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Though fairly well-studied in adults, less is known about the manifestation of resting state networks in children. We examined the validity of resting state networks (RSN) derived in an ethnically diverse group of typically developing 6- to 7-year-old children. We hypothesized that the RSNs in young children would be robust and would reliably show significant concordance with previously published RSN in adults. Additionally, we hypothesized that a smaller sample size using this robust technique would be comparable in quality to pediatric RSNs found in a larger cohort study. Furthermore, we posited that compared to the adult RSNs, the primary sensorimotor and the default mode networks in this pediatric group would demonstrate the greatest correspondence, while the executive function networks would exhibit a lesser degree of spatial overlap. Resting state functional magnetic resonance images (rs-fMRI) were acquired in eighteen children between 6 and 7 years recruited from an ethnically diverse population in the Mid-South region of the United States. Twenty RSNs were derived using group independent component analysis and their spatial correspondence with previously published adult RSNs was examined. We demonstrate that the rs-fMRI in this group can be deconstructed into the fundamental resting state networks as all the major RSNs previously described in adults and in a large sample that included older children can be observed in our sample of young children. Further, the primary visual, auditory, and somatosensory networks, as well as the default mode, and frontoparietal networks derived in this group exhibited a greater spatial concordance with those seen in adults. The motor, temporoparietal, executive control, dorsal attention, and cerebellar networks in children had less spatial overlap with the corresponding RSNs in adults. Our findings suggest that several salient RSNs can be mapped reliably in small and diverse pediatric cohort within a narrow age range and the evolution of these RSNs can be studied reliably in such groups during early childhood and adolescence.

In 1976 an infant boy initially presented with a choroidal vein of Galen malformation (cVOGM). Craniotomy and clipping of the anterior cerebral artery and posterior choroidal arteries was performed, which was reported in the literature 40 years ago. The patient remained asymptomatic until age 42 when he re-presented with an isolated intraventricular hemorrhage. Angiography demonstrated cVOGM with venous sinus occlusive disease leading to venous hypertension and subsequent intraventricular hemorrhage. The angiogram also demonstrated a ‘pseudo-nidus’ composed of multiple arterial-to-arterial anastomoses that had developed as a result of the original surgical treatment. We embolized a portion of the lesion to reduce the venous hypertension. The patient has been asymptomatic for more than 2 years. To our knowledge, this is the first reported case of a symptomatic neonatal VOGM treated with open surgery that required embolization as an adult for a delayed hemorrhagic presentation.

Cerebellar tumors are the most common group of solid tumors in children. MR imaging provides an important role in characterization of these lesions, surgical planning, and postsurgical surveillance. Preoperative imaging can help predict the histologic subtype of tumors, which can provide guidance for surgical planning. Beyond histology, pediatric brain tumors are undergoing new classification schemes based on genetic features. Intraoperative MR imaging has emerged as an important tool in the surgical management of pediatric brain tumors. Effective understanding of the imaging features of pediatric cerebellar tumors can benefit communication with neurosurgeons and neuro-oncologists and can improve patient management.

Background Tics and Tourette syndrome are common problems evaluated by both the general pediatrician and pediatric neurologist. The common comorbidities of tics are well known, but the severe neurological complications are rare and may not be appreciated. Methods This is a retrospective case series and literature review. Results We present here four adolescents with Tourette syndrome who had severe neurological complications secondary to motor tics. We provide the history, neurological examination, and radiological findings in addition to a review of previously reported cases of vascular and cervical cord complications associated with violent motor tics. Conclusions We highlight the importance of recognizing the presenting signs of these complications early and the need to vigorously treat violent motor tics to prevent significant neurological complications.

Background and purposeHigh admission blood pressure (BP) levels have been associated with lower recanalization rates after endovascular treatment (EVT) for patients with acute ischemic stroke (AIS) with emergent large vessel occlusion (ELVO). We sought to evaluate the association of admission BP with early outcomes in patients with ELVO treated with EVT.MethodsConsecutive patients with AIS presenting with ELVO in a tertiary stroke center during a 4-year period were prospectively evaluated. Admission systolic blood pressure (SBP) and diastolic blood pressure (DBP) were measured using automated cuff recordings. A blinded neuroradiologist calculated the final infarct volume (FIV) using standardized ABC/2 methodology. A favorable functional outcome (FFO) at 3 months was defined as modified Rankin Scale score of 0–2.ResultsOur study population consisted of 116 patients with AIS (mean age 63±13 years, median NIH Stroke Scale score 17 points (IQR 14–21), median FIV 30 cm3 (IQR 8–94)). Higher admission SBP correlated with higher FIV (r +0.225; p=0.020). Patients with FFO had lower admission SBP (151±24 mm Hg vs 165±28 mm Hg; p=0.010), while admission SBP levels were higher in patients who died during hospitalization (169±34 mm Hg vs 156±24 mm Hg; p=0.043). A 10 mm Hg increment in admission SBP was independently (p=0.010) associated with an increase of 12 cm3 in FIV (95% CI 3 to 21) in multiple linear regression models adjusting for potential confounders. A 10 mm Hg increment in admission SBP was independently (p=0.012) associated with a lower likelihood of FFO at 3 months (OR 0.64; 95% CI 0.45 to 0.91) in multiple logistic regression models adjusting for potential confounders.ConclusionsHigher admission SBP is an independent predictor of increased FIV and lower likelihood of 3-month FFO in patients with ELVO treated with EVT.

This article provides a summary of how to approach the imaging analysis of lesions of the anterior, central, and posterior skull base. The primary focus is tumors and tumor-mimickers, and representative examples are shown to differentiate the features of lesions that can occur in the same location.

The development of new MRI techniques in the last two decades has provided neuroradiologists and neurosurgeons with additional noninvasive imaging tools for management and treatment of brain tumors. When coupled with standard structural MR sequences in imaging brain tumors, Blood Oxygenation Level Dependent (BOLD) functional MRI (fMRI), Perfusion Weighted Imaging (PWI) and Diffusion Tensor Imaging (DTI) provide additional physiologic information that is very useful for differential diagnosis, presurgical planning and prognosis. In this review after a brief technical description of BOLD fMRI, PWI and DTI, studies are described from the literature that have extensively validated these imaging techniques in comparison with invasive “gold standard” techniques such as intraoperative electrical cortical and subcortical stimulation mapping or biopsy. Additional studies are mentioned that demonstrate the positive impact of BOLD fMRI, PWI and DTI on brain tumor treatment and clinical outcome. In the final section an interesting clinical case treated at our institution is presented that highlights the clinical utility of this integrated physiologic brain tumor imaging approach.

Melanotic neuroectodermal tumor of infancy (MNTI) is a rare lesion that typically manifests in the first year of life, most commonly involving the facial bones. We present 2 infants with MNTI involving the posterior skull with associated compression of the superior sagittal sinus (SSS). A review of the anatomical locations of MNTI is offered, and the implications of SSS involvement are described. This represents the first known description of MNTI with involvement of the posterior SSS.

Objectives The purpose of our study was to conduct an evidence-based evaluation of stress cardiac magnetic resonance imaging (MRI) in the diagnosis of coronary artery disease (CAD). Background Stress cardiac MRI has recently emerged as a noninvasive method in the detection of CAD, with 2 main techniques in use: 1) perfusion imaging; and 2) stress-induced wall motion abnormalities imaging. Methods We examined studies from January 1990 to January 2007 using MEDLINE and EMBASE. A study was included if it: 1) used stress MRI as a diagnostic test for CAD (≥50% diameter stenosis); and 2) used catheter X-ray angiography as the reference standard. Results Thirty-seven studies (2,191 patients) met the inclusion criteria, with 14 datasets (754 patients) using stress-induced wall motion abnormalities imaging and 24 datasets (1,516 patients) using perfusion imaging. Stress-induced wall motion abnormalities imaging demonstrated a sensitivity of 0.83 (95% confidence interval [CI] 0.79 to 0.88) and specificity of 0.86 (95% CI 0.81 to 0.91) on a patient level (disease prevalence = 70.5%). Perfusion imaging demonstrated a sensitivity of 0.91 (95% CI 0.88 to 0.94) and specificity of 0.81 (95% CI 0.77 to 0.85) on a patient level (disease prevalence = 57.4%). Conclusions In studies with high disease prevalence, stress cardiac MRI, using either technique, demonstrates overall good sensitivity and specificity for the diagnosis of CAD. However, limited data are available regarding use of either technique in populations with low disease prevalence.

Recent advances in prenatal imaging have made possible the in utero diagnosis of cleft lip and palate and associated deformities. Postnatal diagnosis of cleft lip is made clinically, but imaging still plays a role in detection of associated abnormalities, surgical treatment planning, and screening for or surveillance of secondary deformities. This article describes the clinical entities of cleft lip with or without cleft palate (CLP) and isolated cleft palate and documents their prenatal and postnatal appearances at radiography, ultrasonography (US), magnetic resonance (MR) imaging, and computed tomography (CT). Imaging protocols and findings for prenatal screening, detection of associated anomalies, and evaluation of secondary deformities throughout life are described and illustrated. CLP and isolated cleft palate are distinct entities with shared radiologic appearances. Prenatal US and MR imaging can depict clefting of the lip or palate and associated anomalies. While two- and three-dimensional US often can depict cleft lip, visualization of cleft palate is more difficult, and repeat US or fetal MR imaging should be performed if cleft palate is suspected. Postnatal imaging can assist in identifying associated abnormalities and dentofacial deformities. Dentofacial sequelae of cleft lip and palate include missing and supernumerary teeth, oronasal fistulas, velopharyngeal insufficiency, hearing loss, maxillary growth restriction, and airway abnormalities. Secondary deformities can often be found incidentally at imaging performed for other purposes, but detection is necessary because they may have considerable implications for the patient.

The end-user of mobile device apps in the practice of clinical radiology should be aware of security measures that prevent unauthorized use of the device, including passcode policies, methods for dealing with failed login attempts, network manager-controllable passcode enforcement, and passcode enforcement for the protection of the mobile device itself. Protection of patient data must be in place that complies with the Health Insurance Portability and Accountability Act and U.S. Federal Information Processing Standards. Device security measures for data protection include methods for locally stored data encryption, hardware encryption, and the ability to locally and remotely clear data from the device. As these devices transfer information over both local wireless networks and public cell phone networks, wireless network security protocols, including wired equivalent privacy and Wi-Fi protected access, are important components in the chain of security. Specific virtual private network protocols, Secure Sockets Layer and related protocols (especially in the setting of hypertext transfer protocols), native apps, virtual desktops, and nonmedical commercial off-the-shelf apps require consideration in the transmission of medical data over both private and public networks. Enterprise security and management of both personal and enterprise mobile devices are discussed. Finally, specific standards for hardware and software platform security, including prevention of hardware tampering, protection from malicious software, and application authentication methods, are vital components in establishing a secure platform for the use of mobile devices in the medical field.

BACKGROUND AND PURPOSE: The growing number of subspecialties within neuroradiology compete for pages in neuroradiology journals. We performed a bibliometric analysis of the American Journal of Neuroradiology to identify the virtual Impact Factor of different journal subsections and article topics. MATERIALS AND METHODS: Original Research and Review Articles published in American Journal of Neuroradiology during 2010–2012 were evaluated. The journal section for each article was recorded, and the number of citations was evaluated by using the Web of Science database. Numbers of citations within the first 2 years after publication were evaluated, normalized to the 2013 journal Impact Factor (for American Journal of Neuroradiology , 3.675), and used to calculate a virtual Impact Factor for different journal subsections. RESULTS: One thousand forty-nine Original Research and Review Articles were published during this time, which obtained an average of 6.59 citations each within their first 2 years after publication; 91.8% of articles obtained at least 1 citation. Expedited Publications had the greatest number of citations, averaging 43.7 citations each (virtual Impact Factor, 24.39), followed by Review Articles averaging 9.39 citations each (virtual Impact Factor 5.23). Virtual Impact Factors for other sections were the following: Interventional, 4.54; Brain, 3.70; Pediatrics, 2.91; Functional, 2.74; Head & Neck, 2.24; and Spine, 1.86. Virtual Impact Factors for article topics were the following: interventional, 4.75; functional/advanced, 3.79; brain, 3.66; pediatrics, 2.99; head and neck, 2.46; and spine, 2.32. CONCLUSIONS: Citation patterns of Original Research and Review Articles in American Journal of Neuroradiology varied widely on the basis of subsections. Understanding the citation patterns of specific topics and subsections of a journal may aid authors and editors in evaluating the appropriate balance among various topics and allow authors to determine whether their articles are being cited at a level expected for similar ones in a journal.

Objective To describe and analyze the chronological evolution of the radiological findings in seven children with febrile infection-related epilepsy syndrome. Methods This is a retrospective study describing the radiological findings and evolution in seven children with febrile infection-related epilepsy syndrome who presented from 2009 to 2013. The children all fit the defined clinical criteria for febrile infection-related epilepsy syndrome; all had a history of normal psychomotor development who presented with acute-onset catastrophic partial status epilepticus associated with a febrile illness or unspecific infectious process. The children were identified from the author's weekly review of the pediatric inpatient service, and then the data were collected and analyzed retrospectively. Results Six males and one female ranging from 3 months to 9 years of age presented with status epilepticus preceded by a febrile illness. Extensive investigations for infectious, autoimmune, and metabolic etiologies were unremarkable. Multiple antiepileptic medications were attempted, including drug-induced coma in all of them, with poor response. Immunotherapy with intravenous steroids or intravenous immunoglobulin (three patients had both) was tried in six of seven patients with a poor response. Ketogenic diet was initiated in four of seven patients with limited response. Serial magnetic resonance imaging studies, done from the initial presentation through 18 months of follow-up, showed evolution from normal imaging to severe cerebral atrophy. Progressive cytotoxic edema involving mostly bilateral hippocampi and temporal lobes was appreciated in one to three weeks. At one month from seizure onset, mild to moderate cerebral atrophy and hippocampal sclerosis was appreciated that continued to progress over the next year. After six to twelve months, most of the patients showed moderate to severe cerebral atrophy and by one year, cerebellar atrophy was also appreciated. Conclusion Febrile infection-related epilepsy syndrome is a devastating epilepsy syndrome of childhood without a diagnostic biologic marker. The magnetic resonance imaging findings appear to be progressive and typical. Thus, combined with the clinical course, imaging findings can help to confirm the diagnosis (until a biologic marker is found). This hopefully will allow multicentered treatment protocols in the future.

Objective The aim of the present study was to compare localization of the language cortex using cortical stimulation mapping (CSM), high gamma electrocorticography (hgECoG), functional magnetic resonance imaging (fMRI), and transcranial magnetic stimulation (TMS). Methods Language mapping using CSM, hgECoG, fMRI, and TMS were compared in nine patients with epilepsy. Considering CSM as reference, we compared language mapping approaches based on hgECoG, fMRI, and TMS using their sensitivity, specificity, and the results of receiver operating characteristic (ROC) analyses. Results Our results show that areas involved in language processing can be identified by hgECoG, fMRI, and TMS. The average sensitivity/specificity of hgECoG, fMRI, and TMS across all patients was 100%/85%, 50%/80%, and 67%/66%, respectively. The average area under the ROC curve of hgECoG, fMRI, and TMS across CSM-positive patients was 0.98, 0.76, and 0.68, respectively. Conclusions There is considerable concordance between CSM, hgECoG, fMRI, and TMS language mapping. Our results reveal that hgECoG, fMRI, and TMS are valuable tools for presurgical language mapping. Significance Language mapping on the basis of hgECoG, fMRI, and TMS can provide important additional information, therefore, these methods can be used in conjunction with CSM or as an alternative, when the latter is deemed impractical.

Bibliometric parameters have become an important part of modern assessment of academic productivity. These parameters exist for the purpose of evaluating authors (publication count, citation count, h-index, m-quotient, hc-index, e-index, g-index, i-10 [i-n] index) and journals (impact factor, Eigenfactor, article influence score, SCImago journal rank, source-normalized impact per paper). Although in recent years there has been a proliferation of bibliometric parameters, the true meaning and appropriate use of these parameters is generally not well understood. Effective use of existing and emerging bibliometric tools can aid in assessment of academic productivity, including readiness for promotions and other awards. However, if not properly understood, the data can be misinterpreted and may be subject to manipulation. Familiarity with bibliometric parameters will aid in their effective implementation in the review of authors-whether individuals or groups-and journals, as well as their possible use in the promotions review process, maximizing the effectiveness of bibliometric analysis.

Background Diffusion weighted imaging (DWI) has been shown to be helpful in characterizing tumor cellularity, and predicting histology. Several works have evaluated this technique for pineal tumors; however studies to date have not focused on pediatric pineal tumors. Objective We evaluated the diffusion characteristics of pediatric pineal tumors to confirm if patterns seen in studies using mixed pediatric and adult populations remain valid. Materials and methods This retrospective study was performed after Institutional Review Board approval. We retrospectively evaluated all patients 18 years of age and younger with pineal tumors from a single institution where preoperative diffusion weighted imaging as well as histologic characterization was available. Results Twenty patients (13 male, 7 female) with pineal tumors were identified: seven with pineoblastoma, four with Primitive Neuroectodermal Tumor (PNET), two with other pineal tumors, and seven with germ cell tumors including two germinomas, three teratomas, and one mixed germinoma-teratoma. The mean apparent diffusion coefficient (ADC) values in pineoblastoma (544 ± 65 × 10–6 mm2/s) and pineoblastoma/PNET (595 ± 144 × 10–6 mm2/s) was lower than that of the germ cell tumors (1284 ± 334 × 10–6 mm2/s; p –6 mm2/s. Conclusion ADC values can aid in differentiation of pineoblastoma/PNET from germ cell tumors in a population of children with pineal masses.

BackgroundAcute ischemic stroke (AIS) due to emergent large-vessel occlusion (ELVO) has a poor prognosis.ObjectiveTo examine the hypothesis that a better collateral score on pretreatment CT angiography (CTA) would correlate with a smaller final infarct volume and a more favorable clinical outcome after endovascular therapy (EVT).MethodsA retrospective chart review of the University of Tennessee AIS database from February 2011 to February 2013 was conducted. All patients with CTA-proven LVO treated with EVT were included. Recanalization after EVT was defined by Thrombolysis in Cerebral Infarction (TICI) score ≥2. Favorable outcome was assessed as a modified Rankin Score ≤3.ResultsFifty patients with ELVO were studied. The mean National Institutes of Health Stroke Scale score was 17 (2–27) and 38 of the patients (76%) received intravenous tissue plasminogen activator. The recanalization rate for EVT was 86.6%. Good clinical outcome was achieved in 32% of patients. Univariate predictors of good outcome included good collateral scores (CS) on presenting CTA (p=0.043) and successful recanalization (p=0.02). Multivariate analysis confirmed both good CS (p=0.024) and successful recanalization (p=0.009) as predictors of favorable outcome. Applying results of the multivariate analysis to our cohort we were able to determine the likelihood of good clinical outcome as well as predictors of smaller final infarct volume after successful recanalization.ConclusionsGood CS predict smaller infarct volumes and better clinical outcome in patients recanalized with EVT. These data support the use of this technique in selecting patients for EVT. Poor CS should be considered as an exclusion criterion for EVT as patients with poor CS have poor clinical outcomes despite recanalization.

Eine wichtige Komponente der Therapie des vasodilatatorischen Schockgeschehens im Rahmen der Intensivmedizin ist der Einsatz von Katecholaminen. Bei prolongierter Anwendung kommt es jedoch zur Wirkungsverminderung durch Abnahme der Rezeptorzahl („Down-Regulation“) und Verminderung der Rezeptorsensibilitat (Desensibilisierung). Die Moglichkeit, diesem Effekt durch zusatzliche Gabe von Vasopressin und dessen Analogon Terlipressin entgegenzuwirken, haben Serpa Neto und Kollegen im Rahmen einer Metaanalyse untersucht.

Autopsy studies have described definitive traumatic avulsion of the oculomotor nerve from the brainstem; however, detailed characterization of mechanisms and localization of traumatic nerve injury has yet to be definitively described in vivo. We report the case of a 13-year-old girl in whom high-resolution magnetic resonance imaging confirmed irreversible injury to the left oculomotor nerve after trauma.

The American Academy of Neurology (AAN) endorsement for the use of fMRI evaluation of hemispheric dominance for language in epilepsy surgery candidates1 appears as an odd and disconcerting sequel to the article by Eckland et al.,2 which reported that the clustering approach in functional MRI (fMRI) data processing may be responsible for an excessively high rate of false-positive findings. The latter report implied that up to 70% of the significant fMRI effects reported in approximately 40,000 peer-reviewed publications could represent no brain physiology facts, but type I statistical errors to the degree that they employed clustering of activated voxels.2 Consequently, it is fitting to suggest users of these popular fMRI software packages (SPM, FSL, AFNI) reconsider conclusions based on differences in activation levels of voxel clusters between task conditions. This raises the question of whether those who use the clustering procedure for the purpose of assessing hemisphere dominance for language should be alarmed for having made incorrect assessments in the past and refrain from using them for the same purpose in the future. Our answer is no, since language laterality judgments are typically made on the basis of laterality indices (i.e., the relative degree of activation defined as the ratio of left- and right-hemisphere activated voxels that are equally likely or unlikely to be activated). However, depending on how users of these automated software packages derive estimates of localization of the language network hubs (a practice not endorsed by the AAN),1 they may need to exercise more caution now that the shortcomings of these data reduction and analysis procedures were directly demonstrated and made widely known.

Supplemental Digital Content is available in the text., In this study, we have addressed the question of functional brain reorganization for language in the presence and absence of anatomical lesions in two patients with epilepsy using cortical stimulation mapping and high gamma (HG) activity in subdural grid recordings. In both, the expressive language cortex was defined as the cortical patch below the electrode(s) that when stimulated resulted in speech arrest, and during speech expression tasks generated HG activity. This patch fell within the borders of Broca’s area, as defined anatomically, in the case of the patient with a lesion, but outside that area in the other, lesion-free patient. Such results highlight the necessity for presurgical language mapping in all cases of surgery involving the language-dominant hemisphere and suggest that HG activity during expressive language tasks can be informative and helpful in conjunction with cortical stimulation mapping for expressive language mapping.

Background Despite advances in nutritional support and intensive care, preterm infants are at higher risk of compromised neurodevelopment. Objective This study evaluated the contribution of total parenteral nutrition (PN) to compromised neurodevelopment after preterm birth. Methods Preterm pigs were provided PN or enteral nutrition (EN) for 10 d. Neurodevelopment was assessed by observations of motor activity and evaluation of sensory/motor reflexes, brain weight, MRI, and cerebellar histology. Results Despite similar gains in body weight, PN pigs had smaller brains (32 ± 0.4 vs. 35 ± 0.6 g; P = 0.0002) including the cerebellum, as well as reduced motor activity (P = 0.005), which corresponded to underdeveloped myelination (P = 0.004) measured by diffusion tensor imaging. PN resulted in lower serum triglycerides (17 ± 5.9 vs. 27 ± 3.1 mg/dL; P = 0.05), total cholesterol (31 ± 9.6 vs. 85 ± 8.1 mg/dL; P = 0.04), VLDL cholesterol (3.7 ± 1.2 vs. 5.7 ± 0.7 mg/dL; P = 0.04), and HDL cholesterol (16 ± 4.6 vs. 57 ± 7.3 mg/dL; P = 0.03) and nonsignificantly lower LDL cholesterol (10.7 ± 4.4 vs. 22.7 ± 2.9 mg/dL; P = 0.09). Conclusions The compromised neurodevelopment caused by total PN is a novel finding, was independent of confounding variables (disease, inconsistent gestational ages, diverse genetics, extrauterine growth retardation, and inconsistent neonatal intensive care unit protocols), and highlights a need to improve current PN solutions. The preterm pig is a translational animal model for improving nutrition support to enhance neurodevelopment of preterm infants requiring PN.

Intraoperative magnetic resonance imaging (iMRI) has emerged as an important tool in guiding the surgical management of children with brain tumors. Recent advances have allowed utilization of high field strength systems, including 3-tesla MRI, resulting in diagnostic-quality scans that can be performed while the child is on the operating table. By providing information about the possible presence of residual tumor, it allows the neurosurgeon to both identify and resect any remaining tumor that is thought to be safely accessible. By fusing the newly obtained images with the surgical guidance software, the images have the added value of aiding in navigation to any residual tumor. This is important because parenchyma often shifts during surgery. It also gives the neurosurgeon insight into whether any immediate postoperative complications have occurred. If any complications have occurred, the child is already in the operating room and precious minutes lost in transport and communications are saved. In this article we review the three main approaches to an iMRI system design. We discuss the possible roles for iMRI during intraoperative planning and provide guidance to help radiologists and neurosurgeons alike in the collaborative management of these children.

BACKGROUND AND PURPOSE: Functional brain mapping is an important technique for neurosurgical planning, particularly for patients with tumors or epilepsy; however, mapping has traditionally involved invasive techniques. Existing noninvasive techniques require patient compliance and may not be suitable for young children. We performed a retrospective review of our experience with passive-motion functional MR imaging in anesthetized patients to determine the diagnostic yield of this technique. MATERIALS AND METHODS: A retrospective review of patients undergoing passive-motion fMRI under general anesthesia at a single institution over a 2.5-year period was performed. Clinical records were evaluated to determine the indication for fMRI, the ability to detect cortical activation, and, if present, the location of cortical activation. RESULTS: We identified 62 studies in 56 patients in this time period. The most common indication for fMRI was epilepsy/seizures. Passive-motion fMRI identified upper-extremity cortical activation in 105 of 119 (88%) limbs evaluated, of which 90 (86%) activations were in an orthotopic location. Lower-extremity cortical activation was identified in 86 of 118 (73%) limbs evaluated, of which 73 (85%) activations were in an orthotopic location. CONCLUSIONS: Passive-motion fMRI was successful in identifying cortical activation in most of the patients. This tool can be implemented easily and can aid in surgical planning for children with tumors or candidates for epilepsy surgery, particularly those who may be too young to comply with existing noninvasive functional measures.

Diffusion tensor imaging (DTI) is a method of specifying and visualizing the functional integrity of white matter tracts that contribute to the functional and structural connectivity among different brain regions through the examination of water diffusion through tissue. It has gained rapid popularity in the past two decades, particularly for elucidating the process of normal white matter development and the effects of aging on it, as well as providing some insights into the possible neuroanatomical correlates of numerous psychiatric and neurologic disorders. This chapter outlines the instrumentation and the procedures employed in deriving estimates of the functional integrity of anatomical connections in the brain, and issues regarding the reliability and validity of the different DTI procedures are systematically addressed.

Mobile devices have fundamentally changed personal computing, with many people forgoing the desktop and even laptop computer altogether in favor of a smaller, lighter, and cheaper device with a touch screen. Doctors and patients are beginning to expect medical images to be available on these devices for consultative viewing, if not actual diagnosis. However, this raises serious concerns with regard to the ability of existing mobile devices and networks to quickly and securely move these images. Medical images often come in large sets, which can bog down a network if not conveyed in an intelligent manner, and downloaded data on a mobile device are highly vulnerable to a breach of patient confidentiality should that device become lost or stolen. Some degree of regulation is needed to ensure that the software used to view these images allows all relevant medical information to be visible and manipulated in a clinically acceptable manner. There also needs to be a quality control mechanism to ensure that a device’s display accurately conveys the image content without loss of contrast detail. Furthermore, not all mobile displays are appropriate for all types of images. The smaller displays of smart phones, for example, are not well suited for viewing entire chest radiographs, no matter how small and numerous the pixels of the display may be. All of these factors should be taken into account when deciding where, when, and how to use mobile devices for the display of medical images.

Gomez–Lopez–Hernandez syndrome (GLHS) is a clinical condition traditionally characterized by rhombencephalosynapsis (RS), parieto–occipital alopecia, and trigeminal anesthesia. It is a neurocutaneous disorder with no known etiology. The underlying cause of the trigeminal anesthesia in GLHS has not been examined or reported; it has merely been identified on clinical grounds. In this report, a 10-month-old white female born at 37 weeks gestational age with GLHS underwent a contrast-enhanced CT for the evaluation of craniofacial dysmorphic features. Thin-section bone algorithm images showed absence of bilateral foramina rotunda and trigeminal nerve fibers. The maxillary branch of the trigeminal nerve passes through the foramen rotundum and carries sensory information from the face. This case is unique because trigeminal nerve absence has not been suggested as a possible etiology for trigeminal anesthesia associated with GLHS. It is not known how many cases of GLHS have agenesis of the trigeminal nerve; however, a review of the literature suggests that this patient is the first. The triad of RS, alopecia, and trigeminal anesthesia is specific to GLHS; therefore, early identification of trigeminal nerve agenesis in patients with RS could expedite diagnosis of GLHS, particularly given that the clinical diagnosis of trigeminal anesthesia in neonates is a challenging one. Diagnosing alopecia in newborns is likewise challenging. Early diagnosis could allow for early intervention, especially for ophthalmic complications, which are known to have significant long-term effects. This case illustrates the benefits of CT imaging in the detection of trigeminal nerve and foramina rotunda abnormalities in neonates with suspected GLHS. © 2014 Wiley Periodicals, Inc.

The main clinical application of functional neuroimaging is mapping cortical regions containing part of the circuitry necessary for somatosensory, motor, and language functions and assessing hemispheric dominance for both language and encoding operations of memory prior to several types of brain surgery. Presently, it is used in conjunction with the classical invasive methods of brain mapping. This chapter presents the case for replacing invasive methods with noninvasive ones given the limitations of the invasive methods that render them unjustifiable as “gold standards.” Evidence is presented that the efficacy of the two types of methods in reducing morbidity, facilitating surgical planning, and enhancing surgical outcome is comparable. Additional advantages of noninvasive presurgical brain mapping are also discussed. The chapter concludes that there are no compelling reasons for invasive mapping in most patients whenever noninvasive methods are available.

Objective Accurate noninvasive assessment of motor function using functional MRI (fMRI) and magnetoencephalography (MEG) is a challenge in patients who are very young or who are developmentally delayed. In such cases, passive mapping of the sensorimotor cortex is performed under sedation. We examined the feasibility of using transcranial magnetic stimulation (TMS) as a motor mapping tool in awake children younger than 3 years of age. Methods Six children underwent motor mapping with TMS while awake as well as passive sensorimotor mapping under conscious sedation with MEG during tactile stimulation (n = 5) and fMRI during passive hand movements (n = 4). Results Stimulation of the motor cortex via TMS successfully elicited evoked responses in contralateral hand muscles in 5 patients. The location of primary motor cortex in the precentral gyrus identified by TMS corresponded with the postcentral location of the primary sensory cortex identified by MEG in 2 patients and to the sensorimotor cortex identified by fMRI in 3 children. In this cohort, we demonstrate that TMS can illuminate abnormalities in motor physiology including motor reorganization. We also demonstrate the feasibility of using TMS-derived contralateral silent periods to approximate the location of motor cortex in the absence of an evoked response. When compared to chronological age, performance functioning level appears to be better in predicting successful mapping outcome with TMS. Conclusions Our findings indicate that awake TMS is a safe alternative to MEG and fMRI performed under sedation to localize the motor cortex and provides additional insight into the underlying pathophysiology and motor plasticity in toddlers.

Diffusion tensor imaging is a magnetic resonance imaging technique that provides insight into the anatomy and integrity of white matter pathways in the brain. Further processing of these data can help map individual tracts, which can aid in surgical planning. Understanding the basics of this technique can improve characterization of white matter development and disorders.

Multiple sclerosis (MS) and its variants are inflammatory as well as neurodegenerative diseases that diffusely affect the central nervous system (CNS). There is a poor correlation between traditional imaging findings and symptoms in patients with MS. Current research in conventional magnetic resonance (MR) imaging of MS and related diseases includes optimization of hardware and pulse sequences and the development of automated and semiautomated techniques to measure and quantify disease burden. Advanced nonconventional MR techniques such as diffusion tensor and functional MR imaging probe the changes found in the CNS, and correlate these findings with clinical measures of disease.

Stroke complicates the postoperative course in 1% to 6% of patients undergoing coronary revascularization. There has been no large scale mandatory database reporting on the incidence of stroke after coronary revascularization.A multicenter regional database from the Bureau of Health Care Research Information Services, New York State Department of Health, on 19,224 patients who underwent coronary revascularization in 31 hospitals within New York State during 1995 was analyzed to determine the risk factors for postoperative stroke.The incidence of postoperative stroke was 1.4% (n = 270). Hospital mortality for patients who had a stroke was 24.8%, compared with 2.0% for the rest of the patient population. Postoperative stroke increased the hospital length of stay threefold (27.9+/-1.9 versus 9.1+/-0.9 days, p0.0001). Multivariable logistic regression identified the following variables to be significantly associated with a postoperative stroke: calcified aorta (p0.0001; odds ratio [OR], 3.013), prior stroke (p = 0.0003; OR, 1.909), age (p0.0001; OR, 1.522 per 10 years), carotid arterial disease (p = 0.002; OR, 1.590), duration of cardiopulmonary bypass (p = 0.0004; OR, 1.27 per 60 minutes), renal failure (p = 0.0062; OR, 2.032), peripheral vascular disease (p = 0.0157; OR, 1.62), cigarette smoking (p = 0.0197; OR, 1.621), and diabetes mellitus (p = 0.0158; OR, 1.373).Postoperative stroke increases mortality and length of stay after coronary revascularization. Several risk factors can be identified, and some of these factors are potentially amenable to intervention, either before or during coronary revascularization, and should also influence patient selection.

Background: Infection remains the single most important challenge to extended left ventricular assist device (LVAD) use and often arises from the percutaneous driveline exit site. We evaluated the ability of an LVAD driveline prototype impregnated with chlorhexidine, triclosan, and silver sulfadiazine to resist bacterial and fungal colonization. Methods The spectrum and duration of antimicrobial activity were evaluated in vitro by daily transfer of driveline segments embedded on agar plates inoculated with 10 8 colony-forming units (CFU) of Staphylococcus aureus ( S. aureus ), Staphlococcus epidermidis, Enterobacter aerogenes, Psuedomonas aeruginosa , and Candida albicans , and then measuring zones of inhibition around the sample subsequent to 24 hours of incubation at 37°C. Antimicrobial activity was demonstrated against all organisms for greater than 14 days, and for over 21 days for gram-positive bacteria. To demonstrate in vivo efficacy of the treated driveline, 3-cm segments of driveline were implanted in the dorsal and ventral surface of rats. The exit site was inoculated with 10 6 CFU of S. aureus . After 7 days, driveline segments were aseptically explanted and assayed for bacterial colonization and retention of antimicrobial activity. One hundred percent of control segments were colonized (10 5 CFU S. aureus /cm) as against 13% of the test explants (≤ 330 CFU/cm; p Results Subcultures of the insertion site and driveline pocket tissue resulted in 10 3 to 10 5 CFU per swab culture for control rats and 0 to 10 2 CFU/swab for test animals. Test drivelines retained 80% of anti– S. aureus activity. Gross and histological examination of the driveline and surrounding pocket revealed minimal tissue reactivity with positive signs of tissue ingrowth. Conclusion An antimicrobial driveline may prevent early infections and facilitate ingrowth of tissue to provide long-term stability and protection against late infection.

Background: Cardiopulmonary bypass can be associated with vasodilatory hypotension requiring pressor support. We have previously found arginine vasopressin to be a remarkably effective pressor in a variety of vasodilatory shock states. We investigated the incidence and clinical predictors of vasodilatory shock in a general population of cardiac surgical patients and the effects of low-dose arginine vasopressin as treatment of this syndrome in patients with heart failure. Methods: Patients undergoing cardiopulmonary bypass (n = 145) were studied prospectively. Preoperative ejection fraction, medications, and perioperative hemodynamics were recorded, and postbypass serum arginine vasopressin levels were measured. Vasodilatory shock was defined as a mean arterial pressure lower than 70 mm Hg, a cardiac index greater than 2.5 L/min/m 2 , and norepinephrine dependence. Predictors of vasodilatory shock were investigated by logistic regression analysis. The hemodynamic responses of patients who received arginine vasopressin infusions for vasodilatory shock after cardiopulmonary bypass for left ventricular assist device placement or heart transplantation were analyzed retrospectively. Results: Eleven of 145 general cardiac surgery patients (8%) met criteria for postbypass vasodilatory shock. By multivariate analysis, an ejection fraction lower than 0.35 and angiotensin-converting enzyme inhibitor use were independent predictors of postbypass vasodilatory shock (relative risks of 9.1 and 11.9, respectively). Vasodilatory shock was associated with inappropriately low serum arginine vasopressin concentrations (12.0 ± 6.6 pg/mL). Retrospective analysis found 40 patients with postbypass vasodilatory shock who received low-dose arginine vasopressin infusions, resulting in increased mean arterial pressure and decreased norepinephrine requirements. Conclusions: Low ejection fraction and angiotensin-converting enzyme inhibitor use are risk factors for postbypass vasodilatory shock, and this syndrome is associated with vasopressin deficiency. In patients exhibiting this syndrome after high-risk cardiac operations, replacement of arginine vasopressin increases blood pressure and reduces catecholamine pressor requirements. (J Thorac Cardiovasc Surg 1998;116:973-80)

The number of citations a publication receives can be used to show its impact on a field of study. It may indicate the educational interest in a given population or underline a perceived or real educational gap. This article identifies and characterizes the 100 top cited publications in radiologic journals as of May 2013.All clinical radiologic journals listed by Thomson Reuters Journal Citation Reports in 2011 were identified. A total of 46 journals were identified, and all articles published within these journals were analyzed for citation counts. The top 100 highly cited articles were recorded.The most frequently cited radiologic articles appeared in 9 of the 46 journals. These included 59 articles in Radiology, 17 in Journal of Nuclear Medicine, 9 in the American Journal of Roentgenology, 5 in the British Journal of Radiology, 4 in Investigative Radiology, 2 in American Journal of Neuroradiology, 2 in European Radiology, 2 in Radiologic Clinics of North America, 1 in the Seminars in Nuclear Medicine, and 1 in Pediatric Radiology. The citation values ranged from 422 to 7506 with a mean of 751. Publication dates ranged from 1967 to 2006 with the 5-year period between 1986 and 1990 accounting for the largest percentage of articles. The most frequently studied radiologic modality was magnetic resonance imaging (MRI; 28 articles), followed by vascular/interventional (19 articles) and nuclear medicine (13 articles). The central nervous system was the most frequently studied organ system (22 articles), followed by mixed organ systems (14 articles) and liver (12 articles).The top cited articles in radiologic journals span a wide range of imaging modalities, subspecialties, and organ systems. Topics that occurred frequently in the top 100 cited articles included contrast and radiopharmaceutical characterization, MRI of motion, percutaneous radiofrequency ablation in the liver and percutaneous vertebroplasty. We present a methodology that uses citation analysis to identify and characterize these articles. Its use may aid radiologists, academic organization, and editorial staff in determining areas of imaging interest or perceived educational gap. It also highlights the importance of including classic articles in current imaging education.

The authors review the course and appearance of the major segments of the upper cranial nerves from their apparent origin at the brainstem through the proximal extraforaminal region, focusing on the imaging and anatomic features of particular relevance to high-resolution magnetic resonance imaging evaluation. Selected pathologic entities are included in the discussion of the corresponding cranial nerve segments for illustrative purposes.

Non-invasive functional evaluation of the brain complements structural MRI imaging and has largely supplanted invasive techniques such as awake craniotomy. Techniques used for functional mapping of the brain include BOLD-functional MRI (fMRI), magnetoencephalography (MEG), and transcranial magnetic stimulation (TMS). We describe the case of a right-handed patient with a lesion centered in the left inferior perirolandic cortex who underwent fMRI, MEG, and TMS on a single day to facilitate maximal lesion resection while preserving eloquent cortex and eloquent white matter tracts.

Rhombencephalosynapsis is a rare genetic aberration characterized by variable vermian hypoplasia/aplasia in conjunction with united cerebellar hemispheres. Genetic defects in the isthmic organizer at the mesencephalic–metencephalic junction are presumably responsible for the associated aqueductal stenosis. We performed a retrospective review of 20 children with rhombencephalosynapsis to evaluate for and emphasize the association of aqueductal stenosis and hydrocephalus. We retrospectively reviewed the MR and CT images of 20 children (0–11 years old) with rhombencephalosynapsis encountered at two academic children’s hospitals. Rhombencephalosynapsis spectrum severity was graded based on pre-existing literature. We analyzed examinations for ventriculomegaly and degree of aqueductal stenosis. The collicular distances were measured from the collicular apices. Imaging studies were also analyzed for malformations of cortical and cerebellar development. Thirteen of the 20 children (65%) with rhombencephalosynapsis presented with clinical or imaging evidence of hydrocephalus and aqueductal stenosis, principally involving the caudal cerebral aqueduct. All children with aqueductal stenosis had collicular fusion. All six children with complete rhombencephalosynapsis had aqueductal stenosis. The cerebral aqueduct varied from normal to stenotic in children with incomplete rhombencephalosynapsis. Corpus callosum dysgenesis was present in four children. Aqueductal stenosis in the setting of rhombencephalosynapsis is an under-recognized cause of noncommunicating hydrocephalus. Our findings support the hypothesis that a defect involving the common gene(s) responsible for the differentiation and development of both the roof plate and midline cerebellar primordium at the mesencephalon/first rhombomere junction may be responsible for the association of aqueductal stenosis and rhombencephalosynapsis.

Pineal cysts, both simple and complex, are commonly encountered in children. More cysts are being detected with MR technology; however, nearly all pineal cysts are benign and require no follow-up. To discover the prevalence of pineal cysts in children at our institution who have undergone high-resolution 3-T MRI. We retrospectively reviewed 100 consecutive 3-T brain MRIs in children ages 1 month to 17 years (mean 6.8 ± 5.1 years). We evaluated 3-D volumetric T1-W imaging, axial T2-W imaging, axial T2-W FLAIR (fluid attenuated inversion recovery) and coronal STIR (short tau inversion recovery) sequences. Pineal parenchymal and cyst volumes were measured in three planes. Cysts were analyzed for the presence and degree of complexity. Pineal cysts were present in 57% of children, with a mean maximum linear dimension of 4.2 mm (range 1.5–16 mm). Of these cysts, 24.6% showed thin septations or fluid levels reflecting complexity. None of the cysts demonstrated complete T2/FLAIR signal suppression. No cyst wall thickening or nodularity was present. There was no significant difference between the ages of children with and without cysts. Cysts were more commonly encountered in girls than boys (67% vs. 52%; P = 0.043). There was a slight trend toward increasing pineal gland volume with age. Pineal cysts are often present in children and can be incidentally detected by 3-T MRI. Characteristic-appearing pineal cysts in children are benign, incidental findings, for which follow-up is not required if there are no referable symptoms or excessive size.

Percutaneous stents are used in vascular applications in conjunction with angioplasty and in combination with graft material for repair of abdominal aneurysms. The authors have designed a collapsible bioprosthetic aortic valve for placement by a transluminal catheter technique. This trileaflet stent valve is composed of stainless steel and bovine pericardium. Stent valves, 23 and 29 mm, were tested in a pulse duplicator system with rigid rings from 21 to 31 mm in 2 mm increments. At a mean flow of 3.1 L/min (+/-0.7), normal systemic aortic pressure was generated with a transvalvular gradient of 14.9 +/- 7 mmHg (mean +/- SD). Regurgitation fraction ranged from 10 to 18% (mean 13.8 +/- 3%) in the best ring size. Valves with the best hemodynamic profile were used for implantation in three 70 kg pigs in an open chest model. The valve was collapsed in a 24 Fr catheter designed to allow slow, controlled release. After resection of the native leaflets, the new valve was placed in the subcoronary position. No additional sutures were used for securing the valve. Two animals were successfully weaned from cardiopulmonary bypass and maintained systemic pressures of 100/45 (+/-10) and 116/70 (+/-15) mmHg, respectively. Intraoperative color echocardiography revealed minimal regurgitation, central flow, full apposition of all leaflets, and no interference with coronary blood flow. Both animals were sacrificed after being off bypass for 2 hr. Postmortem examination revealed the valves to be securely anchored. The third animal was weaned from cardiopulmonary bypass but developed refractory ventricular fibrillation because of valve dislodgment due to structural failure. Although long term survival data are needed, development of a hemodynamically acceptable prosthetic aortic valve for transluminal placement is feasible.

Imaging in traumatic injury to the orbits plays an important role to identify malformation of the globe, retrobulbar pathology, such as hematoma, the presence of fractures, and identification of foreign bodies. MRI can be especially useful in characterizing soft tissue abnormalities without the use of ionizing radiation. The authors report a case of penetrating injury to the orbit with a retained foreign body where the graphite core of a pencil ("pencil lead") resulted in metal-like diamagnetic susceptibility artifact. This was proven to have no metallic components by CT and surgical exploration. MRI performed in the setting of penetrating injury could aid in localization of a graphite foreign body, and if there is a known graphite foreign body, evaluation of immediately adjacent structures may be obscured.

Background and purpose The best imaging selection technique for endovascular treatment (EVT) remains a topic of debate. Collateral scores (CS) on pre-treatment CT angiography (CTA) have been associated with favorable outcome. We hypothesized that low CS on pre-treatment CTA may predict a poor outcome after EVT in successfully recanalised patients with emergent large vessel occlusions (ELVO). Methods A retrospective chart review was performed for the University of Tennessee Health Sciences Center Acute Ischemic Stroke Database evaluating AIS patients presenting with CTA confirmed anterior circulation ELVO in a tertiary stroke center during a 3 year period. Only patients with successful recanalization (TICI 2 b or 3) after EVT were included in the analysis. A blinded neuroradiologist calculated the CTA CS and final infarct volume (FIV). Poor outcome after EVT was defined as symptomatic intracranial hemorrhage (SICH), cerebral edema requiring hypertonic treatment for ≥48 hours, hemicraniectomy, higher FIV, and poor clinical outcome of modified ranking scale (mRS)-score 3–6 at 3 months. Results 58 AIS patients with anterior circulation ELVO (mean age 63 ± 13 years, 48% male, median admission NIHSS-score: 17 points, IQR 14–21) had successful recanalization after EVT. Systemic thrombolysis was administered in 38 patients (65.5%). A total of 31 patients (53%) achieved favorable outcome (FO). There was no significant difference in rates of hemicraniectomy (p = 1.000) and SICH (p = 0.667) after EVT when compared to patients with low and good CS. Patients with low CS tended to have higher rates of cerebral edema requiring hypertonic treatment (30% vs 13%, p = 0.340) after EVT. Patients with low CS had greater FIV (111 ± 71 vs 41 ± 66 cm 3 , p = 0.007) and higher rates of poor clinical outcome (82% vs 39%, p = 0.017) in comparison to patients with high CS. A low CS was independently associated with poor clinical outcome (p = 0.048) in multiple logistic regression models adjusting for demographics, vascular risk factors, pretreatment SBP, admission NIHSS, intravenous thrombolysis, and onset to revascularization time. Conclusion Low CS on pre-treatment CTA was correlated with significantly worse outcome despite successful recanalization as evident by higher FIV and higher rates of poor clinical outcome. Poor CS should be considered an important variable in futures trials comparing the medical versus interventional management of patients with ELVO. Disclosures N. Goyal: None. S. Iftikhar: None. G. Tsivgoulis: None. Y. Khorchid: None. A. Choudhri: None. D. Hoit: None. A. Alexandrov: None. A. Arthur: None. L. Elijovich: None.

Acute aortic syndromes and traumatic aortic injury are often diagnosed on CT angiography, possibly requiring emergent intervention. Advances in handheld computing have created the possibility of viewing full DICOM datasets from a remote location. We evaluated the ability to diagnose and characterize acute aortic pathologies on CT angiograms of the thorax using an iPhone-based DICOM viewer. This study was performed after Institutional Review Board approval. Fifteen CT angiograms of the thorax in suspected acute aortic syndromes were evaluated by three blinded radiologists on a handheld device using a DICOM viewer. Studies were evaluated for the ability to identify and classify aortic dissection, transection, or intramural hematoma, measure aortic dimensions, and identify mediastinal hematoma, arch variants, and pulmonary pathology. Studies were compared to blinded interpretations on a dedicated PACS workstation. The aortic pathology was correctly identified as aortic transection/pseudoaneurysm (n = 5), type A dissection (n = 2), and type A intramural hematoma (n = 1) by all reviewers, with no false-positive interpretations. This represents a sensitivity and specificity of 100 %. Mediastinal hematoma (n = 6), pneumothorax (five right, three left), and arch vessel involvement (n = 2) were identified in all cases. There was 88.5 % accuracy in identifying arch variants. Measurement of the size of the involved aortic segment was similar on handheld device and PACS workstation; however the adjacent normal aorta was 1.2 ± 1.0 mm larger on the handheld device (p = 0.03). Handheld DICOM viewers may be useful for emergent consultations and triage, and may expedite preprocedure planning to reduce the time interval between diagnostic scan and therapeutic intervention.

This article provides a summary of how to approach the imaging analysis of lesions of the anterior, central, and posterior skull base. The primary focus is tumors and tumor-mimickers, and representative examples are shown to differentiate the features of lesions that can occur in the same location.

PURPOSE Superselective intraophthalmic artery chemotherapy (SSIOAC) is being used for treatment of retinoblastoma; however, the hemodynamic consequences and toxicities are not fully known. We developed a nonhuman primate (NHP) model of SSIOAC and reported our clinical observations. For validation, we compared ophthalmic artery (OA) diameters between NHPs and children (

A 51-year-old woman with a history of migraine headaches was found to have an incidental right orbital mass on MRI during neurologic evaluation for headaches. The orbital mass was a well-defined, lobulated, intraosseous soft tissue lesion with circumscribed margins. Clinically, there was noted proptosis, tenderness to palpation, and slight limitation to right abduction. An orbitotomy with incisional biopsy revealed a lesion arising within the lateral orbital rim extending to the subperiosteal space. Intraoperative frozen sections indicated a low grade sarcoma, possibly metastatic. The extraosseous component was excised, and the bone was curetted until all visible tumor was removed. A diagnosis of chondromyxoid fibroma was made. The patient did well until 5 months postoperatively, when right-sided proptosis returned due to recurrent tumor. Repeat surgical resection with removal of the lateral orbital rim was performed. Histopathology was consistent with recurrent chondromyxoid fibroma.

1Department of Neurological Surgery, Saint Louis University, St. Louis, Missouri; 2Division of Pediatric Neurological Surgery, Goryeb Children’s Hospital, Morristown, New Jersey; 3Department of Neurosurgery, University of Tennessee Health Science Center, and 4Le Bonheur Children’s Hospital, Memphis, Tennessee; 5De ­ part ment of Pediatric Neurosurgery, Massachusetts General Hos­ pital, Boston, Massachusetts; 6Department of Neurological Sur­ gery, Oregon Health & Science University, Portland, Oregon; 7De part ment of Pediatric Neurological Surgery, Children’s Hos pital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania; 8Division of Pediatric Neurosurgery, Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Mis souri; 9Department of Neurosurgery, University of Illinois at Chicago, Chicago, and Advocate Children’s Hospital, Oak Lawn, Illinois; 10Division of Pediatric Neurological Surgery, Department of Neurosciences and Pediatrics, Goryeb Children’s Hospital– Morris town Medical Center, Morristown, New Jersey; 11De partment of Neurosurgery, University of California, San Francisco, Cal i ­ fornia; 12Departments of Radiology, Ophthalmology, and Neuro ­ sur gery, University of Tennessee Health Science Center, Mem­ phis, Tennessee, and Le Bonheur Neuroscience Institute, Le Bon heur Children’s Hospital, Memphis, Tennessee; 13Guidelines Department, Congress of Neurological Surgeons, Schaumburg, Illinois; and 14Hydrocephalus Association, Bethesda, Maryland

The purpose of the study was to depict a subset of focal partial tears of the biceps brachii tendon, occurring at the entrance to the bicipital groove, which can be difficult to detect with MRI.The institutional review board approved this HIPAA-compliant study; informed consent was waived. The authors retrospectively reviewed imaging and medical records in 16 consecutive patients (12 men, 4 women; mean age, 57 years) who had prospective MRI diagnoses of tendinopathy and/or partial tearing of the intra-articular segment of the long head of the biceps brachii tendon (LHBT) at the entrance to the bicipital groove (restricted to within 1 cm of the groove entrance) and who also had surgical correlation within 4 months of imaging.Focal intrasubstance signal abnormality was noted in the tendons of 16 out of 16 (100%) patients. Focal tendon enlargement was noted in 8 out of 16 patients (50%). Fifteen out of 16 biceps partial tears (94%) were treated surgically. Shoulder pathology was restricted to the groove entrance in 4 out of 16 patients (25%).We depict a subset of focal partial tears of the biceps tendon, which can be difficult to detect on MRI because of their anatomical location at the entrance to the bicipital groove. Although they may coexist with other causes of shoulder pain, these lesions can also occur in isolation. In either case, they are potential causes of pain that can be addressed surgically.