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Traumatic Brain Injury is a leading cause of morbidity and mortality worldwide. Although CT remains the primary initial imaging modality, MRI is crucial for evaluating white matter injury, brainstem injury, and early ischemia, all of which are 'relative blind spots' for CT. Copyright © 2010 by Elsevier Inc. [ABSTRACT FROM AUTHOR]

Active extravasation into the upper aerodigestive tract is a dramatic and potentially life-threatening complication in patients with head and neck cancers. It prompts presentation to the emergency room and subsequent urgent imaging to identify the source of hemorrhage. Imaging of these patients may be complicated by treatment-altered anatomy, posing a challenge to the emergency radiologist who needs to rapidly identify the presence of active hemorrhage and the potential source vessel. This retrospective review summarizes the clinical and imaging findings of 6 oropharyngeal and oral cavity squamous cell cancer (SCC) patients with active upper aerodigestive tract hemorrhage. Most patients had advanced stage disease and prior radiation therapy. All CECT or CTA exams on presentation demonstrated the "dot-in-sludge" sign of active extravasation, as demonstrated by a "dot" of avidly enhancing extravasated contrast material layered against a background "sludge" of non-enhancing debris in the lumen of the upper aerodigestive tract. Common sources of hemorrhage included the lingual, facial, and superior thyroidal arteries. Familiarity with these findings will help radiologists increase their accuracy and confidence in interpreting these urgent, complex examinations., (© 2023. The Author(s).)

Background: Large analyses of T4 larynx cancer (LC) have raised concerns that larynx preservation (LP) contributes to reduced survival compared with laryngectomy (LGX). The role of operability has not been previously considered as a confounder., Methods: We queried the National Cancer Database for T4M0 LC diagnosed 2004-2015. Patients were categorized as undergoing LGX, chemoradiotherapy but operable (LP-operable), and chemoradiotherapy inoperable (LP-inoperable). Overall survival (OS) was estimated by Kaplan-Meier. Cox multivariate analysis (MVA) identified variables associated with OS., Results: We identified 1405 LGX, 164 LP-operable and 1969 LP-inoperable patients. Compared with LGX, MVA demonstrated worse OS among LP-inoperable (HR 1.28 95%CI 1.17-1.40, p < 0.01) but not LP-operable patients (HR 1.12 95%CI 0.91-1.39, p = 0.28)., Conclusions: LP-operable patients did not have significantly worse OS than those undergoing LGX., (© 2022 Wiley Periodicals LLC.)

Background and Purpose: Due to surgical advancements, the accurate detection of perineural disease spread has become increasingly important in the management and prognostication of head and neck cancers, though MR evaluation has thus far been limited by technical and logistic challenges. The purpose of this study was to specifically evaluate the relative capability of 3D CISS and 3D T2-SPACE imaging to delineate the proximal intracranial divisions of the normal trigeminal nerve, an area important in determining the resectability of intracranial perineural disease., Materials and Methods: A single center HIPAA-compliant, IRB approved retrospective review of 40 patients with clinical temporal bone/internal auditory canal MR imaging was conducted. 20 patients with 3D CISS images and 20 patients with 3D T2-SPACE images met inclusion criteria. Two radiologists scored the sequences on a 3-point scale based on ability to visualize anatomic structures surrounding the trigeminal nerve in Meckel's cave, intracranial trigeminal divisions, skull base neuroforamina, and proximal extracranial mandibular division., Results: The following anatomic locations scored significantly better in the T2-SPACE sequence compared to the CISS sequence for both raters: intracranial V3 ( p < .05), foramen ovale ( p < .05), and extracranial V3 ( p < .01). The average scores for the anterior Meckel's cave and foramen rotundum were higher for the T2-SPACE sequence, although not significantly. Percent interobserver agreement ranged from 50 to 90% and 65-100% for the different anatomic locations on the CISS and T2-SPACE sequences, respectively., Conclusion: 3D T2-SPACE was found to be superior to 3D CISS in the evaluation of the distal intracranial and extracranial portions of the normal trigeminal nerve.

The Neck Imaging Reporting and Data System (NI-RADS) is a guide developed and introduced in 2017 by head and neck radiologists who worked in an academic radiology department. Based on the Breast Imaging Reporting and Data System, the initial goals of NI-RADS were to make posttreatment head and neck cancer imaging dictations more succinct and efficient, guide treating physicians in the next appropriate steps when recurrence was suspected, and encourage institutional and national research. NI-RADS is more than a dictation template, and it is best instituted after a head and neck imaging practice is established. We support the use of NI-RADS once a radiologist understands the nuances of head and neck cancer, including the biology, common subsites involved, essentials of tumor staging, common posttreatment benign imaging appearances, and subtleties of recurrent disease., (© 2022 by American Journal of Neuroradiology.)

Locoregional recurrence remains common after treatment of head and neck cancer, warranting careful surveillance in follow-up. Although randomized data support an initial positron emission tomography/computed tomography several months after treatment, evidence supporting subsequent imaging is limited, and most recurrences ultimately manifest clinically. Cooperative group studies and consensus guidelines vary widely in their recommendations regarding surveillance imaging. Patients with indeterminate findings, new symptoms, or areas difficult to examine in clinic may avoid invasive and potentially morbid interventions with judicious use of subsequent imaging. For any patient undergoing posttreatment imaging, standardized reporting criteria provide a framework for risk-stratification that can enhance communication and potentially guide management., (Copyright © 2022 American Society for Radiation Oncology. Published by Elsevier Inc. All rights reserved.)

Objectives/hypothesis: Neck Imaging Reporting and Data System (NI-RADS) is a radiology reporting system developed for head and neck cancer surveillance imaging, using standardized terminology, numeric levels of suspicion, and linked management recommendations. Through a multidisciplinary, interdepartmental quality improvement initiative, we implemented NI-RADS for the reporting of head and neck cancer surveillance CT. Our objective is to summarize our initial experience from the standpoints of head and neck cancer providers and radiologists., Study Design: Quality improvement study., Methods: Before and 3 months post-implementation, surveys were offered to referring physicians (n = 21 pre-adoption; 22 post-adoption) and radiologists (n = 17 pre- and post-adoption). NI-RADS utilization was assessed over time., Results: Survey response rates were 62% (13/21) and 73% (16/22) for referring physicians pre- and post-adoption, respectively, and 94% (16/17) for radiologists pre- and post-adoption. Among post-adoption provider respondents, 100% (16/16) strongly agreed or agreed with "I want our radiologists to continue using NI-RADS," "The NI-RADS numerical rating of radiologic suspicion is helpful," and "The language and style of NI-RADS neck CT reports are clear and understandable." Among radiologist respondents, 88% (14/16) strongly agreed or agreed with "NI-RADS improves consistency among our radiologists in the reporting of surveillance neck CTs." Radiologist NI-RADS utilization increased over time (46% month 1; 72% month 3)., Conclusions: Most referring physicians and radiologists preferred NI-RADS. Head and neck cancer providers indicated that NI-RADS reports are clear, understandable, direct, and helpful in guiding clinical management. Radiologists indicated that NI-RADS improves radiologist consistency in the reporting of surveillance neck CT, and radiologists increasingly used NI-RADS over time., Level of Evidence: 4 Laryngoscope, 132:349-355, 2022., (© 2021 The American Laryngological, Rhinological and Otological Society, Inc.)

Treatment strategies and recommended surveillance imaging differ for head and neck cancers depending on subsite and neoplasm type, and pose confusion for referring physicians and interpreting radiologists. The superior soft tissue resolution offered by magnetic resonance imaging is most useful in the surveillance of cancers with high propensities for intraorbital, intracranial, or perineural disease spread, which most commonly include those arising from the sinonasal cavities, nasopharynx, orbits, salivary glands, and the skin. This article discusses recommended surveillance protocoling and reviews treatment approaches, common posttreatment changes, and pearls for identifying disease recurrence in a subsite-based approach., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Imaging surveillance is an important component of posttreatment management of head and neck cancers. There is variability in the surveillance regimen used by various practitioners and institutions, with no official National Comprehensive Cancer Network guidelines for patients showing no symptoms beyond 6 months posttreatment. Moreover, imaging of the neck after treatment is a complex examination with significant interreader heterogeneity, particularly in terms of the manner in which degree of suspicion for disease recurrence is expressed. The Neck Imaging Reporting and Data System (NI-RADS) was introduced by the American College of Radiology (ACR) in 2018 as a practical guide for the interpreting radiologist. NI-RADS is a proposed interpretive framework that can be applied to any standardized or institutional surveillance imaging protocol. NI-RADS simplifies communication between radiologists and referring clinicians and provides management guidance linked to specific levels of suspicion. The ACR NI-RADS Committee also provided general best practice recommendations for imaging surveillance modality and timing in the 2018 white paper. This article will review existing literature regarding choice of modality and timeline for surveillance in treated cancer of the head and neck. NI-RADS will then be presented as an approach to imaging reporting, interpretation, and design of next steps in management.

Purpose To evaluate the interrater reliability among radiologists examining posttreatment head and neck squamous cell carcinoma (HNSCC) fluorodeoxyglucose PET/contrast-enhanced CT (CECT) scans using Neck Imaging Reporting and Data System (NI-RADS). Materials and Methods In this retrospective study, images in 80 patients with HNSCC who underwent posttreatment surveillance PET/CECT and immediate prior comparison CECT or PET/CECT (from June 2014 to July 2016) were uploaded to the American College of Radiology's cloud-based website, Cortex. Eight radiologists from seven institutions with variable NI-RADS experience independently evaluated each case and assigned an appropriate prose description and NI-RADS category for the primary site and the neck site. Five of these individuals were experienced readers (> 5 years of experience), and three were novices (< 5 years of experience). In total, 640 lexicon-based and NI-RADS categories were assigned to lesions among the 80 included patients by the eight radiologists. Light generalization of Cohen κ for interrater reliability was performed. Results Of the 80 included patients (mean age, 63 years ± 10 [standard deviation]), there were 58 men (73%); 60 patients had stage IV HNSCC (75%), and the most common tumor location was oropharynx ( n = 32; 40%). Light κ for lexicon was 0.30 (95% CI: 0.23, 0.36) at the primary site and 0.31 (95% CI: 0.24, 0.37) at the neck site. Light κ for NI-RADS category was 0.55 (95% CI: 0.46, 0.63) at the primary site and 0.60 (95% CI: 0.48, 0.69) at the neck site. Percent agreement between lexicon and correlative NI-RADS category was 84.4% (540 of 640) at the primary site and 92.6% (593 of 640) at the neck site. There was no significant difference in interobserver agreement among the experienced versus novice raters. Conclusion Moderate agreement was achieved among eight radiologists using NI-RADS at posttreatment HNSCC surveillance imaging. Keywords: CT, PET/CT, Head/Neck, Neck, Neoplasms-Primary, Observer Performance Supplemental material is available for this article. © RSNA, 2021.

Background: Data objectively evaluating acute post-transoral robotic surgery (TORS) swallow function are limited. Our goal was to characterize and identify clinical variables that may impact swallow function components 3 weeks post-TORS., Methods: Retrospective cohort study. Pre/postoperative use of the Modified Barium Swallow Impairment Profile (MBSImP) and Penetration-Aspiration Scale (PAS) was completed on 125 of 139 TORS patients (2016-2019) with human papillomavirus (HPV)-associated oropharyngeal squamous cell carcinoma. Dynamic Imaging Grade of Swallowing Toxicity (DIGEST) scores were retrospectively calculated. Uni/multivariate analysis was performed., Results: Dysfunctional pre-TORS DIGEST scores were predictive of post-TORS dysphagia (p = 0.015). Pre-TORS MBSImP deficits in pharyngeal stripping wave, swallow initiation, and clearing pharyngeal residue correlated with airway invasion post-TORS based on PAS scores (p = 0.012, 0.027, 0.048, respectively). Multivariate analysis of DIGEST safety scores declined with older age (p = 0.044). Odds ratios (ORs) for objective swallow function components after TORS were better for unknown primary and tonsil primaries compared to base of tongue (BOT) (OR 0.35-0.91)., Conclusions: Preoperative impairments in specific MBSImP components, older patients, and BOT primaries may predict more extensive recovery in swallow function after TORS., (© 2021 Wiley Periodicals LLC.)

Objectives/hypothesis: For locally advanced oral squamous cell carcinoma (OSCC) treated by surgery and adjuvant therapy, consensus has yet to be reached on whether the optimal time to initiate surveillance positron emission tomography/computed tomography (PET/CT) scan is before or after adjuvant therapy. In this study, we characterize the utility of PET/CT scans obtained 3 months after adjuvant therapy., Study Design: PET/CT scans were obtained for 220 patients with stage III, IVA, or IVB OSCC who underwent resection followed by adjuvant radiotherapy or chemoradiotherapy., Methods: Using the Neck Imaging Reporting and Data System, PET/CT scans were dichotomized as suspicious (primary or neck category ≥3, or distant lesion present) versus nonsuspicious. We then computed differences in locoregional progression, distant progression, and overall survival; positive predictive value (PPV), negative predictive value (NPV), sensitivity, and specificity; and success rate of salvage., Results: Sixty-seven patients (30%) had suspicious PET/CT scans, which were significantly associated with local failure (hazard ratio [HR] 14.0, 95% confidence interval [CI] 7.3-26.6), distant failure (HR 18.4, 95% CI 9.6-35.3), and poorer overall survival (HR 9.5, 95% CI 5.0-17.9). Overall PPV, locoregional PPV, NPV, sensitivity, and specificity were 85%, 79%, 73%, 58%, and 92%, respectively. Among those with biopsy-confirmed progression, 37 patients (65%) underwent salvage therapy; four (11%) were without evidence of disease at last follow-up., Conclusions: For locally advanced OSCC, PET/CT scan 3 months after adjuvant therapy is strongly predictive of disease recurrence and survival, demonstrating improved performance over postoperative imaging in previous studies. Following a suspicious post-adjuvant therapy PET/CT scan, cure of locoregional recurrence is possible but unlikely., Level of Evidence: 4 Laryngoscope, 2020., (© 2020 The American Laryngological, Rhinological and Otological Society, Inc.)

Background and Purpose: Early detection of residual or recurrent disease is important for effective salvage treatment in patients with head and neck cancer. Current National Comprehensive Cancer Network guidelines do not recommend standard surveillance imaging beyond 6 months unless there are worrisome signs or symptoms on clinical examination and offer vague guidelines for imaging of high-risk patients beyond that timeframe. Our goal was to evaluate the frequency of clinically occult recurrence in patients with head and neck squamous cell carcinoma with positive imaging findings (Neck Imaging Reporting and Data Systems scores of 2-4), especially after 6 months., Materials and Methods: This institutional review board-approved, retrospective data base search queried neck CT reports with Neck Imaging Reporting and Data Systems scores of 2-4 from June 2014 to March 2018. The electronic medical records were reviewed to determine outcomes of clinical and radiologic follow-up, including symptoms, physical examination findings, pathologic correlation, and clinical notes within 3 months of imaging., Results: A total of 255 cases, all with Neck Imaging Reporting and Data Systems scores of 2 or 3, met the inclusion criteria. Fifty-nine patients (23%) demonstrated recurrence (45 biopsy-proven, 14 based on clinical and imaging progression), and 21 patients (36%) had clinically occult recurrence (ie, no clinical evidence of disease at the time of the imaging examination). The median overall time to radiologically detected, clinically occult recurrence was 11.4 months from treatment completion., Conclusions: Imaging surveillance beyond the first posttreatment baseline study was critical for detecting clinically occult recurrent disease in patients with head and neck squamous cell carcinoma. More than one-third of all recurrences were seen in patients without clinical evidence of disease; and 81% of clinically occult recurrences occurred beyond 6 months., (© 2020 by American Journal of Neuroradiology.)

The Neck Imaging Reporting and Data System (NI-RADS) was conceived in 2016 with the objective of standardizing assessment and reporting in surveillance imaging for patients with head and neck squamous cell carcinomas and their subsequent management. The goals are to simplify radiology reports while increasing the consistency and accuracy of the interpretation of cancer surveillance imaging; enable better communication among clinicians and between clinicians and patients; facilitate outcomes research; and ultimately improve patient survival, morbidity, and mortality. The objective of the current study was to provide the background as to why and how NI-RADS was conceived and what it entails in radiology reporting., (© 2019 American Cancer Society.)

Objective: The Neck Imaging Reporting and Data System (NI-RADS) is a standardized numerical reporting template for surveillance of head and neck squamous cell carcinoma (HNSCC). Our aim was to analyze the accuracy of NI-RADS on the first posttreatment fluorodeoxyglucose positron emission tomography/contrast-enhanced computed tomography (PET/CECT)., Study Design: Retrospective cohort study., Setting: Academic tertiary hospital., Subject and Methods: Patients with HNSCC with a 12-week posttreatment PET/CECT interpreted using the NI-RADS template and 9 months of clinical and radiologic follow-up starting from treatment completion between June 2014 and July 2016 were included. Treatment failure was defined as positive tumor confirmed by biopsy or Response Evaluation Criteria in Solid Tumors criteria. Cox proportional hazards models were performed., Results: This study comprised 199 patients followed for a median of 15.5 months after treatment completion (25% quartile, 11.8 months; 75% quartile, 20.2 months). The rates of treatment failure increased with each incremental increase in NI-RADS category from 1 to 3 (4.3%, 9.1%, and 42.1%, respectively). A Cox proportional hazards model demonstrated a strong association between NI-RADS categories and treatment failure at both primary and neck sites (hazard ratio [HR], 2.60 and 5.22, respectively; P < .001). In the smaller treatment subgroup analysis, increasing NI-RADS category at the primary site in surgically treated patients and treatment failure did not achieve statistically significant association (HR, 0.88; P = .82)., Conclusion: Increasing NI-RADS category at the baseline posttreatment PET/CECT is strongly associated with increased risk of treatment failure in patients with HNSCC.

Background: Pathologic extranodal extension (ENE) has traditionally guided the management of head and neck cancers. The prognostic value of radiographic ENE (rENE) in human papillomavirus (HPV)-associated oropharyngeal squamous cell carcinoma (HPV + OPX) is uncertain., Methods: Patients with HPV + OPX with adequate pretreatment radiographic nodal evaluation from a single institution were analyzed. rENE status was determined by neuroradiologists' at time of diagnosis. Distant metastasis-free survival (DMFS), overall survival (OS), and locoregional recurrence-free survival (LRFS) were estimated using Kaplan-Meier methods. Cox proportional hazards models were fit to assess the impact of rENE on survival endpoints., Results: Hundred sixty-eight patients with OPX + squamous cell carcinomas diagnosed between April 2008 and December 2014 were included for analysis with median follow-up of 3.3 years. Eighty-eight percent of patients received concurrent chemoradiotherapy. rENE was not prognostic; its presence in patients with HPV + OPX did not significantly impact OS, LRFS, or DMFS., Conclusions: In patients with HPV + OPX, rENE was not significantly associated with OS, LRFS, or DMFS., (© 2019 Wiley Periodicals, Inc.)

Background: With an expectation of excellent locoregional control, ongoing efforts to de-intensify therapy for patients with human papillomavirus-associated squamous cell oropharyngeal cancer necessitate a better understanding of the metastatic risk for patients with this disease. The objective of this study was to determine what factors affect the risk of metastases in patients with squamous cell cancers of the oropharynx., Methods: Under a shared use agreement, 547 patients from Radiation Therapy Oncology Group 0129 and 0522 with nonmetastatic oropharyngeal squamous cell cancers who had a known p16 status and smoking status were analyzed to assess the association of clinical features with the development of distant metastases. The analyzed factors included the p16 status, sex, T stage, N stage, age, and smoking history., Results: A multivariate analysis of 547 patients with a median follow-up of 4.8 years revealed that an age ≥ 50 years (hazard ratio [HR], 3.28; P = .003), smoking for more than 0 pack-years (HR, 3.09; P < .001), N3 disease (HR, 2.64; P < .001), T4 disease (HR, 1.63; P = .030), and a negative p16 status (HR, 1.60; P = .044) were all factors associated with an increased risk of distant disease., Conclusions: Age, smoking, N3 disease, T4 disease, and a negative p16 status were associated with the development of distant metastases in patients with squamous cell cancers of the oropharynx treated definitively with concurrent chemoradiation., (© 2018 American Cancer Society.)

Imaging surveillance after treatment for head and neck cancer is challenging because of complicated resection and reconstruction surgery, in addition to posttreatment changes from radiation and chemotherapy. The posttreatment neck is often a source of anxiety for diagnostic radiologists, leading to suboptimal reporting and no standardized guidance for next management steps. Nevertheless, imaging is critical for detecting submucosal recurrences in a timely manner, so that patients remain candidates for salvage surgery. In 2016, the ACR convened the Neck Imaging Reporting and Data Systems (NI-RADS) Committee with the goals to (1) provide recommendations for surveillance imaging; (2) produce a lexicon to distinguish between benign posttreatment change and residual or recurrent tumor in the posttreatment neck; and (3) propose a NI-RADS template for reporting on the basis of this lexicon with defined levels of suspicion and management recommendations. In this article, the authors present the ACR NI-RADS Committee's recommendations, which provide guidance regarding the management of patients after treatment for head and neck cancer., (Copyright © 2018 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

The Neck Imaging Reporting and Data System (NI-RADS) is a practical and clinically useful imaging surveillance template designed to guide appropriate imaging follow-up and next-management steps. This article is a practical guide for using NI-RADS to reduce report-generation time for radiologists and create useful reports for referring clinicians and patients. A review of the report template and legend is followed by a case-based and pictorial review of the proper assignment of NI-RADS categories., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Radiographic concern for lymphatic extranodal extension (ENE) impacts upfront management decisions for patients with human papilloma virus (HPV) oropharyngeal squamous cell carcinoma (OPSCC). Therefore, we set out to evaluate the accuracy of preoperative contrast-enhanced computed tomography (CECT) to predict major ENE (> 2 mm)., Methods: Twenty-seven consecutive patients with HPV-associated OPSCC who presented at our institutional multidisciplinary tumor board were staged radiographically with positron emission tomography (PET/CT) and CECT, and underwent primary transoral robotic resection and neck dissection. CECT imaging results were correlated with pathologic ENE (pENE)., Results: CECT specificity for all pENE was 69 and 75% for radiologist 1 and 2, respectively. For pENE > 2 mm, the sensitivities were 88 and 100%, but specificities were 52.6 and 63.2%. Positive predictive values (PPV) were 43.8 and 53.3%; negative predictive values were 90.9 and 100%. On logistic regression analysis, only size ≥3 cm (OR 4.7-5.4, p < 0.02, 95% CI 1.3-44.0) demonstrated significant correlation with major ENE > 2 mm., Conclusions: Preoperative imaging for HPV-associated OPSCC had a PPV for pENE > 2 mm of 44-55%, based on any interruption in the capsule or invasion into the perinodal fat. The PPV is low and equipoise in treatment decision making for patients with HPV-associated OPSCC may require other imaging characteristics., (© 2018 S. Karger AG, Basel.)

Objective: Using a novel patient-centric approach, we assessed the impact of direct patient radiology reporting on the patient experience and patient perception of radiologists in a high-volume head and neck clinic., Materials and Methods: A single head and neck surgeon at a large academic center identified prospective outpatients who met the following inclusion criteria: having received treatment for head and neck cancer and having recently undergone surveillance imaging using the Neck Imaging Reporting and Data System template at our institution. The surgeon introduced the concept and gave patients a survey with questions before and after the radiology consultation. The radiologist met with the patient in the head and neck clinic's examination room, explaining the role of the radiologist and reviewing imaging findings., Results: Twenty-seven patients completed surveys. An improved understanding of the role of the radiologist was noted (41% of patients before consultation vs 67% after consultation). After the consultation, fewer patients (56-22%) wanted to hear from the referring physician only, and more patients wanted to hear from the radiologist only (26-44%) or from both the referring physician and the radiologist (19-33%). A total of 70-93% of patients had an improved understanding of imaging findings and follow-up recommendations after meeting with the radiologist. Most patients expressed an interest in reviewing future studies with a radiologist (93%) and found the consultation helpful (96%)., Conclusion: Direct patient reporting by the radiologist is feasible in a high-volume head and neck clinic and has a positive impact on the patient experience. Major factors that enabled direct patient reporting included our embedded reading room and the use of a standardized reporting template. After the consultation, more patients wanted to receive information from the radiologist and had a better understanding of the imaging results.

Background and Purpose: The Head and Neck Imaging Reporting and Data System (NI-RADS) surveillance template for head and neck cancer includes a numeric assessment of suspicion for recurrence (1-4) for the primary site and neck. Category 1 indicates no evidence of recurrence; category 2, low suspicion of recurrence; category 3, high suspicion of recurrence; and category 4, known recurrence. Our purpose was to evaluate the performance of the NI-RADS scoring system to predict local and regional disease recurrence or persistence., Materials and Methods: This study was classified as a quality-improvement project by the institutional review board. A retrospective database search yielded 500 consecutive cases interpreted using the NI-RADS template. Cases without a numeric score, non-squamous cell carcinoma primary tumors, and primary squamous cell carcinoma outside the head and neck were excluded. The electronic medical record was reviewed to determine the subsequent management, pathology results, and outcome of clinical and radiologic follow-up., Results: A total of 318 scans and 618 targets (314 primary targets and 304 nodal targets) met the inclusion criteria. Among the 618 targets, 85.4% were scored NI-RADS 1; 9.4% were scored NI-RADS 2; and 5.2% were scored NI-RADS 3. The rates of positive disease were 3.79%, 17.2%, and 59.4% for each NI-RADS category, respectively. Univariate association analysis demonstrated a strong association between the NI-RADS score and ultimate disease recurrence, with P < .001 for primary and regional sites., Conclusions: The baseline performance of NI-RADS was good, demonstrating significant discrimination among the categories 1-3 for predicting disease., (© 2017 by American Journal of Neuroradiology.)

Background and Purpose: Extrinsic tongue muscle invasion in oral cavity cancer upstages the primary tumor to a T4a. Despite this American Joint Committee on Cancer staging criterion, no studies have investigated the accuracy or prognostic importance of radiologic extrinsic tongue muscle invasion, the feasibility of standardizing extrinsic tongue muscle invasion reporting, or the degree of agreement across different disciplines: radiology, surgery, and pathology. The purpose of this study was to assess the agreement among radiology, surgery, and pathology for extrinsic tongue muscle invasion and to determine the imaging features most predictive of extrinsic tongue muscle invasion with surgical/pathologic confirmation., Materials and Methods: Thirty-three patients with untreated primary oral cavity cancer were included. Two head and neck radiologists, 3 otolaryngologists, and 1 pathologist prospectively evaluated extrinsic tongue muscle invasion., Results: Fourteen of 33 patients had radiologic extrinsic tongue muscle invasion; however, only 8 extrinsic tongue muscle invasions were confirmed intraoperatively. Pathologists were unable to determine extrinsic tongue muscle invasion in post-formalin-fixed samples. Radiologic extrinsic tongue muscle invasion had 100% sensitivity, 76% specificity, 57% positive predictive value, and 100% negative predictive value with concurrent surgical-pathologic evaluation of extrinsic tongue muscle invasion as the criterion standard. On further evaluation, the imaging characteristic most consistent with surgical-pathologic evaluation positive for extrinsic tongue muscle invasion was masslike enhancement., Conclusions: Evaluation of extrinsic tongue muscle invasion is a subjective finding for all 3 disciplines. For radiology, masslike enhancement of extrinsic tongue muscle invasion most consistently corresponded to concurrent surgery/pathology evaluation positive for extrinsic tongue muscle invasion. Intraoperative surgical and pathologic evaluation should be encouraged to verify radiologic extrinsic tongue muscle invasion to minimize unnecessary upstaging. Because this process is not routine, imaging can add value by identifying those cases most suspicious for extrinsic tongue muscle invasion, thereby prompting this more detailed evaluation by surgeons and pathologists., (© 2017 by American Journal of Neuroradiology.)

SMARCB1 (INI1)-deficient sinonasal carcinomas were first described in 2014, and this series of 17 cases represents the first imaging description. This tumor is part of a larger group of SMARCB1 -deficient neoplasms, characterized by aggressive behavior and a rhabdoid cytopathologic appearance, that affect multiple anatomic sites. Clinical and imaging features overlap considerably with other aggressive sinonasal malignancies such as sinonasal undifferentiated carcinoma, which represents a common initial pathologic diagnosis in this entity. SMARCB1 (INI1)-deficient sinonasal tumors occurred most frequently in the nasoethmoidal region with invasion of the adjacent orbit and anterior cranial fossa. Avid contrast enhancement, intermediate to low T2 signal, and FDG avidity were frequent imaging features. Approximately half of the lesions demonstrated calcification, some with an unusual "hair on end" appearance, suggesting aggressive periosteal reaction., (© 2016 by American Journal of Neuroradiology.)

Purpose: To identify magnetic resonance imaging (MRI) findings of temporomandibular joints (TMJs) in healthy children., Materials and Methods: This was a retrospective study of children younger than 18 years undergoing MRI of the head for non-autoimmune indications at Children's Healthcare of Atlanta (Atlanta, GA). Patients with congenital or acquired conditions associated with potential TMJ pathology were excluded. Medical records and MRIs were reviewed to document demographic data. Three neuroradiologists independently recorded specific predetermined MRI findings of the TMJ. The outcome variable was the presence or absence of TMJ findings at MRI. Descriptive and bivariate statistics were used to identify associations (significant at P ≤ .05)., Results: Eighty-seven patients (54 boys, 33 girls; mean age, 11.2 yr) met the inclusion criteria. Seventy percent of TMJs had condylar enhancement, 64% of joints had glenoid marginal synovial enhancement, 56% had condylar margin synovial enhancement, and 19% had condylar T1 hyperintense signal. There were no joints with condylar erosion, condylar volume loss, or effusion. Findings of normal marrow development were decreased condylar enhancement and greater condylar T1 signal with increased age., Conclusion: This study found a greater than 60% prevalence of synovial enhancement in healthy children. In a healthy child, MRI findings of TMJ synovial enhancement should be carefully correlated with a clinical evaluation., (Copyright © 2016 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.)

Background and Purpose: The increasing impact of diagnosing extracapsular spread by using imaging, especially in patients with oropharyngeal squamous cell carcinoma, highlights the need to rigorously evaluate the diagnostic accuracy of imaging. Previous analysis suggested 62.5%-80.9% sensitivity and 60%-72.7% specificity. Our goals were to evaluate the accuracy of imaging in diagnosing extracapsular spread in a cohort of patients with oral cavity squamous cell carcinoma (pathologic confirmation of extracapsular spread routinely available), as a proxy for oropharyngeal squamous cell carcinoma, and to independently assess the reliability of imaging features (radiographic lymph node necrosis, irregular borders/stranding, gross invasion, and/or node size) in predicting pathologically proven extracapsular spread., Materials and Methods: One hundred eleven consecutive patients with untreated oral cavity squamous cell carcinoma and available preoperative imaging and subsequent lymph node dissection were studied. Two neuroradiologists blinded to pathologically proven extracapsular spread status and previous radiology reports independently reviewed all images to evaluate the largest suspicious lymph node along the expected drainage pathway. Radiologic results were correlated with pathologic results from the neck dissections., Results: Of 111 patients, 29 had radiographically determined extracapsular spread. Pathologic examination revealed that 28 of 111 (25%) had pathologically proven extracapsular spread. Imaging sensitivity and specificity for extracapsular spread were 68% and 88%, respectively. Radiographs were positive for lymph node necrosis in 84% of the patients in the pathology-proven extracapsular spread group and negative in only 7% of those in the pathologically proven extracapsular spread-negative group. On logistic regression analysis, necrosis (P = .001), irregular borders (P = .055), and gross invasion (P = .068) were independently correlated with pathologically proven extracapsular spread., Conclusions: Although the specificity of cross-sectional imaging for extracapsular spread was high, the sensitivity was low. Combined logistic regression analysis found that the presence of necrosis was the best radiologic predictor of pathologically proven extracapsular spread, and irregular borders and gross invasion were nearly independently significant., (© 2015 by American Journal of Neuroradiology.)

Background: Workup of cerebrospinal fluid (CSF) leaks can be challenging. Patients with intermittent or infrequent clear rhinorrhea that cannot be collected, those with questionable or multiple skull-base (SB) defects on imaging, and those with previous SB surgery can present diagnostic dilemmas. In this patient population, radiologic studies that allow repeat imaging over hours to days can increase the diagnostic yield. We report our experience with magnetic resonance cisternogram with intrathecal gadolinium (MRCgGd) in this patient population., Methods: This study was a retrospective review of patients who underwent MRCgGd for workup of suspected CSF leaks at a tertiary care academic center., Results: Over the past 3 years, 11 patients (10 females; mean age 50 years) underwent MRCgGd. Seven patients had suspected spontaneous CSF leaks from idiopathic intracranial hypertension and 2 had postsurgical defects. All patients had previous imaging that was indeterminate in localizing the site of the leak. Only 3 patients had positive beta-2 transferrin studies, all with multiple potential leak sites. MRCgGd confirmed the absence of leaks at 4 previously repaired SB defects, identified spinal canal leaks but no SB leaks in 2 patients (1 of whom had a nonleaking SB defect), and identified 5 patients with one or more SB leaks. Repeat imaging, from 30 minutes to 20 hours, was beneficial in identifying 4 leaks not confirmed in the immediate imaging, and ruling out leaks in 5 cases, therefore guiding further treatment. No complications occurred., Conclusion: MRCgGd is a useful diagnostic test in the workup of patients with difficult CSF leaks, with delayed imaging providing valuable diagnostic information., (© 2015 ARS-AAOA, LLC.)

Most patients presenting with uncomplicated, nontraumatic, primary headache do not require imaging. When history, physical, or neurologic examination elicits "red flags" or critical features of the headache, then further investigation with imaging may be warranted to exclude a secondary cause. Imaging procedures may be diagnostically useful for patients with headaches that are: associated with trauma; new, worse, or abrupt onset; thunderclap; radiating to the neck; due to trigeminal autonomic cephalgia; persistent and positional; and temporal in older individuals. Pregnant patients, immunocompromised individuals, cancer patients, and patients with papilledema or systemic illnesses, including hypercoagulable disorders may benefit from imaging. Unlike most headaches, those associated with cough, exertion, or sexual activity usually require neuroimaging with MRI of the brain with and without contrast to exclude potentially underlying pathology before a primary headache syndrome is diagnosed. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment., (Copyright © 2014 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Objective: Normal facial nerve enhancement patterns derived from spin-echo (SE) sequences have not been systematically compared on contrast-enhanced 3D inversion recovery-prepared fast spoiled gradient-echo (IR-FSPGR) sequences, now in widespread use. We hypothesize that features unique to IR-FSPGR may engender differences in the appearance of the normal facial nerve, which may confound analysis of pathologic enhancement. We compared unenhanced and contrast-enhanced SE and IR-FSPGR sequences in a cohort of patients without facial nerve pathology., Materials and Methods: Twenty-three patients without facial nerve pathology were examined. Unenhanced and contrast-enhanced signal intensity (SI) of seven facial nerve segments was assessed on SE and IR-FSPGR by two neuroradiologists. SI was assigned a value of 0-3 (0, absent; 1, faint; 2, equivalent to brain; 3, equivalent to enhancing dural sinus). Statistically significant differences were assessed for each segment., Results: Significantly higher unenhanced and contrast-enhanced SI was present in most facial nerve segments on IR-FSPGR compared with SE, including cisternal, canalicular, labyrinthine, and geniculate segments (p ≤ 0.01). Enhancement patterns were generally similar; however, significant enhancement of the labyrinthine segment was detected only on SE (p = 0.011). For unenhanced images, mean kappa statistic was 0.32, and for the contrast-enhanced images, mean kappa statistic was 0.04, implying fair and slight agreement between readers, respectively., Conclusion: Significantly greater SI is observed in most facial nerve segments on both unenhanced and contrast-enhanced IR-FSPGR among healthy subjects and may be misinterpreted as pathologic when evaluated in the context of existing enhancement paradigms. Examiners should remain cognizant of normal deviations from expected enhancement patterns in IR-FSPGR imaging to avoid misdiagnosis and other interpretive pitfalls.

Purpose: Nodal extracapsular extension (ECE) in patients with head-and-neck cancer increases the loco-regional failure risk and is an indication for adjuvant chemoradiation therapy (CRT). To reduce the risk of requiring trimodality therapy, patients with head-and-neck cancer who are surgical candidates are often treated with definitive CRT when preoperative computed tomographic imaging suggests radiographic ECE. The purpose of this study was to assess the accuracy of preoperative CT imaging for predicting pathologic nodal ECE (pECE)., Methods and Materials: The study population consisted of 432 consecutive patients with oral cavity or locally advanced/nonfunctional laryngeal cancer who underwent preoperative CT imaging before initial surgical resection and neck dissection. Specimens with pECE had the extent of ECE graded on a scale from 1 to 4., Results: Radiographic ECE was documented in 46 patients (10.6%), and pECE was observed in 87 (20.1%). Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were 43.7%, 97.7%, 82.6%, and 87.3%, respectively. The sensitivity of radiographic ECE increased from 18.8% for grade 1 to 2 ECE, to 52.9% for grade 3, and 72.2% for grade 4. Radiographic ECE criteria of adjacent structure invasion was a better predictor than irregular borders/fat stranding for pECE., Conclusions: Radiographic ECE has poor sensitivity, but excellent specificity for pECE in patients who undergo initial surgical resection. PPV and NPV are reasonable for clinical decision making. The performance of preoperative CT imaging increased as pECE grade increased. Patients with resectable head-and-neck cancer with radiographic ECE based on adjacent structure invasion are at high risk for high-grade pECE requiring adjuvant CRT when treated with initial surgery; definitive CRT as an alternative should be considered where appropriate., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Sinonasal imaging is performed in 2 major clinical scenarios: inflammatory rhinosinusitis or suspected mass lesion. Rhinosinusitis affects more than 16% of the US population annually. It poses an immense economic burden, accounting for more than 26 million outpatient visits annually and costing more than $4.3 billion annually in direct medical expenses. Most cases of uncomplicated acute and subacute rhinosinusitis are diagnosed clinically and should not require any imaging procedure. CT of the sinuses without contrast is the imaging method of choice in patients with recurrent acute sinusitis or chronic sinusitis. Sinusitis cannot be diagnosed on the basis of imaging findings alone. CT scan findings should be interpreted in conjunction with clinical and endoscopic findings. MRI is currently used for evaluation of sinus disease as a complementary study in cases of aggressive sinus infection with ocular/intracranial complications, potential invasive fungal sinusitis in immunocompromised patients or in the evaluation of a sinonasal mass. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment., (Copyright © 2013 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Oral cavity cancer comprises nearly 30% of all malignant tumors of the head and neck. After a definitive diagnosis has been made, imaging is essential for staging the primary tumor by evaluating submucosal spread and invasion of adjacent structures, and to identify nodal or distant metastasis. Oral cavity anatomy is one of the most complex in the head and neck. Therefore, knowledge of anatomic subsites and spread patterns is critical for accurate staging. This article begins with a discussion of imaging techniques, and then presents a detailed review of normal anatomy followed by imaging's role in tumor staging highlighting potential pitfalls., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Background and Purpose: IIH is a syndrome of elevated intracranial pressure without hydrocephalus, mass, or identifiable cause. Diagnosis is made by clinical presentation, intracranial pressure measurement, and supportive imaging findings. A subset of patients with IIH may have tonsillar ectopia, meeting the criteria for Chiari malformation type I but not responding to surgical decompression for Chiari I. The purpose of this study was to determine the incidence and morphology of cerebellar tonsillar ectopia in patients with IIH., Materials and Methods: Forty-three patients with clinically confirmed IIH and 44 age-matched controls were included. Two neuroradiologists with CAQs reviewed sagittal T1-weighted MRI in a blinded fashion and measured cerebellar tonsil and obex positions relative to the foramen magnum and prepontine cistern width at the level of the midpons., Results: Nine of 43 patients with IIH and 1/44 controls had cerebellar tonsillar ectopia of ≥5 mm. Five of 9 of patients with IIH with ectopia of ≥5 mm also had a "peglike" tonsil configuration. Patients with IIH had a significantly lower tonsillar position (2.1 ± 2.8 mm) than age-matched controls (0.7 ±1.9 mm, P < .05). The obex position was significantly lower in patients with IIH versus controls (-7.9 mm [above the FM] versus -9.4 mm [above the FM], P < .05). The prepontine width was not significantly different between the groups., Conclusions: Cerebellar tonsil position in patients with IIH was significantly lower than that in age-matched controls, often times peglike, mimicking Chiari I. A significantly lower obex position suggests an inferiorly displaced brain stem and cerebellum. When tonsillar ectopia of >5 mm is identified, imaging and clinical consideration of IIH are warranted to avoid misdiagnosis as Chiari I.

Thyroid cancer is a heterogeneous group of malignancies, including differentiated thyroid carcinomas, medullary and anaplastic carcinomas, and non-Hodgkin lymphoma. The incidence, presentation, natural history, prognosis, and treatment vary greatly among this diverse group of malignancies. The primary role of imaging in thyroid cancer is to evaluate for extension of tumor beyond the thyroid capsule and to assess for nodal metastases. Ultrasound is the standard imaging option for uncomplicated thyroid cancer, but patients with symptoms suggesting extrathyroidal extension or palpable lateral lymphadenopathy should be considered for cross-sectional imaging with computed tomography or magnetic resonance imaging., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Background and Purpose: XETA, also known as Cube, is a relatively new 3D FSE sequence that can be used to perform whole-brain FLAIR T2-weighted imaging at isotropic high spatial resolution. This high-resolution volumetric imaging, coupled with both fat and fluid suppression, permits ideal evaluation of optic nerve anatomy and signal intensity; therefore, we hypothesized that XETA FLAIR would be useful for the detection of T2 signal-intensity abnormality in the optic nerve. Our purpose was to evaluate the sensitivity of XETA FLAIR for this abnormality and to compare it with the coronal FSE T2 FS., Materials and Methods: After obtaining approval of the institutional review board, 2 CAQ neuroradiologists retrospectively reviewed all patients with a clinical diagnosis of optic neuropathy who had undergone XETA FLAIR and standard orbital imaging from September 2006 to February 2009. Fifteen patients met these criteria and underwent the following sequences: XETA FLAIR, coronal FSE T2 FS, and T1-weighted postgadolinium sequences with FS., Results: Signal-intensity abnormality was identified on the correct side of the patient's vision loss in all 15 patients on XETA but in only 11/15 patients on the coronal FSE T2-weighted imaging. Reviewer 1 perceived the signal-intensity abnormality better on the XETA versus T2-weighted imaging in 10/15 patients, and reviewer 2, in 9/15 patients. Neither reviewer visualized any of the imaging better by using the conventional coronal FSE T2 FS sequence., Conclusions: XETA FLAIR was more sensitive than coronal FSE T2 FS for identifying abnormal signal intensity within the optic nerves in patients with optic neuropathy.

This article outlines a practical imaging approach to CNS infection and reviews 5 basic imaging patterns commonly seen: (1) extra-axial lesion, (2) ring-enhancing lesion, (3) temporal lobe lesion, (4) basal ganglia lesion, and (5) white matter abnormality. Opportunistic infections in the setting of HIV are also discussed within the context of these 5 basic imaging patterns. Characteristic imaging features in conjunction with clinical history are also highlighted in order to narrow the differential diagnosis or suggest a specific diagnosis in some cases., (Copyright © 2010 Elsevier Inc. All rights reserved.)

Purpose: To study the incidence, pathogenesis, imaging characteristics, and clinical importance of a unique subtype of epidural hematoma (EDH) associated with blunt head trauma., Materials and Methods: This study was reviewed and approved by the hospital's Institutional Review Board and was compliant with HIPAA. Informed consent was waived. The investigation was a retrospective study of 200 patients with acute supratentorial EDH, defined as a biconvex, high-attenuating, extraaxial hematoma. A subgroup of 21 patients in whom the EDH was located at the anterior aspect of the middle cranial fossa was defined. Computed tomographic images and inpatient medical records of these 21 patients were evaluated for imaging characteristics of the EDH, presence or absence of associated fracture, presence or absence of midline shift and/or mass effect, additional intracranial injury, and hospital clinical course., Results: Twenty-one (10.5%) of 200 traumatic EDHs localized to the anterior middle cranial fossa. All of these 21 anterior temporal EDHs were juxtaposed to the sphenoparietal sinus, and all but one were limited laterally by the sphenotemporal suture and medially by the orbital fissure; none extended above the lesser sphenoid wing. Maximum thickness was less than 1 cm in 13 (62%) of 21 and less than 2 cm in 20 (95%) of 21 patients. Isolated fractures of the greater sphenoid wing and ipsilateral zygomaticomaxillary fractures were present in 12 (57%) of 21 and nine (43%) of 21 patients, respectively. Concomitant intracranial injury was identified in 15 (71%) of 21 patients. Twenty (95%) of 21 lesions were present at the admission study, and all 21 were stable or smaller at follow-up imaging. No patient required neurosurgical intervention of their anterior temporal EDH., Conclusion: Acute EDHs isolated to the anterior aspect of the middle cranial fossa constitute a subgroup of traumatic EDHs with a benign natural history. It is postulated that they arise from venous bleeding due to disruption of the sphenoparietal sinus.

The goal of our study was to determine the interobserver variability between observers with different backgrounds and experience when interpreting computed tomography (CT) imaging features of traumatic brain injury (TBI). We retrospectively identified a consecutive series of 50 adult patients admitted at our institution with a suspicion of TBI, and displaying a Glasgow Coma Scale score < or =12. Noncontrast CT (NCT) studies were anonymized and sent to five reviewers with different backgrounds and levels of experience, who independently reviewed each NCT scan. Each reviewer assessed multiple CT imaging features of TBI and assigned every NCT scan a Marshall and a Rotterdam grading score. The interobserver agreement and coefficient of variation were calculated for individual CT imaging features of TBI as well as for the two scores. Our results indicated that the imaging review by both neuroradiologists and neurosurgeons were consistent with each other. The kappa coefficient of agreement for all CT characteristics showed no significant difference in interpretation between the neurosurgeons and neuroradiologists. The average Bland and Altman coefficients of variation for the Marshall and Rotterdam classification systems were 12.7% and 21.9%, respectively, which indicates acceptable agreement among all five reviewers. In conclusion, there is good interobserver reproducibility between neuroradiologists and neurosurgeons in the interpretation of CT imaging features of TBI and calculation of Marshall and Rotterdam scores.

Background and Purpose: Non-neoplastic, calcified, fibro-osseous lesions known as "calcifying pseudoneoplasms of the neuraxis" (CAPNON) are rare and can occur anywhere within the neuraxis. The radiologic and histopathologic characteristics of this unusual entity are not well understood. We present the largest series reviewing the MR imaging features of CAPNON., Materials and Methods: The MR and CT imaging features in 4 patients with a pathologic diagnosis of "calcifying pseudoneoplasms of the neuraxis" were retrospectively reviewed. A neuropathologist also analyzed the histopathologic features for typical and atypical patterns., Results: Imaging features were strikingly similar for all 4 patients. All lesions appeared T1 and T2 hypointense without vasogenic edema. All tumors had dense calcification, and 3 tumors showed minimal linear internal or rim enhancement on MR imaging., Conclusions: CAPNON may mimic more common vascular malformations or neoplasms and are often not considered in the differential diagnosis of calcified lesions. CAPNON should be included in the differential diagnosis of a calcified mass with marked T1 and T2 hypointensity and limited to no enhancement. Careful CT and MR imaging evaluation can suggest this entity, and this preoperative recognition may help subsequent management decisions.

Purpose: To compare temporal patterns of recurrent contrast enhancement in patients with glioblastoma multiforme (GBM) treated with brachytherapy plus external beam radiotherapy (EBRT) vs. EBRT alone., Methods and Materials: We evaluated serial MRI scans for 15 patients who received brachytherapy followed by EBRT (6000 cGy) and 20 patients who received standard EBRT alone (5940-6000 cGy). Brachytherapy consisted of permanent, low-activity (125)I seeds placed around the resection cavity at the time of initial gross total resection. Contrast enhancement (linear, nodular, feathery, or solid), serial progression, and location of contrast enhancement were described., Results: In the EBRT group, 14 patients demonstrated focal nodular contrast enhancement along the resection cavity within 4 months. The 6 remaining EBRT patients developed either transient linear enhancement or no abnormal enhancement. In the brachytherapy plus EBRT group, 7 patients initially developed linear rim enhancement within 4 months that progressed to feathery contrast enhancement over the course of 1 to 2 years. Histopathology confirmed radiation necrosis in all 7 patients. The remaining 8 brachytherapy patients eventually developed focal nodular contrast enhancement along the resection cavity and tumor recurrence., Conclusions: Our data suggest that longitudinal MRI features differ between GBM patients treated with EBRT vs. brachytherapy plus EBRT. In both groups, nodular enhancement adjacent to or remote from the resection cavity strongly suggested tumor recurrence. Feathery enhancement, which progressed from linear rim enhancement immediately adjacent to the cavity, seen only in brachytherapy patients, strongly indicated radiation necrosis.

Background: Presyrinx is a reversible state of spinal cord edema caused by alterations in CSF flow dynamics. Only three pediatric cases have been reported previously. We describe the clinical and radiologic features of presyrinx in six pediatric patients., Methods: We electronically searched pediatric spine MRI reports generated at our institution from January 1995 to April 2007 for the keyword "presyrinx" and identified six patients with this radiologic diagnosis. We reviewed the neuroimaging studies and medical records for information regarding symptoms, treatment, and outcome., Results: Of six patients identified with presyrinx, four had a Chiari I malformation and two had a Chiari II malformation. The MRI characteristics of the presyrinx included T2 prolongation, mild indistinct T1 prolongation, and cord enlargement without frank cavitation. Cine phase-contrast MRI studies were performed in three patients and showed severely diminished or absent CSF flow at the foramen magnum. Five patients underwent surgical decompression. All three patients with postoperative spine imaging showed restoration of CSF flow and resolution of the presyrinx. Symptoms of chronic or acute myelopathy attributable to the presyrinx were present in two patients. These symptoms resolved postoperatively., Conclusions: Chiari I and II malformations obstructing CSF flow at the craniocervical junction may cause presyrinx in children. Presyrinx should be considered in the differential diagnosis of chronic or acute myelopathy in patients at risk for abnormal CSF flow dynamics.

Hodgkin (HL) and non-Hodgkin lymphoma (NHL) involving the head and neck have many overlapping imaging features. Definitive diagnosis depends on histology, but imaging trends may help distinguish lymphoma from other common pathologic entities in the head and neck. CT is useful for staging and assessing bony involvement, whereas MR imaging is performed for soft tissue detail in extranodal disease, especially when there is transpatial disease or intracranial or intraspinal extension. Positron emission tomography has become an important part of staging and surveillance imaging and is particularly useful to distinguish posttreatment fibrosis and residual tumor.

Purpose: To investigate the potential value and relationship of in vivo quantification of apparent diffusion coefficients (ADCs) and T2 relaxation times for characterizing brain tumor cellularity and tumor-related edema., Materials and Methods: A total of 26 patients with newly diagnosed gliomas, meningiomas, or metastases underwent diffusion-weighted and six-echo multisection T2-preparation imaging. Regions of interest (ROIs) were drawn on conventional MR images to include tumor (as defined by contrast agent enhancement) and immediate and peripheral edema. Areas of necrosis were excluded. Median values of ADCs and T2 in the ROIs were calculated., Results: ADCs for gliomas were similar to those for meningiomas or metastases in all regions. Tumor T2 values for gliomas (159.5+/-30.6 msec) were significantly higher than those for meningiomas or metastases (125.0+/-31.1 msec; P=0.005). Immediate-edema T2 values for meningiomas or metastases (226.0+/-44.1 msec) were significantly higher than those for gliomas (203.5+/-32.8 msec; P=0.033). Peripheral-edema T2 values for gliomas (219.5+/-41.9 msec) were similar to those for meningiomas or metastases (202.5+/-26.5 msec; P=0.377). Both immediate- and peritumoral-edema ADCs and T2 values were significantly higher than those in tumor for both tumor types. ADCs and T2 values from all regions correlated significantly for gliomas (r=0.95; P<0.0001) and for meningiomas or metastases (r=0.81; P<0.0001)., Conclusion: The higher immediate-edema T2 values for nonglial tumors than for gliomas suggest tumor-related edema (vasogenic vs. infiltrated) can be further characterized by using T2 values. There were significant correlations between ADC and T2 values., (Copyright (c) 2005 Wiley-Liss, Inc.)