Faculty Bibliography

Injury to the pudendal nerve in men presents with pain, paresthesia, or numbness of the perineum, and/or scrotum, and/or penis. There is evidence implicating the brachytherapy seeds used to treat prostate cancer as source of pudendal nerve injury. Compared to surgical prostatectomy, brachytherapy has the advantage of being less invasive, but seeds may not only lead to well-established complications such as urinary, bowel, and erectile dysfunction, but also injury to the sensory branches of the pudendal nerve. We report and document a case of pudendal nerve injury secondary to brachytherapy seeds diagnosed with magnetic resonance (MR) neurography, nerve blocks, and histopathological examination; and successful treatment via sensory branch neurectomy.

The spectrum of effective musculoskeletal (MSK) interventions is broadening and rapidly evolving. Increasing demands incite a perpetual need to optimize services and interventions by maximizing the diagnostic and therapeutic yield, reducing exposure to ionizing radiation, increasing cost efficiency, as well as identifying and promoting effective procedures to excel in patient satisfaction ratings and outcomes. MSK interventions for the treatment of oncological conditions, and conditions related to sports injury can be performed with different imaging modalities; however, there is usually one optimal image guidance modality for each procedure and individual patient. We describe our patient-centered workflow as a model of care that incorporates state-of-the-art imaging techniques, up-to-date evidence, and value-based practices with the intent of optimizing procedural success and outcomes at a patient-specific level. This model contrasts interventionalist- and imaging modality-centered practices, where procedures are performed based on local preference and selective availability of imaging modality or interventionalists. We discuss rationales, benefits, and limitations of fluoroscopy, ultrasound, computed tomography, and magnetic resonance imaging procedure guidance for a broad range of image-guided MSK interventions to diagnose and treat sports and tumor-related conditions.

Team handball is a fast high-scoring indoor contact sport with > 20 million registered players who are organized in > 150 federations worldwide. The combination of complex and unique biomechanics of handball throwing, permitted body tackles and blocks, and illegal fouls contribute to team handball ranging among the four athletic sports that carry the highest risks of injury. The categories include a broad range of acute and overuse injuries that most commonly occur in the shoulder, knee, and ankle. In concert with sports medicine, physicians, surgeons, physical therapists, and radiologists consult in the care of handball players through the appropriate use and expert interpretations of radiography, ultrasonography, CT, and MRI studies to facilitate diagnosis, characterization, and healing of a broad spectrum of acute, complex, concomitant, chronic, and overuse injuries. This article is based on published data and the author team's cumulative experience in playing and caring for handball players in Denmark, Sweden, Norway, Germany, Switzerland, and Spain. The article reviews and illustrates the spectrum of common handball injuries and highlights the contributions of sports imaging for diagnosis and management.

PURPOSE/OBJECTIVE:Venous malformations (VMs) are low-flow vascular anomalies that are commonly treated with image-guided percutaneous sclerotherapy. Although many VMs can be safely accessed and treated using ultrasonography and fluoroscopy, some lesions may be better treated with magnetic resonance imaging (MRI)-guided sclerotherapy. The aim of this study is to evaluate the feasibility, efficiency, and outcomes of MRI-guided sclerotherapy of VMs using a 3T MRI system. METHODS:Six patients with VMs in the neck (n = 2), chest (n = 1), and extremities (n = 3) underwent sclerotherapy with 3T MRI guidance. Feasibility was assessed by calculating the technical success rate and procedural efficiency. Efficiency was evaluated by using planning, targeting, intervention, and total procedure times. Outcomes were assessed by measuring VM volumes before and after sclerotherapy, patient-reported pain scores, and occurrence of complications. RESULTS:Technical success was achieved in all 6 procedures. There was a non-significant 30% decrease in mean VM volume after the procedure (P = .350). The procedure resulted in a decrease in mean pain score (on an 11-point scale) of 2.6 points (P = .003). After the procedure, 4 patients reported complete pain resolution, 1 reported partial pain resolution, and 1 reported no change in pain. Procedural efficiency was consistent with similar sclerotherapy procedures performed at our institution. There were no major or minor complications. CONCLUSION/CONCLUSIONS:3T MRI guidance is feasible for percutaneous sclerotherapy of VMs, with promising initial technical success rates, procedural efficiency, and therapeutic outcomes without complications.

Identifying MRI-based radiomics features capable to assess response to systemic treatment in multiple myeloma (MM) patients. Retrospective analysis of whole-body MR-image data in 67 consecutive stage III MM patients (40 men; mean age, 60.4 years). Bone marrow involvement was evaluated using a standardized MR-imaging protocol consisting of T1w-, short-tau inversion recovery- (STIR-) and diffusion-weighted-imaging (DWI) sequences. Ninety-two radiomics features were evaluated, both in focally and diffusely involved bone marrow. Volumes of interest (VOI) were used. Response to treatment was classified according to International Myeloma Working Group (IMWG) criteria in complete response (CR), very-good and/or partial response (VGPR + PR), and non-response (stable disease (SD) and progressive disease (PD)). According to the IMWG-criteria, response categories were CR (n = 35), VGPR + PR (n = 19), and non-responders (n = 13). On apparent diffusion coefficient (ADC)-maps, gray-level small size matrix small area emphasis (Gray Level Size Zone (GLSZM) small area emphasis (SAE)) significantly correlated with CR (p < 0.001), whereas GLSZM non-uniformity normalized (NUN) significantly (p < 0.008) with VGPR/PR in focal medullary lesions (FL), whereas in diffuse involvement, 1st order root mean squared significantly (p < 0.001) correlated with CR, whereas for VGPR/PR Log (gray-level run-length matrix (GLRLM) Short Run High Gray Level Emphasis) proved significant (p < 0.003). On T1w, GLRLM NUN significantly (p < 0.002) correlated with CR in FL, whereas gray-level co-occurrence matric (GLCM) informational measure of correlation (Imc1) significantly (p < 0.04) correlated with VGPR/PR. For diffuse myeloma involvement, neighboring gray-tone difference matrix (NGTDM) contrast and 1st order skewness were significantly associated with CR and VGPR/PR (p < 0.001 for both). On STIR-images, CR correlated with gray-level co-occurrence matrix (GLCM) Informational Measure of Correlation (IMC) 1 (p < 0.001) in FL and 1st order mean absolute deviation in diffusely involved bone marrow (p < 0.001). VGPR/PR correlated at best in FL with GSZLM size zone NUN (p < 0.019) and in all other involved medullary areas with GLSZM large area low gray level emphasis (p < 0.001). GLSZM large area low gray level emphasis also significantly correlated with the degree of bone marrow infiltration assessed histologically (p = 0.006). GLCM IMC 1 proved significant throughout T1w/STIR sequences, whereas GLSZM NUN in STIR and ADC. MRI-based texture features proved significant to assess clinical and hematological response (CR, VPGR, and PR) in multiple myeloma patients undergoing systemic treatment.

BACKGROUND:Restoration of anatomical relationship between talus and tibia is crucial for longevity of total ankle replacement (TAR). Weight-bearing (WB) radiographs are the standard for evaluating the sagittal balance alignment, but are prone to rotational misalignment and altered measurements. Metal artifact reduction sequence (MARS) MRI allows visualization of periprosthetic landmarks and alignment of the image plane to the true sagittal axis of the implant. The purpose of this study was to compare TAR sagittal balance measurements on MARS MRI and WB radiographs. METHODS:Twenty-three subjects with TAR [10 men/13 women, age 60 (41-73) years; 13 (3-24) months post-op] underwent MARS MRI and standard lateral WB radiographs. Standardized MARS MR images were aligned to the sagittal talar component axis. Three observers performed sagittal balance alignment measurements twice in an independent, random and blinded fashion. Lateral Talar Station (LTS), tibial axis-to-talus (T-T) ratio and normalized tibial axis-to-lateral-process (T-L) distance were measured. Concordance correlation coefficients (CCC) and intraclass correlation coefficients (ICC) were used for statistical analysis. In addition, mixed effects linear models were employed to assess overall concordance of the two image types. RESULTS:The intraobserver agreement was excellent for radiographic (CCC=0.96) and MRI (CCC=0.90-0.97) measurements. Interobserver agreements were good-to-excellent with overall slightly higher agreements for MRI (ICC=0.78-0.94) than radiography (ICC=0.78-0.90) measurements. The T-T ratios of radiographs and MRI showed a high degree of concordance, whereas LTS was significantly lower on MRI when compared with radiographs, and T-L distance showed notable disagreement between the two imaging types. CONCLUSION/CONCLUSIONS:Sagittal balance measurements performed on standardized weight-bearing radiographs and standardized MARS MRI demonstrate substantial correlation and similarity. Given its high intra and interobserver agreement, MARS MRI may be helpful for the evaluation of TAR sagittal balance. LEVEL OF EVIDENCE/METHODS:Level II - Prospective Comparative Study.

BACKGROUND:Despite the advantages of 3D MRI in evaluation of cruciate ligament injuries, its use in clinical practice is still a matter of debate due to controversy regarding its diagnostic performance. PURPOSE/OBJECTIVE:To evaluate the diagnostic performance of 3D MRI for detecting cruciate ligament injuries, using surgery or arthroscopy as the reference standard. STUDY TYPE/METHODS:Meta-analysis. POPULATION/METHODS:Patients with knee pain. FIELD STRENGTH/SEQUENCE/UNASSIGNED:3D and 2D MRI. ASSESSMENT/RESULTS:Four databases were reviewed according to PRISMA guidelines. STATISTICAL TESTS/UNASSIGNED:Pooled values of sensitivity, specificity, and diagnostic odds ratio (DOR) were calculated using a random-effects model. To investigate the effect of relevant covariates on the diagnostic performance of 3D MRI, sensitivity analysis was performed using meta-regression to calculate relative DOR. RESULTS:Of 731 initially identified reports, 22 (1298 3D MRI examinations) met our criteria and were included. Pooled estimates of sensitivity and specificity for 3D sequences were 91.4% (95% confidence interval [CI]: 87.4-94.2%) and 96.1% (95% CI: 93.8-97.6%), respectively. Fourteen studies also reported the results of 2D MRI, with pooled sensitivity of 90.6% (95% CI: 84.1-94.6%) and specificity of 97.1% (95% CI: 94.7-98.4%), which were not significantly different from 3D sequences. 3D MRI sequences performed using 3T scanners had significantly higher DOR compared with 3D sequences performed on 1.5T or lower scanners (relative DOR: 6.04, P = 0.01). DATA CONCLUSION/UNASSIGNED:3D MRI is equivalent to 2D MRI in the diagnosis of cruciate ligament injuries. The use of 3T scanners improves the performance of 3D MRI for detecting cruciate ligament injuries. LEVEL OF EVIDENCE/METHODS:2 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2019;50:1545-1560.