Christopher R. Ingraham

The occurrence of velopharyngeal insufficiency in Pierre Robin Sequence patients

OBJECTIVE Children born with Pierre-Robin Sequence (PRS) have cleft palate, micrognathia, and macroglossia. After the repair of the cleft palate, velopharyngeal insufficiency (VPI) can occur in a subset of patients. We hypothesize that the need for the surgical correction of VPI in PRS children is no different than cleft palate only (CPO) patients. METHODS A retrospective study of 21 children with non-syndromic PRS who were matched to 42 non-syndromic, CPO controls for age and sex. We reviewed incidence of VPI, the need for secondary speech surgery, and speech outcomes post-operatively. RESULTS Secondary surgery to correct VPI was necessary in 3 of 21 (14.29%) PRS patients (2 Pharyngeal Flaps, 1 Z-plasty), vs. 10 of 42 (23.81%) CPO (9 Pharyngeal Flaps, 1 Z-plasty) controls. Mean age for VPI surgery for PRS vs. controls: 5.33 vs. 6.41 years, respectively. For final speech outcomes, 73.68% of PRS vs. 71.88% of controls showed no evidence of hypernasality, 89.47% of PRS patients vs. 93.75% of controls showed no evidence of hyponasality, and 76.47% of PRS patients vs. 78.13% of controls had normal velopharyngeal competence (p>0.90 for all three measures). CONCLUSION Our findings suggest that children born with a Pierre-Robin Sequence do not have a higher rate of post-operative VPI after cleft palate repair and are no more likely to require additional surgical intervention.

Frequency of External Iliac Artery Branch Injury in Blunt Trauma: Improved Detection with Selective External Iliac Angiography

PURPOSE To assess the utility of selective external iliac artery (EIA) angiography and the frequency of injury to branches of the EIA in cases of blunt pelvic trauma. MATERIALS AND METHODS A retrospective review of pelvic angiograms in 66 patients with blunt pelvic trauma was conducted over a 12-month period. Pelvic and femur fracture patterns were correlated to the presence of EIA injury. Pelvic arteriography was compared versus selective EIA angiography for the detection of arterial injury. RESULTS Fifty-four of 66 patients (82%) exhibited pelvic arterial injury or elicited enough suspicion for injury to warrant embolization. Internal iliac artery embolization was performed in 50 of 66 (76%). EIA branch injury was identified in 11 of 66 patients (17%), and 10 were successfully embolized. EIA branch vessel injury was identified more frequently when there was ipsilateral intertrochanteric fracture (P = .07) or ipsilateral ilium fracture (P = .07). The sensitivity of nonselective pelvic angiography in the detection of EIA branch vessel injury was 45%. CONCLUSIONS EIA branch injury occurs in a substantial fraction of patients with blunt pelvic trauma who undergo pelvic angiography. Selective EIA angiography should be considered in all patients undergoing pelvic angiography in this situation.

Surgical Resection of a Malignant Liver Lesion: What the Surgeon Wants the Radiologist to Know

OBJECTIVE Hepatic malignancy is a common and lethal disease, whether due to a primary tumor or metastasis. There are numerous treatment options available depending on the stage of the disease and medical condition of the patient, including systemic chemotherapy, transcatheter embolization, thermal ablation, and surgical resection. In a subset of patients with liver malignancy, surgical resection can offer the best chance of long-term survival and potentially even cure. This article reviews the major indications and contraindications for resection, basic surgical techniques and terminology, key clinical and imaging preoperative workup, and pertinent interventional oncology procedures in the management of hepatic malignancy. CONCLUSION Diagnostic and interventional radiology plays an important role in the assessment and treatment of malignant hepatic lesions. Radiologists should be familiar with how surgeons select, work up, and treat candidates for liver resection to provide the most clinically valuable service.

Noncleft Velopharyngeal Insufficiency: Etiology and Need For Surgical Treatment

Objective. Velopharyngeal insufficiency (VPI) occurs frequently in cleft palate patients. VPI also occurs in patients without cleft palate, but little is known about this patient population and this presents a diagnostic dilemma. Our goal is to review the etiology of noncleft VPI and the surgical treatment involved. Design/Patients. A retrospective review of VPI patients from 1990 to 2005. Demographic, genetic, speech, and surgical data were collected. We compared the need for surgery and outcomes data between noncleft and cleft VPI patients using a Students t-test. Results. We identified 43 patients with noncleft VPI, of which 24 were females and 19 were males. The average age at presentation of noncleft VPI was 9.6 years (range 4.5–21). The average patient age at the time of study was 13.4 years. The etiology of VPI in these noncleft patients was neurologic dysfunction 44%, syndrome-associated 35%, postadenotonsillectomy 7%, and multiple causes 14%. The need for surgical intervention in the noncleft VPI group was 37% (15/43) compared to the cleft palate controls, which was 27% (12/43). There was not a statistical difference between these two groups (P > 0.5). Conclusion. Noncleft VPI often occurs in patients who have underlying neurologic disorders or have syndromes. The rate of speech surgery to address VPI is similar to that of cleft palate patients. We propose that newly diagnosed noncleft VPI patients should undergo a thorough neurologic and genetic evaluation prior to surgery.

Cone-Beam CT with Fluoroscopic Overlay Versus Conventional CT Guidance for Percutaneous Abdominopelvic Abscess Drain Placement

PURPOSE To compare technical success and procedure time for percutaneous abscess drain placement with fluoroscopic cone-beam computed tomography (CT) and two-axis needle guidance versus conventional CT guidance. MATERIALS AND METHODS A total of 85 consecutive patients undergoing abdominopelvic abscess drain placement guided by fluoroscopic cone-beam CT or conventional CT were retrospectively reviewed over a 2-year period. Forty-three patients underwent drain placement with cone-beam CT using XperGuide navigation and 42 underwent placement with conventional 64-slice CT. Patient characteristics, median abscess size (6.8 cm vs 7.8 cm; P = .14), and depth to abscess (7.2 cm vs 7.7 cm; P = .88) were similar between groups. RESULTS Technical success rates were 98% (42 of 43) in the cone-beam CT group and 100% (42 of 42) in the conventional CT group (P = .32), with a 10-F pigtail drainage catheter inserted in the majority of cases. There were no complications in either group. There was no significant difference in effective dose between groups (9.6 mSv vs 10.7 mSv; P = .30). Procedure times were significantly shorter in the cone-beam CT group (43 min vs 62 min; P = .02). In addition, during the study period, there was a gradual improvement in procedure time in the cone-beam CT group (50% reduction), whereas procedure time did not change for the conventional CT group. CONCLUSIONS Cone-beam CT guidance appears to be equivalent to conventional CT guidance for drain placement into medium-sized abdominopelvic collections, yielding similar technical success rates and radiation doses, with the additional benefit of reduced procedure times.

Nontarget Embolization Complicating Transarterial Chemoembolization in a Patient with Hepatocellular Carcinoma

Nontarget embolization during transarterial chemoembolization, although infrequent, can be a serious complication. The authors describe a case of nontarget gastric embolization to the stomach after transarterial chemoembolization and describe the published incidence of nontarget embolization to various organs, its diagnosis, treatment, and possible outcomes.

Radiology of foreign bodies: how do we image them?

To assess the sensitivity of detecting the most commonly encountered foreign bodies in Emergency Radiology using all imaging modalities (conventional radiography, computed tomography, ultrasound, and magnetic resonance imaging). The following materials were inserted into a pig-leg phantom and imaged using conventional radiography, computed tomography, ultrasound, and magnetic resonance imaging: Plastics #1, 2, 3, 5, and compostable plastic; dry and wet wood, aluminum, gravel, glass (tinted and non-tinted), and Salmon and Halibut fish bones. The visibility of plastic is variable on both conventional radiography and computed tomography, depending on composition, but all types of plastic are well visualized on ultrasound. Wood is most easily identified and localized on both computed tomography and ultrasound, is only faintly visible on conventional radiography, and is not well visualized on magnetic resonance imaging. Gravel, glass, and aluminum are well visualized on all modalities, with the exception of magnetic resonance imaging, where there is significant artifact surrounding the foreign body. Fish bones (Halibut and Salmon) are well visualized on conventional radiography, computed tomography, and ultrasound. Conventional radiography and computed tomography are great modalities for detecting foreign bodies of various compositions. Computed tomography is particularly useful at localizing the foreign body and determining its relationship to surrounding structures and its depth of involvement. All foreign bodies are visualized on ultrasound if the location is known and the foreign body is in the plane of the transducer. Magnetic resonance imaging is not helpful in detecting foreign bodies.

Interventional and Surgical Techniques in Solid Organ Transplantation.

Liver, kidney, and pancreas transplants are complex procedures that have evolved over the past several decades from pioneering, experimental procedures into well-developed, refined procedures that have saved countless lives. Previously encountered technical, immunologic, and perioperative obstacles have now been overcome and improved upon, allowing for the success of these procedures today. This article reviews the basic surgical techniques used for solid organ transplantation that are relevant to, and are currently encountered by radiologists. This article also reviews commonly encountered postoperative complications, and the techniques and strategies that have evolved in interventional radiology to overcome these complications.

Finding the Nidus: Detection and Workup of Non–Central Nervous System Arteriovenous Malformations

Vascular anomalies are a diverse group of pathologic conditions. They have different manifestations, natural histories, and treatments. Compared with other vascular malformations, arteriovenous malformations (AVMs) are considered the most symptomatic and difficult to manage. AVMs inherently progress and have a high rate of recurrence after treatment. Imaging helps provide an accurate and early diagnosis, which can then be used to direct appropriate management, with embolization evolving as the primary therapy. Thus, radiology plays a crucial role in the detection, workup, and management of AVMs. Ultrasonography (US) is a useful initial imaging modality, particularly when AVMs involve the extremities or a superficial or accessible location. Limitations include poor identification of soft-tissue and bone components, as well as suboptimal evaluation of deep or complex AVMs. Magnetic resonance (MR) angiography is the preferred imaging modality for AVMs and should be considered in any symptomatic patient or in the initial evaluation of vascular anomalies that are equivocal at US. Computed tomographic angiography should be reserved for those patients who are unable to undergo MR angiography or for evaluation of acute symptoms, such as bleeding or airway compromise. Conventional catheter-based angiography is useful for real-time depiction and evaluation of AVMs, particularly in the planning and execution of endovascular treatment and in the diagnosis of an AVM when findings from noninvasive imaging are equivocal for a high-flow component. As with the diagnostic workup, MR angiography is the preferred posttreatment modality. (©)RSNA, 2016.

Clinical implications for imaging of vascular invasion in hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the second largest cause of cancer mortality in the world, with vascular invasion being one of the most important prognostic factors. HCC with tumor thrombus was traditionally considered to have very limited treatment options. However, multiple promising treatment strategies have emerged in recent years, with diagnostic and interventional radiologists playing a major role in patient management. We provide a comprehensive update on the diagnosis and management of HCC with vascular invasion and the role of the radiologist in this condition.