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PURPOSE: For glioblastoma (GBM), imaging response (IR) or pseudoprogression (PSP) is frequently observed after chemoradiation and may connote a favorable prognosis. With tumors categorized by the Cancer Genome Atlas Project (mesenchymal, classical, neural, and proneural) and by methylguanine-methyltransferase (MGMT) methylation status, we attempted to determine if certain genomic or molecular subtypes of GBM were specifically associated with IR or PSP. METHODS: Patients with GBM treated at two institutions were reviewed. Kaplan-Meier method was used to estimate overall survival (OS) and progression-free survival (PFS). Mantel-cox test determined effect of IR and PSP on OS and PFS. Fisher’s exact test was utilized to correlate IR and PSP with genomic subtypes and MGMT status. RESULTS: Eighty-two patients with GBM were reviewed. The median OS and PFS were 17.9 months and 8.9 months. IR was observed in 28 (40%) and was associated with improved OS (median 29.4 vs 14.5 months p < 0.01) and PFS (median 17.7 vs 5.5 months, p < 0.01). PSP was observed in 14 (19.2%) and trended towards improved PFS (15.0 vs 7.7 months p = 0.08). Tumors with a proneural component had a higher rate of IR compared to those without a proneural component (IR 60% vs 28%; p = 0.03). MGMT methylation was associated with IR (58% vs 24%, p = 0.032), but not PSP (34%, p = 0.10). CONCLUSION: IR is associated with improved OS and PFS. The proneural subtype and MGMT methylated tumors had higher rates of IR.

Prolonged survival in brain metastasis patients increases recurrence rates and places added importance on salvage therapies. Research examining carmustine polymer wafers as an adjuvant therapy for brain metastasis is limited. We present a single institution retrospective series documenting the use of BCNU wafers placed in the cavity of resected recurrent brain metastases that had failed prior stereotactic radiosurgery (SRS). Between February 2002 and April 2013, a total of 31 patients with brain metastases failed SRS and underwent resection with intracavitary placement of carmustine wafers. Clinical outcomes including local control, survival, cause of death, and toxicity were determined from electronic medical records. Kaplan-Meier analysis was performed to assess local control and survival. Imaging features were reviewed and described for patients with serial post-operative follow-up imaging examinations over time. Overall survival at 6 months and 12 months was 63% and 36%, respectively. Fourteen of 31 patients (45%) died from neurologic causes. Local control within the resection cavity was 87% and 70% at 6 and 12 months, respectively. Five patients (16%) underwent further salvage therapy following carmustine wafer placement after local failure. Resection cavities of all six patients with follow-up imaging showed linear peripheral enhancement. Pericavity and wafer enhancement was present as early as the same day as surgery and persisted in all cases to 6 months or longer. Carmustine polymer wafers are an effective salvage treatment following resection of a brain metastasis that has failed prior SRS. For patients with successful local control after wafer implantation, linear enhancement at the cavity is common.

OBJECTIVE:: We investigate the patterns of failure in the treatment of glioblastoma (GBM) based on clinical target volume (CTV) margin size, dose delivered to the site of initial failure, and the use of temozolomide and intensity-modulated radiotherapy (IMRT). METHODS:: Between August 2000 and May 2010, 161 patients with GBM were treated with radiotherapy with or without concurrent temozolomide. Patients were treated with CTV expansions that ranged from 5 to 20 mm using a shrinking field technique. Patterns of failure and time to progression and overall survival were compared based on CTV margin, use of temozolomide, and use of IMRT. Kaplan Meier analysis was used to estimate survival times, and χ test was used for comparison of cohorts. RESULTS:: For patients treated with 5-, 10-, and 15- to 20-mm CTV, 79%, 77%, and 86% experienced failures in the 60 Gy volume, respectively. Forty-eight percent, 55%, and 66% of patients with 5-, 10-, and 15- to 20-mm CTV experienced failures in the 46 Gy volume, respectively. There was no statistical difference between patients treated with 5-, 10-, 15- to 20-mm margins with regard to 60 Gy failure (P=0.76), 46 Gy failure (P=0.51), or marginal failure (P=0.73). Eighty percent of patients receiving temozolomide experienced failures in the 60 Gy volume. There was no increased likelihood of marginal failures in patients receiving IMRT (P=0.97). CONCLUSIONS:: Modern treatment techniques including use of concurrent temozolmide, limited CTV margin size, and IMRT have not greatly changed the patterns of failure of GBM.

Introduction The goal of this study was to determine if clinically relevant endpoints were changed by improved MRI resolution during radiosurgical treatment planning. Methods and Materials Between 2003 and 2008, 200 consecutive patients with brain metastases treated with Gamma Knife radiosurgery (GKRS) using either 1.5 T or 3.0 T MRI for radiosurgical treatment planning were retrospectively analysed. The number of previously undetected metastases at time of radiosurgery, distant brain failures, time delay to whole brain radiotherapy (WBRT), overall survival and likelihood of neurological death were determined. Results Additional metastases were detected in 31.3% and 24.5% of patients at time of radiosurgery with 3.0 T and 1.5 T MRI, respectively (P = 0.27). Patients with multiple metastases at diagnostic scan were more likely to have additional metastases detected by 3.0 T MRI (P

Trigeminal trophic syndrome (TTS) is the historic name for neuropathic self-induced facial ulceration from abnormal sensory symptoms leading to uncontrolled scratching. Anatomic co-localization of sensory loss (numbness) plus neuropathic itch and pain permits painless scratching. If the itch is severe, some patients will scratch to the point of causing self-injury. Patients may be unaware or may conceal the fact that their lesions are self-induced and thus the diagnosis presents a clinical challenge. Many cases remain undiagnosed, leading to unnecessary and ineffective tests, procedures, and prescribing. We document a patient with a central cause of TTS - multiple cerebral vascular accidents - and summarize the presentation, pathogenesis, and treatment options.

Novel therapeutic options for patients with recurrent primary central nervous system lymphoma (RPCNSL) are needed. Bendamustine, a bifunctional purine analog/alkylating agent, is approved for use in patients with progressive systemic indolent non-Hodgkin's B-cell lymphomas. Limited data suggests that bendamustine may partition into the brain in the setting of a disrupted blood-brain barrier. This report describes the first known experience of patients with RPCNSL treated with bendamustine. Therapy was well-tolerated and best response was noted as stable disease after eight cycles of bendamustine followed by a subsequent local systemic recurrence found at five months follow-up. CNS involvement in this patient remained stable 20 + months post-bendamustine treatment. Based on our observations, further neuropharmacokinetic and efficacy studies with bendamustine may be warranted in this patient population.

BACKGROUND AND PURPOSE: MR perfusion imaging can be used to help predict glial tumor grade and disease progression. Our purpose was to evaluate whether perfusion imaging has a diagnostic or therapeutic impact on clinical management planning in patients with glioma. MATERIALS AND METHODS: Standard MR imaging protocols were interpreted by a group of 3 NRs in consensus, with each case being interpreted twice: first, including routine sequences; and second, with the addition of perfusion imaging. A multidisciplinary team of treating physicians assessed tumor status and created hypothetical management plans, on the basis of clinical presentation and routine MR imaging and then routine MR imaging plus perfusion MR imaging. Physicians9 confidence in the tumor status assessment and management plan was measured by using Likert-type items. RESULTS: Fifty-nine consecutive subjects with glial tumors were evaluated; 50 had known pathologic diagnoses. NRs and the treatment team agreed on tumor status in 45/50 cases (κ = 0.81). With the addition of perfusion, confidence in status assessment increased in 20 (40%) for NRs and in 28 (56%) for the treatment team. Of the 59 patient-care episodes, the addition of perfusion was associated with a change in management plan in 5 (8.5%) and an increase in the treatment team9s confidence in their management plan in 34 (57.6%). NRs and the treatment team found perfusion useful in most episodes of care and wanted perfusion included in future MR images for >80% of these subjects. CONCLUSIONS: Perfusion imaging appears to have a significant impact on clinical decision-making and subspecialist physicians9 confidence in management plans for patients with brain tumor.

In recent years, there has been evidence of increasing patient interest in easy, timely and complete access to all personal health information [1–4,101]. Breadth of interest has perhaps been increased by the recent American Recovery and Reinvestment Act of 2009 (ARRA) legislation which offers tangible incentives to providers who develop systems that offer patients access to electronic health records in order to maintain personal health records [5,102]. While the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 with ARRA outlines some specific required content for the patient-accessed medical records (e.g., allergies, medications and problem lists) in order for provider systems to qualify for financial incentives, inclusion of radiology reports has not been in early guidelines. However, there is evidence that patients specifically desire access to radiology results and so the question of how increased patient access to these test results might affect quality of care is raised [1,3,6–8].

Purpose The aim of this study was to determine if radiology residents who use a structured reporting system (SRS) produce reports of greater clarity than residents who use free-text dictation to report cranial MR imaging in patients with clinical suspicion of stroke. Methods This double-cohort study included residents creating reports for 25 cranial MR imaging studies using an SRS in the intervention group and free text in the control group (report n=1,685). Attending physicians from multiple subspecialties were surveyed seeking clarity ratings of randomly selected reports. Two neuroradiology fellows rated the clarity of 180 of the reports. Clarity ratings were analyzed by using Wilcoxon's signed-rank test for paired data and the Mann-Whitney U test for unpaired data. Results Forty-three of 95 surveyed physicians returned completed surveys, with mean clarity ratings for SRS (4.9) and free-text (5.1) reports that did not differ significantly. Respondents' comments most often referred to confusing syntax, unfamiliar terms, or format preferences. Fellow raters rated the clarity of SRS reports lower than that of free-text reports ( P Conclusions The use of an SRS to create MRI reports did not seem to improve or worsen attending physicians' perceptions of report clarity. Experience level may affect clarity-related report preferences. Future SRS should probably include definitions of key terms and be formatted to minimize syntactical errors.

Split cord malformation and lateral hemimyelomeningocele are 2 rare spinal anomalies, which were both discovered in a female newborn. The constellation of anomalies is presented in the setting of Chiari II malformation. Cross-sectional imaging of the salient abnormalities in the form of computed tomography and magnetic resonance imaging along with 3-dimensional and multiplanar reformatting is highlighted.

This trial investigated anxiety levels and effect of an educational coloring book (CB) among pediatric patients about to undergo radiology imaging tests. Control group ( N = 101) and intervention group ( N = 175) children ages 3—10 years and their parents were surveyed to determine anxiety levels before the imaging test, with the intervention group being surveyed after patient and parental review of the CB. Anxiety was low for all subjects overall compared with findings from previously published literature, perhaps related to systemic measures to make children’s hospitals more child friendly in recent years. Review of the CB was not associated with decreased anxiety among patients or parents. However, among a subgroup with higher baseline parental anxiety, there was a trend toward lower patient anxiety in the intervention group. Most parents indicated that the CB was informative and helped them and their child be less worried, and that they were pleased to have received the CB.

To determine if radiology residents who used a structured reporting system (SRS) produced higher quality reports than residents who used conventional free-text dictation to report cranial magnetic resonance (MR) imaging in patients suspected of having a stroke.The study was approved by an institutional review board and was HIPAA compliant; informed consent was obtained. This study included residents, with 16 in the control group and 18 in the intervention group. For phase 1, each subject reviewed the same set of 25 brain MR imaging cases and dictated the cases by using free-text conventional dictation. For phase 2, 4 months later, the control group repeated the same process, whereas the intervention group reread the same MR imaging cases by using SRS to create reports. Resident-generated reports were graded for accuracy and completeness by a neuroradiologist on the basis of consensus interpretations and criterion standard diagnoses as established with at least 6 months of clinical follow-up, imaging follow-up, and/or histologic examination where appropriate. Accuracy and completeness scores were analyzed by using a Wilcoxon signed rank test for paired data and a Mann-Whitney U test for nonpaired data. Intervention group residents were surveyed regarding their opinions of SRS.For phase 1 reports, no significant difference in accuracy or completeness scores between control and intervention groups was found. Decreases in accuracy (91.5 to 88.7) and completeness (68.7 to 54.3) scores for phase 2 compared with phase 1 for the intervention group were found; increases in accuracy (91.4 to 92.4) and completeness (67.8 to 71.7) scores for phase 2 compared with phase 1 for the control group were found (all P values.001). The most common complaints were that the SRS was overly constraining with regard to report content and was time-consuming to use.While there are many potential benefits of structuring radiology reports, such changes cannot be assumed to improve report accuracy or completeness. Any SRS should be tested for effect on intrinsic report quality.

To investigate the use of clinical head magnetic resonance imaging (MRI) in determining body composition and to evaluate how well it correlates with established measures based on abdominal computed tomography (CT).Ninety-nine consecutive patients were identified who had undergone both brain MRI and abdominal CT within a 2-week span. Volumes of fat and muscle in the extracranial head were measured utilising several techniques by both abdominal CT and head MRI.MRI-based total fat volumes in the head correlated with CT-based measurements of fat in the abdomen using both single-section (r=0.64, p0.01) and multisection (r=0.60, p0.01) techniques. No significant correlation was found between muscle volumes in the abdomen and head.Based on the present results, head MRI-based measures may provide a useful surrogate for CT measurements of abdominal fat, particularly in patients with neurological cancers, as head MRI (and not abdominal CT) is routinely and repeatedly obtained for the purpose of clinical care for these patients.

Purpose Our long-term goal is to improve the quality of reports in radiology imaging interpretation. The rationale for this project focused on identifying the characteristics of a high-quality report from the perspective of referring physicians and radiologists. Methods We undertook a survey of physician faculty at a large Midwestern academic medical center (including university, children's, veteran's, county and private practice hospitals) regarding radiology report quality concepts. Results Using a 5-point Likert scale, >95% of respondents indicated the highest importance rating (score=5) for radiology report characteristic "Accurate," with mean score of 4.94. Seventy-eight to 83% of respondents considered "Clear," "Complete" and "Timely" to have the highest importance rating, with means of these scores between 4.73 and 4.79. Somewhat less desirable characteristics included "Well-organized" and "Mentions pertinent negatives"—though radiologists tended to think the latter was less important than did all other categories of physician respondents. The single greatest problem area in reporting is lack of timeliness. Using a 10-point Likert scale, respondents gave a median score of seven for overall satisfaction with current reporting. Conclusions For high-quality radiology reporting, accuracy is most important. Clarity, completeness and timeliness are also very important. Radiologists tend to consider mentioning pertinent negatives as less important than do referring physicians; otherwise, respondents from different specialties largely agreed on which characteristics are most important for high-quality reports. There is room for improvement in physician satisfaction with radiology reporting.

Rationale and Objectives Research is a critical component of the mission of academic radiology, and success in research is necessary for the future of neuroradiology. Thus, the authors set out to establish a baseline of research activities of American Society of Neuroradiology (ASNR) members. Materials and Methods The authors surveyed 100 fellowship program directors. The survey was Web based, with recruitment from the ASNR Fellowship Database survey site and with e-mail and fax solicitations to the Web site. Questions focused on neuroradiologist and neuroradiology fellow involvement in research. Results Forty-eight of the 100 program directors (48%) responded. Several key findings emerged: (a) About one-third of fellowship programs require all fellows to do some research, with most fellows receiving less than 1 day per week of academic time; (b) just over half of the programs expect fellows to publish a paper; (c) about two-thirds of academic neuroradiologists get at least 1 academic day per week; (d) most academic neuroradiologists perform research, but most of this research is unfunded; and (e) about nine of 10 academic sections have at least one neuroradiologist with some extramural funding. Conclusion The relative lack of extramural funding among academic neuroradiologists is a reality that is probably multifactorial; however, there may be a direct relationship between amount of academic time free from clinical duties and successful competition for funding. The time (and, thus, financial) support of research-oriented fellows and faculty should be increased.

The blood-brain-barrier (BBB) presents a significant obstacle to the delivery of systemically administered chemotherapeutics for the treatment of brain cancer. Irreversible electroporation (IRE) is an emerging technology that uses pulsed electric fields for the non-thermal ablation of tumors. We hypothesized that there is a minimal electric field at which BBB disruption occurs surrounding an IRE-induced zone of ablation and that this transient response can be measured using gadolinium (Gd) uptake as a surrogate marker for BBB disruption. The study was performed in a Good Laboratory Practices (GLP) compliant facility and had Institutional Animal Care and Use Committee (IACUC) approval. IRE ablations were performed in vivo in normal rat brain (n = 21) with 1-mm electrodes (0.45 mm diameter) separated by an edge-to-edge distance of 4 mm. We used an ECM830 pulse generator to deliver ninety 50-μs pulse treatments (0, 200, 400, 600, 800, and 1000 V/cm) at 1 Hz. The effects of applied electric fields and timing of Gd administration (-5, +5, +15, and +30 min) was assessed by systematically characterizing IRE-induced regions of cell death and BBB disruption with 7.0-T magnetic resonance imaging (MRI) and histopathologic evaluations. Statistical analysis on the effect of applied electric field and Gd timing was conducted via Fit of Least Squares with α = 0.05 and linear regression analysis. The focal nature of IRE treatment was confirmed with 3D MRI reconstructions with linear correlations between volume of ablation and electric field. Our results also demonstrated that IRE is an ablation technique that kills brain tissue in a focal manner depicted by MRI (n = 16) and transiently disrupts the BBB adjacent to the ablated area in a voltage-dependent manner as seen with Evan's Blue (n = 5) and Gd administration.

The goal of this study was to determine if clinically relevant endpoints were changed by improved MRI resolution during radiosurgical treatment planning.Between 2003 and 2008, 200 consecutive patients with brain metastases treated with Gamma Knife radiosurgery (GKRS) using either 1.5 T or 3.0 T MRI for radiosurgical treatment planning were retrospectively analysed. The number of previously undetected metastases at time of radiosurgery, distant brain failures, time delay to whole brain radiotherapy (WBRT), overall survival and likelihood of neurological death were determined.Additional metastases were detected in 31.3% and 24.5% of patients at time of radiosurgery with 3.0 T and 1.5 T MRI, respectively (P = 0.27). Patients with multiple metastases at diagnostic scan were more likely to have additional metastases detected by 3.0 T MRI (P 0.1). Median time to distant brain failure was 4.87 months and 5.43 months for the 3.0 T and 1.5 T cohorts, respectively (P = 0.44). Median time to WBRT was 5.8 months and 5.3 months for the 3.0 T and 1.5 T cohorts, respectively (P = 0.87). Median survival was 6.4 months for the 3.0 T cohort, and 6.1 months for the 1.5 T cohort (P = 0.71). Likelihood of neurological death was 25.3% and 16.7% for the 3.0 and 1.5 T populations, respectively (P = 0.26).The 3.0 T MRI-based treatment planning for GKRS did not appear to affect the likelihood of distant brain failure, the need for WBRT or the likelihood of neurological death in this series.

The aim of this study was to determine (1) the patient-preferred timing characteristics of a system for online patient access to radiologic reports and (2) patient resource needs and preferences after exposure to reports.Adult outpatients from a single imaging center completed researcher-administered electronic questionnaires. Participants were exposed to 3 simulated clinical scenarios and asked to answer questions on the basis of what they thought they would do in each. Scenarios included symptomatology and written radiology reports that were nearly normal, seriously abnormal, and indeterminate, with reports containing typical medical terminology. Participants were asked about preferred timing for online access to reports, communication methods, educational resources, and alternative formats. McNemar's test correlated proportions and generalized estimating equations were used to evaluate responses.Participants (n = 53) most often preferred immediate access to reports: 32 (60.2%) for the nearly normal scenario, 25 (47.2%) for the seriously abnormal scenario, and 24 (45.3%) for the indeterminate scenario. Three-day delayed access was next most commonly preferred: 15 (28.3%), 19 (35.8%), and 19 (35.8%), respectively. Forty-two participants (79.2%) preferred the portal method of notification over ways they have historically gotten results, with an increased proportion being satisfied with it overall (P.04). Most would use a variety of educational resources and found alternative lay language conclusions and hyperlinks helpful.Some outpatients want immediate online access to complete, written radiologic reports and would use multiple resources to understand report contents. Effects of immediate access on provider workflow and on anxiety and autonomy among a diverse population of patients still need to be studied.

The purpose of this study was continuous quality improvement (CQI) of head and neck CT angiography (CTA) in the neuroradiology practice of a tertiary care medical center.We conducted baseline quality audits of 50 consecutive head or neck CTAs, including referrals for a variety of indications from emergency department, ambulatory, and inpatient settings. Neuroradiologists as a group used Likert-type questionnaire items to assess scan quality. Based on identified opportunities for CQI, the group evaluated alternative scanning methods, proposed action items, and implemented changes in scanning methods. After implementing the changes, the group performed follow-up quality audits of 61 consecutive CTAs. Quality of scans was compared for baseline and postimplementation patients using chi-square or McNemar tests.Several key opportunities for CQI were identified, namely related to coverage levels and timing. These opportunities were translated into protocol changes, standardization of methods, and in-service sessions to implement specific process changes. Using a Likert-type scale with 1 anchored at "excellent" and 5 at "poor," the overall quality of CTAs improved from 2.46 at baseline to 1.64 after implementation of QI measures (P .01). There were significant improvements in timing and coverage, and fewer scans required quality disclaimers after CQI implementation.Using basic CQI techniques of assessment, analysis, change implementation, and reassessment, the quality of CTA scans in a busy neuroradiology clinical practice can be improved. These techniques are amenable to repeated use, so that CQI can be a routine practice to help optimize the quality of care in radiology.

Purpose To investigate the efficacy of 3.0-T magnetic resonance imaging (MRI) for detecting brain metastases for stereotactic radiosurgery (SRS) planning. Methods and Materials All adult patients scheduled for SRS treatment for brain metastases at our institution between October 2005 and January 2008 were eligible for analysis. All patients underwent radiosurgery treatment planning 3.0-T MRI on the day of scheduled radiosurgery and a diagnostic 1.5-T MRI in the days or weeks prior to radiosurgery for comparison. Both scans were interpreted by neuroradiologists who reported their findings in the radiology reports. We performed a retrospective review of the radiology reports to determine the number of brain metastases identified using each MRI system. Results Of 254 patients scheduled for treatment from October 2005 to January 2008, 138 patients had radiology reports that explicitly described the number of metastases identified on both scans. With a median interval of 17 days (range, 1–82) between scans, the number of metastases detected using 1.5-T MRI system ranged from 1 to 5 and from 1 to 8 using the 3.0 T-MRI system. Twenty-two percent of patients were found to have a greater number of metastases with the 3.0 T-MRI system. The difference in number of metastases detected between the two scans for the entire cohort ranged from 0 to 6. Neither histology (p = 0.52 by chi-sq test) nor time between scans (p = 0.62 by linear regression) were significantly associated with the difference in number of metastases between scans. Conclusions The 3.0-T MRI system appears to be superior to a 1.5-T MRI system for detecting brain metastases, which may have significant implications in determining the appropriate treatment modality. Our findings suggest the need for a prospectively designed study to further evaluate the use of a 3.0 T-MRI system for stereotactic radiosurgery planning in the treatment of brain metastases.

Purpose The aim of this study was to seek physicians' perspectives on radiology reporting systems, so that reporting systems can begin to be reorganized and made more patient centered by giving patients greater access to their personal health information. Methods Focus-group methodology was used to explore physicians' views on direct patient access to radiologic test results. Subjects for the two groups were physicians at a single academic medical center. Transcripts were analyzed using thematic content analysis. Results Most participants were dissatisfied with current reporting systems. Both radiologists and referring physicians (RPs) were aware that patients are not satisfied with the current system for notification of radiologic test results, and both thought that patients should have access to personal health information and take responsibility for their own health care. Regarding direct patient online access to results, both radiologists and RPs were concerned that patients would not understand report contents and that such access would lead to greater patient anxiety and demands on RPs' time. Referring physicians were also concerned that direct patient access to results would cause RPs to lose some control in the patient-physician relationship. Both radiologists and RPs preferred that any system for direct patient access incorporate a time delay and be tested for effect before being implemented. Conclusions Revisions attempting to increase the patient-centeredness of care in the area of radiology reporting should be developed and tested to 1) minimize adverse effects on patient anxiety; 2) optimize timing, considering effects on both patients and RPs; and 3) simultaneously address problems with between-physician reporting methods.

Purpose The aim of this study was to seek patients' perspectives on radiology reporting systems, so that reporting systems can begin to be reorganized and made more patient-centered by giving patients greater access to their personal health information. Methods Focus group methodology was used to explore which aspects of radiology information are important to patients and to identify their preferred means of access to and format of this information. Subjects for the two groups were outpatients who had recently undergone MR imaging at a single academic medical center. Transcripts were analyzed using thematic content analysis. Results Most subjects were dissatisfied with current reporting systems, citing delays and a lack of detail as the most important problems. Subjects varied with regard to preferences for who should relay results to them, with some expressing a desire for increased direct input from radiologists because they have greater expertise in imaging interpretation. Most subjects wanted results in writing and in detail, with attached lay language explanations, though a few subjects preferred less detail. Subjects were decidedly in favor of having the option to access results immediately via an online system, proposing some potential problems and potentially multiple benefits of such a system. Conclusions Whatever system revisions are attempted to increase the patient-centeredness of care as regards to radiology reporting, patients will need to be able to choose their preferred levels of access and will need to have the option of accessing full details.

BACKGROUND AND PURPOSE: To minimize diagnostic confusion, a CSF specimen should be free from traumatically introduced red blood cells (RBCs). The purpose of this research is to determine if patient age, sex, gauge of the lumbar puncture (LP) needle, or the level of LP is associated with an increased risk for traumatic fluoroscopy-guided LP. MATERIALS AND METHODS: Data were collected retrospectively for consecutive male and female patients of all ages ( n = 756) who underwent a fluoroscopy-guided LP for a 2-year period. We defined traumatic LP as a CSF sample with an RBC count more than 500 cells/mm3 without xanthochromia. RESULTS: Rate of traumatic LP was 13.3%. The rate of traumatic LP at the L4-L5 level (19%) was significantly higher than at the L2-L3 (9%) or L3-L4 level (10%). Patients older than 80 years had higher traumatic LP rates (25.9%) compared with patients between ages 11 and 80 years (12.4%). Sex and gauge of the spinal needle were not associated with increased rate of traumatic LP. Patients younger than 1 year had failed LP rate of 58.8% compared with 3.2% failure rate in older patients. CONCLUSIONS: Fluoroscopy-guided LP at the L4-L5 level is associated with nearly twice the risk for traumatic puncture compared with the L2-L3 or L3-L4 level. Rates of traumatic result are twice as high in adults older than 80 years compared with younger patients. Failure rates for fluoroscopy-guided LP are low except in children younger than 1 year, in whom failure occurs in most cases.

Radiologists face substantial challenges in the timely and appropriate communication of diagnostic test results. As with other systems in health care delivery, the radiology reporting system is not designed to be optimally safe, timely, and patient centered. To improve the quality of care, there must be a new commitment to organizing services around patients' needs, including the reporting of diagnostic test results directly from radiologists to patients. The rationale for this change is that if both referring physicians and patients are given imaging examination results from radiologists immediately after their interpretation, it would be less likely that important diagnostic information would be lost or overlooked. The results would be provided to all stakeholders in a more timely fashion, the potential for important information to "fall through the cracks" would be diminished, and safety would be improved. Providing these results to patients directly online would also allow radiologists to facilitate increased patient satisfaction and patient-centered care by treating patients as "co-customers" and equal partners with referring physicians with regard to access to information and shared decision making.

To compare a reduced (three-sequence) magnetic resonance (MR) imaging protocol with a full (eight- to 10-sequence) MR imaging protocol in adults suspected of having stroke.Six neuroradiologists interpreted a consecutive sample of 265 MR images in patients suspected of having stroke. Each read reduced-protocol images in a discrete series of 40 patients (one read images in only 15) and corresponding full-protocol images 1 month later (reduced/full protocol). Five of the readers each read images in 10 additional cases, five each as full/full and reduced/reduced protocol controls. kappa values between full and reduced protocols, reader assessment of protocol adequacy, confidence level, and need for additional sequences or examinations were evaluated.In the reduced/full protocol, the kappa value for detecting ischemia was 0.797; and that for detecting any clinically important abnormality, 0.635. Statistically similar kappa values were found with the full/full control design (kappa = 0.802 and 0.715, respectively). The full protocol was judged more adequate than the reduced protocol (2.0 of 5.0 points vs 1.6, P.001) and generated greater diagnostic confidence (8.6 of 10.0 points vs 8.9, P =.01), less need for additional sequences (2.7 of 6.0 points vs 1.5, P.001), and more requests for additional examinations (28.4% vs 36.3%).Disagreement between interpretations of reduced- and full-protocol images might be attributable to baseline-level intraobserver inconsistency, as demonstrated in control designs. A greater number of sequences did not lead to greater consistency.

Our objective was to examine the effectiveness of echoplanar diffusion-weighted (DW) imaging in detecting CNS ischemia in neonates and infants and to determine how well the imaging findings using this technique correlate with short-term neurologic deficit.Echoplanar DW images, turbo T2-weighted images, and fluid-attenuated inversion recovery (FLAIR) sequences were obtained in a clinically defined cohort of 26 consecutive neonates and infants with suspected hypoxic-ischemic injury. Echoplanar DW imaging was performed with the diffusion gradient in the slice-select direction: b value, 1200 sec/mm2; matrix, 128 x 128, interpolated to 256 x 256. Four scans (4 sec per scan) were obtained and averaged to optimize the signal-to-noise ratio. Most patients were not sedated (n = 19). Abnormalities seen on DW imaging were correlated with clinical findings at short-term follow-up and compared with findings on FLAIR and turbo T2-weighted images.Short-term clinical follow-up showed neurologic deficit in 10 (83%) of 12 patients with DW images with abnormal findings, and no neurologic sequelae in 12 (86%) of 14 patients with DW images with normal findings. Echoplanar DW images revealed a greater extent of and a larger number of abnormalities compared with FLAIR or turbo T2-weighted images in 11 (92%) of 12 patients with DW images with abnormal findings.Echoplanar DW imaging reveals abnormalities poorly depicted on turbo T2-weighted and FLAIR images in neonates and infants with clinically suspected hypoxic-ischemic injury. DW imaging may be able to identify which patients are likely to develop at least short-term neurologic deficits and may afford the best early evaluation of short-term neurologic prognosis in these patients.

Physicians displayed significantly greater satisfaction with the content and clarity of structured reports than with the content and clarity of conventional reports.