patients with positive T2 TSE scans had negative DIR imaging. Compared to PD and T2, DIR had greater LCCR (DIR 1.51+/-0.09 vs. PD TSE 0.26+/-0.02, P<0.0001; DIR vs. T2 TSE 0.30+/-0.03, P<0.0001), and higher SNR (DIR 126.90+/-5.94 vs. PD TSE 52.63+/-4.00, P<0.0001; DIR vs. T2 TSE 53.02+/-4.99, P<0.0001). CONCLUSIONS DIR detected lesions demonstrate superior contrast resolution and SNR compared to T2 TSE and PD TSE imaging. However mul