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Low back and neck pain are common and result in significant patient disability and health care expenditure. When conservative treatment fails or worrisome clinical findings are present, magnetic resonance imaging (MRI) is the imaging modality of choice to assess the cause and complicating features of spine pain. There are many potential aetiologies of spine pain with similar clinical presentation, including degenerative changes, infection, and insufficiency and pathologic fractures. MRI allows for the differentiation of these sources of spine pain and potential complicating features, permitting the appropriate direction of therapy.

A 74-year-old woman with primary hyperparathyroidism diagnosed from routine laboratory tests described symptoms of fatigue and difficulty with concentration. During surgical consultation, the cervical and thoracic spine MRI scans from the preceding 10-year period, performed for relapsing-remitting multiple sclerosis, were reviewed. In this clinical context, the slowly enlarging left upper paraesophageal lesion, reported as a lateral proximal esophageal (Killian-Jamieson) diverticulum, was reevaluated for a potential parathyroid adenoma. 99mTc-sestamibi SPECT/CT demonstrated focal uptake in the paraesophageal lesion with surgical resection, confirming it to be a large parathyroid adenoma.

This article discusses instrumented spinal surgeries, the radiologic assessment of spinal fixation hardware, and the potential complications of spinal hardware. Radiography is the standard for the postoperative assessment of spinal hardware. Computed tomography and magnetic resonance imaging play a valuable role in the detection of hardware and postsurgical-related complications such as infection, pseudarthrosis, and malpositioned instrumentation. Familiarity with the normal imaging appearance of implanted spinal hardware along with the expected progression of normal postoperative osseous arthrodesis enables recognition of potential complications and helps facilitate appropriate clinical management.

A 17-year-old girl with World Health Organization grade IV glioblastoma with primitive neuronal components (histone H3 G34-mutant and IDH1 wild type) underwent whole-body FDG PET/CT staging due to vertebral metastases on initial MRI. PET/CT revealed extracranial metastatic disease with spinal leptomeningeal dissemination, osseous metastases, and peritoneal seeding via a ventriculoperitoneal shunt. Glioblastoma is uncommon in pediatric patients and particularly those with primitive neuronal components. Extracranial metastases from glioblastoma are more common in those with primitive neuronal components. This case demonstrates the utility of FDG PET/CT for revealing distant metastases from glioblastoma.

Upper respiratory tract infections are the most frequent outpatient disease processes treated by the pediatricians. Although upper respiratory tract infections are typically self-limited viral illnesses, a subset of children will develop acute bacterial sinusitis, which is differentiated from the former viral nasopharyngitis by prolonged illness, worsening course, or severe onset of symptoms. Although diagnostic imaging is not indicated in the differentiation of a viral upper respiratory tract infection from acute bacterial sinusitis, contrast-enhanced computed tomography (CT) or magnetic resonance imaging (MRI) are critical in the detection and classification of potentially serious complications of acute bacterial sinusitis resulting from intraorbital or intracranial spread of infection. Orbital infections are the most frequently associated complications of paranasal sinus inflammatory disease given the proximity of the paranasal sinuses and orbits. Imaging is essential in differentiating preseptal cellulitis from orbital cellulitis and guiding appropriate therapy. Cross-sectional imaging is also important in the characterization of noninvasive fungal sinusitis, forms of chronic sinusitis in the setting of an intact immune system, and invasive fungal sinusitis, an acute fulminant sinusitis induced by angioinvasive fungi in immunocompromised children requiring emergent surgical management.

Despite the popularity of flow-diverting stents for the treatment of cerebral aneurysms, there is no widely accepted scale for the characterization of results. We present an outcomes-based grading scale that considers factors related to failure of flow diversion.The grading scale was developed using the results from consecutive patients at two institutions who were treated with flow diversion for a cerebral aneurysm. The initial treatment results were graded on patient, aneurysm, and treatment characteristics. A 6-point grading scale was developed based on these data.One hundred and seventy-one patients were included in the patient cohort. When compared by multivariate analysis with patients without residuals, patients with aneurysm residuals were found to be older (age ≥60 years, p=0.01, OR 1.17, 95% CI 1.03 to 1.33), to have larger aneurysms (size ≥15 mm, p0.01, OR 1.38, 95% CI 1.17 to 1.62), to have aneurysms with associated side branches (p=0.02, OR 1.17, 95% CI 1.03 to 1.33), and to have a post-treatment Raymond score of 2 or 3 (p=0.01, OR 1.28, 95% CI 1.06 to 1.56). Using the Raymond score (1-3) as the foundation for the grading scale, additional points (0 or 1) were given for the other three identified factors, creating a 6-point scale. We found that patients with residual aneurysms had statistically higher final tabulated scores (p0.01).We propose a novel straightforward outcomes-based scale to characterize results after flow diversion treatment of cerebral aneurysms. This scale may provide the basis for the common reporting of results in future studies.

BackgroundWith increasing use of flow-diverting stents for the treatment of intracranial aneurysms, standardized methods and a common language to evaluate angiographic outcomes are needed. Multiple grading scales have been developed for this purpose but none has been widely adopted.ObjectiveTo analyze these scales to determine interobserver reliability.MethodsFour independent assessors scored the intraprocedural angiograms of patients who underwent flow-diverting stent deployment for an intracranial saccular or fusiform aneurysm at our institution between October 2012 and June 2015. Angiographic outcome immediately after flow-diverting stent deployment was scored using three grading scales (Kamran–Byrne (KB), Simple Measurement of Aneurysm Residual after Treatment (SMART), and O'Kelley, Krings, Marotta (OKM)). Statistical analysis was performed using Light's κ for multiple raters (κ), Kendall's coefficient of concordance (W), and intraclass correlation (ICC).ResultsWe included the angiograms of 50 consecutive patients (mean age 58 years, range 30–79) who underwent flow-diverting stent deployment for an intracranial aneurysm (40 saccular, 10 fusiform). Six aneurysms were located in the posterior circulation. The inter-rater reliability was typically poor or fair: SMART aneurysm filling (κ=0.30, W=0.36, ICC=0.12), SMART parent vessel stenosis (κ=0.07, W=0.33, ICC=0.12), KB axis I (κ=0.24, W=0.50, ICC=0.25), KB axis II (κ=0.07, W=0.30, ICC=0.06), OKM aneurysm filling (κ=0.23, W=0.45, ICC=0.13), OKM contrast stasis (κ=0.36,W=0.71, ICC=0.54).ConclusionsExisting flow-diverting stent grading scales have low inter-rater reliability for most categories.

A 56-y-old man underwent total thyroidectomy and bilateral central and right lateral neck dissection for papillary thyroid carcinoma with lymph nodes metastases. Before radioiodine ablation, a 123I scan established the diagnosis of primary nasolacrimal duct obstruction (dacryostenosis).

Diagnostic imaging has become critical in the care of patients suffering from traumatic or nontraumatic emergent orbital conditions. Multidetector computed tomography (MDCT) has become the standard imaging modality for assessing orbital trauma because of its accurate assessment of orbital skeletal and soft tissues injuries. Contrast-enhanced MR imaging is the first-line examination in the assessment of nontraumatic orbital conditions given its excellent evaluation of the orbital soft tissues. Conventional angiography is necessary in some vascular orbital complications and allows for endovascular treatment. This article discusses the spectrum of orbital pathology encountered in the imaging of orbital trauma and nontraumatic orbital emergencies.

A 63-year-old woman with epilepsy and chronic headaches was admitted for status epilepticus. A lumbar puncture revealed increased opening pressure of 320 mm H2O and bacterial meningitis. MRI brain demonstrated a partial empty sella, tortuous optic nerve sheaths, flattening of the optic papillae, and numerous prominent arachnoid granulations, consistent with chronic idiopathic intracranial hypertension (IIH), as well as bright CSF signal and brain parenchyma within a left meningoencephalocele (figure, A). A CT cisternogram confirmed communication of the subarachnoid space of the meningoencephalocele with the left sphenoid sinus through a small osseous defect (figure, B). While most CSF leaks are related to trauma, IIH is increasingly recognized as a cause of spontaneous leaks.1,2 While the increased opening pressure may have been due to her acute meningitis, her headache symptoms and MRI findings are suggestive of longstanding intracranial hypertension. Monitoring and medical treatment of IIH must accompany surgical repair to avoid recurrence.2

We report the case of a 15-month-old boy with retinoblastoma who developed exotropia secondary to a right medial rectus infarct after intra-arterial chemotherapy. He had unilateral sporadic group C tumor (International Classification of Retinoblastoma) and was treated with intra-arterial melphalan. One week after the first session of intra-ophthalmic arterial melphalan chemotherapy, he was noted to have orbital congestion, exotropia, and right adduction limitation. Magnetic resonance imaging was suggestive of a right medial rectus infarct. The tumor showed a good response to intra-arterial chemotherapy but the exotropia persisted.