Hoxworth, Joseph M.

Pial arteriovenous fistulae (AVFs) are rare vascular abnormalities that are distinct from arteriovenous malformations and dural AVFs. These vascular lesions have been linked with trauma, ischemic syndromes, venous thrombotic diseases, and intracranial surgical procedures. In this report we describe a case of an intracranial ruptured pial AVF immediately following uneventful spinal surgery in an elderly patient with subsequent spontaneous resolution. He was a previous heavy smoker with a 60-pack-year history and alcohol abuse. His examination was positive for morbid obesity and mild weakness of the anterior tibialis and gastrocnemius muscles bilaterally. He underwent uneventful spinal surgery, suffering a generalized seizure shortly after extubation. Imaging studies demonstrated acute subarachnoid hemorrhage and cerebral angiography identified a pial AVF. He was stabilized medically and follow-up angiography demonstrated spontaneous resolution of the pial AVF. This case highlights a rare vascular malformation with rupture following uneventful spinal surgery.

Objective This study sought to estimate the prevalence of median lingual lymph node (MLLN) metastases from oral cavity squamous cell carcinoma (OCSCC) and determine the frequency with which MLLNs can be identified with magnetic resonance imaging (MRI) in control subjects. Methods Pathology reports were used to identify patients with surgically treated OCSCC who underwent preoperative positron emission tomography–computed tomography to define the prevalence of MLLN metastases. As a control group, 500 consecutive face-neck MRIs from noncancer patients were reviewed for structures consistent with MLLNs. Results In the study group, 1 (0.95%) of 105 OCSCC cases demonstrated a single MLLN metastasis from a lateral tongue tumor (T4aN2c). The MLLN exceeded 1 cm in all planes and was abnormal in morphology. The frequency of suspected MLLNs in controls was 1.0%, with a maximum measurement of 0.9 cm. Conclusions Median lingual lymph nodes are infrequently identified with MRI in controls, concordant with the low prevalence of metastases from OCSCC to this inconstant nodal group.

Pantopaque (iophendylate) is an oily contrast medium historically used during spine imaging. Due to its persistence in the subarachnoid space and the potential to lead to severe arachnoiditis, it is no longer used today. We present a 40‐year‐old male with new‐onset headaches, imbalance, and vertigo. Brain magnetic resonance imaging revealed a 2‐mm T1 ‐hyperintense intracanalicular lesion. Numerous hyperdense foci were scattered throughout the subarachnoid space on computed tomography. Further history revealed the patient received Pantopaque 30 years prior, after sustaining spinal trauma. Remnant Pantopaque contrast is an important differential when evaluating a patient with a suspected intracranial tumor in order to avoid unwarranted surgical intervention. Laryngoscope, 127:1916–1919, 2017

AbstractBackgroundGlioblastoma (GBM) exhibits profound intratumoral genetic heterogeneity. Each tumor comprises multiple genetically distinct clonal populations with different therapeutic sensitivities. This has implications for targeted therapy and genetically informed paradigms. Contrast-enhanced (CE)-MRI and conventional sampling techniques have failed to resolve this heterogeneity, particularly for nonenhancing tumor populations. This study explores the feasibility of using multiparametric MRI and texture analysis to characterize regional genetic heterogeneity throughout MRI-enhancing and nonenhancing tumor segments.MethodsWe collected multiple image-guided biopsies from primary GBM patients throughout regions of enhancement (ENH) and nonenhancing parenchyma (so called brain-around-tumor, [BAT]). For each biopsy, we analyzed DNA copy number variants for core GBM driver genes reported by The Cancer Genome Atlas. We co-registered biopsy locations with MRI and texture maps to correlate regional genetic status with spatially matched imaging measurements. We also built multivariate predictive decision-tree models for each GBM driver gene and validated accuracies using leave-one-out-cross-validation (LOOCV).ResultsWe collected 48 biopsies (13 tumors) and identified significant imaging correlations (univariate analysis) for 6 driver genes: EGFR, PDGFRA, PTEN, CDKN2A, RB1, and TP53. Predictive model accuracies (on LOOCV) varied by driver gene of interest. Highest accuracies were observed for PDGFRA (77.1%), EGFR (75%), CDKN2A (87.5%), and RB1 (87.5%), while lowest accuracy was observed in TP53 (37.5%). Models for 4 driver genes (EGFR, RB1, CDKN2A, and PTEN) showed higher accuracy in BAT samples (n = 16) compared with those from ENH segments (n = 32).ConclusionMRI and texture analysis can help characterize regional genetic heterogeneity, which offers potential diagnostic value under the paradigm of individualized oncology.

Background Sinus computed tomography (CT) is performed for the diagnosis of paranasal sinus disease and to assess response to medical therapy. In addition, sinus CT is used for intraoperative imaging guidance. Multiple CTs increase cost and radiation exposure. Objective To determine potential cost savings and radiation dose reduction that result from the use of a single universal sinus CT protocol for diagnostic imaging and intraoperative navigation. Materials and Methods For sinus CT at the authors' institution, a single imaging protocol was begun and deemed acceptable by neuroradiologists and surgeons for diagnostic imaging and intraoperative guidance. The electronic medical record was queried over a 4-year period to determine the number of sinus CTs performed, dose-length products, referring providers' specialties, percentage of CTs used for intraoperative navigation, and the elapsed time between CT and surgery. Results A total of 6187 sinus CTs were performed by using a 64-detector scanner during the study period (2759 women and 3428 men; 53.6 ± 16.7 years [mean ± SD]), and 596 endoscopic sinus surgery cases used imaging guidance, for which all the CTs were deemed technically adequate. The mean dose-length product for the CTs was 338.4 ± 31.9 mGy-cm (mean ± SD). Of the 3702 sinus CTs ordered by nonotolaryngology providers, 167 surgeries with intraoperative navigation (4.5%) were performed. A higher percentage of CT referrals from sinus surgeons (23.9%) and other otolaryngology providers (11.4%) was used for imaging guidance (p < 0.0001). The time interval between sinus CT and surgery was greatest for nonotolaryngology providers (63.1 days, p < 0.01). Based on Medicare reimbursement, the total estimated saving was $147,628. Conclusions Adopting a single universal sinus CT protocol for diagnostic imaging and intraoperative navigation can be an effective means of decreasing cost and radiation exposure. However, successful implementation must take into account multiple practice-based considerations.

Objective. To recognize intrathoracic abnormalities, including expansion or rupture of aortic aneurysms, as a source of acute onset vocal fold immobility.Methods. A case report and review of the literature.Results. An 85-year-old female with prior history of an aortic aneurysm presented to a tertiary care facility with sudden onset hoarseness. On laryngoscopy, the left vocal fold was immobile in the paramedian position. A CT scan obtained that day revealed a new, large hematoma surrounding the upper descending aortic stent graft consistent with an acute contained ruptured aortic aneurysm. She was referred to the emergency department for evaluation and treatment by vascular surgery. She was counseled regarding surgical options and ultimately decided not to pursue further treatment. Her vocal fold immobility was subsequently treated via office-based injection medialization two weeks after presentation and again 5 months after the initial injection which dramatically improved her voice. Follow-up CT scan at 8 months demonstrated a reduction of the hematoma. The left vocal cord remains immobile to date.Conclusion. Ortner’s syndrome, or cardiovocal syndrome, is hoarseness secondary to left recurrent laryngeal nerve palsy caused by cardiovascular pathology. It is a rare condition and, while typically presenting gradually, may also present with acute symptomatology.