Publications by authors named "Nancy Fischbein"

122 Publications

Differential Diagnosis of Corpus Callosum Lesions: Beyond the Typical Butterfly Pattern.

Radiographics 2021 May-Jun;41(3):E79-E80

From the Department of Radiology, Aventura Hospital and Medical Center, 20900 Biscayne Blvd, Miami, FL 33180-1407 (Y.Y., A.C.); and Department of Radiology, Division of Neuroimaging and Neurointervention, Stanford Health Care, Stanford, Calif (N.F., A.C).

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http://dx.doi.org/10.1148/rg.2021200146DOI Listing
May 2021

Toxoplasmosis Among 38,751 Hematopoietic Stem Cell Transplant Recipients: A Systematic Review of Disease Prevalence and a Compilation of Imaging and Autopsy Findings.

Transplantation 2021 Feb 4. Epub 2021 Feb 4.

Division of Infectious Diseases, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA Dr. Jack S. Remington Laboratory for Specialty Diagnostics, Palo Alto Medical Foundation, Palo Alto, CA, USA Stanford University School of Medicine, Stanford Prevention Research Center, Stanford, CA, USA Division of Hematology Oncology and Stem Cell Transplantation and Regenerative Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA Department of Radiology, Thoracic Imaging, Stanford University School of Medicine, Stanford, CA, USA Department of Radiology, Neuroimaging and Neuro-intervention, Stanford University School of Medicine, Stanford, CA, USA.

Background: Toxoplasmosis in hematopoietic stem cell transplant-recipients (HSCT) can be life threatening if not promptly diagnosed and treated.

Methods: We performed a systematic review (PubMed last search 03/29/2020) of toxoplasmosis among HSCT-recipients and calculated the toxoplasmosis prevalence across studies. We also created a compilation list of brain imaging, chest imaging and autopsy findings of toxoplasmosis among HSCT-recipients.

Results: We identified 46 eligible studies (47 datasets) with 399 toxoplasmosis cases among 38751 HSCT-recipients. There was large heterogeneity in the reported toxoplasmosis prevalence across studies, thus formal meta-analysis was not attempted. The median toxoplasmosis prevalence among 38751 HSCT-recipients was 2.14% (range 0-66.67%). Data on toxoplasmosis among at-risk R+HSCT-recipients were more limited (25 studies; 2404 R+HSCT-recipients [6.2% of all HSCT-recipients]) although the median number of R+HSCT-recipients was 56.79% across all HSCT-recipients. Median toxoplasmosis prevalence across studies among 2404 R+HSCT was 7.51% (range 0-80%) vs 0% (range 0-1.23%) among 7438 R-HSCT. There were limited data to allow meaningful analyses of toxoplasmosis prevalence according to prophylaxis-status of R+HSCT-recipients.

Conclusion: Toxoplasmosis prevalence among HSCT-recipients is underestimated. The majority of studies report toxoplasmosis prevalence among all HSCT-recipients rather than only among the at-risk R+HSCT-recipients. In fact, the median toxoplasmosis prevalence among all R+/R- HSCT-recipients is 3.5-fold lower compared to the prevalence among only the at-risk R+HSCT-recipients and the median prevalence among R+HSCT-recipients is 7.51-fold higher than among R-HSCT-recipients. The imaging findings of toxoplasmosis among HSCT-recipients can be atypical. High-index of suspicion is needed in R+HSCT-recipients with fever, pneumonia or encephalitis.
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http://dx.doi.org/10.1097/TP.0000000000003662DOI Listing
February 2021

Microsurgical Resection of an Orbital Arteriovenous Malformation With Intraoperative Digital Subtraction Angiography.

Ophthalmic Plast Reconstr Surg 2021 May-Jun 01;37(3S):S141-S144

Department of Ophthalmology, Byers Eye Institute, Stanford University School of Medicine.

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http://dx.doi.org/10.1097/IOP.0000000000001815DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8191182PMC
May 2021

COVID-19-induced anosmia associated with olfactory bulb atrophy.

Neuroradiology 2021 Jan 15;63(1):147-148. Epub 2020 Sep 15.

Division of Neuroradiology, Department of Radiology, Stanford University, 300 Pasteur Drive, Room S047, Stanford, CA, 94305-5105, USA.

As the global COVID-19 pandemic evolves, our knowledge of the respiratory and non-respiratory symptoms continues to grow. One such symptom, anosmia, may be a neurologic marker of coronavirus infection and the initial presentation of infected patients. Because this symptom is not routinely investigated by imaging, there is conflicting literature on neuroimaging abnormalities related to COVID-19-related anosmia. We present a novel case of COVID-19 anosmia with definitive olfactory bulb atrophy compared with pre-COVID imaging. The patient had prior MR imaging related to a history of prolactinoma that provided baseline volumes of her olfactory bulbs. After a positive diagnosis of COVID-19 and approximately 2 months duration of anosmia, an MRI was performed that showed clear interval olfactory bulb atrophy. This diagnostic finding is of prognostic importance and indicates that the olfactory entry point to the brain should be further investigated to improve our understanding of COVID infectious pathophysiology.
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http://dx.doi.org/10.1007/s00234-020-02554-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7490479PMC
January 2021

CT-based Radiomic Signatures for Predicting Histopathologic Features in Head and Neck Squamous Cell Carcinoma.

Radiol Imaging Cancer 2020 05 15;2(3):e190039. Epub 2020 May 15.

Department of Medicine, Stanford Center for Biomedical Informatics Research (BMIR), Stanford, Calif (P.M., M.C., C.H., M.Z., O.G.); Department of Radiology, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil (M.C.); Department of Nutrition and Food Hygiene, Chronic Disease Research Institute, School of Public Health, School of Medicine, Zhejiang University, Zhejiang, China (C.H., S.Z.); Division of Oncology, Department of Medicine (A.D.C.), Department of Radiology (N.F.), and Department of Biomedical Data Science (O.G.), Stanford University, 1265 Welch Rd, Stanford, CA 94305-5479.

Purpose: To determine the performance of CT-based radiomic features for noninvasive prediction of histopathologic features of tumor grade, extracapsular spread, perineural invasion, lymphovascular invasion, and human papillomavirus status in head and neck squamous cell carcinoma (HNSCC).

Materials And Methods: In this retrospective study, which was approved by the local institutional ethics committee, CT images and clinical data from patients with pathologically proven HNSCC from The Cancer Genome Atlas ( = 113) and an institutional test cohort ( = 71) were analyzed. A machine learning model was trained with 2131 extracted radiomic features to predict tumor histopathologic characteristics. In the model, principal component analysis was used for dimensionality reduction, and regularized regression was used for classification.

Results: The trained radiomic model demonstrated moderate capability of predicting HNSCC features. In the training cohort and the test cohort, the model achieved a mean area under the receiver operating characteristic curve (AUC) of 0.75 (95% confidence interval [CI]: 0.68, 0.81) and 0.66 (95% CI: 0.45, 0.84), respectively, for tumor grade; a mean AUC of 0.64 (95% CI: 0.55, 0.62) and 0.70 (95% CI: 0.47, 0.89), respectively, for perineural invasion; a mean AUC of 0.69 (95% CI: 0.56, 0.81) and 0.65 (95% CI: 0.38, 0.87), respectively, for lymphovascular invasion; a mean AUC of 0.77 (95% CI: 0.65, 0.88) and 0.67 (95% CI: 0.15, 0.80), respectively, for extracapsular spread; and a mean AUC of 0.71 (95% CI: 0.29, 1.0) and 0.80 (95% CI: 0.65, 0.92), respectively, for human papillomavirus status.

Conclusion: Radiomic CT models have the potential to predict characteristics typically identified on pathologic assessment of HNSCC.© RSNA, 2020.
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http://dx.doi.org/10.1148/rycan.2020190039DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7263288PMC
May 2020

Radiographic surveillance of abdominal free fat graft in complex parotid pleomorphic adenomas: A case series.

Heliyon 2020 May 4;6(5):e03894. Epub 2020 May 4.

Department of Otolaryngology - Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA, USA.

Background: Free abdominal fat transfer is commonly used to restore facial volume and improve cosmesis after parotidectomy for pleomorphic adenomas. We describe the radiographic characteristics of these grafts on follow-up imaging.

Methods: Medical records of four patients who underwent parotidectomy with abdominal fat graft in 2016 and had follow up imaging available were retrospectively analyzed. An otolaryngologist and neuroradiologist reviewed imaging studies, evaluated the fat grafts, and monitored for residual or recurrent disease.

Results: The abdominal fat was successfully grafted in all four patients. Post-operative baseline magnetic resonance imaging and additional surveillance imaging showed fat grafts with minimal volume loss. However, there was development of irregular enhancement consistent with fat necrosis in two of the four patients.

Conclusions: Radiographic surveillance of free fat graft reconstruction after pleomorphic adenoma resection shows minimal contraction in size but development of fat necrosis. Recognition of expected changes should help avoid confusion with residual or recurrent disease, reassuring both patient and treating physician.
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http://dx.doi.org/10.1016/j.heliyon.2020.e03894DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7210407PMC
May 2020

Prognostic value of diffusion-weighted MRI for post-cardiac arrest coma.

Neurology 2020 04 8;94(16):e1684-e1692. Epub 2020 Apr 8.

From the Departments of Neurology (K.G.H., M. Mlynash, S.K., I.E., C.V., A.F.C., G.A.) and Radiology (N.F., M. Moseley), Stanford University, CA; Department of Radiology (R.B.), University of Melbourne, Parkville, VIC, Australia; and Department of Medicine (J.T.), University of California, Los Angeles.

Objective: To validate quantitative diffusion-weighted imaging (DWI) MRI thresholds that correlate with poor outcome in comatose cardiac arrest survivors, we conducted a clinician-blinded study and prospectively obtained MRIs from comatose patients after cardiac arrest.

Methods: Consecutive comatose post-cardiac arrest adult patients were prospectively enrolled. MRIs obtained within 7 days after arrest were evaluated. The clinical team was blinded to the DWI MRI results and followed a prescribed prognostication algorithm. Apparent diffusion coefficient (ADC) values and thresholds differentiating good and poor outcome were analyzed. Poor outcome was defined as a Glasgow Outcome Scale score of ≤2 at 6 months after arrest.

Results: Ninety-seven patients were included, and 75 patients (77%) had MRIs. In 51 patients with MRI completed by postarrest day 7, the prespecified threshold of >10% of brain tissue with an ADC <650 ×10 mm/s was highly predictive for poor outcome with a sensitivity of 0.63 (95% confidence interval [CI] 0.42-0.80), a specificity of 0.96 (95% CI 0.77-0.998), and a positive predictive value (PPV) of 0.94 (95% CI 0.71-0.997). The mean whole-brain ADC was higher among patients with good outcomes. Receiver operating characteristic curve analysis showed that ADC <650 ×10 mm/s had an area under the curve of 0.79 (95% CI 0.65-0.93, < 0.001). Quantitative DWI MRI data improved prognostication of both good and poor outcomes.

Conclusions: This prospective, clinician-blinded study validates previous research showing that an ADC <650 ×10 mm/s in >10% of brain tissue in an MRI obtained by postarrest day 7 is highly specific for poor outcome in comatose patients after cardiac arrest.
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http://dx.doi.org/10.1212/WNL.0000000000009289DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7282878PMC
April 2020

Predicting Therapeutic Antibody Delivery into Human Head and Neck Cancers.

Clin Cancer Res 2020 06 24;26(11):2582-2594. Epub 2020 Jan 24.

Department of Otolaryngology - Head and Neck Surgery, Stanford University School of Medicine, Stanford, California.

Purpose: The efficacy of antibody-based therapeutics depends on successful drug delivery into solid tumors; therefore, there is a clinical need to measure intratumoral antibody distribution. This study aims to develop and validate an imaging and computation platform to directly quantify and predict antibody delivery into human head and neck cancers in a clinical study.

Experimental Design: Twenty-four patients received systemic infusion of a near-infrared fluorescence-labeled therapeutic antibody followed by surgical tumor resection. A computational platform was developed to quantify the extent of heterogeneity of intratumoral antibody distribution. Both univariate and multivariate regression analyses were used to select the most predictive tumor biological factors for antibody delivery. Quantitative image features from the pretreatment MRI were extracted and correlated with fluorescence imaging of antibody delivery.

Results: This study not only confirmed heterogeneous intratumoral antibody distribution in-line with many preclinical reports, but also quantified the extent of interpatient, intertumor, and intratumor heterogeneity of antibody delivery. This study demonstrated the strong predictive value of tumor size for intratumoral antibody accumulation and its significant impact on antibody distribution in both primary tumor and lymph node metastasis. Furthermore, this study established the feasibility of using contrast-enhanced MRI to predict antibody delivery.

Conclusions: This study provides a clinically translatable platform to measure antibody delivery into solid tumors and yields valuable insight into clinically relevant antibody tumor penetration, with implications in the selection of patients amenable to antibody therapy and the design of more effective dosing strategies.
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http://dx.doi.org/10.1158/1078-0432.CCR-19-3717DOI Listing
June 2020

Risks of Neoplasia and Malignancy in Surgically Resected Cystic Parotid Lesions.

Otolaryngol Head Neck Surg 2020 01 3;162(1):79-86. Epub 2019 Dec 3.

Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, California, USA.

Objectives: To evaluate the risks of neoplasm and malignancy in surgically treated cystic parotid masses compared with solid or mixed lesions and to evaluate the performance of fine-needle aspiration (FNA) in parotid cysts.

Study Design: Retrospective cross-sectional study.

Setting: Single-institution academic tertiary care center.

Subjects And Methods: Patients without a history of human immunodeficiency virus or head and neck cancer who underwent parotidectomy for parotid masses and had preoperative imaging to characterize lesions as cystic, solid, or mixed (ie, partially cystic and partially solid). We assessed the risks of neoplasia and malignancy, adjusting for age, sex, race/ethnicity, facial nerve weakness, and history of malignancy. We also evaluated the sensitivity and specificity of FNA.

Results: We included 308 patients, 27 of whom had cystic parotid masses (5 simple and 22 complex). Cystic masses were less likely to be neoplastic compared to solid or mixed masses (44% vs 97%; odds ratio [OR], 0.03; 95% confidence interval [CI], 0.01-0.07); however, there was no difference in the risk of malignancy (22% vs 26%; OR, 0.81; 95% CI, 0.32-2.10). Cystic masses were more likely to yield nondiagnostic FNA cytology results, but for diagnostic samples, FNA was 86% sensitive and 33% specific for diagnosing neoplasia and 75% sensitive and 83% specific for diagnosing malignancy.

Conclusion: In our population, cystic masses undergoing surgery were less likely to be neoplastic but had a similar risk of malignancy as solid masses. The risk of malignancy should be considered in the management of cystic parotid masses.
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http://dx.doi.org/10.1177/0194599819889699DOI Listing
January 2020

Nodular Leptomeningeal Disease-A Distinct Pattern of Recurrence After Postresection Stereotactic Radiosurgery for Brain Metastases: A Multi-institutional Study of Interobserver Reliability.

Int J Radiat Oncol Biol Phys 2020 03 10;106(3):579-586. Epub 2019 Oct 10.

Department of Radiation Oncology, Stanford Cancer Institute, Stanford, California. Electronic address:

Purpose: For brain metastases, surgical resection with postoperative stereotactic radiosurgery is an emerging standard of care. Postoperative cavity stereotactic radiosurgery is associated with a specific, underrecognized pattern of intracranial recurrence, herein termed nodular leptomeningeal disease (nLMD), which is distinct from classical leptomeningeal disease. We hypothesized that there is poor consensus regarding the definition of LMD, and that a formal, self-guided training module will improve interrater reliability (IRR) and validity in diagnosing LMD.

Methods And Materials: Twenty-two physicians at 16 institutions, including 15 physicians with central nervous system expertise, completed a 2-phase survey that included magnetic resonance imaging and treatment information for 30 patients. In the "pretraining" phase, physicians labeled cases using 3 patterns of recurrence commonly reported in prospective studies: local recurrence (LR), distant parenchymal recurrence (DR), and LMD. After a self-directed training module, participating physicians completed the "posttraining" phase and relabeled the 30 cases using the 4 following labels: LR, DR, classical leptomeningeal disease, and nLMD.

Results: IRR increased 34% after training (Fleiss' Kappa K = 0.41 to K = 0.55, P < .001). IRR increased most among non-central nervous system specialists (+58%, P < .001). Before training, IRR was lowest for LMD (K = 0.33). After training, IRR increased across all recurrence subgroups and increased most for LMD (+67%). After training, ≥27% of cases initially labeled LR or DR were later recognized as nLMD.

Conclusions: This study highlights the large degree of inconsistency among clinicians in recognizing nLMD. Our findings demonstrate that a brief self-guided training module distinguishing nLMD can significantly improve IRR across all patterns of recurrence, and particularly in nLMD. To optimize outcomes reporting, prospective trials in brain metastases should incorporate central imaging review and investigator training.
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http://dx.doi.org/10.1016/j.ijrobp.2019.10.002DOI Listing
March 2020

Automated Detection of Intracranial Large Vessel Occlusions on Computed Tomography Angiography: A Single Center Experience.

Stroke 2019 10 9;50(10):2790-2798. Epub 2019 Sep 9.

Department of Radiology, University of Melbourne, Parkville, Australia (R.B.).

Background and Purpose- Endovascular thrombectomy is highly effective in acute ischemic stroke patients with an anterior circulation large vessel occlusion (LVO), decreasing morbidity and mortality. Accurate and prompt identification of LVOs is imperative because these patients have large volumes of tissue that are at risk of infarction without timely reperfusion, and the treatment window is limited to 24 hours. We assessed the accuracy and speed of a commercially available fully automated LVO-detection tool in a cohort of patients presenting to a regional hospital with suspected stroke. Methods- Consecutive patients who underwent multimodal computed tomography with thin-slice computed tomography angiography between January 1, 2017 and December 31, 2018 for suspected acute ischemic stroke within 24 hours of onset were retrospectively identified. The multimodal computed tomographies were assessed by 2 neuroradiologists in consensus for the presence of an intracranial anterior circulation LVO or M2-segment middle cerebral artery occlusion (the reference standard). The patients' computed tomography angiographies were then processed using an automated LVO-detection algorithm (RAPID CTA). Receiver-operating characteristic analysis was used to determine sensitivity, specificity, and negative predictive value of the algorithm for detection of (1) an LVO and (2) either an LVO or M2-segment middle cerebral artery occlusion. Results- CTAs from 477 patients were analyzed (271 men and 206 women; median age, 71; IQR, 60-80). Median processing time was 158 seconds (IQR, 150-167 seconds). Seventy-eight patients had an anterior circulation LVO, and 28 had an isolated M2-segment middle cerebral artery occlusion. The sensitivity, negative predictive value, and specificity were 0.94, 0.98, and 0.76, respectively for detection of an intracranial LVO and 0.92, 0.97, and 0.81, respectively for detection of either an intracranial LVO or M2-segment middle cerebral artery occlusion. Conclusions- The fully automated algorithm had very high sensitivity and negative predictive value for LVO detection with fast processing times, suggesting that it can be used in the emergent setting as a screening tool to alert radiologists and expedite formal diagnosis.
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http://dx.doi.org/10.1161/STROKEAHA.119.026259DOI Listing
October 2019

Cerebral Blood Flow Predicts the Infarct Core: New Insights From Contemporaneous Diffusion and Perfusion Imaging.

Stroke 2019 10 29;50(10):2783-2789. Epub 2019 Aug 29.

Department of Radiology and Florey Department of Neuroscience and Mental Health (R.B.), University of Melbourne, Australia.

Background and Purpose- The aim of this study is to determine the spatial and volumetric accuracy of infarct core estimates from relative cerebral blood flow (rCBF) by comparison with near-contemporaneous diffusion-weighted imaging (DWI), and evaluate whether it is sufficient for patient triage to reperfusion therapies. Methods- One hundred ninety-three patients enrolled in the DEFUSE 2 (Diffusion and Perfusion Imaging Evaluation for Understanding Stroke Evolution) and SENSE 3 (Sensitivity Encoding) stroke studies were screened, and 119 who underwent acute magnetic resonance imaging with DWI and perfusion imaging within 24 hours of onset were included. Infarct core was estimated using reduced rCBF at 12 thresholds (<0.20-<0.44) and compared against DWI (apparent diffusion coefficient <620 10mm2/s). For each threshold, volumetric agreement between the rCBF and DWI core estimates was assessed using Bland-Altman, correlation, and linear regression analyses; spatial agreement was assessed using receiver operating characteristic analysis. Results- An rCBF threshold of 0.32 yielded the smallest mean absolute volume difference (14.7 mL), best linear regression fit (R=0.84), and best spatial agreement (Youden index, 0.38; 95% CI, 0.34-0.41) between rCBF and DWI, with high correlation (=0.91, <0.05), a small mean volume difference (1.3 mL) and no fixed bias (<0.05). At this threshold, 110 of 119 (92.4%) patients were correctly triaged when applying 70 mL as the volume limit for thrombectomy. Spatial agreement was better for prediction of large infarcts (>70 mL) than small infarcts (≤70 mL), with Youden indices of 0.53 (95% CI, 0.49-0.56) and 0.34 (95% CI, 0.30-0.37), respectively. Conclusions- Strong correlation and agreement with near-contemporaneous DWI indicate that infarct core estimates obtained using rCBF are sufficiently accurate for patient triage to reperfusion therapies. The identified optimal rCBF threshold of 0.32 closely approximates the threshold currently used in clinical practice.
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http://dx.doi.org/10.1161/STROKEAHA.119.026640DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6788788PMC
October 2019

Tumor Subregion Evolution-Based Imaging Features to Assess Early Response and Predict Prognosis in Oropharyngeal Cancer.

J Nucl Med 2020 03 16;61(3):327-336. Epub 2019 Aug 16.

Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California; and

The incidence of oropharyngeal squamous cell carcinoma (OPSCC) has been rapidly increasing. Disease stage and smoking history are often used in current clinical trials to select patients for deintensification therapy, but these features lack sufficient accuracy for predicting disease relapse. Our purpose was to develop an imaging signature to assess early response and predict outcomes of OPSCC. We retrospectively analyzed 162 OPSCC patients treated with concurrent chemoradiotherapy, equally divided into separate training and validation cohorts with similar clinical characteristics. A robust consensus clustering approach was used to spatially partition the primary tumor and involved lymph nodes into subregions (i.e., habitats) based on F-FDG PET and contrast CT imaging. We proposed quantitative image features to characterize the temporal volumetric change of the habitats and peritumoral/nodal tissue between baseline and midtreatment. The reproducibility of these features was evaluated. We developed an imaging signature to predict progression-free survival (PFS) by fitting an L1-regularized Cox regression model. We identified 3 phenotypically distinct intratumoral habitats: metabolically active and heterogeneous, enhancing and heterogeneous, and metabolically inactive and homogeneous. The final Cox model consisted of 4 habitat evolution-based features. In both cohorts, this imaging signature significantly outperformed traditional imaging metrics, including midtreatment metabolic tumor volume for predicting PFS, with a C-index of 0.72 versus 0.67 (training) and 0.66 versus 0.56 (validation). The imaging signature stratified patients into high-risk versus low-risk groups with 2-y PFS rates of 59.1% versus 89.4% (hazard ratio, 4.4; 95% confidence interval, 1.4-13.4 [training]) and 61.4% versus 87.8% (hazard ratio, 4.6; 95% confidence interval, 1.7-12.1 [validation]). The imaging signature remained an independent predictor of PFS in multivariable analysis adjusting for stage, human papillomavirus status, and smoking history. The proposed imaging signature allows more accurate prediction of disease progression and, if prospectively validated, may refine OPSCC patient selection for risk-adaptive therapy.
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http://dx.doi.org/10.2967/jnumed.119.230037DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7067523PMC
March 2020

Comparison of T2*GRE and DSC-PWI for hemorrhage detection in acute ischemic stroke patients: Pooled analysis of the EPITHET, DEFUSE 2, and SENSE 3 stroke studies.

Int J Stroke 2020 02 10;15(2):216-225. Epub 2019 Jul 10.

Department of Radiology, Stanford University, Stanford, CA, USA.

Aims: The objective of this study was to compare the diagnostic performance of the baseline pre-contrast images of dynamic susceptibility contrast perfusion-weighted imaging (DSC-PWI) with conventional T2*gradient recalled echo (GRE) imaging for detection of hemorrhage in acute ischemic stroke patients.

Material And Methods: T2*GRE and DSC-PWI from 393 magnetic resonance imaging scans from 221 patients enrolled in three prospective stroke studies were independently evaluated by two readers blinded to clinical and other imaging data. Agreement between T2*GRE and DSC-PWI for the presence of hemorrhage, and acute hemorrhagic transformation, was assessed using the kappa statistic. Inter-reader agreement was also assessed using the kappa statistic.

Results: Agreement between the baseline images of DSC-PWI and T2*GRE regarding the presence of hemorrhage was almost perfect (k : 0.90, 95% confidence interval 0.86-0.95 and k : 0.91, 95% confidence interval 0.87-0.96). Agreement between the sequences was still higher for detection of acute hemorrhagic transformation (k : 0.94, 95% confidence interval 0.91-0.98 and k : 0.95, 95% confidence interval 0.92-0.98). Inter-reader agreement for detection of hemorrhage was also almost perfect for both T2*GRE (k: 0.95, 95% confidence interval 0.91-0.98) and DSC-PWI (k: 0.96, 95% confidence interval 0.93-0.99). Acute hemorrhagic transformation detected on T2*GRE was missed on DSC-PWI by one or both readers in 5/393 (1.3%) scans.

Conclusion: The almost perfect statistical agreement between DSC-PWI and conventional T2*GRE suggests that DSC-PWI is sufficient for hemorrhage screening prior to thrombolysis in stroke patients. T2*GRE can therefore be omitted when DSC-PWI is included, thereby shortening the acute ischemic stroke magnetic resonance imaging protocol and expediting treatment. ClinicalTrials.gov Identifier: NCT02586415.
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http://dx.doi.org/10.1177/1747493019858781DOI Listing
February 2020

Development and validation of radiomic signatures of head and neck squamous cell carcinoma molecular features and subtypes.

EBioMedicine 2019 Jul 27;45:70-80. Epub 2019 Jun 27.

Department of Medicine, Stanford Center for Biomedical Informatics Research (BMIR), USA; Department of Biomedical Data Science, Stanford University, USA. Electronic address:

Background: Radiomics-based non-invasive biomarkers are promising to facilitate the translation of therapeutically related molecular subtypes for treatment allocation of patients with head and neck squamous cell carcinoma (HNSCC).

Methods: We included 113 HNSCC patients from The Cancer Genome Atlas (TCGA-HNSCC) project. Molecular phenotypes analyzed were RNA-defined HPV status, five DNA methylation subtypes, four gene expression subtypes and five somatic gene mutations. A total of 540 quantitative image features were extracted from pre-treatment CT scans. Features were selected and used in a regularized logistic regression model to build binary classifiers for each molecular subtype. Models were evaluated using the average area under the Receiver Operator Characteristic curve (AUC) of a stratified 10-fold cross-validation procedure repeated 10 times. Next, an HPV model was trained with the TCGA-HNSCC, and tested on a Stanford cohort (N = 53).

Findings: Our results show that quantitative image features are capable of distinguishing several molecular phenotypes. We obtained significant predictive performance for RNA-defined HPV+ (AUC = 0.73), DNA methylation subtypes MethylMix HPV+ (AUC = 0.79), non-CIMP-atypical (AUC = 0.77) and Stem-like-Smoking (AUC = 0.71), and mutation of NSD1 (AUC = 0.73). We externally validated the HPV prediction model (AUC = 0.76) on the Stanford cohort. When compared to clinical models, radiomic models were superior to subtypes such as NOTCH1 mutation and DNA methylation subtype non-CIMP-atypical while were inferior for DNA methylation subtype CIMP-atypical and NSD1 mutation.

Interpretation: Our study demonstrates that radiomics can potentially serve as a non-invasive tool to identify treatment-relevant subtypes of HNSCC, opening up the possibility for patient stratification, treatment allocation and inclusion in clinical trials. FUND: Dr. Gevaert reports grants from National Institute of Dental & Craniofacial Research (NIDCR) U01 DE025188, grants from National Institute of Biomedical Imaging and Bioengineering of the National Institutes of Health (NIBIB), R01 EB020527, grants from National Cancer Institute (NCI), U01 CA217851, during the conduct of the study; Dr. Huang and Dr. Zhu report grants from China Scholarship Council (Grant NO:201606320087), grants from China Medical Board Collaborating Program (Grant NO:15-216), the Cyrus Tang Foundation, and the Zhejiang University Education Foundation during the conduct of the study; Dr. Cintra reports grants from São Paulo State Foundation for Teaching and Research (FAPESP), during the conduct of the study.
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http://dx.doi.org/10.1016/j.ebiom.2019.06.034DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6642281PMC
July 2019

Neuroimaging selection for thrombectomy in pediatric stroke: a single-center experience.

J Neurointerv Surg 2019 Sep 16;11(9):940-946. Epub 2019 May 16.

Department of Radiology, Division of Neuroimaging & Neurointervention, Stanford University School of Medicine, Stanford, CA, USA.

Background: The extended time window for endovascular therapy in adult stroke represents an opportunity for stroke treatment in children for whom diagnosis may be delayed. However, selection criteria for pediatric thrombectomy has not been defined.

Methods: We performed a retrospective cohort study of patients aged <18 years presenting within 24 hours of acute large vessel occlusion. Patient consent was waived by our institutional IRB. Patient data derived from our institutional stroke database was compared between patients with good and poor outcome using Fisher's exact test, t-test, or Mann-Whitney U-test.

Results: Twelve children were included: 8/12 (66.7%) were female, mean age 9.7±5.0 years, median National Institutes of Health Stroke Scale (NIHSS) 11.5 (IQR 10-14). Stroke etiology was cardioembolic in 75%, dissection in 16.7%, and cryptogenic in 8.3%. For 2/5 with perfusion imaging, Tmax >4 s appeared to better correlate with NIHSS. Nine patients (75%) were treated: seven underwent thrombectomy alone; one received IV alteplase and thrombectomy, and one received IV alteplase alone. Favorable outcome was achieved in 78% of treated patients versus 0% of untreated patients (P=0.018). All untreated patients had poor outcome, with death (n=2) or severe disability (n=1) at follow-up. Among treated patients, older children (12.8±2.9 vs 4.2±5.0 years, P=0.014) and children presenting as outpatient (100% vs 0%, P=0.028) appeared to have better outcomes.

Conclusions: Perfusion imaging is feasible in pediatric stroke and may help identify salvageable tissue in extended time windows, though penumbral thresholds may differ from adult values. Further studies are needed to define criteria for thrombectomy in this unique population.
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http://dx.doi.org/10.1136/neurintsurg-2019-014862DOI Listing
September 2019

Integrating Tumor and Nodal Imaging Characteristics at Baseline and Mid-Treatment Computed Tomography Scans to Predict Distant Metastasis in Oropharyngeal Cancer Treated With Concurrent Chemoradiotherapy.

Int J Radiat Oncol Biol Phys 2019 07 30;104(4):942-952. Epub 2019 Mar 30.

Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California. Electronic address:

Purpose: Prognostic biomarkers of disease relapse are needed for risk-adaptive therapy of oropharyngeal cancer (OPC). This work aims to identify an imaging signature to predict distant metastasis in OPC.

Methods And Materials: This single-institution retrospective study included 140 patients treated with definitive concurrent chemoradiotherapy, for whom both pre- and midtreatment contrast-enhanced computed tomography (CT) scans were available. Patients were divided into separate training and testing cohorts. Forty-five quantitative image features were extracted to characterize tumor and involved lymph nodes at both time points. By incorporating both imaging and clinicopathological features, a random survival forest (RSF) model was built to predict distant metastasis-free survival (DMFS). The model was optimized via repeated cross-validation in the training cohort and then independently validated in the testing cohort.

Results: The most important features for predicting DMFS were the maximum distance among nodes, maximum distance between tumor and nodes at mid-treatment, and pretreatment tumor sphericity. In the testing cohort, the RSF model achieved good discriminability for DMFS (C-index = 0.73, P = .008), and further divided patients into 2 risk groups with different 2-year DMFS rates: 96.7% versus 67.6%. Similar trends were observed for patients with p16+ tumors and smoking ≤10 pack-years. The RSF model based on pretreatment CT features alone achieved lower performance (concordance index = 0.68, P = .03).

Conclusions: Integrating tumor and nodal imaging characteristics at baseline and mid-treatment CT allows prediction of distant metastasis in OPC. The proposed imaging signature requires prospective validation and, if successful, may help identify high-risk human papillomavirus-positive patients who should not be considered for deintensification therapy.
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http://dx.doi.org/10.1016/j.ijrobp.2019.03.036DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6579673PMC
July 2019

Arterial-spin labeling MRI identifies residual cerebral arteriovenous malformation following stereotactic radiosurgery treatment.

J Neuroradiol 2020 Feb 15;47(1):13-19. Epub 2019 Jan 15.

Department of Radiology, Neuroimaging and Neurointervention Division, Stanford University Hospital, 300, Pasteur Drive, Stanford, CA 94305, US.

Background And Purpose: Brain arteriovenous malformation (AVM) treatment by stereotactic radiosurgery (SRS) is effective, but AVM obliteration following SRS may take two years or longer. MRI with arterial-spin labeling (ASL) may detect brain AVMs with high sensitivity. We determined whether brain MRI with ASL may accurately detect residual AVM following SRS treatment.

Materials And Methods: We performed a retrospective cohort study of patients who underwent brain AVM evaluation by DSA between June 2010 and June 2015. Inclusion criteria were: (1) AVM treatment by SRS, (2) follow-up MRI with ASL at least 30 months after SRS, (3) DSA within 3 months of the follow-up MRI with ASL, and (4) no intervening AVM treatment between the MRI and DSA. Four neuroradiologists blindly and independently reviewed follow-up MRIs. Primary outcome measure was residual AVM indicated by abnormal venous ASL signal.

Results: 15 patients (12 females, mean age 29 years) met inclusion criteria. There were three posterior fossa AVMs and 12 supratentorial AVMs. Spetzler-Martin (SM) Grades were: SM1 (8%), SM2 (33%), SM3 (17%), SM4 (25%), and SM5 (17%). DSA demonstrated residual AVM in 10 patients. The pooled sensitivity, specificity, positive predictive value, and negative predictive value of venous ASL signal for predicting residual AVM were 100% (95% CI: 0.9-1.0), 95% (95% CI: 0.7-1.0), 98% (95% CI: 0.9-1.0), and 100% (95% CI: 0.8-1.0), respectively. High inter-reader agreement as found by Fleiss' Kappa analysis (k = 0.92; 95% CI: 0.8-1.0; P < 0.0001).

Conclusions: ASL is highly sensitive and specific in the detection of residual cerebral AVM following SRS treatment.
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http://dx.doi.org/10.1016/j.neurad.2018.12.004DOI Listing
February 2020

Malignant optic glioma masked by suspected optic neuritis and central retinal vein occlusion.

Radiol Case Rep 2019 Feb 13;14(2):226-229. Epub 2018 Nov 13.

Division of Neuroradiology, Department of Radiology, Stanford University School of Medicine, 300 Pasteur Drive, Room S-047, Stanford, CA 94305-5105, USA.

Malignant optic glioma presents a clinical and diagnostic challenge, as early imaging findings overlap with other more common causes of optic nerve enhancement and enlargement, potentially leading to delay in diagnosis. This rare diagnosis carries an extremely poor prognosis, with death usually occurring within 1 year. We present a case of malignant optic glioma that was initially diagnosed as optic neuritis and central retinal vein occlusion, and we emphasize the importance of serial imaging and definitive biopsy to promote early diagnosis and treatment of this entity.
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http://dx.doi.org/10.1016/j.radcr.2018.10.023DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6234704PMC
February 2019

Intracranial Hemorrhage Imaging.

Semin Ultrasound CT MR 2018 Oct 27;39(5):441-456. Epub 2018 Feb 27.

Department of Radiology, Stanford University School of Medicine, Stanford, CA.

Intracranial hemorrhage is a medical event frequently encountered in the clinical practice of radiology that has significant potential for patient morbidity and mortality. The expedient and accurate identification of intracranial hemorrhage as well as elucidation of the underlying cause can assist in optimizing the care of these patients. In this review, we attempt to familiarize the reader with the imaging appearance of multiple types of intracranial hemorrhage, both intra-axial and extra-axial and utilizing both computed tomography and magnetic resonance imaging, as well as to provide a framework for assessment of the underlying cause of the hemorrhage.
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http://dx.doi.org/10.1053/j.sult.2018.01.003DOI Listing
October 2018

Practical Pearl: Use of MRI to Differentiate Pseudo-subarachnoid Hemorrhage from True Subarachnoid Hemorrhage.

Neurocrit Care 2018 08;29(1):113-118

Department of Neurosurgery, Stanford University School of Medicine, Stanford University Medical Center, 300 Pasteur Dr. MC5327, Stanford, CA, 94303, USA.

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http://dx.doi.org/10.1007/s12028-018-0547-3DOI Listing
August 2018

A Diffuse Leptomeningeal Glioneuronal Tumor Without Diffuse Leptomeningeal Involvement: Detailed Molecular and Clinical Characterization.

J Neuropathol Exp Neurol 2018 09;77(9):751-756

Department of Neurology, Duke University Medical Center, Durham, North Carolina.

Prior to their provisional WHO classification as a distinct entity in 2016, diffuse leptomeningeal glioneuronal tumors (DLGNT) were often regarded as diffuse leptomeningeal presentations of oligodendrogliomas or extraventricular neurocytomas. Their classification as a distinct entity partly relies on their pattern of growth, but DLGNTs without radiological leptomeningeal involvement have been described. In a patient with a DLGNT of the spinal cord without evidence of leptomeningeal involvement, we review in depth the clinical course and the histologic and molecular features of the neoplasm, in the context of other reported cases without diffuse leptomeningeal involvement. Our findings highlight the advantages of molecular analysis in making accurate diagnoses on small spinal tissue samples and underline the need for more long-term clinical follow-up of these rare neoplasms to inform treatment decisions.
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http://dx.doi.org/10.1093/jnen/nly053DOI Listing
September 2018

Lobular capillary hemangioma of the mandible: A case report.

Clin Imaging 2018 Jul - Aug;50:246-249. Epub 2018 Apr 13.

Stanford University School of Medicine, 300 Pasteur Drive, Room S-047, Stanford, CA 94305, United States.

Lobular capillary hemangiomas are acquired benign vascular neoplasms which typically affect the skin and mucous membranes. While these lesions commonly involve the head and neck, particularly the oral cavity, there are no reports in the literature of lobular capillary hemangioma arising from the mandible. The diagnosis of such a rare entity can therefore be challenging, especially as it may mimic more aggressive lesions, including malignancy. We present a rare case of an 8-year-old male with a lobular capillary hemangioma of the mandible, highlighting its imaging features and discussing the differential diagnosis of primary mandibular lesions in the pediatric population.
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http://dx.doi.org/10.1016/j.clinimag.2018.04.012DOI Listing
October 2018

Conus Medullaris Dural Arteriovenous Fistula Arising From the Artery of the Filum Terminale: 2-Dimensional Operative Video.

Oper Neurosurg (Hagerstown) 2018 Oct;15(4):471

Department of Neurosurgery, Stanford University, Stanford, California.

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http://dx.doi.org/10.1093/ons/opx297DOI Listing
October 2018

Current Clinical State of Advanced Magnetic Resonance Imaging for Brain Tumor Diagnosis and Follow Up.

Semin Roentgenol 2018 Jan 20;53(1):45-61. Epub 2017 Nov 20.

Department of Neuroimaging and Neurointervention, Stanford University Medical Center, Stanford, CA.

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http://dx.doi.org/10.1053/j.ro.2017.11.005DOI Listing
January 2018

Clinical and Arterial Spin Labeling Brain MRI Features of Transitional Venous Anomalies.

J Neuroimaging 2018 05 4;28(3):289-300. Epub 2017 Dec 4.

Department of Radiology, Neuroimaging and Neurointervention, Stanford University Medical Center, Stanford, CA.

Background And Purpose: Transitional venous anomalies (TVAs) are rare cerebrovascular lesions that resemble developmental venous anomalies (DVAs), but demonstrate early arteriovenous shunting on digital subtraction angiography (DSA) without the parenchymal nidus of arteriovenous malformations (AVMs). We investigate whether arterial spin labeling (ASL) magnetic resonance imaging (MRI) can distinguish brain TVAs from DVAs and guide their clinical management.

Methods: We conducted a single-center retrospective review of patients with brain parenchymal DVA-like lesions with increased ASL signal on MRI. Clinical histories and follow-up information were obtained. Two readers assessed ASL signal location relative to the vascular lesion on MRI and, if available, the presence of arteriovenous shunting on DSA.

Results: Thirty patients with DVA-like lesions with increased ASL signal were identified. Clinical symptoms prompted MRI evaluation in 83%. Symptoms did not localize to the venous anomaly in 90%. Ten percent presented with acute symptoms, only one of whom presented with hemorrhage. ASL signal in relation to the venous anomaly was identified in: 50% in the adjacent parenchyma, 33% in the lesion, 7% in a distal draining vein/sinus, and 10% in at least two of these sites. Follow-up DSA confirmed arteriovenous shunting in 71% of ASL-positive venous anomalies. Interrater agreement was very good (κ = .81-1.0, P < .001).

Conclusion: A DVA-like lesion with increased ASL signal likely represents a TVA with arteriovenous shunting. Our study indicates that these lesions are usually incidentally detected and have a lower risk of hemorrhage than AVMs. ASL-MRI may be a useful tool to identify TVAs and guide further management of patients with TVAs.
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http://dx.doi.org/10.1111/jon.12487DOI Listing
May 2018

Imaging changes over 18 months following stereotactic radiosurgery for brain metastases: both late radiation necrosis and tumor progression can occur.

J Neurooncol 2018 Jan 2;136(1):207-212. Epub 2017 Nov 2.

Department of Radiation Oncology, Stanford Cancer Institute, Stanford University, 875 Blake Wilbur Drive, Stanford, CA, 94305-5847, USA.

Following stereotactic radiosurgery (SRS) for brain metastases, the median time range to develop adverse radiation effect (ARE) or radiation necrosis is 7-11 months. Similarly, the risk of local tumor recurrence following SRS is < 5% after 18 months. With improvements in systemic therapy, patients are living longer and are at risk for both late (defined as > 18 months after SRS) tumor recurrence and late ARE, which have not previously been well described. An IRB-approved, retrospective review identified patients treated with SRS who developed new MRI contrast enhancement > 18 months following SRS. ARE was defined as stabilization/shrinkage of the lesion over time or pathologic confirmation of necrosis, without tumor. Local failure (LF) was defined as continued enlargement of the lesion over time or pathologic confirmation of tumor. We identified 16 patients, with a median follow-up of 48.2 months and median overall survival of 73.0 months, who had 19 metastases with late imaging changes occurring a median of 32.9 months (range 18.5-63.2 months) after SRS. Following SRS, 12 lesions had late ARE at a median of 33.2 months and 7 lesions had late LF occurring a median of 23.6 months. As patients with cancer live longer and as SRS is increasingly utilized for treatment of brain metastases, the incidence of these previously rare imaging changes is likely to increase. Clinicians should be aware of these late events, with ARE occurring up to 5.3 years and local failure up to 3.8 years following SRS in our cohort.
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http://dx.doi.org/10.1007/s11060-017-2647-xDOI Listing
January 2018

Tumefactive demyelination associated with developmental venous anomaly: Report of two cases.

Clin Imaging 2017 May - Jun;43:194-198. Epub 2017 Feb 28.

Department of Radiology, Stanford University Medical Center, Stanford, CA, United States.

We present two cases of tumefactive demyelination (TD) occurring in close association with a developmental venous anomaly (DVA). Our purpose is to describe the association between demyelinating lesions and venous anomalies, as only one case of TD associated with a DVA has been published in the literature. Appropriate recognition of this "do not touch" lesion may avoid invasive and potentially harmful procedures such as biopsy or resection.
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http://dx.doi.org/10.1016/j.clinimag.2017.02.012DOI Listing
November 2017

Differentiation of idiopathic spinal cord herniation from dorsal arachnoid webs on MRI and CT myelography.

J Neurosurg Spine 2017 Jun 24;26(6):754-759. Epub 2017 Mar 24.

Departments of 1 Diagnostic Radiology and Nuclear Medicine, and.

OBJECTIVE Dorsal arachnoid webs (DAWs) and spinal cord herniation (SCH) are uncommon abnormalities affecting the thoracic spinal cord that can result in syringomyelia and significant neurological morbidity if left untreated. Differentiating these 2 entities on the basis of clinical presentation and radiological findings remains challenging but is of vital importance in planning a surgical approach. The authors examined the differences between DAWs and idiopathic SCH on MRI and CT myelography to improve diagnostic confidence prior to surgery. METHODS Review of the picture archiving and communication system (PACS) database between 2005 and 2015 identified 6 patients with DAW and 5 with SCH. Clinical data including demographic information, presenting symptoms and neurological signs, and surgical reports were collected from the electronic medical records. Ten of the 11 patients underwent MRI. CT myelography was performed in 3 patients with DAW and in 1 patient with SCH. Imaging studies were analyzed by 2 board-certified neuroradiologists for the following features: 1) location of the deformity; 2) presence or absence of cord signal abnormality or syringomyelia; 3) visible arachnoid web; 4) presence of a dural defect; 5) nature of dorsal cord indentation (abrupt "scalpel sign" vs "C"-shaped); 6) focal ventral cord kink; 7) presence of the nuclear trail sign (endplate irregularity, sclerosis, and/or disc-space calcification that could suggest a migratory path of a herniated disc); and 8) visualization of a complete plane of CSF ventral to the deformity. RESULTS The scalpel sign was positive in all patients with DAW. The dorsal indentation was C-shaped in 5 of 6 patients with SCH. The ventral subarachnoid space was preserved in all patients with DAW and interrupted in cases of SCH. In no patient was a web or a dural defect identified. CONCLUSIONS DAW and SCH can be reliably distinguished on imaging by scrutinizing the nature of the dorsal indentation and the integrity of the ventral subarachnoid space at the level of the cord deformity.
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http://dx.doi.org/10.3171/2016.11.SPINE16696DOI Listing
June 2017

Fusion of Computed Tomography and PROPELLER Diffusion-Weighted Magnetic Resonance Imaging for the Detection and Localization of Middle Ear Cholesteatoma.

JAMA Otolaryngol Head Neck Surg 2016 10;142(10):947-953

Department of Otolaryngology-Head and Neck Surgery, Stanford University, Stanford, California.

Importance: A method to optimize imaging of cholesteatoma by combining the strengths of available modalities will improve diagnostic accuracy and help to target treatment.

Objective: To assess whether fusing Periodically Rotated Overlapping Parallel Lines With Enhanced Reconstruction (PROPELLER) diffusion-weighted magnetic resonance imaging (DW-MRI) with corresponding temporal bone computed tomography (CT) images could increase cholesteatoma diagnostic and localization accuracy across 6 distinct anatomical regions of the temporal bone.

Design, Setting, And Participants: Case series and preliminary technology evaluation of adults with preoperative temporal bone CT and PROPELLER DW-MRI scans who underwent surgery for clinically suggested cholesteatoma at a tertiary academic hospital. When cholesteatoma was encountered surgically, the precise location was recorded in a diagram of the middle ear and mastoid. For each patient, the 3 image data sets (CT, PROPELLER DW-MRI, and CT-MRI fusion) were reviewed in random order for the presence or absence of cholesteatoma by an investigator blinded to operative findings.

Main Outcomes And Measures: If cholesteatoma was deemed present on review of each imaging modality, the location of the lesion was mapped presumptively. Image analysis was then compared with surgical findings.

Results: Twelve adults (5 women and 7 men; median [range] age, 45.5 [19-77] years) were included. The use of CT-MRI fusion had greater diagnostic sensitivity (0.88 vs 0.75), positive predictive value (0.88 vs 0.86), and negative predictive value (0.75 vs 0.60) than PROPELLER DW-MRI alone. Image fusion also showed increased overall localization accuracy when stratified across 6 distinct anatomical regions of the temporal bone (localization sensitivity and specificity, 0.76 and 0.98 for CT-MRI fusion vs 0.58 and 0.98 for PROPELLER DW-MRI). For PROPELLER DW-MRI, there were 15 true-positive, 45 true-negative, 1 false-positive, and 11 false-negative results; overall accuracy was 0.83. For CT-MRI fusion, there were 20 true-positive, 45 true-negative, 1 false-positive, and 6 false-negative results; overall accuracy was 0.90.

Conclusions And Relevance: The poor anatomical spatial resolution of DW-MRI makes precise localization of cholesteatoma within the middle ear and mastoid a diagnostic challenge. This study suggests that the bony anatomic detail obtained via CT coupled with the excellent sensitivity and specificity of PROPELLER DW-MRI for cholesteatoma can improve both preoperative identification and localization of disease over DW-MRI alone.
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http://dx.doi.org/10.1001/jamaoto.2016.1663DOI Listing
October 2016