Publications

RATIONALE AND OBJECTIVES: Our purpose is to understand patient preferences towards contrast-enhanced imaging such as CEM or MRI for breast cancer screening.

METHODS AND MATERIALS: An anonymous survey was offered to all patients having screening mammography at a single academic institution from December 27 th 2019 to March 6 th 2020. Survey questions related to: (1) patients' background experiences (2) patients' concern for aspects of MRI and CEM measured using a 5-point Likert scale, and (3) financial considerations.

RESULTS: 75% (1011/1349) patients completed the survey. 53.0% reported dense breasts and of those, 47.6% had additional screening. 49.6% had experienced a callback, 29.0% had a benign biopsy, and 13.7% had prior CEM/MRI. 34.7% were satisfied with mammography for screening. A majority were neutral or not concerned with radiation exposure, contrast allergy, IV line placement, claustrophobia, and false positive exams. 54.7% were willing to pay at least $250-500 for screening MRI. Those reporting dense breasts were less satisfied with mammography for screening (p<0.001) and willing to pay more for MRI (p<0.001). If patients had prior CEM/MRI, there was less concern for an allergic reaction (p<0.001), IV placement (p=0.025), and claustrophobia (p=0.006). There was less concern for false positives if they had a prior benign biopsy (p=0.029) or prior CEM/MRI (p=0.005) and less concern for IV placement if they had dense breasts (p=0.007) or a previous callback (p=0.013).

CONCLUSION: The screening population may accept CEM or MRI as a screening exam despite its risks and cost, especially patients with dense breasts and patients who have had prior CEM/MRI.

Abdominal radiology as a field has historically played an important role in the training, research, and performance of image-guided procedures. With the emphasis on increased subspecialization and the more formal and rigorous interventional radiology training programs, the question of the future of image-guided procedures within abdominal radiology is explored. A survey conducted by the Cross-Sectional Interventional Radiology Emerging Technology Commission on members of the Society of Abdominal Radiology showed that image-guided procedures are overwhelmingly being performed by abdominal radiology groups, and the vast majority of programs are training their fellows in this regard. We explore some of the challenges radiology and health care in general may face should abdominal radiologists no longer perform procedures and outline strategies departments can employ to meet the needs of both abdominal and interventional radiologists.

OBJECTIVE: To implement and evaluate outcomes from a comprehensive, multi-disciplinary debulking program in the United States.

SUMMARY OF BACKGROUND DATA: Interest in and access to surgical treatment for chronic lymphedema (LE) in the United States have increased in recent years, yet there remains little attention on liposuction, or debulking, as an effective treatment option. In some other countries, debulking is a common procedure for the surgical treatment of LE, is covered by insurance, and has demonstrated excellent, reproducible outcomes. In this study we describe our experience implementing a debulking technique from Sweden in the United States.

METHODS: Patients who presented with chronic LE followed a systematic multi-disciplinary work-up. For debulking with power assisted liposuction, the surgical protocol was modeled after that developed by Håkan Brorson. A retrospective review of consecutive patients who underwent debulking at our institution was conducted.

RESULTS: Between December 2017 and January 2020, 39 patients underwent 41 debulking procedures with power assisted liposuction, including 23 upper and 18 lower extremities. Mean patient age was 58 years and 85% of patients had LE secondary to cancer, the majority of which (64%) was breast cancer. Patients experienced excess volume reductions of 116% and 115% in the upper and lower extremities, respectively, at 1 year postoperatively. Overall quality of life (LYMQOL) improved by a mean of 33%. Finally, patients reported a decreased incidence of cellulitis and decreased reliance on conservative therapy modalities postoperatively.

CONCLUSIONS: Debulking with power assisted liposuction is an effective treatment for patients with chronic extremity LE. The operation addresses patient goals and improves quality of life, and additionally reduces extremity volumes, infection rates and reliance on outpatient therapy. A comprehensive, multi-disciplinary debulking program can be successfully implemented in the United States healthcare system.

BACKGROUND: The perceived acuity of intracerebral hemorrhage (ICH) impacts the management of patients, both within emergent and outpatient/urgent settings. Morphology enabled dipole inversion (MEDI) quantitative susceptibility imaging (QSM) has improved characterization of ICH acuity, despite outstanding limitations in distinguishing blood products.

PURPOSE/HYPOTHESIS: Using improved susceptibility quantification, novel postprocessing QSM method from multiecho complex total field inversion (mcTFI) may better discriminate between acute and subacute ICH, compared to MEDI.

STUDY TYPE: Retrospective cohort study.

SUBJECTS: A total of 121 subjects enrolled following positive computerized tomography (CT) findings for ICH. Subjects were grouped based on time between admission and MR imaging: hyperacute (<24 hours), acute (1-3 days), early subacute (3-7 days), and late subacute (7-18 days).

FIELD STRENGTH/SEQUENCE: A multiecho gradient echo sequence at 3.0 T was paired with clinical noncontrast CT imaging.

ASSESSMENT: A quantitative index (CTindex ) was derived based on relative intensities of blood on noncontrast CT. All images were co-registered, from which QSM parameters within the ICH area were assessed across groups, as well as the correlation with CTindex .

STATISTICAL TESTS: Group differences were assessed using ANOVAs. Linear regressions between the CTindex , MEDI, and mcTFI measurements were used to assess their relationships. Statistical significance was set at P < 0.05.

RESULTS: A total of 21 hyperacute, 72 acute, 21 early subacute, and 7 late-subacute patients were included in this analysis. Significant changes in blood susceptibility were found over time for the MEDI and mcTFI, although mcTFI better differentiated the hyperacute/acute from subacute stages. CTindex values within the ICH were more strongly correlated with mcTFI QSM (r = 0.727) than MEDI (r = 0.412) QSM.

DATA CONCLUSION: McTFI susceptibility estimation demonstrated better correlation with ICH acuity as suggested by CT, providing an improved method to assess acuity of intracranial blood products in clinical settings to identify cases that may require acute intervention.

LEVEL OF EVIDENCE: 4 TECHNICAL EFFICACY STAGE: 2.

OBJECTIVE: To assess the diagnostic contribution of contrast-enhanced 3D STIR (ce3D-SS) high-resolution magnetic resonance (MR) imaging of peripheral nerve pathology relative to conventional 2D sequences.

MATERIALS AND METHODS: In this IRB-approved retrospective study, two radiologists reviewed 60 MR neurography studies with nerve pathology findings. The diagnostic contribution of ce3D-SS imaging was scored on a 4-point Likert scale (1 = no additional information, 2 = supports interpretation, 3 = moderate additional information, and 4 = diagnosis not possible without ce3D-SS). Image quality, nerve visualization, and detection of nerve pathology were also assessed for both standard 2D neurography and ce3D-SS sequences utilizing a 3-point Likert scale. Descriptive statistics are reported.

RESULTS: The diagnostic contribution score for ce3D-SS imaging was 2.25 for the brachial plexus, 1.50 for extremities, and 1.75 for the lumbosacral plexus. For brachial plexus, the mean consensus scores for image quality, nerve visualization, and detection of nerve pathology were 2.55, 2.5, and 2.55 for 2D and 2.35, 2.45, and 2.45 for 3D. For extremities, the mean consensus scores for image quality, nerve visualization, and detection of nerve pathology were 2.60, 2.80, and 2.70 for 2D and 1.8, 2.20, and 2.10 for 3D. For lumbosacral plexus, the mean consensus scores for image quality, nerve visualization, and detection of nerve pathology were 2.45, 2.75, and 2.65 for 2D and 2.0, 2.45, and 2.25 for 3D.

CONCLUSION: Overall, our study supports the potential application of ce3D-SS imaging for MRN of the brachial plexus but suggests that 2D MRN protocols are sufficient for MRN of the extremities and lumbosacral plexus.

The coronavirus disease 2019 (COVID -19) pandemic caused by the novel severe acute respiratory syndrome coronavirus (SARS-CoV-2) has affected almost every country in the world, resulting in severe morbidity, mortality and economic hardship, and altering the landscape of healthcare forever. Although primarily a pulmonary illness, it can affect multiple organ systems throughout the body, sometimes with devastating complications and long-term sequelae. As we move into the second year of this pandemic, a better understanding of the pathophysiology of the virus and the varied imaging findings of COVID-19 in the involved organs is crucial to better manage this complex multi-organ disease and to help improve overall survival. This manuscript provides a comprehensive overview of the pathophysiology of the virus along with a detailed and systematic imaging review of the extra-thoracic manifestation of COVID-19 with the exception of unique cardiothoracic features associated with multisystem inflammatory syndrome in children (MIS-C). In Part I, extra-thoracic manifestations of COVID-19 in the abdomen in adults and features of MIS-C will be reviewed. In Part II, manifestations of COVID-19 in the musculoskeletal, central nervous and vascular systems will be reviewed.

There is currently no consensus regarding preferred clinical outcome measures following image-guided tumor ablation or clear definitions of oncologic end points. This consensus document proposes standardized definitions for a broad range of oncologic outcome measures with recommendations on how to uniformly document, analyze, and report outcomes. The initiative was coordinated by the Society of Interventional Oncology in collaboration with the Definition for the Assessment of Time-to-Event End Points in Cancer Trials, or DATECAN, group. According to predefined criteria, based on experience with clinical trials, an international panel of 62 experts convened. Recommendations were developed using the validated three-step modified Delphi consensus method. Consensus was reached on when to assess outcomes per patient, per session, or per tumor; on starting and ending time and survival time definitions; and on time-to-event end points. Although no consensus was reached on the preferred classification system to report complications, quality of life, and health economics issues, the panel did agree on using the most recent version of a validated patient-reported outcome questionnaire. This article provides a framework of key opinion leader recommendations with the intent to facilitate a clear interpretation of results and standardize worldwide communication. Widespread adoption will improve reproducibility, allow for accurate comparisons, and avoid misinterpretations in the field of interventional oncology research. Published under a CC BY 4.0 license. Online supplemental material is available for this article. See also the editorial by Liddell in this issue.

PURPOSE: The purpose of the study is to determine if a combination of dermal thickening and subcutaneous fluid honeycombing on non-contrast MRI, termed the dermal rim sign (DRS), can be diagnostically analogous to dermal backflow seen on lymphoscintigraphy in patients with secondary upper extremity lymphedema.

MATERIALS AND METHODS: Upper extremity MRI and lymphoscintigraphy were performed on patients referred to a multidisciplinary lymphedema clinic for suspicion of secondary lymphedema. Sensitivity, specificity, and positive and negative predictive values of DRS on MRI in detecting dermal backflow on lymphoscintigraphy and the correlation between DRS, Indocyanine Green (ICG) lymphography, bioimpedence L-Dex® ratio and MRI Lymphedema Staging were calculated. Weighted interobserver agreements on the presence and location of DRS on MRI were calculated.

RESULTS: Of the 45 patients in the study, 91.1% (41/45) of patients had history of breast cancer. The average age was 58.4 ± 10.5 years, with a mean symptom duration of 4.7 ± 4.4 years. The mean BMI was 30.5 ± 7.0 kg/m2. Interobserver agreement on the presence and the extent of DRS on MRI was 0.93 [95% confidence-interval: 0.80-1]. DRS was present in 97% (32/33) of patients who demonstrated dermal backflow on lymphoscintigraphy. Sensitivity, specificity, PPV, and NPV of DRS were 96.6% [81.7%-99.9%], and 75.0% [47.6%-92.7%], 87.5% [74.9%-94.3%], and 92.3% [63.1%-98.8%]. DRS was associated with severity on ICG lymphography and bioimpedance (both p < 0.001).

CONCLUSIONS: DRS on non-contrast MRI is highly predictive of dermal backflow and correlates with clinical measures of lymphedema severity. DRS may be used as an independent diagnostic biomarker to identify patients who would benefit from dedicated exams.

BACKGROUND: Alzheimer's disease (AD) is associated with alterations in cortical perfusion that correlate with cognitive impairment. Recently, neural activity in the gamma band has been identified as a driver of arteriolar vasomotion while, on the other hand, gamma activity induction on preclinical models of AD has been shown to promote protein clearance and cognitive protection.

METHODS: In two open-label studies, we assessed the possibility to modulate cerebral perfusion in 15 mild to moderate AD participants via 40Hz (gamma) transcranial alternating current stimulation (tACS) administered 1 h daily for 2 or 4 weeks, primarily targeting the temporal lobe. Perfusion-sensitive MRI scans were acquired at baseline and right after the intervention, along with electrophysiological recording and cognitive assessments.

RESULTS: No serious adverse effects were reported by any of the participants. Arterial spin labeling MRI revealed a significant increase in blood perfusion in the bilateral temporal lobes after the tACS treatment. Moreover, perfusion changes displayed a positive correlation with changes in episodic memory and spectral power changes in the gamma band.

CONCLUSIONS: Results suggest 40Hz tACS should be further investigated in larger placebo-controlled trials as a safe, non-invasive countermeasure to increase fast brain oscillatory activity and increase perfusion in critical brain areas in AD patients.

TRIAL REGISTRATION: Studies were registered separately on ClinicalTrials.gov ( NCT03290326 , registered on September 21, 2017; NCT03412604 , registered on January 26, 2018).