Faculty Bibliography

We present a case of an 85-year-old woman with a 40-year history of progressive bilateral sensorineural hearing loss. Imaging studies demonstrated bilateral pseudoaneurysms of the petrous portion of the internal carotid arteries eroding into both cochleas. To our knowledge, this is the first case report of such lesions.

The widespread acceptance of functional endoscopic sinus surgery (FESS) underscores the importance of understanding the relevant anatomy of the paranasal sinuses as a means of providing a roadmap to the otorhinolaryngologist prior to surgery. The radiologist can address important imaging issues for the ear, nose, and throat (ENT) surgeon before FESS is undertaken. There are two main questions that the radiologist should address: 1. Are there anatomic features on the computed tomography (CT) scan that predispose the patient to impaired mucociliary clearance? 2. Are there anatomic features that pose a surgical hazard?

BACKGROUND AND PURPOSE/OBJECTIVE:Patients referred to tertiary care centers frequently arrive with images obtained at outside institutions; these images require reinterpretation. We assessed the clinical value of reinterpreting cross-sectional imaging studies of patients with head and neck cancer, in the setting of a multidisciplinary cancer center. METHODS:Outside CT and MR images of 136 patients with known or presumed head and neck cancer were reinterpreted by a neuroradiologist. Clinical history and findings on physical examination were available. Reinterpretation was performed before review of outside reports, which were subsequently compared with those generated at the cancer center. Changes in interpretation were noted, and their effects on TNM staging, patient care, and prognosis were assessed. Reliability and statistical significance of rates of change in diagnosis were analyzed with 95% confidence intervals (CIs) and the sign test, respectively. Verification of change in diagnosis was confirmed by pathologic analysis (75%), characteristic radiologic findings (18%), or clinical and imaging follow-up (7%). RESULTS:Change in interpretation occurred in 56 patients (41%) (95% CI: 33-49%, P <.001). Forty-six patients (34%) had a change in T, N, and/or M staging (26-42%, P <.001). Change in T stage occurred in 27 cases (20%) (13-27%, P <.001) (upstaged in 22, downstaged in five), and a change in N stage in 26 cases (19%) (12-26%, P <.001) (upstaged in 20, downstaged in six). Two patients (1.5%) had missed systemic metastases. Three patients with an initial diagnosis of cancer were found to be cancer-free, and six patients had a diagnosis of new second primary cancers that were missed at original interpretation. One patient had a missed middle cerebral artery aneurysm. Changes in image interpretation altered treatment in 55 (98%) of 56 patients and affected prognosis in 53 patients (95%) (P <.001). CONCLUSION/CONCLUSIONS:Reinterpretation of cross-sectional images in the setting of a multidisciplinary cancer center has a significant effect on staging, management, and prognosis in patients with head and neck cancer.

Imaging is of paramount importance in early diagnosis of epidural abscess and its intracranial complications. Typical CT imaging features of an epidural abscess include a hypodense lentiform extra-axial collection with rim enhancement. We present a case of epidural abscess that was hyperdense on CT scan due to the presence of associated epidural hematoma. The literature is reviewed regarding this unusual complication of epidural abscess.

OBJECTIVES/HYPOTHESIS/OBJECTIVE:Lipomas of the retropharyngeal space are rare and do not cause symptoms until they reach a large size. Although retropharyngeal lipoma is an uncommon entity, several reports of it appear in the literature, and the treatment has routinely been surgical excision. Such fatty tumors also carry the rare possibility of being liposarcomas, which further warrants their excision. We present the case of a lipoma of the retropharyngeal space extending from the nasopharynx to the superior mediastinum causing symptoms of obstructive sleep apnea. The patient had multiple medical problems and was on a regimen of anticoagulation therapy; therefore, he opted against surgical treatment. He has used continuous positive airway pressure and has been followed clinically and radiographically for 5 years. Radiographic follow-up of a retropharyngeal lipoma after a needle biopsy confirming its benign nature is a legitimate means of management of this rare condition. STUDY DESIGN/METHODS:Case report of a 64-year-old man presenting with this rare lesion. METHODS:Computed tomography-guided needle biopsy of the mass was performed to obtain tissue diagnosis. Thereafter, the patient has been followed for 5 years with annual magnetic resonance imaging scans to determine growth or changes of the retropharyngeal mass. RESULTS:Fine-needle aspiration of the mass revealed mature adipose tissue intermixed with fibroconnective tissue, consistent with lipoma. Based on this result, we opted to follow this patient with serial magnetic resonance imaging scans, which have shown no change in size. There has also been no change in the patient's symptoms. CONCLUSIONS:Large lipomas warrant excision, especially when their location produces pressure symptoms. However, when surgical morbidity is high, fine-needle aspiration biopsy and serial magnetic resonance imaging scans are a safe alternative.

The authors describe a 36-year-old man with Sturge-Weber syndrome who presented with focal seizures and subsequently developed a temporary post-ictal hemianopia. Magnetic resonance imaging of the brain demonstrated focal leptomeningeal enhancement, which subsequently resolved.

BACKGROUND AND PURPOSE/OBJECTIVE:Reproducible measurements of brain tumor volume are helpful in evaluating the response to therapy and the need for changing treatment plans. Our purpose was to adapt the fuzzy-connectedness segmentation technique to measure tumor volume. This technique requires only limited operator interaction. METHODS:Routine postoperative brain MR imaging was performed in 19 patients with primary malignant gliomas of the brain. Segmentation was performed on axial and coronal gadolinium-enhanced and axial fluid-attenuated inversion recovery (FLAIR) images by using a fuzzy-connectedness algorithm, and tumor volumes were generated. Operator interaction was limited to selecting representative seed points within the tumor and, if necessary, editing the segmented image to include or exclude improperly classified regions. RESULTS:Measurements of tumor volume were highly reproducible when they were obtained with no editing; intraobserver coefficients of variation were 0.15-0.37% and 0.29-0.38%, respectively, for enhanced images and FLAIR images. Editing consistently produced smaller volumes, at the cost of greater variability in volume measurements. Coefficients of variation for volumes with editing ranged from 0.2% to 1.3%. CONCLUSIONS:Fuzzy-connected segmentation permits rapid, reliable, consistent and highly reproducible measurement of tumor volume from MR images with limited operator interaction.