Medico-legal claims against English radiologists: 1995-2006.

A list of claims against radiologists from 1995-2006 was obtained from the NHS Litigation Authority. It shows a total of 440 claims. The largest number of claims (199) related to delayed or missed diagnoses of cancer, and 73 claims related to breast radiology. There is a trend for a mild increase in the number of claims each year. 30 claims were made after a false-positive diagnosis of cancer. Just under pound8.5 million has so far been paid in damages, with a further pound5 million in legal fees. A claim for multiple missed diagnoses of breast cancer led to a pay-out of pound464 000 ( pound673 000 after legal fees); the largest sum awarded following a delay in the diagnosis of an individual cancer was pound300 000. The subtle legal distinction between error and negligence is reviewed here. The reason why breast radiologists are more likely to be sued than any other type of British radiologist is also discussed, along with the implications for UK radiological practice, particularly in light of the recent Chief Medical Officer's report on revalidation. A method is proposed that may protect radiologists from allegations of clinical negligence in the future.

Brain imaging using multislice CT: a personal perspective.

This article outlines the use of multislice CT of the brain with regard to routine scanning, as well as high speed and/or high resolution multiplanar reconstructions. It describes in detail the recent developments in cerebral perfusion scanning and CT arteriography. It will also outline the approach of the University Hospital of Wales to imaging with this new technology, emphasizing the differences between helical and non-helical techniques. Most of the images are taken from 16-slice machines, but the methods described are applicable to 4- and 8-slice scanners, and can readily be modified for the forthcoming 64-detector array equipment that will be available within the next few months.

Are T1 weighted images helpful in MRI of cervical radiculopathy?

MRI in patients with cervical myelopathy or radiculopathy usually includes T(1) weighted (T(1)W) and T(2) weighted (T(2)W) images. We prospectively examined a hypothesis that T(2)W alone is sufficient to diagnose the cause of cervical myelopathy and radiculopathy and that the T(1)W sagittal images do not provide additional useful information. 30 patients presenting with a history of cervical radiculopathy with or without myelopathy were prospectively assessed by MRI. Those with a history suggestive of intrinsic primary cord disease or who had previously had surgery were excluded. Two neuroradiologists, blinded to the clinical information, separately viewed the sagittal and axial T(2)W images alone, and at a later time, the full set of T(1)W and T(2)W images. Image quality, location and severity of disease and confidence of diagnosis at each level were scored on 4- or 5-point scales. The T(1) sequences did not demonstrate any significant lesions not already seen on the T(2)W images alone. The T(1)W sequence may safely be omitted in patients with radiculopathy.

[Tortuosity of the internal carotid artery and its implications for the oropharyngeal and skull base surgery]. / Tortuosidad de la arteria carótida interna y sus implicaciones en la cirugía de la base de cráneo y de la cirugía orofaríngea.

Conventional textbooks on anatomy emphasize the consistency in the pathway of the cervical internal carotid artery (ICA) from the carotid bifurcation to the skull base. Deviations in its route as result of developmental and acquired conditions have received little attention in the literature. A case of a tortuous cervical ICA presenting as pharyngeal pulsatile swelling is presented. The differential diagnosis includes an enlarged ascending pharyngeal artery, aneurysm of the cervical ICA, and displacement of the cervical ICA by a tumour. Its presence warrants radiological assessment to establish a diagnosis and modify any planned surgery. Inadvertent injury or ligation of a tortuous cervical ICA can result in serious if not fatal complications. Clinical, radiological and cadaver studies on the tortuosity of the cervical ICA are reviewed.

Diagnosing CADASIL using MRI: evidence from families with known mutations of Notch 3 gene.

Clinical data and MRI findings are presented on 18 subjects from two families with neuropathologically confirmed CADASIL. DNA analysis revealed mutations in exon 4 of Notch 3 gene in both families. All family members with mutations in Notch 3 gene had extensive abnormalities on MRI, principally lesions in the white matter of the frontal lobes and in the external capsules. Of several family members in whom a diagnosis of CADASIL was suspected on the basis of minor symptoms, one had MRI changes consistent with CADASIL; none of these cases carried a mutation in the Notch 3 gene. MRI and clinical features that may alert the radiologist to the diagnosis of CADASIL are reviewed. However, a wide differential diagnosis exists for the MRI appearances of CADASIL, including multiple sclerosis and small-vessel disease secondary to hypertension. The definitive diagnosis cannot be made on MRI alone and requires additional evidence, where available, from a positive family history and by screening DNA for mutations of Notch 3 gene.

A prospective comparison of brain contrast characteristics and lesion detection using single-shot fast spin-echo and fast spin-echo.

MRI is limited by movement artefact, even with current imagers, when examining a restless or claustrophobic patient. We prospectively analysed the images of 92 patients produced by a single-shot fast spin-echo (SSFSE) pulse sequence and compared them with conventional (FSE) and reduced-time fast spin-echo (RT-FSE) techniques, with regard to lesion detection and movement artefact in brain imaging. Images obtained in each case were independently reviewed and scored for overall diagnosis, number of lesions detected, and movement artefact. FSE showed 1217 lesions, RT-FSE 1137, and SSFSE 1044. This discrepancy arose mainly in patients with multiple sclerosis or small-vessel disease, since with SSFSE we were less able to separate small, adjacent low-contrast lesions than with FSE. Arbitrary movement scores were 36, 25 and zero respectively. There were, however, no clinically significant differences in overall diagnosis between the three techniques. SSFSE thus proved a reliable, fast, accurate method for obtaining T2-weighted images, and may be of particular use in the restless, claustrophobic or obtunded patient.

Posterior fossa epithelial cyst: case report and review of the literature.

A 49-year old woman with progressive cranial nerve signs and hemiparesis was found at MR imaging and at surgery to have a cyst at the foramen magnum. Immunohistochemistry and electron microscopy showed an epithelial cyst of endodermal origin. MR findings were of an extraaxial mass, with short T1 and T2 times. Unless immunohistochemistry and electron microscopy are used in the final diagnosis of such cysts, all posterior fossa cysts lined by a single layer of epithelium should be described simply as epithelial cysts.

The vessel wall remodelling technique using a coronary angioplasty balloon and a single guide catheter.

SUMMARY: The vessel wall remodelling technique was created by Moret to enable endovascular therapy of relatively wide-necked cerebral aneurysms. As originally described, two guide catheters are placed in the relevant vertebral or carotid artery, and a Solstice balloon (Micro Interventional Systems, Ca, USA) inflated across the neck of the aneurysm while coils are placed inside. I describe a modification of this technique, using a single guide catheter, and a "monorail" coronary artery angioplasty catheter.

MRI of the anterior optic pathways following enucleation.

We examined five patients who had enucleation of one eye for inflammatory or neoplastic disease, using MRI at 1.5 Tesla. None had symptoms referable to the enucleated orbit. In addition, age- and-sex matched individuals were imaged as control subjects, and a further 15 subjects, referred for other than orbital disease, were reviewed. Measurements were made retrospectively of the dimensions of the optic chiasm to establish normal values. All five patients showed abnormalities on MRI following enucleation: abnormal signal within the optic nerve remnant on short tau inversion recovery (STIR) images, and atrophy of the nerve remnant and the chiasm. These findings were not apparent in the control or normal subjects. Such findings are to be expected following enucleation and should not be interpreted as indicating active pathology.

Percutaneous transluminal angioplasty of an innominate artery occlusion.

A middle-aged woman presented with recent-onset left hemiparesis and right subclavian steal syndrome. She was found to have an obstructed innominate artery. We successfully performed balloon angioplasty of the occluded innominate artery and encountered no complications during follow-up of currently 8 months.

MRI of idiopathic orbital inflammatory syndrome using fat saturation and Gd-DTPA.

Idiopathic orbital inflammatory syndrome encompasses a group of inflammatory conditions for which no systemic or local cause can be found, and is commonly referred to as orbital pseudotumour. On conventional MRI sequences subtle areas of inflammation or enhancing tissue can easily be masked by the high signal intensity of orbital fat and involvement of the fat itself may not be appreciated. We describe the MRI features of three patients with idiopathic orbital inflammation using frequency-selective fat saturation and Gd-DTPA.

Uncommon posterior cranial fossa anomalies: MRI with clinical correlation.

The clinical and MRI findings in two cases of rhombencephalosynapsis (RS) and two of tectocerebellar dysraphia (TCD) with an associated occipital encephalocele were studied to elucidate the clinical picture and embryogenesis of these rare anomalies. To our knowledge, only one case of TCD [1] and four of RS [2, 3] examined by MRI during life have been reported. The clinical picture in the cases of RS was rather constant and there were similarities with TCD. Consideration of the embryogenesis of the neural tube suggests a temporal proximity of the abnormalities, with TCD arising at a slightly earlier time.

Corticosteroid prophylaxis for patients with increased risk of adverse reactions to intravascular contrast agents: a survey of current practice in the UK.

There is no definite experimental evidence that prophylactic corticosteroids reduce the frequency or severity of adverse effects from low-osmolar contrast agents in patients at increased risk of reaction. There is no consensus in terms of how prophylaxis should be conducted. We have studied current radiologists' practice in the UK by sending postal questionnaires to 212 radiologists randomly selected from a list of current consultants who are Fellows of the Royal College of Radiologists. One hundred and seventy (80.2%) of the 212 questionnaires were completed. The majority of radiologists routinely use non-ionic low osmolar contrast media for intravenous administration, only 30 (17.6%) routinely using conventional ionic agents and six (3.5%) ionic low osmolar agents. All 170 use low osmolar contrast media for those patients perceived to be at increased risk of adverse reactions. Seventy-six radiologists (44.7%) never use steroid cover. There is no consistent practice amongst the 94 consultants (55.3%) who do use steroid cover. The indications for prophylaxis vary, as do the corticosteroid used and the dose regime employed. The total dose used varied from the equivalent of 7.5 mg to 400 mg of prednisolone, and the duration of prophylaxis varied from a single dose to a 4 day course. One hundred and forty-two radiologists (83.5%) would welcome nationally agreed guidelines for the use of steroid cover. The great variation in the use of steroid cover in the UK reflects the lack of clear evidence of its benefit in combination with low osmolar contrast media.

Prospective evaluation of cerebral angiography and computed tomography in cerebral haematoma.

One hundred and two consecutive patients with cerebral haematoma were prospectively allocated to one of two groups according to their CT on admission. Group 1 patients were thought to have a high probability of an underlying structural lesion and underwent cerebral angiography acutely. If normal, this was repeated at three months. Group 2 patients were thought not to have such a lesion and underwent angiography at three months. Patients older than the mean age of the study population, and hypertensive patients were much less likely to harbour an aneurysm or arteriovenous malformation than younger or normotensive patients (p < 0.01; sensitivity 87.9%, specificity 88.6%). An aneurysm or arteriovenous malformation was the cause of haemorrhage in 12.8% of hypertensive patients, in 30.9% of patients with haematoma involving the basal ganglia, and 18.2% of those with posterior fossa haemorrhage. Features of CT in isolation give a sensitivity of 77.2% and a specificity of 84.2%. Follow up angiography in group 1 showed an arteriovenous malformation in one of seven patients in whom the original study was normal. These results contrast sharply with data from previous retrospective studies. The decision to investigate a patient with cerebral haematoma should be primarily based on the patient's clinical condition, rather than on the site of haemorrhage.

A comparison between fast and conventional spin-echo in the detection of multiple sclerosis lesions.

Long repetition time (TR) spin-echo (SE) with T2- or proton density weighting is the sequence of choice to detect the brain lesions of multiple sclerosis (MS). Fast spin-echo (FSE) permits the generation of T2-weighted images with similar contrast to SE but in a fraction of the time. We compared the sensitivity of FSE and SE in the detection of the brain lesions of MS. Six patients with clinically definite MS underwent brain imaging with both dual echo (long TR, long and short echo time (TE) SE and dual echo FSE. The SE and FSE images were first reviewed independently and then compared. A total of 404 lesions was detected on SE and 398 on FSE. Slightly more periventricular lesions were detected using SE than FSE (145 vs 127), whereas more posterior cranial fossa lesions were detected by FSE (77 vs 57). With both SE and FSE the short TE images revealed more lesions than the long echo. These results suggest that FSE could replace SE as the long TR sequence of choice in the investigation of MS.

Dysembryoplastic neuroepithelial tumor. Features in 16 patients.

Dysembryoplastic neuroepithelial tumour (DNT) is a newly recognized brain mass lesion with distinctive pathological features and a favourable prognosis. We reviewed the clinical, electroencephalographic, neuroimaging and pathological features of 16 patients with DNT who underwent surgery; only one patient did not have epilepsy. Mean age at seizure onset was 9.5 years (range: 1 week to 30 years) and surgery 17 years (range: 7 months to 37 years). The mean verbal IQ was 94.6 (range: 79-110) and performance IQ 105 (range: 79-130) (n = 10). The EEG was abnormal in all cases reviewed (n = 13): localized slow activity was seen in 12 and interictal spiking in 10 patients, being less extensive than or concordant with the lesion in three and more extensive than or distant to the lesion in seven. X-ray CT was normal in three out of 11 patients. Magnetic resonance imaging provided detailed anatomical information: the lesion was predominantly intracortical, although in six patients, there was also white matter involvement. The lesion involved the temporal lobe in all but one patient where it was in the cingulate gyrus. Of the temporal lobe cases, MRI showed that the lesion involved, or was in close proximity to, mesial temporal structures in 11 out of 14 patients. Other magnetic resonance features included: circumscribed hyperintensity on long TE/TR images (10 patients), hypointensity on short TR images (12 patients), and cyst formation (five patients). Calcification was seen on CT in four patients. Post surgical follow-up ranged from 8 to 30 months (mean 16.2 months): 12 patients are seizure free and two have a > 80% reduction in seizure frequency (n = 14). Histopathological characteristics included a heterogeneous composition in all cases, calcification (13 cases), dysplastic features (12 cases) and isolated foci of subpial spread (five cases). The presence of occasional mitoses in 12 cases and immunoreactivity to the proliferating cell nuclear antigen in six cases indicate that these lesions have cellular proliferative activity and that there may be a need to follow these patients postoperatively.

Radiographic examination of the lumbar spine in a community hospital: an audit of current practice.

OBJECTIVE: To assess general practitioners' decisions to request lumbar spine radiographs according to the guidelines of the Royal College of Radiologists. DESIGN: Prospective questionnaire survey of outpatients attending for lumbar spine radiography. SETTING: London community hospital. SUBJECTS: 100 consecutive adult outpatients attending for lumbar spine radiography at their general practitioner's request. MAIN OUTCOME MEASURES: Patient's history and clinical signs; radiological diagnosis; change in management of patients with significant radiological abnormality in response to the radiologist's report. RESULTS: 60 patients were aged between 18 and 45, 27 (45%) of whom were women. Five patients were fully examined by their doctor before radiographs were requested, 76 were partially examined, and 19 were not examined. In 37 patients the examinations showed radiologically normal findings; 30 had radiologically significant disc or degenerative disease. Pain score and radiological diagnosis was not correlated (6.43 (range 1-10) for patients with significant disease v 6.14 (range 1-10) for those without, p greater than 0.05). There were no cases of malignancy or infection. One patient with radiologically significant disease was referred to a hospital specialist, and the management of only two such patients was altered by the report. 52 of the examinations should not have been requested if the guidelines had been strictly applied. CONCLUSIONS: There is a need to inform doctors of the efficacy of radiological examinations. An awareness of the college's guidelines among general practitioners should be actively promoted by radiologists.