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This article presents guidelines for initial imaging utilization in patients presenting with sinonasal disease, including acute rhinosinusitis without and with suspected orbital and intracranial complications, chronic rhinosinusitis, suspected invasive fungal sinusitis, suspected sinonasal mass, and suspected cerebrospinal fluid leak. CT and MRI are the primary imaging modalities used to evaluate patients with sinonasal disease. Given its detailed depiction of bony anatomy, CT can accurately demonstrate the presence of sinonasal disease, bony erosions, and anatomic variants, and is essential for surgical planning. Given its superior soft tissue contrast, MRI can accurately identify clinically suspected intracranial and intraorbital complications, delineate soft tissue extension of tumor and distinguish mass from obstructed secretions.The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Maxillofacial trauma patients comprise a significant subset of patients presenting to emergency departments. Before evaluating for facial trauma, an emergency or trauma physician must perform a primary survey to ensure patient stabilization. Following this primary survey, this document discusses the following clinical scenarios for facial trauma: tenderness to palpation or contusion or edema over frontal bone (suspected frontal bone injury); pain with upper jaw manipulation or pain overlying zygoma or zygomatic deformity or facial elongation or malocclusion or infraorbital nerve paresthesia (suspected midface injury); visible nasal deformity or palpable nasal deformity or tenderness to palpation of the nose or epistaxis (suspected nasal bone injury); and trismus or malocclusion or gingival hemorrhage or mucosal hemorrhage or loose teeth or fractured teeth or displaced teeth (suspected mandibular injury). The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Hyperparathyroidism is defined as excessive parathyroid hormone production. The diagnosis is made through biochemical testing, in which imaging has no role. However, imaging is appropriate for preoperative parathyroid gland localization with the intent of surgical cure. Imaging is particularly useful in the setting of primary hyperparathyroidism whereby accurate localization of a single parathyroid adenoma can facilitate minimally invasive parathyroidectomy. Imaging can also be useful to localize ectopic or supernumerary parathyroid glands and detail anatomy, which may impact surgery. This document summarizes the literature and provides imaging recommendations for hyperparathyroidism including primary hyperparathyroidism, recurrent or persistent primary hyperparathyroidism after parathyroid surgery, secondary hyperparathyroidism, and tertiary hyperparathyroidism. Recommendations include ultrasound, CT neck without and with contrast, and nuclear medicine parathyroid scans. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Objectives Idiopathic intracranial hypertension (IIH) is a disease defined by elevated intracranial pressure (ICP) without an established etiology. Arachnoid granulations (AG) are conduits for CSF resorption from the subarachnoid space to the venous system. AG have been implicated to play a central role in maintaining CSF homeostasis. We tested the hypothesis that patients with fewer visible AG on MRI are more likely to present with IIH. Methods In this institutional review board (Institutional Review Board)-approved retrospective chart review study, 65 patients with a clinical diagnosis of idiopathic intracranial hypertension were compared to 144 control patients who met inclusion/exclusion criteria. Patients’ signs and symptoms pertaining to IIH were obtained through the electronic medical record Brain MR images were reviewed for the number and distribution of AGs indenting the dural venous sinuses. The presence of imaging and clinical findings associated with long standing increased ICP was noted. Propensity score method (with inverse probability weighting technique) was used to compare case and control groups. Results In the control group, the number of AG indenting the dural venous sinuses on MRI (NAG) was lower in women compared to men when matched for age (20–45 yo) and BMI (>30 kg/m2). The NAG was lower in 20–45 yo females in the IIH group as compared to the 20–45 yo females in the control group. This statistically significant difference persists when controlled for BMI. In contrast, the NAG in >45 yo females in the IIH group trended higher compared to the >45 yo females in the control group. Conclusion Our results suggest that alterations in arachnoid granulations could play a role in the development of IIH.

Hypopharyngeal perforation (HP) is a potentially life-threatening condition most associated with iatrogenic injury and foreign body impaction. Additionally, a number of cases of posterior HP have been reported following blunt cervical trauma. We present a case of a construction accident causing lateral hypopharyngeal rupture. Visceral perforation was initially diagnosed on computed tomography (CT) imaging and managed conservatively. We speculate this region may be particularly vulnerable to injury due to an anatomic transition in adjacent fascial support. A review of 29 prior cases suggests that this may be the first reported case of blunt trauma causing rupture of the pyriform sinus. However, significant heterogeneity exists in diagnostic approach. Radiography and CT are rapid, sensitive modalities for suggesting pharyngeal perforation, while fluoroscopy and endoscopy can better assess injury size and location and monitor resolution. Early radiologic recognition of hypopharyngeal injury is essential to initiate appropriate treatment. In certain cases, including our own, both the presence and specific location of perforation may be identified on initial CT images.

We sought to determine if interhemispheric asymmetry of cortical and medullary veins evaluated on CT angiography can provide a more accurate prediction of outcome in patients with acute ischemic stroke when compared to hemispheric asymmetry of cortical or medullary vein drainage alone.We retrospectively reviewed a database of patients with anterior circulation distribution acute ischemic stroke, who were evaluated by multiphase CTA. Cortical veins were evaluated using the adopted Prognostic Evaluation based on Cortical vein score difference In Stroke (PRECISE) system. Medullary veins were evaluated by the presence of asymmetry determined by 5 or more medullary veins visualized in one hemisphere as compared to the contralateral. Good clinical outcome was defined as a Modified Rankin Scale of 0-2 at 90 days.64 patients were included. The adopted PRECISE score was associated with a good clinical outcome in patients with AIS (OR=3.29; 95 % CI: 1.16 - 9.30; p = 0.023) and had a stronger association with clinical outcome (AUC=0.644) as compared to the asymmetry of MV (AUC=0.609). In a multivariable logistic regression model, combined medullary and cortical vein asymmetry were independently associated with clinical outcomes (AUC=0.721).Combined cortical and medullary vein interhemispheric asymmetry is a stronger predictor of clinical outcome in acute ischemic stroke compared to cortical or medullary vein asymmetry alone.

Neuroendocrine dysfunction includes suspected hyper- and hypofunction of the pituitary gland. Causative lesions may include primary masses of the pituitary such as pituitary microadenomas and macroadenomas, as well as extrinsic masses, typically centered in the suprasellar cistern. Clinical syndromes related to hormonal dysfunction can be caused by excessive hormonal secretion or by inhibited secretion due to mass effect upon elements of the hypothalamic-pituitary axis. Additionally, complications such as hemorrhage may be seen in the setting of an underlying mass and can result in hormonal dysfunction. MRI with high-resolution protocols is the best first-line test to evaluate the sella turcica and parasellar region. CT provides complementary information regarding bony anatomy, and may be appropriate as a first-line test in certain instances, but it provides less detail and lesion characterization when compared to MRI. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Synchronous bilateral palatine tonsillar Squamous Cell Carcinoma (SCC) is a rare presentation and less than 10 cases of Human Papillomavirus (HPV) mediated synchronous bilateral palatine tonsillar SCC has been reported. We report case of a patient who presents with a painless left sided neck swelling and was subsequently diagnosed by imaging and histopathology with bilateral Squamous Cell Carcinoma (SCC) of the palatine tonsil and cervical nodal metastasis. Due to its excellent soft tissue/tumor contrast resolution, Magnetic Resonance Imaging (MRI) is the preferred imaging modality for initial staging. Improved sensitivity for the detection of synchronous tumors can be achieved by Positron Emission Tomography (PET)/ Computed Tomography (CT) examination. Due to the rare nature of this pathology, no specific treatment guideline has been provided by National Comprehensive Cancer Network (NCCN). Treatment options available include bilateral Transoral Robotic Surgery (TORS) radical tonsillectomy combined with bilateral neck dissection with adjuvant radiotherapy or chemoradiotherapy and/or upfront concurrent chemoradiotherapy.

Optic pathway cavernous malformations represent less than 1% of all central nervous system cavernomas. They can lead to visual loss with indeterminate speed, and therefore, the timing of intervention is controversial. We present a patient with an optic nerve cavernoma, which was discovered incidentally 3 years before the onset of visual symptoms. The evolution of her symptoms, visual function and radiographic findings are reported in detail. The cavernoma was eventually removed via a transciliary orbitocranial keyhole approach with the goal to protect the optic chiasm from progressive involvement. The function in the affected optic nerve was not salvageable. This is the second reported case of a cavernoma selectively involving the intracranial portion of the optic nerve. The debate on the timing of intervention is highlighted with reference to the natural history of these rare lesions.

BACKGROUND AND PURPOSE Ultrasound (US) measurement of the optic nerve sheath diameter (ONSD) and optic nerve diameter (OND) is a method frequently used to screen for an increased intracranial pressure. The aim of this study was to assess the accuracy of US measurements of ONSD and OND, when compared to magnetic resonance imaging (MRI) measurements as the criterion standard. METHODS In this prospective, single-institution study, orbital US was performed for those patients requiring an emergent brain MRI. ONSD and OND of both eyes were measured in the axial and coronal planes in straight gaze by US. ONSD and OND from brain and orbital MRI were measured by two neuroradiologists. Correlation and agreement between readings were assessed using Pearson's correlations. RESULTS Eighty-two patients met inclusion criteria. The mean axial and coronal ONSD in the MRI examinations was 5.6 and 5.7 mm at 3-5.9 mm behind the globe, respectively. The mean ONSD from the US measurements was 6.22 and 5.52 mm in the axial and coronal planes, respectively. The mean OND in US examinations was 4.31 mm (axial) and 3.68 mm (coronal). Axial versus coronal measurements of ONSD had a modest correlation in US assessment with an r2 of .385 (P < .001) but there were no correlations between any of the US and MRI measurements. CONCLUSIONS In measuring ONSD and OND, US measurements showed a modest correlation between axial and coronal measurements, but no concordance was found between US and MRI in our setting.

Selective catheter-guided digital subtraction angiography remains a critical step in the characterization and treatment of intracranial aneurysms, vascular malformations, vasospasm, vascular injury, vasculitis, and arterial/venous occlusive disease. It also provides clear visualization of the vascular supply of intracranial masses. Digital subtraction angiography offers unique information about vascular pathology, including high spatial resolution, selective vascular characterization, and the ability to evaluate hemodynamics. Neurologic complications of angiography are rare but are more likely to occur in patients of advanced age and with prolonged procedure time. An understanding of the technical components of the procedure along with a knowledge of basic vascular anatomy and relevant bony landmarks improve visualization of certain pathologies and decrease potential complications.

Objective We tested the hypothesis that a single-phase neck computed tomography (CT) is not inferior to multiphase neck CT (MPNCT), ultrasound, or nuclear medicine sestamibi scan in identifying parathyroid adenomas (PAs). Methods A total of 29 patients who had an MPNCT for the evaluation of a PA were identified; 11 patients met the inclusion criteria. During the 30-second arterial phase CT (APNCT), a normalized Hounsfield unit of suspected PA was compared to Hounsfield unit of a normal-appearing level I and a level II lymph node. A PA was defined as a lesion with a ratio of greater than 1.4 when compared to the level I and level II lymph node. This cutoff was determined based on the normalized ratios between level II and level I lymph nodes. Results of intraoperative parathyroid hormone assays and surgical pathology were used to validate the accuracy of this technique. Results The sensitivity of this method in APNCT is 90.9% whereas positive predictive value is 100%. The sensitivity or positive predictive value of ultrasound and nuclear medicine are 60% or 100% and 90% or 100%, respectively. Conclusion The sensitivity of APNCT is equivalent to that of MPNCT in identifying PA.

Background The purpose of this study was to present our evaluation of the outcome of oropharyngeal cancer managed with neoadjuvant chemotherapy and transoral surgery (TOS) with neck dissection as definitive treatment. Methods This is a case series of 17 patients with advanced oropharyngeal cancer who were treated with neoadjuvant chemotherapy followed by TOS. The treatment details and oncologic outcome are reported. The volumetric response of the tumor to neoadjuvant chemotherapy is evaluated and validated by histopathology. Results Seventeen patients with TNM stages III and IV oropharyngeal cancer constitute this series for survival analysis. On a median and mean follow-up of 31 and 40 months, respectively, 16 of the 17 patients were alive without recurrence. Disease-specific survival (DSS) and overall survival (OS) at 3 years were 94.1%. Conclusion Adjuvant chemotherapy followed by TOS and neck dissection is a feasible and efficacious novel therapeutic approach for definitive management of moderately advanced oropharyngeal cancer, reserving radiotherapy (RT) for salvage or adverse features. © 2016 Wiley Periodicals, Inc. Head Neck 38: 1837–1846, 2016

Objectives Lumbar arachnoiditis is a rare and debilitating neurologic disorder with multiple etiologies and a spectrum of imaging and clinical characteristics. Prior reports have anecdotally claimed that no association exists between findings of arachnoiditis observed on magnetic resonance imaging (MRI) and those assessed clinically. The purpose of this study was to determine if MRI features of lumbar arachnoiditis associate with the clinical findings of the disorder. Patients and methods Twenty eight patients with lumbar arachnoiditis reported on MRI between 2012 and 2018 were retrospectively identified. A variety of MRI and clinical features of lumbar arachnoiditis were cataloged for these patients based on common findings discovered through literature review. Imaging findings included cauda equina nerve root contour and thickening, adhesion location, level of involvement, enhancement, and Delamarter group. Clinical findings included demographics, etiology, symptom dynamics, and signs/symptoms. Fisher’s exact tests were used to determine associations between the imaging and clinical features of lumbar arachnoiditis. Results In general, MRI findings did not associate with the clinical features of lumbar arachnoiditis with a few exceptions. Most notably, confounding lumbar pathology was associated with symptom dynamics (p = 0.004) and nerve root contour was associated with motor and sensory symptoms (p = 0.01). The suspected arachnoiditis etiology of the majority of patients was either post-operative or post-infectious in nature. Conclusion MRI findings in lumbar arachnoiditis offer limited insight into the clinical presentation of the disorder.

CONTEXT Web-based learning (WBL) modules are effectively used to improve medical education curriculum; however, they have not been evaluated to improve head computed tomography (CT) scan interpretation in an emergency medicine (EM) setting. OBJECTIVE To evaluate the effectiveness of a WBL module to aid identification of cranial structures on CT and to improve ability to distinguish between normal and abnormal findings. DESIGN Prospective, before-and-after trial in the Emergency Department of an academic center. Baseline head CT knowledge was assessed via a standardized test containing ten head CT scans, including normal scans and those showing hemorrhagic stroke, trauma, and infection (abscess). All trainees then participated in a WBL intervention. Three weeks later, they were given the same ten CT scans to evaluate in a standardized posttest. MAIN OUTCOME MEASURES Improvement in test scores. RESULTS A total of 131 EM clerkship students and 32 EM residents were enrolled. Pretest scores correlated with stage of training, with students and first-year residents demonstrating the lowest scores. Overall, there was a significant improvement in percentage of correctly classified CT images after the training intervention from a mean pretest score of 32% ± 12% to posttest score of 67% ± 13% (mean improvement = 35% ± 13%, p < 0.001). Among subsets by training level, all subgroups except first-year residents demonstrated a statistically significant increase in scores after the training. CONCLUSION Incorporating asynchronous WBL modules into EM clerkship and residency curriculum provides early radiographic exposure in their clinical training and can enhance diagnostic head CT scan interpretation.

An elderly female with progressive proptosis was found to have an aggressive retrobulbar solid orbital mass. The mass was distinct from the optic nerve sheath and intracranial meninges, and produced concave erosion of the sphenoid wing. Operative findings demonstrated an orbital mass adherent to the dura of the superior orbital fissure. The mass did not demonstrate meningeal violation, infiltrate the superior orbital fissure, or display intracranial spread. The dura remained intact after gross total resection. Histopathology revealed a malignant meningioma with papillary and focal rhabdoid morphology and bony invasion (WHO grade III). The patient received 2500cGy of stereotactic radiotherapy in addition to gross total resection. Postoperatively, the signs and symptoms of orbital mass effect resolved (proptosis, relative afferent papillary defect, and periorbital edema) and the vision improved. There was no orbital recurrence or intracranial extension. The follow-up time was limited to eight months secondary to the patient succumbing to metastatic lung adenocarcinoma, which was demonstrated to be a separate process from the orbital meningioma. We propose the etiology of this tumor to be most consistent with an orbital malignant primary extradural meningioma - the first case reported in the literature.

OBJECTIVE This study was aimed to determine the utility of quantitative dynamic contrast-enhanced magnetic resonance imaging (MRI) in differentiating benign and malignant lesions in patients with known thyroid gland lesions scheduled for resection. METHODS Patients scheduled for resection of a thyroid mass were prospectively enrolled. Dynamic contrast-enhanced MRI scans of the neck were performed before surgery. After resection, patients were divided into benign and malignant groups. Quantitative and semiquantitative MRI kinetic measurements of benign and malignant lesions were compared and analyzed. RESULTS Twelve benign and 9 malignant lesions were identified in 19 patients. Mean Ktrans, Ve, and Kep for benign lesions were 1.69 ± 1.59 min, 0.44 ± 0.21 min, and 4.51 ± 2.96 min, respectively; for the malignant lesions, 0.96 ± 0.57 min, 0.45 ± 0.19 min, and 3.57 ± 3.53 min, respectively (P = 0.1886, 0.8036, and 0.3028, respectively). Tpeak, ERmax, slopemax, and iAUGC60 for benign lesions were 7.00 ± 8.09 seconds, 293.27 ± 141.25 seconds, 76.45 ± 65.80 seconds, and 63.46 ± 46.84, respectively; for malignant lesions, 8.11 ± 8.55 seconds, 227.6 ± 113.37 seconds, 81.17 ± 109.71 seconds, and 43.69 ± 26.19, respectively (P = 0.7525, 0.4941, 0.4474, and 0.3028, respectively). CONCLUSIONS Dynamic contrast-enhanced MRI pattern of kinetics was not significantly different for benign and malignant lesions of the thyroid using quantitative or semiquantitative methods.

Purpose The aim of this article was to study the significance of arachnoid granulations (AGs) in patients with idiopathic intracranial hypertension (IIH). Methods In an institutional review board-approved retrospective chart review study, 79 patients with clinical diagnosis of idiopathic increased intracranial pressure were compared with 63 patients with a diagnosis of multiple sclerosis. Inclusion criteria also included available magnetic resonance imaging (MRI) of the brain, older than 18 years, and female sex. Patients with elevated intracranial pressure due to other causes were excluded. The electronic medical records were mined for presence of the following: body mass index, age, headache, vision changes, tinnitus, and vertigo. The MRI of the brain was reviewed for the presence of the following features: empty sella, prominent cerebrospinal fluid space in the optic sheaths, tortuosity of the optic nerves and enlarged Meckel cave. In addition, the number, size, and location of AGs associated with major venous drainage sinuses were documented in all patients. Using statistical analysis, association between various imaging and clinical signs were evaluated. Results The association between AG and various imaging and clinical signs were evaluated. The percentage of patients with AG were significantly higher in patients with IIH. Patients with IIH tended to have 0 to 3 AG. The most common imaging findings observed in MRI of the brain of patients with IIH were empty sella and prominent cerebrospinal fluid space in the optic sheaths. The prevalence of these MRI findings in patients with IIH was inversely proportional to the number of AG. A similar inverse trend was also noted with the opening pressure of patients with IIH and number of AG. Conclusions The study establishes that there is a relationship between presence of AG and IIH. Arachnoid granulation seems to act in a compensatory mechanism in patients with IIH.

We sought to determine the prevalence of vocal cord paralysis in patients with incidentally discovered lymphadenopathy along the expected course of the recurrent laryngeal nerve (RLN).We reviewed the positron-emission tomographic (PET) and computed tomographic (CT) scans of 936 consecutive patients with a variety of diagnoses. Enlarged lymph nodes (short-axis diameter of more than 1 cm) along the expected course of the RLN were identified. Patients with lymphadenopathy were evaluated for CT signs of vocal cord paralysis. The medical records of patients with lymphadenopathy were reviewed for clinical signs of vocal cord paralysis. Patients with head and neck malignancies were excluded from the study.Lymphadenopathy along the course of the RLN was identified in 57 of the 936 patients studied. Fifty-three of the 57 patients (93%) were found to have a malignancy. Thirty-four enlarged nodes (60%) had FDG uptake as shown on a PET/CT scan. Twenty enlarged nodes (35%) had CT evidence of extracapsular spread. Four patients (7%) had CT evidence of vocal cord paralysis. One patient (2%) had clinical evidence of vocal cord paralysis.In asymptomatic patients with incidental lymphadenopathy along the course of the RLN, vocal cord paralysis is rare.

Spontaneous rectus sheath hematoma is an uncommon condition that can mimic other conditions associated with an acute abdomen. We report the case of a patient with a spontaneous rectus sheath hematoma due to a ruptured inferior epigastric artery pseudoaneurysm who presented with hypotension and severe abdominal pain and was diagnosed using emergency department point-of-care ultrasonography. Point-of-care ultrasonography has been increasingly used in the evaluation of emergency department patients with acute abdomen and hypotension to expedite the diagnosis and management of aortic aneurysm and intraperitoneal bleeding. Resuscitation and urgent surgical and interventional radiology consultations resulted in the successful embolization of a branch of the inferior epigastric artery and a good outcome.

OBJECTIVE We hypothesized that the degree of the exophytic nature of the base of the tongue and vallecular cancers (BOTs) impacts the feasibility of transoral resection. The growth pattern of these cancers can be measured by the vallecular line (VL), which is the distance between the hyoid bone and the vallecular tip. MATERIALS AND METHODS The normal VL was measured by 3 radiologists on 50 magnetic resonance imaging scans. The VL was then measured on magnetic resonance imaging scans of patients with BOT cancers. RESULTS The mean VL was 8.2 mm (6.4-10 mm) in the healthy patients. The mean VL of the patients with predominantly exophytic BOT cancer was 22.7 mm (20.6-24.8 mm). Postoperative images of these patients demonstrate minimal loss of the native tongue after transoral resection. CONCLUSIONS The VL is a valuable objective measurement of the exophytic nature of BOT cancers. Predominantly exophytic BOT cancers are deemed more amenable for successful and functional transoral surgical resection.

Objective The purpose of this study is to identify an accurate and reliable computed tomographic (CT) measurement that can identify those patients presenting to the emergency department (ED) with orbital floor fracture (BOF) who require surgical repair to prevent ensuing visually debilitating diplopia and/or enophthalmos. Methods In this retrospective institutional review board–approved study, we reviewed 99 patients older than 18 years with orbital fractures treated in a level I trauma center from 2011 through 2015. Thirty-three patients met the inclusion criteria of having an isolated BOFs with or without a minimally displaced medial wall fracture. The maxillofacial CT of these patients, which included axial, coronal, and sagittal reconstruction of the face in both soft tissue and bone algorithm, were independently reviewed by a neuroradiologist and an oculoplastic surgeon. Each reviewer analyzed the images to answer the following 3 questions: (1) extent of the fracture fragment; greater than or less than 50%? (2) involvement of the inframedial strut (IMS)? and (3) cranial-caudal discrepancy of the orbits. This novel measurement was defined as the difference between the cranial-caudal dimension (CCD), measured just posterior to the globe, of the fractured orbit minus the CCD of the normal side. Electronic medical record was reviewed to determine the course of recovery, ophthalmologist assessment of the globe, motility, diplopia, and the need for operative repair. Statistical analysis was performed to determine the accuracy of the measured CT parameters for the prediction of those who would ultimately require surgical repair. Results Of the 33 patients included in the study, 8 patients required surgical correction of their BOFs. Others were managed conservatively. The accuracy of BOF > 50% for predicting those requiring surgical repair was 48%. The accuracy of IMS involvement was 74%. Using a threshold CCD value of 0.8 cm, the accuracy of CCD was 94%. Cranial-caudal discrepancy had a sensitivity of 100% and specificity of 92%. κ Agreement between the 2 readers evaluating the CT images was 0.93. Conclusion Initial maxillofacial CT studies obtained in the ED for those with BOF is used to predict which patients may need urgent surgical repair. In this report, we introduce a new CT measurement, called CCD. Cranial-caudal discrepancy greater than 0.8 cm is predictive of the development of diplopia and/or enophthalmos that will require surgical correction. Orbital floor fracture greater than 50% and IMS involvement were much less accurate in making similar predictions. Cranial-caudal discrepancy should be used by the ED physicians to identify those patients who should be referred sooner than later to an oculoplastic surgeon for surgical evaluation and intervention. Correct and timely triaging can prevent the complications of delayed correction including scarring, difficult surgical repair, and/or poor functional and aesthetic outcomes.

A young, previously healthy girl presented with a 10-day history of progressive, leftsided facial palsy accompanied by ipsilateral hearing loss and decreased facial sensation. Shehadnotexperiencedheadaches,disequilibrium,or tinnitus.Shehadnohistoryof trauma, and therewas no response to steroids. Findings from a physical examinationwere notable for leftHouse-Brackmanngrade III/VI facial palsy, hypoesthesia in left trigeminal nervedistribution, andno left audiologic responses toboneor air stimuli. A non–contrast-enhanced computed tomographic (CT) scan showeda left petrous apexexpansile lesion involving the internal auditory canal (Figure, A). Magnetic resonance imaging (MRI) showed a wellcircumscribed lesion (Figure, B) extending into the fundus of the internal auditory canal (Figure, C). There was a fluid-fluid level in the lesion (Figure, B), consistent with presence of blood products. The displaced adjacent cranial nerve V (Figure, C) extended along the surface of the lesion. After the administration of an intravenous contrast agent, there was a nodular focus of enhancement at the anterior aspect of the lesion (Figure, D) and linear areasofenhancementat theperipheryandof internal septations (Figure,D). The lesionwas completely excisedvia amiddle fossa craniotomy.Postoperatively, thepatient regained full function of all cranial nerve deficits, including the hearing loss. Bone window, axial view A

Seizures in children are common and represent a final pathway for a variety of brain insults. Although most children with seizures do not require imaging, when indicated, imaging plays an important role in the clinical workup. Imaging in the pediatric seizure population is reserved for a particular subset of patients depending on factors, such as age of onset, symptomatology, physical examination findings, and specific electroencephalography changes to name a few. The etiologies of seizures are extensive and include disorders of cortical migration and organization. Cortical migration and organization disorders are multifactorial and complex and a major cause of seizure disorders. Although magnetic resonance imaging is the most common imaging modality used to identify the seizure focus, positron emission tomographic and/or diffusion tensor imaging are beginning to provide complementary information about the involved areas. Early and accurate detection is key to better treatment and overall improved patient prognosis.

Cranial fasciitis (CF) is a rare benign neoplastic lesion affecting the pericranium and deep fascia of the scalp. We report a case confined to the temporal bone, resembling a malignant destructive lesion. The mass was identified during myringotomy for recurrent unilateral otitis media. Biopsy was consistent with CF, which was partially resected. The patient has remained disease free for 12 months. Due to its rarity, no defined treatment algorithm for CF exists. Despite aggressive features on radiology, they may respond very well to partial resection.

Lymphoma can involve all genitourinary organs, albeit with different rates of prevalence. Recognizing the diverse imaging presentations of this disease can facilitate its identification and hone patient management. This article provides a pictorial review of the genitourinary lymphoma and the pertinent organ-specific clinical manifestations of this disease.

With advancing technology, the sensitivity of computed tomography (CT) for the detection of traumatic subarachnoid hemorrhage (tSAH) continues to improve. Increased resolution has allowed for the detection of hemorrhage that is limited to one or two images of the CT exam. At our institution, all patients with a SAH require intensive care unit (ICU) admission, regardless of size. It was our hypothesis that patients with small subarachnoid hemorrhage experience favorable outcomes, and may not require the intensive monitoring offered in the ICU. This retrospective study evaluated 62 patients between 2011 and 2014 who presented to our Level I trauma center emergency room for acute traumatic injuries, and found to have subarachnoid hemorrhages on CT examination. The grade of subarachnoid hemorrhage was determined using previously utilized scoring systems, such as the Fisher, Modified Fisher, and Claassen grading systems. Electronic medical records were used to evaluate for medical decline, neurological decline, neurosurgical intervention, and overall hospital course. Admitting co-morbidities were noted, as were the presence of patient intoxication and use of anticoagulants. Patient outcomes were based on discharge summaries upon which the neurological status of the patient was assessed. Each patient was given a score based on the Glasgow outcome scale. The clinical and imaging profile of 62 patients with traumatic SAH were studied. Of the 62 patients, 0 % underwent neurosurgical intervention, 6.5 % had calvarial fractures, 25.8 % had additional intracranial hemorrhages, 27.4 % of the patients had significant co-morbidities, and 1.6 % of the patients expired. Patients with low-grade tSAH spent less time in the ICU, demonstrated neurological and medical stability during hospitalization. None of the patients with low-grade SAH experienced seizure during their admission. In our study, patients with low-grade tSAH demonstrated favorable clinical outcomes. This suggests that patients may not require as aggressive monitoring as is currently provided for those with tSAH.

With advancing technology, the sensitivity of computed tomography (CT) for the detection of subdural hematoma (SDH) continues to improve. In some cases, the finding is limited to one or 2 images of the CT examination. At our institution, all patients with an SDH require intensive care unit (ICU) admission, regardless of size. In this report, we tested the hypothesis that patients with a small traumatic SDH on their presenting CT examination do not require the intensive monitoring offered in the ICU and can instead be managed on a hospital unit with a lower level of monitoring. This is a retrospective study of patients evaluated and treated at a level I trauma center for acute traumatic intracranial hemorrhage between 2011 and 2014. The clinical and imaging profile of 87 patients with traumatic SDH were studied. Patients with small isolated traumatic subdural hemorrhage (tSDH) (

Ganglioneuromas, which arise from neural crest cells, are typically seen in adolescent and young adults. We describe an unusual case of posterior mediastinal ganglioneuroma with a large fatty component in a middle-aged male. This imaging feature has only been reported in five published manuscripts in the English literature.

Objectives We present the case of a choroid plexus papilloma (CPP) in the cerebellopontine angle (CPA), describe the different appearances of CPPs with a variety of imaging techniques, and discuss the differential diagnosis of CPA tumors. Participant and Design We report the case of a 52-year-old woman with headache, tinnitus, and unilateral hearing impairment whose preoperative magnetic resonance imaging revealed a heterogeneously enhancing CPA mass that extended into the internal auditory canal. Main Outcome Measures, Results, and Conclusion The preoperative imaging appearance of the lesion was most consistent with that of a schwannoma. Postoperative histopathologic examination found the tumor to be a CPP with cuboidal epithelial cells overlying fibrovascular stroma. CPPs are rare benign central nervous system neoplasms arising from choroid plexus epithelium. The most common site of presentation is in the fourth ventricle in adults and the lateral ventricles in children. CPPs rarely occur in the CPA, and when they do, clinical-radiologic diagnosis is difficult due to both the rarity of this presentation and to nonspecific radiological features.

Objective: The objective of our study is to describe the technique of distal endotracheal tube (ETT) positioning for avoiding cuff rupture and validate the technique in a virtual tracheostomy model. Methods: A prospective nonrandomized case series of 129 patients who had undergone tracheostomy using the senior author’s technique were evaluated. Primary outcome was ETT cuff rupture. One hundred normal patient computed tomography (CT) scans were used to generate a virtual tracheostomy model, and the probability of cuff rupture, among other values, was obtained. Results: One hundred twenty-three of 129 patients underwent tracheostomy without cuff rupture when the distal tip of the ETT was placed just proximal to the carina. After analysis of 100 3-dimensional CT scans, the average distance from the tracheotomy to the superior aspect of the cuff was 54.6 mm in men and 39.87 mm in women when a 6.5-size ETT was used, and 44.8 mm in men and 30.07 mm in women when a 7.5-size ETT was used. Virtual tracheotomy between the second and third tracheal rings resulted in no probability of inadvertent ETT cuff rupture. Conclusion: Distal ETT positioning during tracheostomy should be considered for avoiding inadvertent ETT cuff rupture.

Abstract —In the brain, pressure-induced myogenic constriction of cerebral arteriolar muscle contributes to autoregulation of cerebral blood flow (CBF). This study examined the role of 20-HETE in autoregulation of CBF in anesthetized rats. The expression of P-450 4A protein and mRNA was localized in isolated cerebral arteriolar muscle of rat by immunocytochemistry and in situ hybridization. The results of reverse transcriptase–polymerase chain reaction studies revealed that rat cerebral microvessels express cytochrome P-450 4A1, 4A2, 4A3, and 4A8 isoforms, some of which catalyze the formation of 20-HETE from arachidonic acid. Cerebral arterial microsomes incubated with [ 14 C]arachidonic acid produced 20-HETE. An elevation in transmural pressure from 20 to 140 mm Hg increased 20-HETE concentration by 6-fold in cerebral arteries as measured by gas chromatography/mass spectrometry. In vivo, inhibition of vascular 20-HETE formation with N -methylsulfonyl-12,12-dibromododec-11-enamide (DDMS), or its vasoconstrictor actions using 15-HETE or 20-hydroxyeicosa-6(Z),15(Z)-dienoic acid (20-HEDE), attenuated autoregulation of CBF to elevations of arterial pressure. In vitro application of DDMS, 15-HETE, or 20-HEDE eliminated pressure-induced constriction of rat middle cerebral arteries, and 20-HEDE and 15-HETE blocked the vasoconstriction action of 20-HETE. Taken together, these data suggest an important role for 20-HETE in the autoregulation of CBF. ( Circ Res. 2000;87:60-65.)

Abstract —The present study examined whether inhibition of P4504A enzyme activity and the formation of 20-HETE contributes to the activation of K + channels and vasodilator effects of nitric oxide (NO) in renal arterioles. Addition of an NO donor to the P4504A2 enzyme that produces 20-HETE increased visible light absorbance at 440 nm indicating that NO binds to heme in this enzyme. NO donors also dose-dependently inhibited the formation of 20-HETE in microsomes prepared from renal arterioles. In patch-clamp experiments, NO donors increased the open-state probability of a voltage-sensitive, large-conductance (195±9 pS) K + channel recorded with cell-attached patches on renal arteriolar smooth muscle cells. Blockade of guanylyl cyclase with [1H-[1,2,4]Oxadiazolo[4,3-a] quinoxalin-1-one] (ODQ, 10 μmol/L), or cGMP-dependent kinase with 8 R ,9 S ,11 S -(−)-9-methoxycarbamyl-8-methyl-2,3,9,10-tetrahydro-8,11-epoxy-1 H ,8 H ,11 H -2,7 b ,11 a -trizadibenzo-( a , g )-cy-cloocta-( c , d , e )-trinden-1-one (KT-5823) (1 μmol/L) did not alter the effects of NO on this channel. In contrast, inhibition of the formation of 20-HETE with 17-octadecynoic acid (1 μmol/L) activated this channel and masked the response to NO. Preventing the NO-induced reduction in intracellular 20-HETE levels also blocked the effects of NO on this channel. Sodium nitroprusside (SNP) increased the diameter of renal interlobular arteries preconstricted with phenylephrine to 80±4% of control. Blockade of guanylyl cyclase with ODQ (10 μmol/L) attenuated the response to SNP by 26±2%; however, fixing 20-HETE levels at 100 nmol/L reduced the response by 67±8%. Blockade of both pathways eliminated the response to SNP. These results indicate that inhibition of the formation of 20-HETE contributes to the activation of K + channels and the vasodilator effects of NO in the renal microcirculation.

Spontaneous rectus sheath hematoma is an uncommon condition that can mimic other conditions associated with an acute abdomen. We report the case of a patient with a spontaneous rectus sheath hematoma due to a ruptured inferior epigastric artery pseudoaneurysm who presented with hypotension and severe abdominal pain and was diagnosed using emergency department point-of-care ultrasonography. Point-of-care ultrasonography has been increasingly used in the evaluation of emergency department patients with acute abdomen and hypotension to expedite the diagnosis and management of aortic aneurysm and intraperitoneal bleeding. Resuscitation and urgent surgical and interventional radiology consultations resulted in the successful embolization of a branch of the inferior epigastric artery and a good outcome.

A 21 year-old man, who was an unrestrained passenger in a high-speed motor vehicle crash with 2 fatalities and a prolonged extrication, was brought to the emergency department at Harborview Medical Center. The patient was intubated after arrival because of hemodynamic instability. The initial chest radiograph (CXR) showed a slight contour abnormality of the right hemidiaphragm (Fig 1). Diagnostic peritoneal lavage was grossly and microscopically negative for blood but did contain chyle, so he was taken for an emergent exploratory laparotomy. The CXR normalized by the time the patient was admitted to the intensive care unit and remained as such while the patient was mechanically ventilated (Fig 2). During his first 4 days in the intensive care unit, his mechanical ventilator was set at assist control with a positive end-expiratory pressure of 10 cm of H 2 O, a tidal volume of 650 mL, and a respiratory rate of 30 breaths per minute. On hospital day 6, after extubation, a right hemidiaphragmatic contour abnormality was noted. This became more apparent 6 days post extubation (Fig 3), at which time a computed tomography scan showed herniation of a portion of the liver through a right hemidiaphragmatic rupture (Fig 4). At surgery, a large right anterolateral hemidiaphragmatic tear was identified extending from the central ligament across the dome that was subsequently repaired. Discussion

Bi-valvular pneumococcal endocarditis in Austrian syndrome, which includes a triad of pneumococcal endocarditis, pneumonia, and meningitis, is a rare but life-threatening disease. We present a case of a woman found to have Austrian syndrome who presented to the emergency department (ED) with dehydration and radiographical signs of lobar pneumonia and quickly deteriorated to fulminant cardiogenic shock in less than four hours. An early echocardiogram in the ED confirmed a diagnosis of bi-valvular endocarditis with severe aortic and mitral valve insufficiency and large vegetations on the valve leaflets requiring emergent surgical intervention with double valve replacement. Assumed meningitis as a part of the triad of Austrian syndrome was confirmed by imaging the day after hospital admission. Early diagnosis of endocarditis by obtaining the echocardiogram in the ED along with emergent surgical intervention allowed for a favorable outcome for the patient.

Rapidly progressive acute respiratory distress along with life-threatening gram-negative anaerobic sepsis in a young, immunocompetent individual should always raise concern for Lemierre's syndrome. Although still rare, the incidence of Lemierre's syndrome has been increasing over the past 20 years. Lemierre's syndrome is characterized by postanginal septicemia and secondary internal jugular vein suppurative thrombophlebitis. In the emergency department (ED), patients often present with evidence of sepsis and secondary septic emboli to different organs, primarily the lungs.We report a case of a 24-year-old patient who presented to the ED with acute respiratory distress with an atypical and rapidly deteriorating course. She was later diagnosed with Lemierre's syndrome and recovered well after antibiotic treatment, respiratory support, and a lengthy intensive care unit stay. This case report represents an atypical presentation of acute respiratory distress and pharyngitis but is classic for Lemierre's syndrome.

We present the clinical presentation, sonography, CT, and MR imaging as well as correlative intra-operative and gross pathological findings of ovarian torsion in a 14-year-old girl. Our findings are discussed in the context of prior imaging studies performed for the evaluation of ovarian torsion. Ovarian torsion is not an uncommon cause of acute abdominal pain in children and teenage girls. Diagnosis of this entity can be difficult based on clinical presentation or on imaging appearance alone.