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Rationale and Objectives Fluoroscopy-guided lumbar puncture (FGLP) is a basic procedural component of radiology residency and neuroradiology fellowship training. Performance of the procedure with limited experience is associated with increased patient discomfort as well as increased radiation dose, puncture attempts, and complication rate. Simulation in health care is a developing field that has potential for enhancing procedural training. We demonstrate the design and utility of a virtual reality simulator for performing FGLP. Materials and Methods An FGLP module was developed on an ImmersiveTouch platform, which digitally reproduces the procedural environment with a hologram-like projection. From computed tomography datasets of healthy adult spines, we constructed a 3-D model of the lumbar spine and overlying soft tissues. We assigned different physical characteristics to each tissue type, which the user can experience through haptic feedback while advancing a virtual spinal needle. Virtual fluoroscopy as well as 3-D images can be obtained for procedural planning and guidance. The number of puncture attempts, the distance to the target, the number of fluoroscopic shots, and the approximate radiation dose can be calculated. Preliminary data from users who participated in the simulation were obtained in a postsimulation survey. Results All users found the simulation to be a realistic replication of the anatomy and procedure and would recommend to a colleague. On a scale of 1–5 (lowest to highest) rating the virtual simulator training overall, the mean score was 4.3 (range 3–5). Conclusions We describe the design of a virtual reality simulator for performing FGLP and present the initial experience with this new technique.

Intensity-modulated radiotherapy (IMRT) is not widely used in developing countries due to technical challenges and a lack of expertise and resources. We outline head and neck cancer IMRT implementation challenges and highlight how improvised solutions allowed successful IMRT transition in Jordan. This article showcases a 'peer-assisted learning' model, promoting IMRT transition in other developing countries. Unlike the 'top-down' approach, this model is uncommonly addressed in oncology journals. Developing countries could benefit from this article to enhance the adoption of modern radiotherapy technology.

Purpose:To evaluate the predictive value of magnetic resonance imaging in retinoblastoma for the likelihood of high-risk pathologic features.Methods:A retrospective study of 64 eyes enucleated from 60 retinoblastoma patients. Contrast-enhanced magnetic resonance imaging was performed before enucleation. Main outcome measures included demographics, laterality, accuracy, sensitivity, and specificity of magnetic resonance imaging in detecting high-risk pathologic features.Results:Optic nerve invasion and choroidal invasion were seen microscopically in 34 (53%) and 28 (44%) eyes, respectively, while they were detected in magnetic resonance imaging in 22 (34%) and 15 (23%) eyes, respectively. The accuracy of magnetic resonance imaging in detecting prelaminar invasion was 77% (sensitivity 89%, specificity 98%), 56% for laminar invasion (sensitivity 27%, specificity 94%), 84% for postlaminar invasion (sensitivity 42%, specificity 98%), and 100% for optic cut edge invasion (sensitivity100%, specificity 100%). The accuracy of magnetic resonance imaging in detecting focal choroidal invasion was 48% (sensitivity 33%, specificity 97%), and 84% for massive choroidal invasion (sensitivity 53%, specificity 98%), and the accuracy in detecting extrascleral extension was 96% (sensitivity 67%, specificity 98%).Conclusions and relevance:Magnetic resonance imaging should not be the only method to stratify patients at high risk from those who are not, eventhough it can predict with high accuracy extensive postlaminar optic nerve invasion, massive choroidal invasion, and extrascleral tumor extension.

Synchronous primary malignant brain tumors are rare. We present a 5-year-old boy with synchronous glioblastoma and medulloblastoma. Both tumor samples had positive p53 stain and loss of PMS2 and MLH1 stains. The child had multiple café au lait spots and a significant family history of cancer. After subtotal resection of both tumors, he received craniospinal radiation with concomitant temozolomide followed by chemotherapy, alternating cycles of cisplatin/lomustine/vincristine with temozolomide. Then, he started maintenance treatment with cis-retinoic acid (100 mg/m(2)/day for 21 days). He remained asymptomatic for 34 months despite a follow-up brain MRI consistent with glioblastoma relapse 9 months before his death. Cis-retinoic acid may have contributed to prolong survival in this child with a probable biallelic mismatch repair syndrome.

Fluoroscopy-guided lumbar puncture (FGLP) is a basic procedural component of radiology residency and neuroradiology fellowship training. Performance of the procedure with limited experience is associated with increased patient discomfort as well as increased radiation dose, puncture attempts, and complication rate. Simulation in health care is a developing field that has potential for enhancing procedural training. We demonstrate the design and utility of a virtual reality simulator for performing FGLP.An FGLP module was developed on an ImmersiveTouch platform, which digitally reproduces the procedural environment with a hologram-like projection. From computed tomography datasets of healthy adult spines, we constructed a 3-D model of the lumbar spine and overlying soft tissues. We assigned different physical characteristics to each tissue type, which the user can experience through haptic feedback while advancing a virtual spinal needle. Virtual fluoroscopy as well as 3-D images can be obtained for procedural planning and guidance. The number of puncture attempts, the distance to the target, the number of fluoroscopic shots, and the approximate radiation dose can be calculated. Preliminary data from users who participated in the simulation were obtained in a postsimulation survey.All users found the simulation to be a realistic replication of the anatomy and procedure and would recommend to a colleague. On a scale of 1-5 (lowest to highest) rating the virtual simulator training overall, the mean score was 4.3 (range 3-5).We describe the design of a virtual reality simulator for performing FGLP and present the initial experience with this new technique.

Individuals with biallelic truncating PRF1 mutations typically present with fulminant early-onset familial hemophagocytic lymphohistiocytosis (FHL). We report a 19-year-old male with a 5-year history of recurrent fever and headaches progressing to refractory seizures. Brain imaging revealed multiple ring enhancing lesions. Laboratory investigations demonstrated that the patient displayed defective lymphocyte cytotoxicity and carried a homozygous missense PRF1 mutation, c.394G > A (p.Gly132Arg). The patient was successfully treated with chemo-immunotherapy followed by matched related allogeneic hematopoietic stem cell transplantation (HSCT). Our findings demonstrate that prompt HSCT of late-onset FHL with primarily neurological manifestation can reverse central nervous system symptoms and improve long-term outcome. Pediatr Blood Cancer 2014;61:2313–2315. © 2014 Wiley Periodicals, Inc.

CT-guided needle biopsy is a common procedure for obtaining a tissue diagnosis and consequently correctly managing patients. This procedure has many potential complications, ranging from simple pneumothorax or self-limiting hemoptysis to life-threatening pulmonary hemorrhage and air embolism. Though the latter is a rare complication of CT-guided needle biopsy, it has attracted a lot of interest. We report a case of right coronary air embolism resulting in myocardial infarction after a CT-guided percutaneous needle biopsy of the lung.

Individuals with biallelic truncating PRF1 mutations typically present with fulminant early-onset familial hemophagocytic lymphohistiocytosis (FHL). We report a 19-year-old male with a 5-year history of recurrent fever and headaches progressing to refractory seizures. Brain imaging revealed multiple ring enhancing lesions. Laboratory investigations demonstrated that the patient displayed defective lymphocyte cytotoxicity and carried a homozygous missense PRF1 mutation, c.394G A (p.Gly132Arg). The patient was successfully treated with chemo-immunotherapy followed by matched related allogeneic hematopoietic stem cell transplantation (HSCT). Our findings demonstrate that prompt HSCT of late-onset FHL with primarily neurological manifestation can reverse central nervous system symptoms and improve long-term outcome.

We aimed to characterize specific MRI findings seen in immune competent patients with intracranial primary CNS lymphoma (PCNSL) and to determine their value in the management of such patients. Pre-treatment MRI examinations of 21 immunocompetent patients with biopsy-proven PCNSL were retrospectively evaluated. T1 and T2 signal characteristics as well as contrast enhancement features are described in all patients. Diffusion, perfusion and proton-MR-spectroscopy features are described in a subset of these patients. In the proper clinical and radiologic setting, suggesting the diagnosis of PCNSL can help institute proper treatment in a timely fashion and avoid unnecessary attempts at surgical resection and the associated morbidity.

This case report describes the MR findings of Wernicke encephalopathy seen in an 11-year-old boy with leukemia. The examination showed multiple hyperintense lesions on FLAIR and T2-weighted examinations involving both thalami, mammilary bodies, quadrigeminal plate, posterior aspect of medulla oblongata and the periaqueductal region, but no abnormalities could be detected on either T1 or contrast-enhanced T1 studies.

We present two cases with combat-related hepatic injury. These patients presented later with obstructive jaundice as seen on the percutaneous transhepatic cholangiography. Combat-related injuries are a rare cause of obstructive jaundice.