Michael Brant-Zawadzki

Magnetic resonance imaging of the lumbar spine in people without back pain

BACKGROUND The relation between abnormalities in the lumbar spine and low back pain is controversial. We examined the prevalence of abnormal findings on magnetic resonance imaging (MRI) scans of the lumbar spine in people without back pain. METHODS We performed MRI examinations on 98 asymptomatic people. The scans were read independently by two neuroradiologists who did not know the clinical status of the subjects. To reduce the possibility of bias in interpreting the studies, abnormal MRI scans from 27 people with back pain were mixed randomly with the scans from the asymptomatic people. We used the following standardized terms to classify the five intervertebral disks in the lumbosacral spine: normal, bulge (circumferential symmetric extension of the disk beyond the interspace), protrusion (focal or asymmetric extension of the disk beyond the interspace), and extrusion (more extreme extension of the disk beyond the interspace). Nonintervertebral disk abnormalities, such as facet arthropathy, were also documented. RESULTS Thirty-six percent of the 98 asymptomatic subjects had normal disks at all levels. With the results of the two readings averaged, 52 percent of the subjects had a bulge at at least one level, 27 percent had a protrusion, and 1 percent had an extrusion. Thirty-eight percent had an abnormality of more than one intervertebral disk. The prevalence of bulges, but not of protrusions, increased with age. The most common nonintervertebral disk abnormalities were Schmorls nodes (herniation of the disk into the vertebral-body end plate), found in 19 percent of the subjects; annular defects (disruption of the outer fibrous ring of the disk), in 14 percent; and facet arthropathy (degenerative disease of the posterior articular processes of the vertebrae), in 8 percent. The findings were similar in men and women. CONCLUSIONS On MRI examination of the lumbar spine, many people without back pain have disk bulges or protrusions but not extrusions. Given the high prevalence of these findings and of back pain, the discovery by MRI of bulges or protrusions in people with low back pain may frequently be coincidental.

Carotid Stenting and Angioplasty A Statement for Healthcare Professionals From the Councils on Cardiovascular Radiology, Stroke, Cardio-Thoracic and Vascular Surgery, Epidemiology and Prevention, and Clinical Cardiology, American Heart Association

Carotid artery stenosis, particularly involving the origin of the internal carotid artery, is a frequent clinical problem. These stenoses, almost invariably atherosclerotic, can present as asymptomatic bruits discovered on physical examination, one or more transient ischemic attacks related to embolization of thrombus from stenotic lesions or to hypoperfusion, or less commonly, as an ischemic stroke. From the results of three high-quality prospective randomized trials,1 2 3 it has become apparent that symptomatic stenoses that narrow the diameter of the carotid artery more than 60% to 70% lead to a significant incidence of stroke if treated medically. The risk of stroke associated with such a lesion in symptomatic patients treated with antiplatelet therapy alone is thought to be 26%.3 With carotid endarterectomy and aspirin, this risk is lowered to 9%, a statistically significant difference.3 In patients with or without symptoms who have a stenosis ≤60%, the effectiveness of either medical therapy or carotid endarterectomy in preventing significant neurological events is not known. In symptomatic patients with <30% stenosis, medical therapy is superior to surgical therapy.2 Studies attempting to define the benefit of therapy in symptomatic patients with <60% stenosis are currently under way. Accrual of patients has slowed, however, because data show clear efficacy in symptomatic patients with stenoses ≥70%, leading to a bias toward surgery in symptomatic patients with less severe stenoses. In general the role of surgery for asymptomatic stenosis remains controversial, with some recent opinions suggesting that it may not be indicated.4 In one high-quality trial with selected experienced surgeons, there was a modest reduction in absolute risk in asymptomatic patients with stenosis ≥60%, but the significance of this finding has been debated.5 6 Although mortality associated with conventional antiplatelet therapy has been minimal,7 surgery clearly has significant perioperative morbidity and …

Fluid-Attenuated Inversion Recovery (FLAIR) for Assessment of Cerebral Infarction Initial Clinical Experience in 50 Patients

BACKGROUND AND PURPOSE Our aim was to evaluate fluid-attenuated inversion recovery (FLAIR) sequence in the diagnosis of cerebral infarction with MRI. METHODS A retrospective review was undertaken of 50 consecutive MRI studies ordered for suspected cerebrovascular accident. All studies included FLAIR and rapid acquisition with relaxation enhancement (RARE) T2-weighted spin-echo sequences. The two sequences were compared independently by four observers at two different institutions. Detectability of lesions and image quality were scored. RESULTS Overall, FLAIR sequences proved superior in 10 patients, detecting acute cortical infarcts missed with RARE spin-echo technique in five patients. In five additional patients, improved characterization of chronic infarction and improved detection of microangiopathic deep hemispheric changes were observed. One brain stem infarct was missed with the FLAIR sequence. CONCLUSIONS FLAIR offers advantages in detection of acute infarcts affecting the cortical ribbon, is a useful, rapid adjunct to conventional T2-weighted spin-echo sequences, and has the potential to replace these in the future.

Magnetic resonance angiography of cervicocranial dissection.

Background A retrospective study of five patients with the clinical or magnetic resonance-based diagnosis of carotid dissection was done. Clinical data, imaging studies, treatment, and outcome were reviewed. The potential applicability of three-dimensional time-of-flight magnetic resonance angiography in these settings was evaluated. Summary of Report This modality reliably showed vascular abnormalities and focal, segmental, or aneurysmal dilatation when correlated with conventional angiograms in three patients. Turbulence and magnetic susceptibility at the acute turn of the carotid in the petrous canal led to a false-positive diagnosis on magnetic resonance angiography in one patient (in whom subtle fibromuscular hyperplasia was found with conventional angiography but missed with magnetic resonance angiography). Conclusions When combined with appropriate clinical signs, magnetic resonance imaging and magnetic resonance angiography can reliably establish the diagnosis of carotid dissection. Pitfalls of magnetic resonance angiography are discussed.

Effects of Diagnostic Information, Per Se, on Patient Outcomes in Acute Radiculopathy and Low Back Pain

BACKGROUND AND PURPOSE: We conducted a prospective randomized study of patients with acute low back pain and/or radiculopathy to assess the effect of knowledge of diagnostic findings on clinical outcome. The practice of ordering spinal imaging, perhaps unintentionally, includes a large number of patients for whom the imaging test is performed for purposes of reassurance or because of patient expectations. If this rationale is valid, one would expect to see a measurable effect from diagnostic information, per se. MATERIALS AND METHODS: A total of 246 patients with acute (<3 weeks) low back pain (LBP) and/or radiculopathy (150 LBP and 96 radiculopathy patients) were recruited. Patients were randomized using a stratified block design with equal allocation to either the unblinded group (MR imaging results provided within 48 hours) or the blinded group (both patient and physician blinded to MR imaging results.) After the initial MR imaging, patients followed 6 weeks of conservative management. Roland function, visual pain analog, absenteeism, Short Form (SF)-36 Health Status Survey, self-efficacy scores, and Fear Avoidance Questionnaire were completed at presentation; 2, 4, 6, and 8 weeks; and 6, 12, and 24 months. Improvement of Roland score by 50% or more and patient satisfaction assessed by Cherkin symptom satisfaction measure were considered a positive outcome. RESULTS: Clinical outcome at 6 weeks was similar for unblinded and blinded patients. Self-efficacy, fear avoidance beliefs, and the SF-36 subscales were similar over time for blinded and unblinded patients, except for the general health subscale on the SF-36. General health of the blinded group improved more than for the unblinded group (P = .008). CONCLUSIONS: Patient knowledge of imaging findings do not alter outcome and are associated with a lesser sense of well-being.

ACR White Paper: Strategies for Radiologists in the Era of Health Care Reform and Accountable Care Organizations: A Report From the ACR Future Trends Committee

Accountable care organizations have received considerable attention as a component of health care reform and have been specifically addressed in recent national legislation and demonstration projects by CMS. The role or roles of radiologists in such organizations are currently unclear, as are changes to the ways in which imaging services will be delivered. The authors review concepts fundamental to accountable care organizations and describe roles for radiologists that may facilitate their success in such health care delivery systems.

Carotid stenting and angioplasty: A statement for healthcare professionals from the councils on cardiovascular radiology, stroke, cardio-thoracic and vascular surgery, epidemiology and prevention, and clinical cardiology, american heart association

Carotid artery stenosis, particularly involving the origin of the internal carotid artery, is a frequent clinical problem. These stenoses, almost invariably atherosclerotic, can present as asymptomatic bruits discovered on physical examination, one or more transient ischemic attacks related to embolization of thrombus from stenotic lesions or to hypoperfusion, or less commonly, as an ischemic stroke. From the results of three high-quality prospective randomized trials,1 2 3 it has become apparent that symptomatic stenoses that narrow the diameter of the carotid artery more than 60% to 70% lead to a significant incidence of stroke if treated medically. The risk of stroke associated with such a lesion in symptomatic patients treated with antiplatelet therapy alone is thought to be 26%.3 With carotid endarterectomy and aspirin, this risk is lowered to 9%, a statistically significant difference.3 In patients with or without symptoms who have a stenosis ≤60%, the effectiveness of either medical therapy or carotid endarterectomy in preventing significant neurological events is not known. In symptomatic patients with <30% stenosis, medical therapy is superior to surgical therapy.2 Studies attempting to define the benefit of therapy in symptomatic patients with <60% stenosis are currently under way. Accrual of patients has slowed, however, because data show clear efficacy in symptomatic patients with stenoses ≥70%, leading to a bias toward surgery in symptomatic patients with less severe stenoses. In general the role of surgery for asymptomatic stenosis remains controversial, with some recent opinions suggesting that it may not be indicated.4 In one high-quality trial with selected experienced surgeons, there was a modest reduction in absolute risk in asymptomatic patients with stenosis ≥60%, but the significance of this finding has been debated.5 6 Although mortality associated with conventional antiplatelet therapy has been minimal,7 surgery clearly has significant perioperative morbidity and …

Carotid Stenting and Angioplasty: A Statement for Healthcare Professionals from the Councils on Cardiovascular Radiology, Stroke, Cardiovascular Surgery, Epidemiology and Prevention, and Clinical Cardiology, American Heart Association

Carotid artery stenosis, particularly involving the origin of the internal carotid artery, is a frequent clinical problem. These stenoses, almost invariably atherosclerotic, can present as asymptomatic bruits discovered on physical examination, one or more transient ischemic attacks related to embolization of thrombus from stenotic lesions or to hypoperfusion, or less commonly, as an ischemic stroke. From the results of three high-quality prospective randomized trials,1-3 it has become apparent that symptomatic stenoses that narrow the diameter of the carotid artery more than 60% to 70% lead to a significant incidence of stroke if treated medically. The risk of stroke associated with such a lesion in symptomatic patients treated with antiplatelet therapy alone is thought to be 26%.3 With carotid endarterectomy and aspirin, this risk is lowered to 9%, a statistically significant difference.3 In patients with or without symptoms who have a stenosis #60%, the effectiveness of either medical therapy or carotid endarterectomy in preventing significant neurological events is not known. In symptomatic patients with ,30% stenosis, medical therapy is superior to surgical therapy.2 Studies attempting to define the benefit of therapy in symptomatic patients with ,60% stenosis are currently under way. Accrual of patients has slowed, however, because data show clear efficacy in symptomatic patients with stenoses

Sodium nitroprusside in the treatment of ergotism.

70%, leading to a bias toward surgery in symptomatic patients with less severe stenoses. In general the role of surgery for asymptomatic stenosis remains controversial, with some recent opinions suggesting that it may not be indicated.4 In one high-quality trial with selected experienced surgeons, there was a modest reduction in absolute risk in asymptomatic patients with stenosis

ACR White Paper: New Practice Models—Hospital Employment of Radiologists: A Report From the ACR Future Trends Committee

60%, but the significance of this finding has been debated.5,6 Although mortality associated with conventional antiplatelet therapy has been minimal,7 surgery clearly has significant perioperative morbidity and mortality. This risk varies as a function of the skill and experience of the surgeon and ancillary personnel. In one large study of symptomatic patients,3 surgical complication rates were 0.6% mortality; 5.5% perioperative cerebrovascular events; and 2.1% major stroke. By contrast, over the same 32-day observation period, patients treated medically had a 0.3% fatality rate, a 3.3% risk of a cerebrovascular event, and a 0.9% risk of a major event. In a recent review of the published literature, risk of stroke and/or death following carotid endarterectomy in symptomatic patients was found to be 5.6%, although there was substantial variation in incidence as a function of the type of study and the nature of postoperative evaluation and surveillance.8 Surgery, then, in this symptomatic group of patients with significant carotid artery stenosis has a low but significant incidence of periprocedural complications. More importantly, however, according to actuarial analysis, by 2 years the risk of an ipsilateral stroke was 9% for surgical patients and 26% for medically treated patients, a 17% reduction in absolute risk with surgery.3 Since its development by Gruentzig9 in the early 1970s, use of balloon angioplasty for treatment of atherosclerotic and other vascular stenoses has gained wide acceptance. In many trials involving many organ systems, percutaneous transluminal angioplasty (PTA) has been shown to be effective. Despite several large studies, however, there is still debate about its relative efficacy and applicability compared with surgery, primarily because long-term patency after PTA is limited by restenosis as well documented in coronary, renal, and peripheral applications.10-12 Vascular stents have gained wide popularity over the last several years. There are many types with different characteristics, in different stages of clinical use and FDA approval. More