Falgun H. Chokshi

Screening CT Angiography for Pediatric Blunt Cerebrovascular Injury with Emphasis on the Cervical "Seatbelt Sign"

The authors investigated the significance of several clinical and imaging risk factors, most specifically the “cervical seatbelt sign,” in the anterior neck in pediatric patients with suspected blunt cerebrovascular injury as seen by CTA. They found that this common indication for neck CTA was not associated with blunt cerebrovascular injury. With the exception of Glasgow Coma Scale score, no single risk factor was statistically significant in predicting vascular injury. BACKGROUND AND PURPOSE: There are no standard screening guidelines to evaluate blunt cerebrovascular injury in children. The purpose of this retrospective study was to understand the clinical and radiologic risk factors associated with pediatric blunt cerebrovascular injury on CTA of the neck with primary attention to the cervical “seatbelt sign.” MATERIALS AND METHODS: Radiology reports from 2002 to 2012 were queried for the examination “CTA neck.” The electronic medical record was reviewed for mechanism of injury, Glasgow Coma Scale score, and physical examination findings. Radiology reports from adjunct radiographic studies were reviewed. CTA neck examinations with reported blunt cerebrovascular injury were reviewed to confirm imaging findings. Patients with penetrating injury or those without a history of trauma were excluded. RESULTS: Four hundred sixty-three patients underwent CTA of the neck; 137 had blunt trauma. Forty-two of 85 patients involved in a motor vehicle collision had a cervical seatbelt sign; none had blunt cerebrovascular injury. Nine vessels (4 vertebral arteries, 4 ICAs, 1 common carotid artery) in 8 patients ultimately were diagnosed with various grades (I–IV) of blunt cerebrovascular injury, representing 5.8% (8/137) of the population screened for blunt neck trauma. The mean Glasgow Coma Scale score was significantly lower (P = .02) in the blunt cerebrovascular injury group versus the non-blunt cerebrovascular injury group. Although not statistically significant, patients with blunt cerebrovascular injury had a higher tendency to have additional traumatic injuries, primarily basilar skull fractures (P = .05) and intracranial hemorrhage (P = .13). CONCLUSIONS: A common indication for neck CTA, the cervical seatbelt sign, was not associated with blunt cerebrovascular injury. With the exception of Glasgow Coma Scale score, no single risk factor was statistically significant in predicting vascular injury in this series.

Diagnostic Radiology Resident and Fellow Workloads: A 12-Year Longitudinal Trend Analysis Using National Medicare Aggregate Claims Data

PURPOSE The aim of this study was to evaluate changes in diagnostic radiology resident and fellow workloads in recent years. METHODS Berenson-Eggers Type of Service categorization was applied to Medicare Part B Physician/Supplier Procedure Summary Master Files to identify total and resident-specific claims for radiologist imaging services between 1998 and 2010. Data were extracted and subgroup analytics performed by modality. Volumes were annually normalized for active diagnostic radiology trainees. RESULTS From 1998 to 2010, Medicare claims for imaging services rendered by radiologists increased from 78,901,255 to 105,252,599 (+33.4%). Service volumes increased across all modalities: for radiography from 55,661,683 to 59,654,659 (+7.2%), for mammography from 5,780,624 to 6,570,673 (+13.7%), for ultrasound from 5,851,864 to 9,853,459 (+68.4%), for CT from 9,351,780 to 22,527,488 (+140.9%), and for MR from 2,255,304 to 6,646,320 (+194.7%). Total trainee services nationally increased 3 times as rapidly. On an average per trainee basis, however, the average number of diagnostic services rendered annually to Medicare Part B beneficiaries increased from 499 to 629 (+26.1%). By modality, this represents an average change from 333 to 306 examinations (-8.1%) for radiography, from 20 to 18 (-7.4%) for mammography, from 37 to 56 (+49.7%) for ultrasound, from 88 to 202 (+129.1%) for CT, and from 20 to 47 (+132.0%) for MRI. CONCLUSIONS Between 1998 and 2010, the number of imaging examinations interpreted by diagnostic radiology residents and fellows on Medicare beneficiaries increased on average by 26% per trainee, with growth largely accounted for by disproportionate increases in more complex services (CT and MRI).

Early Cranioplasty is Associated with Greater Neurological Improvement: A Systematic Review and Meta-Analysis

BACKGROUND Cranioplasty after decompressive craniectomy is a common neurosurgical procedure, yet the optimal timing of cranioplasty has not been well established. OBJECTIVE To investigate whether the timing of cranioplasty is associated with differences in neurological outcome. METHODS A systematic literature review and meta-analysis was performed using MEDLINE, Scopus, and the Cochrane databases for studies reporting timing and neurological assessment for cranioplasty after decompressive craniectomy. Pre- and postcranioplasty neurological assessments for cranioplasty performed within (early) and beyond (late) 90 d were extracted. The standard mean difference (SMD) was used to normalize all neurological measures. Available data were pooled to compare pre-cranioplasty, postcranioplasty, and change in neurological status between early and late cranioplasty cohorts, and in the overall population. RESULTS Eight retrospective observational studies were included for a total of 528 patients. Studies reported various outcome measures (eg, Barthel Index, Karnofsky Performance Scale, Functional Independence Measure, Glasgow Coma Scale, and Glasgow Outcome Score). Cranioplasty, regardless of timing, was associated with significant neurological improvement (SMD .56, P = .01). Comparing early and late cohorts, there was no difference in precranioplasty neurological baseline; however, postcranioplasty neurological outcome was significantly improved in the early cohort (SMD .58, P = .04) and showed greater magnitude of change (SMD 2.90, P = .02). CONCLUSION Cranioplasty may improve neurological function, and earlier cranioplasty may enhance this effect. Future prospective studies evaluating long-term, comprehensive neurological outcomes will be required to establish the true effect of cranioplasty on neurological outcome.

Multidetector CT of Blunt Cervical Spine Trauma in Adults

A number of new developments in cervical spine imaging have transpired since the introduction of 64-section computed tomographic (CT) scanners in 2004. An increasing body of evidence favors the use of multidetector CT as a stand-alone screening test for excluding cervical injuries in polytrauma patients with obtundation. A new grading scale that is based on CT and magnetic resonance (MR) imaging findings, the cervical spine Subaxial Injury Classification and Scoring (SLIC) system, is gaining acceptance among spine surgeons. Radiographic measurements described for the evaluation of craniocervical distraction injuries are now being reevaluated with the use of multidetector CT. Although most patients with blunt trauma are now treated nonsurgically, evolution in the understanding of spinal stability, as well as the development of new surgical techniques and hardware, has driven management strategies that are increasingly favorable toward surgical intervention. It is therefore essential that radiologists recognize findings that distinguish injuries with ligamentous instability or a high likelihood of nonfusion that require surgical stabilization from those that are classically stable and can be treated with a collar or halo vest alone. The purpose of this article is to review the spectrum of cervical spine injuries, from the craniocervical junction through the subaxial spine, and present the most widely used grading systems for each injury type.

Multi-Detector Row CT Angiography of the Neck in Blunt Trauma

Blunt cerebrovascular injury (BCVI) is uncommon but potentially catastrophic; 80% are caused by vehicle collisions. Ischemic events secondary to untreated BCVI are common, with high injury-specific mortality. This has led to implementation of screening programs based on mechanism of injury, clinical presentation, and injury patterns identified on noncontrast computed tomography (CT) imaging. The standard of reference for diagnosis is four-vessel digital subtraction angiography. Given its availably in trauma service institutions, use of multidetector CT angiography has increased. This article presents the evidence and the controversies surrounding its use. Available protocols, injury description, and grading, as well as potential pitfalls are reviewed.

Myelography CPT Coding Updates: Effects of 4 New Codes and Unintended Consequences.

SUMMARY: The Current Procedural Terminology of the American Medical Association has recently introduced coding changes for myelography with the introduction of new bundled codes. The aim of this review was to help neuroradiologists understand these code changes and their unintended consequences and to discuss various scenarios in which permutations of various codes could occur in clinical practice.

Practice Management and Health Policy Education in Radiology: An Emerging Imperative.

As society places increased responsibility on practicing physicians for addressing accelerating health care costs and delivery system inefficiencies, traditional education and training programs have left most physicians ill equipped to assume this responsibility. A variety of new initiatives are underway that dramatically change how radiology training programs address these issues. We review the emerging need for better physician education in health policy and practice management, detail the history and requirements of the ACGME and the ABR Healthcare Economics Milestone Project, and outline mechanisms by which radiology residency programs can comply with these requirements. We describe our own new comprehensive pilot curriculum, Practice Management, Health Policy, and Professionalism for Radiology Residents (P(3)R(2)), which may serve as a potential model for other training programs seeking to develop targeted curricula in these newly required areas.

Diagnostic Quality of 3D T2-SPACE Compared with T2-FSE in the Evaluation of Cervical Spine MRI Anatomy

BACKGROUND AND PURPOSE: Spinal anatomy has been variably investigated using 3D MRI. We aimed to compare the diagnostic quality of T2 sampling perfection with application-optimized contrasts by using flip angle evolution (SPACE) with T2-FSE sequences for visualization of cervical spine anatomy. We predicted that T2-SPACE will be equivalent or superior to T2-FSE for visibility of anatomic structures. MATERIALS AND METHODS: Adult patients undergoing cervical spine MR imaging with both T2-SPACE and T2-FSE sequences for radiculopathy or myelopathy between September 2014 and February 2015 were included. Two blinded subspecialty-trained radiologists independently assessed the visibility of 12 anatomic structures by using a 5-point scale and assessed CSF pulsation artifact by using a 4-point scale. Sagittal images and 6 axial levels from C2–T1 on T2-FSE were reviewed; 2 weeks later and after randomization, T2-SPACE was evaluated. Diagnostic quality for each structure and CSF pulsation artifact visibility on both sequences were compared by using a paired t test. Interobserver agreement was calculated (κ). RESULTS: Forty-five patients were included (mean age, 57 years; 40% male). The average visibility scores for intervertebral disc signal, neural foramina, ligamentum flavum, ventral rootlets, and dorsal rootlets were higher for T2-SPACE compared with T2-FSE for both reviewers (P < .001). Average scores for remaining structures were either not statistically different or the superiority of one sequence was discordant between reviewers. T2-SPACE showed less degree of CSF flow artifact (P < .001). Interobserver variability ranged between −0.02–0.20 for T2-SPACE and −0.02–0.30 for T2-FSE (slight to fair agreement). CONCLUSIONS: T2-SPACE may be equivalent or superior to T2-FSE for the evaluation of cervical spine anatomic structures, and T2-SPACE shows a lower degree of CSF pulsation artifact.

Translating New Imaging Technologies to Clinical Practice

Radiology continues to benefit from constant innovation and technological advances. However, for promising new imaging technologies to reach widespread clinical practice, several milestones must be met. These include regulatory approval, early clinical evaluation, payer reimbursement, and broader marketplace adoption. Successful implementation of new imaging tests into clinical practice requires active stakeholder engagement and a focus on demonstrating clinical value during each phase of translation.

Test-Retest and Interreader Reproducibility of Semiautomated Atlas-Based Analysis of Diffusion Tensor Imaging Data in Acute Cervical Spine Trauma in Adult Patients

BACKGROUND AND PURPOSE: DTI is a tool for microstructural spinal cord injury evaluation. This study evaluated the reproducibility of a semiautomated segmentation algorithm of spinal cord DTI. MATERIALS AND METHODS: Forty-two consecutive patients undergoing acute trauma cervical spine MR imaging underwent 2 axial DTI scans in addition to their clinical scan. The datasets were put through a semiautomated probabilistic segmentation algorithm that selected white matter, gray matter, and 24 individual white matter tracts. Regional and white matter tract volume, fractional anisotropy, and mean diffusivity values were calculated. Two readers performed the nonautomated steps to evaluate interreader reproducibility. The coefficient of variation and intraclass correlation coefficient were used to assess test-retest and interreader reproducibility. RESULTS: Of 42 patients, 30 had useable data. Test-retest reproducibility of fractional anisotropy was high for white matter as a whole (coefficient of variation, 3.8%; intraclass correlation coefficient, 0.93). Test-retest coefficient-of-variation ranged from 8.0%–18.2% and intraclass correlation coefficients from 0.47–0.80 across individual white matter tracts. Mean diffusivity metrics also had high test-retest reproducibility (white matter: coefficient-of-variation, 5.6%; intraclass correlation coefficient, 0.86) with coefficients of variation from 11.6%–18.3% and intraclass correlation coefficients from 0.57–0.74 across individual tracts, with better agreement for larger tracts. The coefficients of variation of fractional anisotropy and mean diffusivity both had significant negative relationships with white matter volume (26%–27% decrease for each doubling of white matter volume, P < .01). CONCLUSIONS: DTI spinal cord segmentation is reproducible in the setting of acute spine trauma, specifically for larger white matter tracts and total white or gray matter.