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Approximately half of head and neck carcinomas arise from the oral cavity. Imaging plays an essential role in the preoperative evaluation of oral cavity carcinomas. MR imaging is particularly advantageous in the evaluation of the oral cavity, with better depiction of the anatomy in this region and reduction of dental artifacts compared with CT. MR is also the preferred imaging modality for the evaluation of bone marrow invasion and perineural tumor spread, which are findings critical for treatment planning. Advanced MR imaging techniques may potentially better delineate true tumor extent, determine lymph node metastases, and predict treatment response.

This single-institution phase II study was performed to estimate the response rate to lapatinib in neurofibromatosis type 2 (NF2) patients with progressive vestibular schwannoma (VS). Twenty-one eligible patients were enrolled. Brain and spine MRIs, including 3-dimensional volumetric tumor analysis, and audiograms were performed once at baseline and again every 12 weeks. The primary response end point was evaluable in 17 patients and defined as ≥15% decrease in VS volume. Hearing was evaluable as a secondary end point in 13 patients, with responses defined as an improvement in the pure tone average of at least 10 dB or a statistically significant increase in word recognition scores. Four of 17 evaluable patients experienced an objective volumetric response (23.5%; 95% confidence interval [CI], 10%–47%), with median time to response of 4.5 months (range, 3–12). In responders, reduction in VS volumes ranged from −15.7% to −23.9%. Four of 13 patients evaluable for hearing met hearing criteria for response (30.8%; 95% CI, 13%–58%). One sustained response exceeded 9 months in duration. Median time to overall progression (ie, volumetric progression or hearing loss) was 14 months. The estimated overall progression-free survival and volumetric progression-free survival at 12 months were 64.2% (95% CI, 36.9%–82.1%) and 70.6% (95% CI, 43.1%–86.6%), respectively. Toxicity was generally minor, and no permanent dose modifications were required. Lapatinib carries minor toxicity and has objective activity in NF2 patients with progressive VS, including volumetric and hearing responses. Future studies could explore combination therapy with other molecular targeted agents such as bevacizumab.

With the availability of high-resolution computed tomography (CT), a great deal of attention has been paid to the anatomy of the paranasal sinuses. But while investigators have focused on the osteomeatal complex and its relation to chronic rhinosinusitis, there has been little discussion of the superior turbinate. Although a few anatomic studies have tried to quantify pneumatization of the superior turbinate, the prevalence of this finding on radiography is not well addressed in the literature. We prospectively studied 100 consecutively presenting patients who underwent coronal CT of the paranasal sinuses (200 sides) for the evaluation of symptoms of chronic rhinosinusitis at an academic tertiary referral center to determine the prevalence of pneumatization of the superior turbinate. We found evidence of pneumatization in 44 of the 200 sides, for a prevalence of 22%. In all, pneumatized superior turbinates were found in 27 patients (27%)—bilaterally in 17 (17%) and unilaterally in 10 (10%).

Background It is essential to critically assess bone deposition in midface distraction. The aim of this study was to characterize the quality and volume of bone deposition at specific osteotomy sites following midface distraction. Methods At approximately 6 months after distraction, computed tomographic scans with three-dimensional reconstruction were obtained on 10 craniosynostosis syndromal patients who had undergone LeFort III osteotomy and midface distraction. Patient age ranged from 37 to 109 months (mean, 63.7 months) and the distractions ranged from 7 to 15 mm. Both the reconstructed scans and axial cuts were independently evaluated by four blinded observers (two plastic surgeons, an orthodontist, and a radiologist) and graded for bone deposition in predetermined anatomical sites correlated to the osteotomy. Results The authors found that variable bony bridging occurred at all sites along the osteotomy, but bone deposition was most reliably seen at the pterygomaxillary buttress and nasofrontal junction. In addition, the medial orbital walls tended to show greater consistency in bone deposition than the lateral orbital walls, and deposition at the zygomatic arches was shown to be least likely to occur. The technique of evaluation and the clinically significant findings are discussed. Conclusions Bony deposition occurs more reliably in the medial facial skeleton following LeFort III osteotomy, and osteotomy through the zygomatic body was more likely to result in deposition than one through the arch.

A 30-year-old woman with myopia (−8 diopters) developed binocular horizontal diplopia over a year. She had chronic migraine and no other symptoms. Ocular motility showed a comitant esotropia (20 diopters), and 2-diopter right hypertropia. MRI (figures 1 and 2) showed features of heavy eye syndrome,1 which is associated with superotemporal prolapse of the posterior globe, degeneration of lateral rectus–superior rectus band, and displacement of the lateral rectus downward.2 The abduction failure may be confused with a sixth nerve palsy. Our patient was treated with prisms with partial success, which along with strabismus correction are the treatment options.

Objective The preferential delayed enhancement of the perilymphatic space enables detection of the non-enhancing endolymphatic hydrops present in patients with Meniere's disease. The aim of this study was to evaluate the diagnostic utility of delayed postcontrast 3D FLAIR images and a color map of fused postcontrast FLAIR and constructive interference steady state (CISS) images in the identification of endolymphatic hydrops in patients with clinically diagnosed Meniere's disease. Study design Case control, blinded study. Setting Tertiary referral center. Patients Ten patients with Meniere's disease and five volunteer controls. Intervention Diagnostic. Main outcome measure Two neuroradiologists blinded to the clinical history independently evaluated for the presence of endolymphatic hydrops on the images of both inner ears for test and control subjects. Both the standard gray-scale FLAIR images and the fused color map images were independently reviewed. Results The gray-scale 3D FLAIR images demonstrated 68.2% sensitivity and 97.4% specificity, and the fused color map images demonstrated 85.0% sensitivity and 88.9% specificity in the identification of endolymphatic hydrops in Meniere's disease. There was significant correlation between the gray-scale 3D FLAIR images and fused color map images with the categorization of involvement (p = 0.002). Inter-evaluator reliability was excellent (kappa = 0.83 for gray-scale images, kappa = 0.81 for fused color map). Conclusion Delayed 3D FLAIR and fused 3D FLAIR-CISS color map images of the inner ears after intravenous contrast administration are potentially useful diagnostic tools in the evaluation of patients with suspected Meniere's disease.

Objective: To determine whether quantitative whole-brain MR diffusion histograms in patients with MS differ from those of normal control subjects. Background: MRI detects macroscopic cerebral lesions in MS, but the white matter lesion burden on MRI correlates imperfectly to clinical disability. Previous reports have further suggested abnormalities in white matter of MS patients with no visible lesions on conventional MRI. Methods: A total of 25 subjects (13 with MS [9 relapsing–remitting, 4 secondary progressive] and 12 healthy control subjects) underwent diffusion-weighted echoplanar MRI encompassing the entire brain. The average apparent diffusion coefficient (ADC ave , or diffusion trace) was calculated on a pixel-by-pixel basis after segmentation of intracranial space from calvarium and extracranial soft tissues. Whole-brain ADC ave histograms were calculated and plotted for statistical comparison. Results: Mean whole-brain MR ADC ave in MS patients was elevated and histograms were shifted to higher values compared with normal control subjects. Mean whole-brain ADC ave of secondary progressive patients was shifted to higher values compared with relapsing–remitting patients. Whole-brain ADC ave histograms of relapsing–remitting patients showed no significant difference from normal control subjects. Conclusion: Whole-brain MR diffusion histograms may quantitate overall cerebral lesion load in patients with MS and may be able to discern differences between clinical subgroups.

With the availability of high-resolution computed tomography (CT), a great deal of attention has been paid to the anatomy of the paranasal sinuses. But while investigators have focused on the osteomeatal complex and its relation to chronic rhinosinusitis, there has been little discussion of the superior turbinate. Although a few anatomic studies have tried to quantify pneumatization of the superior turbinate, the prevalence of this finding on radiography is not well addressed in the literature. We prospectively studied 100 consecutively presenting patients who underwent coronal CT of the paranasal sinuses (200 sides) for the evaluation of symptoms of chronic rhinosinusitis at an academic tertiary referral center to determine the prevalence of pneumatization of the superior turbinate. We found evidence of pneumatization in 44 of the 200 sides, for a prevalence of 22%. In all, pneumatized superior turbinates were found in 27 patients (27%)-bilaterally in 17 (17%) and unilaterally in 10 (10%).

BACKGROUND AND PURPOSE: Patients with nonlesional temporal lobe epilepsy have long been known to have abnormalities of memory. Recently, these patients have been shown to have increased diffusivity in the hippocampus. We hypothesized that in these patients, a negative correlation would exist between diffusivity measures of the mesial temporal lobe and performance on neuropsychological tests. METHODS: Twenty presurgical patients with temporal lobe epilepsy and 20 age- and sex-matched healthy controls underwent MR imaging of the brain. Apparent diffusion coefficient region of interest measures were taken in both hippocampi and parahippocampal gyri by 2 independent observers. Mean whole brain diffusivity was calculated. All patients completed neuropsychological testing. Electroencephalogram and pathology results were collected. Patients and controls were compared with respect to each apparent diffusion coefficient measure. In patients, apparent diffusion coefficients ipsilateral and contralateral to the seizure focus were compared. Associations were assessed between diffusivity measures and neuropsychological scores. RESULTS: Eleven patients had right-sided seizure foci and 9 had left-sided seizure foci. Patients demonstrated higher apparent diffusion coefficient values than controls over the whole brain, in the hippocampi, and in the parahippocampal gyri (P < .05). Patients demonstrated higher apparent diffusion coefficient within the ipsilateral hippocampus (1.19 ± 0.22 × 10(−3) s/mm(2)) and parahippocampal gyrus (1.02 ± 0.12 × 10(−3) s/mm(2)) compared with the contralateral side (1.02 ± 0.16 × 10(−3) s/mm(2) and 0.96 ± 0.09 × 10(−3) s/mm(2), respectively) (P < .05). Negative correlations were seen between hippocampal apparent diffusion coefficients and multiple memory tests (P < .05). CONCLUSION: Quantitative diffusion measurements in the hippocampus correlate with memory dysfunction in patients with temporal lobe epilepsy.

This study used fMRI to examine the response of the amygdala in the evaluation and short-term recognition memory of unpleasant vs. neutral words in nine right-handed healthy adult women. To establish specificity of the amygdala response, we examined the fMRI BOLD signal in one control region (visual cortex). Alternating blocks of unpleasant and neutral trials were presented. During the emotional decision task, subjects viewed sets of three unpleasant or three neutral words while selecting the most unpleasant or neutral word, respectively. During the memory task, subjects identified words that were presented during the emotional decision task (0.50 probability). Images were detrended, filtered, and coregistered to standard brain coordinates. The Talairach coordinates for the center of the amygdala were chosen before analysis. The BOLD signal at this location in the right hemisphere revealed a greater amplitude signal for the unpleasant relative to the neutral words during the emotional decision but not the memory task, confirmed by Time Course x Word Condition ANOVAs. These results are consistent with the memory modulatory view of amygdala function, which suggests that the amygdala facilitates long-term, but not short-term, memory consolidation of emotionally significant material. The control area showed only an effect for Time Course for both the emotional decision and memory tasks, indicating the specificity of the amygdala response to the evaluation of unpleasant words. Moreover, the right-sided amygdala activation during the unpleasant word condition was strongly correlated with the BOLD response in the occipital cortex. These findings corroborate those by other researchers that the amygdala can modulate early processing of visual information in the occipital cortex. Finally, an increase in subject's state anxiety (evaluated by questionnaire) while in the scanner correlated with amygdala activation under some conditions.

There are a multitude of tumors that may spread to the extra-axial compartment (i.e., meninges, skull base, and calvarium). The role of imaging in the search for metastases is to detect the full extent of and to correctly localize the disease. This unit presents basic protocols for imaging extra-axial metastatic tumors. Specific modifications are discussed where necessary. The sequences described in this unit are based on a 1.5 T scanner (Echospeed GE Medical Systems, Milwaukee, Wisconsin), but can be expected to be equally applicable to other field strengths and scanners from other manufacturers.

This unit presents the preferred protocol for imaging the brain following the institution of chemotherapy, radiation therapy, or surgery for brain tumors and specific modifications are discussed where necessary. The sequences described in this unit are based on a 1.5 T scanner (Echospeed GE Medical Systems), but can be expected to be equally applicable to other field strengths and scanners from other manufacturers.

The majority of primary brain tumors in adults are found in the supratentorial compartment, while tumors in pediatric patients are usually infratentorial in location. This unit presents basic protocols for imaging all types of primary intra-axial brain tumors, whether infiltrative (i.e., astrocytoma, oligodendroglioma, lymphoma) or circumscribed (i.e., ganglioglioma, cystic astrocytoma). Specific modifications are discussed where necessary. The sequences described in this unit are based on a 1.5 T scanner (Echospeed GE Medical Systems), but can be expected to be equally applicable to other field strengths and scanners from other manufacturers.

Extra-axial tumors most commonly arise from the meninges, calvarium, or skull base. Localization of a lesion as extra-axial or extra-cerebral in origin has significant clinical importance in terms of treatment planning and predicting prognosis. High-resolution fat-suppressed imaging is crucial for specific evaluation of the skull base, and correlation with computed tomography (CT) is often helpful in these cases. This unit presents basic MRI protocols for imaging extra-axial tumors in specific locations; sequence modifications are discussed where necessary. The sequences described in this unit are based on a 1.5 T scanner (GE Medical Systems), but can be expected to be equally applicable to other field strengths and scanners from other manufacturers.

The role of MRI imaging in the metastatic work-up is to detect the spread of tumor to the brain parenchyma, and define the location. Intravenous contrast (gadolinium-DTPA) provides the greatest sensitivity for detecting brain lesions and is almost always indicated except when there is no intravenous access. This unit presents a Basic Protocol for imaging intra-axial brain metastases and specific modifications are discussed for the case of metastatic brain tumors demonstrating evidence of hemorrhage. The sequences described in this unit are based on 1.5 T scanner (Echospeed GE Medical Systems, Milwaukee, Wisconsin), but can be expected to be equally applicable to other field strengths and scanners from other manufacturers.

Relative hypointensity on T1-weighted MR imaging has been suggested as a putative disability marker. The purpose of our study was to determine if there are quantifiable diffusion differences among focal multiple sclerosis lesions that appear differently on conventional T1-weighted MR images. We hypothesized that markedly hypointense lesions on unenhanced T1-weighted images would have significantly increased diffusion compared with other lesions, and enhancing portions of lesions would have different diffusion compared with nonenhancing lesions.Average apparent diffusion coefficient (ADC) was calculated for 107 lesions identified on T2-weighted images in 16 patients with multiple sclerosis and was compared with the ADC of normal white matter in 16 age- and sex-matched control subjects. Seventy-five nonenhancing lesions (29 isointense, 46 hypointense) and 32 enhancing lesions (6 isointense, 26 hypointense) were categorized on the basis of unenhanced T1-weighted MR imaging.Hypointense and isointense nonenhancing lesions both showed significantly higher ADC than normal white matter (p0.0001). Hypointense nonenhancing lesions showed higher ADC values than isointense nonenhancing lesions (p0.0001). Diffusion in enhancing portions of enhancing lesions was decreased when compared with nonenhancing portions.Quantitative diffusion data from MR imaging differ among multiple sclerosis lesions that appear different from each other on T1-weighted images. These quantitative diffusion differences imply microstructural differences, which may prove useful in documenting irreversible disease.

Objective To discuss the computed tomographic (CT) and clinical findings of those entities that may present as recurrent deep neck infections. Patients and Methods Twelve patients with recurrent deep neck infections and CT scans were retrospectively identified since 1990. Their CT scans and medical histories were reviewed. The diagnosis was pathologically confirmed in all cases. Results The CT scans revealed an abscess or a localized infected cyst in the deep soft tissues of the neck, with varying degrees of associated inflammatory change in the adjacent soft tissues. The diagnoses in these cases included 1 first branchial cleft cyst, 3 second branchial cleft cysts, 1 third branchial cleft cyst, 2 fourth branchial cleft cysts, 2 infected lymphangiomas, 2 thyroglossal duct cysts, and 1 cervical thymic cyst. Conclusions Most deep neck infections are the result of suppurative adenitis. The location of the primary focus is usually from the mucosa of the upper aerodigestive tract or from an odontogenic source. Less common causes are perforations due to a foreign body, thrombophlebitis of the internal jugular vein, or osteomyelitis of the spine. Recurrences in these situations are unusual. Less commonly, congenital lesions can present as deep neck infections, and recurrences are common. Our cases suggest that the recurrence of a deep neck infection should alert the physician to the possibility of an underlying congenital lesion and that CT is helpful in the early recognition of these lesions.