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PURPOSE The Response Assessment in Neuro-Oncology (RANO) criteria are widely used in high-grade glioma clinical trials. We compared the RANO criteria with updated modifications (modified RANO [mRANO] and immunotherapy RANO [iRANO] criteria) in patients with newly diagnosed glioblastoma (nGBM) and recurrent GBM (rGBM) to evaluate the performance of each set of criteria and inform the development of the planned RANO 2.0 update. MATERIALS AND METHODS Evaluation of tumor measurements and fluid-attenuated inversion recovery (FLAIR) sequences were performed by blinded readers to determine disease progression using RANO, mRANO, iRANO, and other response assessment criteria. Spearman's correlations between progression-free survival (PFS) and overall survival (OS) were calculated. RESULTS Five hundred twenty-six nGBM and 580 rGBM cases were included. Spearman's correlations were similar between RANO and mRANO (0.69 [95% CI, 0.62 to 0.75] v 0.67 [95% CI, 0.60 to 0.73]) in nGBM and rGBM (0.48 [95% CI, 0.40 to 0.55] v 0.50 [95% CI, 0.42 to 0.57]). In nGBM, requirement of a confirmation scan within 12 weeks of completion of radiotherapy to determine progression was associated with improved correlations. Use of the postradiation magnetic resonance imaging (MRI) as baseline scan was associated with improved correlation compared with use of the pre-radiation MRI (0.67 [95% CI, 0.60 to 0.73] v 0.53 [95% CI, 0.42 to 0.62]). Evaluation of FLAIR sequences did not improve the correlation. Among patients who received immunotherapy, Spearman's correlations were similar among RANO, mRANO, and iRANO. CONCLUSION RANO and mRANO demonstrated similar correlations between PFS and OS. Confirmation scans were only beneficial in nGBM within 12 weeks of completion of radiotherapy, and there was a trend in favor of the use of postradiation MRI as the baseline scan in nGBM. Evaluation of FLAIR can be omitted. The iRANO criteria did not add significant benefit in patients who received immune checkpoint inhibitors.

Binary expression systems are useful genetic tools for experimentally labeling or manipulating the function of defined cells. The Q-system is a repressible binary expression system that consists of a transcription factor QF (and the recently improved QF2/QF2

Mosquitoes transmit a multitude of diseases to humans and animals through biting and blood feeding. To locate their hosts, mosquitoes primarily use their sense of smell. Therefore, an understanding of mosquito olfaction will help develop strategies to control the diseases they transmit. A mosquito's sense of smell is determined by the response of olfactory neurons on its peripheral olfactory organs. Traditionally, mosquito olfactory neuron activity has been examined using electrophysiological techniques such as electroantennography and single sensillum recordings. Electroantennography examines if an odorant is detectable by the ensemble of all antennal neurons. In contrast, single sensillum electrophysiology allows detailed recordings of the activity of two to three neurons at a time. However, single sensillum recording of olfactory neurons is difficult, laborious, and typically allows examination of only a few neurons on the antenna. A promising new approach is to use optical imaging techniques to provide a way to visualize the global response of olfactory organs to an odor, as well as the specific responses of several olfactory neurons to that odor. In particular, calcium imaging has progressed significantly, from the use of chemical calcium indicators to the development of genetically encoded calcium sensors. These advances have opened the way to study the mode of action of known mosquito attractants and repellents as well as a way to screen potential new attractants and repellents. Here, we provide an introduction to the different types of calcium indicators and their uses for investigating the function of mosquito sensory neurons.

Calcium imaging is a technique used to measure functional neuronal activities in response to stimuli. It has been used for years to study odorant-induced responses in insects (i.e., honeybees,iDrosophila/i, and moths) and was recently introduced into mosquitoes. Traditionally, calcium imaging in mosquitoes was performed using nonspecific calcium indicator dyes to examine neuronal responses in whole insect brain regions, but the development of genetically encoded calcium indicators (GECIs) has facilitated the ability to perform functional calcium imaging on specific tissues. For example, by specifically expressing a GECI in olfactory neurons, the odor-induced responses of these neurons in peripheral organs can be examined. Calcium imaging of mosquito antennae further provides an advantageous method for simultaneously visualizing the activity of several antennal neurons in a single experiment. In this protocol, we describe a calcium imaging method to study odor-evoked responses iniAnopheles coluzzii/iantennae expressing the calcium indicator GCaMP6f. This method requires imaging equipment (compound microscope, light sources, and camera), an odorant delivery system, and image acquisition software. The mosquito preparation is straightforward but requires practice to minimize mosquito movement during imaging. Recorded videos can be analyzed using Fiji software to generate heatmaps and activity traces for odorant-evoked responses. This protocol can also be used, with some modifications, to study other peripheral organs (such as labella, palps, and tarsi).

Dual-energy computed tomography (DECT) has developed into a robust set of techniques with increasingly validated clinical applications in neuroradiology. We review some of the most common applications in neuroimaging along with demonstrative case examples that showcase the use of this technology in intracranial hemorrhage, stroke imaging, trauma imaging, artifact reduction, and tumor characterization.

Half the world's human population is at risk for mosquito-borne diseases. Mosquitoes rely mainly on their sense of smell to find a vertebrate blood host, nectar source, and a suitable oviposition site. Advances in neurogenetic tools have now aided our understanding of the receptors that mediate the detection of sensory cues that emanate from humans. Recent studies in the anthropophilic mosquito vectors, Aedes aegypti and Anopheles gambiae, have implicated the chemosensory ionotropic-receptor (IR) family in the detection of behaviorally relevant odors and uncovered functions beyond chemical sensing. Here, we highlight the multifunctional roles of the chemosensory ionotropic receptors in anthropophilic mosquito vectors and suggest future directions to improve our understanding of the IR family.

We use gravity, magnetic, seismic reflection, well, and outcrop data to determine the three-dimensional shape and structural features of south-central Alaska’s Susitna basin. This basin is located within the Aleutian-Alaskan convergent margin region and is expected to show effects of regional subduction zone processes. Aeromagnetic data, when filtered to highlight anomalies associated with sources within the upper few kilometers, show numerous linear northeast-trending highs and some linear north-trending highs. Comparisons to seismic reflection and well data show that these highs correspond to areas where late Paleocene to early Eocene volcanic layers have been locally uplifted due to folding and/or faulting. The combined magnetic and seismic reflection data suggest that the linear highs represent northeast-trending folds and north-striking faults. Several lines of evidence suggest that the northeast-trending folds formed during the middle Eocene to early Miocene and may have continued to be active in the Pliocene. The north-striking faults, which in some areas appear to cut the northeast-trending folds, show evidence of Neogene and probable modern movement. Gravity data facilitate estimates of the shape and depth of the basin. This was accomplished by separating the observed gravity anomaly into two components—one representing low-density sedimentary fill within the basin and one representing density heterogeneities within the underlying crystalline basement. We then used the basin anomaly, seismic reflection data, and well data to estimate the depth of the basin. Together, the magnetic, gravity, and reflection seismic analyses reveal an asymmetric basin comprising sedimentary rock over 4 km thick with steep, fault-bounded sides to the southwest, west, and north and a mostly gentle rise toward the east. Relations to the broader tectonic regime are suggested by fold axis orientations within the Susitna basin and neighboring Cook Inlet basin, which are roughly parallel to the easternmost part of the Alaska-Aleutian trench and associated Wadati-Benioff zone as it trends from northeast to north-northeast to northeast. An alignment between forearc basin folds and the subduction zone trench has been observed at other convergent margins, attributed to strain partitioning generated by regional rheologic variations that are associated with the subducting plate and arc magmatism. The asymmetric shape of the basin, especially its gentle rise to the east, may reflect uplift associated with flat-slab subduction of the Yakutat microplate, consistent with previous work that suggested Yakutat influence on the nearby Talkeetna Mountains and western Alaska Range. Yakutat subduction may also have contributed to Neogene and later reverse slip along north-striking faults within the Susitna basin.

Cas9 and a guide RNA (gRNA) function to target specific genomic loci for generation of a double-stranded break. Catalytic dead versions of Cas9 (dCas9) no longer cause double-stranded breaks and instead can serve as molecular scaffolds to target additional enzymatic proteins to specific genomic loci. To generate mutations in selected genomic residues, dCas9 can be used for genomic base editing by fusing a cytidine deaminase (CD) to induce C > T (or G>A) mutations at targeted sites. In this study, we test base editing in Drosophila by expressing a transgenic Drosophila base editor (based on the mammalian BE2) that consists of a fusion protein of CD, dCas9, and uracil glycosylase inhibitor. We utilized transgenic lines expressing gRNAs along with pan-tissue expression of the Drosophila base editor (Actin5C-BE2) and found high rates of base editing at multiple targeted loci in the 20 bp target sequence. Highest rates of conversion of C > T were found in positions 3–9 of the gRNA-targeted site, with conversion reaching ∼100% of targeted DNA in somatic tissues. Surprisingly, the simultaneous use of two gRNAs targeting a genomic region spaced ∼50 bp apart led to mutations between the two gRNA targets, implicating a method to broaden the available sites accessible to targeting. These results indicate base editing is efficient in Drosophila, and could be used to induce point mutations at select loci.

BACKGROUND Accurate response criteria are crucial for determining treatment efficacy. The response assessment in neuro-oncology (RANO) criteria was developed to standardize response assessment in neuro-oncology. Modified RANO (m-RANO) criteria were recently proposed to address some limitations of the initial criteria including the use of a post-radiation baseline and an additional scan to confirm progression. We sought to identify differences in the association of progression-free survival (PFS) and overall survival (OS) using RANO and m-RANO criteria. METHODS We conducted a retrospective review of newly diagnosed glioblastoma (GBM) patients treated at Dana-Farber Cancer Institute from January 2013 until December 2019. Patients with available clinical and imaging data obtained before initiation of treatment, after radiation completion and at intervals of 1 to 3 months were included. MRIs were evaluated by two independent readers, and PD dates determined using RANO and m-RANO criteria. RESULTS 552 patients were included. 97.1% of the tumors were IDH wild-type. MGMT promoter was unmethylated in 51.4%, methylated in 35.1% and undetermined in 8.5%. Median OS among patients was 18.1 months. 72 patients (13%) did not have PD at the end of the study. 83 patients had treatment change while being clinically stable and without a confirmation scan and were excluded from the final analysis. PFS was 8.2 months with RANO and 8.4 months with mRANO. Difference in PD dates between RANO and m-RANO was detected in 76 patients (14%), where PFS was 3.5 months with RANO and 5.1 months with m-RANO. These patients had a worse median OS than those with identical RANO and m-RANO PD dates (15.2 vs. 22.4 months, p< 0.0001). CONCLUSION RANO and m-RANO criteria resulted in identical PFS for most patients. 14% of patients had discordant PD dates and a worse prognosis. These patients progressed early, and their PD was identified sooner with RANO criteria.

CT is the primary imaging modality used for selecting appropriate treatment in patients with acute stroke. Awareness of the typical findings, pearls, and pitfalls of CT image interpretation is therefore critical for radiologists, stroke neurologists, and emergency department providers to make accurate and timely decisions regarding both (a) immediate treatment with intravenous tissue plasminogen activator up to 4.5 hours after a stroke at primary stroke centers and (b) transfer of patients with large-vessel occlusion (LVO) at CT angiography to comprehensive stroke centers for endovascular thrombectomy (EVT) up to 24 hours after a stroke. Since the DAWN and DEFUSE 3 trials demonstrated the efficacy of EVT up to 24 hours after last seen well, CT angiography has become the operational standard for rapid accurate identification of intracranial LVO. A systematic approach to CT angiographic image interpretation is necessary and useful for rapid triage, and understanding common stroke syndromes can help speed vessel evaluation. Moreover, when diffusion-weighted MRI is unavailable, multiphase CT angiography of collateral vessels and source-image assessment or perfusion CT can be used to help estimate core infarct volume. Both have the potential to allow distinction of patients likely to benefit from EVT from those unlikely to benefit. This article reviews CT-based workup of ischemic stroke for making tPA and EVT treatment decisions and focuses on practical skills, interpretation challenges, mimics, and pitfalls.©RSNA, 2019.

Trends and transitions in the MODerate resolution Imaging Spectroradiometer (MODIS) Normalized Difference Vegetation Index (NDVI) time series at 250-m resolution were analyzed for the period from 2000 to 2018 to understand recent patterns of vegetation change in Yellowstone National Park (USA). Statistical change in the NDVI time series was detected using the “Breaks for Additive Seasonal and Trend” (BFAST) method. This structural change analysis showed that around 30% of abrupt negative shifts in NDVI over the years 2000 to 2018 could be explained by the impacts of recent wildfires. At least one breakpoint could be detected at 12% of the 250-m MODIS pixel locations within the entire YNP study area since the year 2000, but that the majority (about 70%) of NDVI breakpoints detected in vegetation greenness could be not be explained by the impacts of recent wildfires. Positive growing season NDVI trends were detected across most young forests and regrowing (from recent fire disturbance) woodland cover. Evidence further suggested that the 1988 wildfire burns did not pre-dispose vegetation cover in YNP to a higher number of abrupt negative shifts in NDVI since the year 2000. The wildfires of 1988 were associated with significantly higher NDVI recovery trends over the recent 18-year MODIS time series, compared to areas unburned in 1988. Locations on the Northern Range that showed the highest greening trends since 2000 were commonly located in sagebrush steppe-dominated vegetation communities growing at lower than 2500 m elevation. Results from NDVI trend analysis supported the hypothesis that years with relatively high snowpack water content, such as 2007–2008 and 2010–2011, were most closely associated with abrupt negative shifts in NDVI, but no findings strongly supported the supposition that vegetation cover in YNP is changing in greenness in association solely with warming in surface air temperatures or with extreme drought periods across the study region over the past two decades.

Jupiter's Moon Europa has one of the youngest geological surfaces in our solar system with an age of 40–90 Ma, implying an intense history of resurfacing. The surface of Europa indeed shows abundant evidence of tectonic deformation related to extension, strike-slip, and shortening. However, observed features related to shortening are scarce compared with pervasive extensive extensional features such as dilational bands, and do not suffice as the sole mechanism for recycling aging terranes. Recently, evidence for potential plate tectonics, associated with subduction zones, has been discovered on Europa; this could be responsible for recycling most of Europa's surface. However, basic physical parameters needed to initiate subduction on Europa, such as thickness of the brittle layer, deformation rates, and orientation of pre-existing zones of weakness at which subduction could start, are not well understood. Here, we aim to better understand the process and the conditions that could lead to initiation of subduction on Europa through physical experiments, using wax to simulate Europa's two-layered (i.e. convective) icy crust. By deforming the wax, strain on Europa's surface—possibly caused by diurnal tides or its nonsynchronous rotation—is simulated. Our results indicate that subduction could initiate over a broad range of surface thicknesses and deformation rates above a minimum conductive layer thickness, but is strongly dependent on the orientation of the pre-existing zones of weakness. Very thin conductive layer experiments, however, result in a previously undescribed process that we term ductile rolldown, which creates surface features similar to double ridges observed on Europa. Thus, subduction and ductile rolldown represent physically plausible mechanisms that could play a critical role in resurfacing Europa throughout its geologic history. These results could yield significant implications for Europa's thermal history and evolution, habitability, and future spacecraft missions.

Visits to the emergency department by patients who have recently undergone neurosurgery are a common occurrence, and these patients frequently receive emergent cross-sectional head imaging in order to evaluate for complications. Different neurosurgical approaches may have typical postoperative imaging findings that can be confused with pathology. Furthermore, particular abnormal postoperative imaging findings may signal an evolving complication. It is essential for the radiologist to understand common neurosurgical procedures and their potential complications in order to provide proper diagnostic evaluation of the postoperative neurosurgical patient. The purpose of this review is to assist radiologists in the evaluation of the postoperative neurosurgical patient and educate them on associated complications. Familiarity with common neurosurgical techniques and postoperative complications will help radiologists make the correct diagnosis, communicate effectively with the neurosurgeon, and expedite patient care.

Trends and transitions in the growing season MODerate resolution Imaging Spectroradiometer (MODIS) Normalized Difference Vegetation Index (NDVI) time series at 250-m resolution were analyzed for the period from 2000 to 2018 to understand recent patterns of vegetation change in ecosystems of the Yukon River basin in interior Alaska. Statistical analysis of changes in the NDVI time series was conducted using the “Breaks for Additive Seasonal and Trend” method (BFAST). This structural change analysis indicated that NDVI breakpoints and negative 18-yr trends in vegetation greenness over the years since 2000 could be explained in large part by the impacts of severe wildfires, commonly affecting shrubland and forested ecosystems at relatively low elevations (< 300 m). At least one NDVI breakpoint was detected at 29% of the MODIS pixels within the Yukon River basin study area. The warmest and wettest years in the study time period were found to be associated with a sizeable fraction (30%) of NDVI breakpoints. Among pixels with no NDVI breakpoints detected, both forest and shrubland trends were strongly skewed toward positive trend values. Results from gradual NDVI trend analysis supported the hypothesis that air temperature warming has enhanced the rates of (unburned) vegetation growth in shrubland and woodlands across interior Alaska over the past two decades.

Spontaneous mutations in the SHANK-associated RH domain interacting protein (Sharpin) resulted in a severe autoinflammatory type of chronic proliferative dermatitis, inflammation in other organs, and lymphoid organ defects. To determine whether cell-type restricted loss of Sharpin causes similar lesions, a conditional null mutant was created. Ubiquitously expressing cre-recombinase recapitulated the phenotype seen in spontaneous mutant mice. Limiting expression to keratinocytes (using a Krt14-cre) induced a chronic eosinophilic dermatitis, but no inflammation in other organs or lymphoid organ defects. The dermatitis was associated with a markedly increased concentration of serum IgE and IL18. Crosses with S100a4-cre resulted in milder skin lesions and moderate to severe arthritis. This conditional null mutant will enable more detailed studies on the role of SHARPIN in regulating NFkB and inflammation, while the Krt14-Sharpin-/- provides a new model to study atopic dermatitis.

The Sichuan Basin, China, is commonly considered to contain the world’s most abundant shale gas resources. Although its Paleozoic marine shales share many basic characteristics with successful United States gas shales, numerous geologic uncertainties exist, and Sichuan Basin shale gas production is nascent. Gas retention was likely compromised by the age of the shale reservoirs, multiple uplifts and orogenies, and migration pathways along unconformities. High thermal maturities raise questions about gas storage potential in lower Paleozoic shales. Given these uncertainties, a new look at Sichuan Basin shale gas resources is advantageous. As part of a systematic effort to quantitatively assess continuous oil and gas resources in priority basins worldwide, the US Geological Survey (USGS) completed an assessment of Paleozoic shale gas in the Sichuan Basin in 2015. Three organic-rich marine Paleozoic shale intervals meet the USGS geologic criteria for quantitative assessment of shale gas resources: the lower Cambrian Qiongzhusi Formation, the uppermost Ordovician Wufeng through lowermost Silurian Longmaxi Formations (currently producing shale gas), and the upper Permian Longtan and Dalong Formations. This study defined geologically based assessment units and calculated probabilistic distributions of technically recoverable shale gas resources using the USGS well productivity–based method. For six assessment units evaluated in 2015, the USGS estimated a mean value of 23.9 tcf (677 billion cubic meters) of undiscovered, technically recoverable shale gas. This result is considerably lower than volumes calculated in previous shale gas assessments of the Sichuan Basin, highlighting a need for caution in this geologically challenging setting.

Background In the summer of 2015, hundreds of wildfires burned across the state of Alaska, and consumed more than 1.6 million ha of boreal forest and wetlands in the Yukon–Koyukuk region. Mapping of 113 large wildfires using Landsat satellite images from before and after 2015 indicated that nearly 60% of this area was burned at moderate-to-high severity levels. Field measurements near the town of Tanana on the Yukon River were carried out in July of 2017 in both unburned and 2015 burned forested areas (nearly adjacent to one-another) to visually verify locations of different Landsat burn severity classes (low, moderate, or high; LBS, MBS, HBS). Results Field measurements indicated that the loss of surface organic layers in boreal ecosystem fires is a major factor determining post-fire soil temperature changes, depth of thawing, and carbon losses from the mineral topsoil layer. Measurements in forest sites showed that soil temperature profiles to 30 cm depth at burned forest sites were higher by an average of 8–10 °C compared to unburned forest sites. Sampling and laboratory analysis indicated a 65% reduction in soil carbon content and a 58% reduction in soil nitrogen content in severely burned sample sites compared to soil mineral samples from nearby unburned spruce forests. Conclusions Combined with nearly unprecedented forest areas severely burned in the Interior region of Alaska in 2015, total ecosystem fire-related losses of carbon to the atmosphere exceeded most previous estimates for the state, owing mainly to inclusion of potential “mass wasting” and decomposition in the mineral soil carbon layer in the 2 years following these forest fires.

Mus pahari is a wild-derived, inbred mouse strain. M. pahari colony managers observed fragility of this strain’s skin resulting in separation of tail skin from the mouse if handled incorrectly. Tail skin tension testing of M. pahari resulted in significantly lowered force threshold for caudal skin rupture and loss in comparison to closely related inbred mouse species and subspecies and even more than a model for junctional epidermolysis bullosa. Histologically, the tail skin separated at the subdermal level with the dermis firmly attached to the epidermis, excluding the epidermolysis bullosa complex of diseases. The dermal collagen bundles were abnormally thickened and branched. Elastin fiber deposition was focally altered in the dermis adjacent to the hair follicle. Collagens present in the skin could not be differentiated between the species in protein gels following digestion with pepsin. Together these data suggest that M. pahari have altered extracellular matrix development resulting in separation of the skin below the level of the dermis with moderate force similar to the African spiny mouse (Acomys spp.).

Purpose To quantify the rate of detection of aneurysms at follow-up digital subtraction angiography (DSA) after initial DSA with results negative for aneurysms in subjects with perimesencephalic (PM) nonaneurysmal subarachnoid hemorrhage. Materials and Methods This single-center retrospective study and meta-analysis was approved by the institutional review board. At a single institution from 2000 to 2013, 252 consecutive patients with subarachnoid hemorrhage at computed tomography (CT) and two DSA examinations negative for aneurysm within 10 days were evaluated for inclusion in the study, and 131 met CT criteria for PM nonaneurysmal subarachnoid hemorrhage (53 women; mean age, 53 years [range, 33-88 years]). DS angiographic reports were reviewed for causative abnormalities. Three reviewers searched MEDLINE and electronic databases for studies that reported detection of aneurysm in subjects with PM hemorrhage who had undergone multiple DSA examinations. Main inclusion criteria were PM hemorrhage at CT per van Gijn classification, head CT performed within 72 hours of symptom onset, initial DS angiographic results negative for aneurysm, and two DSA examinations within 10 days. Studies with fewer than 25 subjects were excluded. Methodology was assessed by using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The summary rate of aneurysm detection for subsequent DSA was calculated by using a fixed-effects model. Results Six studies with 298 subjects and a single-institution study with 131 subjects were included. No aneurysms were seen at follow-up DSA in the single-center study (0.0%). Three aneurysms were detected at follow-up DSA in three of six studies from the literature (one of 29 [3.4%], one of 65 [1.5%], and one of 34 [2.9%] patients). Two occurred in cases that likely preceded the use of the current DSA technique. The summary aneurysm detection rate at subsequent DSA was 1.6% (95% confidence interval: 0.7%, 3.8%; range of individual study detection rate: 0.0%-3.4%). Conclusion In patients with PM nonaneurysmal subarachnoid hemorrhage and initial DSA negative for aneurysms, the yield of follow-up DSA for detection of causative aneurysms is very low. © RSNA, 2016 Online supplemental material is available for this article.

Background Diagnostic uncertainty in CT of possible intracranial hemorrhage requires short-interval follow-up imaging, resulting in reduced efficiency of care and higher costs. Purpose To quantify the diagnostic performance of dual-energy CT versus simulated single-energy CT in the differentiation of small foci of intracranial hemorrhage from calcium. Materials and Methods Images from consecutive unenhanced dual-energy CT of the head in patients from a single emergency department obtained from December 2014 to April 2016 were reviewed retrospectively for hyperattenuating intracranial foci. Ground truth was established from reference standard comparison CT or MRI. Foci were divided into development and test sets. Development set foci regions of interest were used to derive candidate CT attenuation thresholds for virtual noncalcium (VNCa) and calcium images. Test set foci were used for threshold validation, and diagnostic performance and confidence were evaluated for two readers blinded to final diagnosis. Statistical comparisons were made with exact binomial tests or repeated-measures analysis of variance. Results The study included 137 patients (65 years ± 17; 70 men) with 146 foci. Foci were divided into a development set (n = 105) and a test set (n = 41). Quantitative analysis of the development set produced candidate thresholds of 44 HU for VNCa images and 7 HU for calcium-only images, yielding diagnostic accuracies for the test set of 88% (36 of 41 foci; 95% confidence interval [CI]: 78%, 98%) and 95% (39 of 41 foci; 95% CI: 88%, 100%), respectively. Dual-energy CT improved reader accuracy from 90% (reader 1, 37 of 41 foci; 95% CI: 81%, 99%) and 93% (reader 2, 38 of 41 foci; 95% CI: 85%, 100%) to 100% (both readers, 41 of 41 foci; 95% CI: 100%, 100%). Diagnostic confidence (classifications rated as "certain") increased from 71% (29 of 41 foci; 95% CI: 57%, 85%) to 90% (37 of 41 foci; 95% CI: 81%, 99%) for reader 1 (P = .019) and from 46% (19 of 41 foci; 95% CI: 31%, 62%) to 85% (35 of 41 foci; 95% CI: 75%, 96%) for reader 2 (P = .0001). Conclusion Dual-energy CT showed high diagnostic performance in the differentiation of small foci of intracranial hemorrhage from calcium and improved diagnostic accuracy and confidence in the initial evaluation of suspected hemorrhage. © RSNA, 2019 See also the editorial by Kotsenas in this issue.

Blunt laryngeal trauma is associated with high morbidity and mortality. However, owing to their relatively rare occurrence, laryngeal injuries may be missed or underdiagnosed. Even subtle abnormalities at multidetector CT may correspond to significant functional abnormalities. It is important to understand normal CT laryngeal anatomy and develop a systematic review of the cervical soft tissues and laryngeal skeleton in patients who undergo screening CT cervical spine or other neck examinations in the setting of trauma, such as CT angiography. Multidetector CT findings of the normal larynx are reviewed, and blunt laryngeal injuries including soft-tissue edema, hematoma, mucosal lacerations, cartilage fracture, cricoarytenoid dislocation, and vocal fold paralysis are presented. The radiologist plays an important role in diagnosis and may be the first to identify laryngeal injuries that are not evident at physical examination. This article reviews normal laryngeal anatomy, presents various blunt laryngeal injuries at multidetector CT with case examples, discusses the role of multidetector CT in acute management, and describes pitfalls of diagnosis. ©RSNA, 2019.

To describe and categorize diagnostic errors in cervical spine CT (CsCT) interpretation performed for trauma and to assess their clinical significance. All CsCTs performed for trauma with diagnostic errors that came to our attention based on clinical or imaging follow-up or quality assurance peer review from 2004 to 2017 were included. The number of CsCTs performed at our institution during the same time interval was calculated. Errors were categorized as spinal/extraspinal, involving osseous/soft tissue structures, by anatomical site and level. Images were reviewed by a radiologist and two spine surgeons. For each error, the need for surgery, immobilization, CT angiogram of the neck, and MRI was assessed; if any of these were needed, the error was considered clinically significant. Of an approximate total 59,000 CsCTs, 56 reports containing diagnostic errors were included. Twelve were extraspinal, and 44 were spinal (26 fractures, 15 intervertebral disc protrusions, two subluxations, one lytic bone lesion). The most common sites of spinal fractures were vertebral body (n = 10) and transverse process (n = 8); the most common levels were C5 (n = 8) and C7 (n = 6). All (n = 26) fractures and two atlantooccipital subluxations were considered clinically significant, including three patients who would have required urgent surgical stabilization (two subluxations and one facet fracture). Two transverse processes fractures did not alter the need for surgical intervention/surgical approach, immobilization, or MRI. In our study, 66% of spinal diagnostic errors on CsCT were considered clinically significant, potentially altering clinical management. Transverse process and vertebral body fractures were commonly missed.