Ankle MRI and preceding radiographs: an evaluation of physician ordering practices.

OBJECTIVE: Multiple guidelines have been published for appropriate imaging in patients with ankle-related symptoms which suggest radiographs as the initial imaging examination for both acute and chronic ankle abnormalities. Few studies have evaluated adherence to these imaging guidelines. This study retrospectively evaluated the utilization of ankle MRI and preceding radiographs based on ordering provider group and MRI indication. MATERIALS AND METHODS: A total of 4186 ankle MRIs performed over a 9-year period at a single institution were evaluated for the presence of preceding ankle and/or foot radiographs at two time points, within 3 months and within 6 months of the MRI examination. Ankle MRIs were then categorized based on 6 ordering provider groups and 13 MRI indications. RESULTS: Of the 4186 MRIs evaluated, 68% had preceding radiographs within 3 months and 77% had radiographs within 6 months. Primary care, sports medicine, and podiatry had the lowest rates of preceding radiographs (73%, 68%, and 64%, respectively, within 6 months). Eighty-six percent of ankle MRIs ordered by orthopedic surgery had preceding radiographs within 6 months and 89% of ankle MRIs ordered by emergency medicine and inpatient providers had preceding radiographs. MRIs intended for evaluation of Achilles tendon or plantar fascia abnormalities were among the least likely indications to have preceding radiographs. CONCLUSION: Based on established clinical guidelines, there was a lower-than-expected rate of obtaining preceding radiographs for ankle MRIs among most provider groups, particularly non-orthopedic outpatient providers. Additional research is needed to address the lack of adherence to clinical imaging guidelines and ensure appropriate imaging.

Retained Morbidly Adherent Placenta Presenting as a Myometrial Mass in Patients With Vaginal Bleeding: A Case Series and Review of Current Literature.

ABSTRACT: The differential diagnosis for a uterine mass and vaginal bleeding after abortion or delivery is broad and includes both benign and malignant causes. A rare etiology for this condition is retained morbidly adherent placenta. Few cases of retained morbidly adherent placenta presenting as a myometrial mass in the setting of vaginal bleeding have been described in the medical literature. In this case series and review of the current literature, we describe the ultrasound features of 3 retained morbidly adherent placentae, along with correlative magnetic resonance imaging findings.

Prevalence of Malignancy on Contrast-Enhanced Computed Tomography of the Abdomen and Pelvis in Patients With Unexplained, Unintentional Weight Loss.

OBJECTIVE: The aim of the study was to evaluate the prevalence of malignancy on contrast-enhanced computed tomography (CT) of the abdomen and pelvis in patients with unexplained, unintentional weight loss (UUWL). METHODS: This is a retrospective review of 999 adult outpatient contrast-enhanced CT of the abdomen and pelvis for UUWL. Patients were stratified into 2 groups: (1) weight loss only (WLO, n = 222) and (2) UUWL with additional symptoms (UUWL+, n = 777). χ2 test was performed to compare malignancy detection rate in the WLO and UUWL+ groups. RESULTS: Prevalence of malignancy was 5.3% (95% confidence interval [CI], 4.2%-7.1%; 55 of 999). Prevalence of malignancy in the WLO group was 2.3% (95% CI, 0.7%-5.2%; 5 of 222), lower than the prevalence of 6.2% (95% CI, 4.6%-8.1%; 48 of 777) in the UUWL+ group (P = 0.02). Prevalence of malignancy was lower in patients younger than 60 years in all patients and in the UUWL+ subgroup (P < 0.01 in both cases). CONCLUSIONS: There is low prevalence of malignancy on contrast-enhanced CT of the abdomen and pelvis in patients with UUWL, particularly in younger patients and those without additional symptoms.

Increased rupture risk in small intracranial aneurysms associated with methamphetamine use.

BACKGROUND: Aneurysmal subarachnoid hemorrhage (SAH) is the most common cause of nontraumatic SAH. Current guidelines generally recommend observation for unruptured intracranial aneurysms smaller than 7 mm, for those are considered at low risk for spontaneous rupture according to available scoring systems. OBJECTIVE: We observed a tendency for SAH in small intracranial aneurysms in patients who are methamphetamine users. A retrospective, single center study to characterize the size and location of ruptured and unruptured intracranial aneurysms in methamphetamine users was performed. MATERIALS AND METHODS: Clinical characteristics and patient data were collected via retrospective chart review of patients with intracranial aneurysms and a history of methamphetamine use with a specific focus on aneurysm size and location. RESULTS: A total of 62 patients were identified with at least one intracranial aneurysm and a history of methamphetamine use, yielding 73 intracranial aneurysms (n = 73). The mean largest diameter of unruptured aneurysms (n = 44) was 5.1 mm (median 4.5, SD 2.5 mm), smaller than for ruptured aneurysms (n = 29) with a mean diameter of 6.3 mm (median 5.5, SD 2.5 mm). Aneurysms measuring less than 7 mm presented with SAH in 36.5%. With regard to location, 28% (n = 42) of anterior circulation aneurysms less than 7 mm presented with rupture, in contrast to 70% (n = 10) of posterior circulation aneurysms which were found to be ruptured. CONCLUSIONS: Methamphetamine use may be considered a significant risk factor for aneurysmal SAH at a smaller aneurysm size than for other patients. These patients may benefit from a lower threshold for intervention and/or aggressive imaging and clinical follow-up.

Hemangioma of the Cavernous Sinus: A Case Series.

Introduction Cavernous sinus hemangiomas (CSHs) are rare, vascular, extra-axial tumors that are diagnosed with a combination of imaging and biopsy. We describe the clinical presentations, imaging findings, and management of two male patients with CSHs. Case Report Case 1 describes a 57-year-old man who presented with vision changes and cranial nerve palsies. Initial imaging and surgical biopsy were nondiagnostic. Follow-up Tc-99m tagged red blood cell (RBC) imaging supported CSH diagnosis. He was treated with surgical resection and radiotherapy. Case 2 describes a 57-year-old man who presented with chronic headache. Imaging findings were suggestive of CSH. He underwent endoscopic endonasal surgical resection and a final diagnosis of CSH was made via biopsy. Discussion CSHs often present with headache, vision changes, and cranial nerve palsies. Characteristic findings of a T2 hyperintense lesion with homogeneous contrast enhancement has been described in the literature. There is also a role for tagged RBC imaging studies in the setting of nondiagnostic imaging and biopsy. Surgical resection can be difficult due to tumor vascularity and encasement of internal carotid arteries. Stereotactic radiosurgery and adjuvant radiotherapy can play a role in the treatment of patients who have inoperable lesions or subtotal resections.

microRNA expression in peripheral blood cells following acute ischemic stroke and their predicted gene targets.

BACKGROUND: microRNA (miRNA) are important regulators of gene expression. In patients with ischemic stroke we have previously shown that differences in immune cell gene expression are present. In this study we sought to determine the miRNA that are differentially expressed in peripheral blood cells of patients with acute ischemic stroke and thus may regulate immune cell gene expression. METHODS: miRNA from peripheral blood cells of forty-eight patients with ischemic stroke and vascular risk factor controls were compared. Differentially expressed miRNA in patients with ischemic stroke were determined by microarray with qRT-PCR confirmation. The gene targets and pathways associated with ischemic stroke that may be regulated by the identified miRNA were characterized. RESULTS: In patients with acute ischemic stroke, miR-122, miR-148a, let-7i, miR-19a, miR-320d, miR-4429 were decreased and miR-363, miR-487b were increased compared to vascular risk factor controls. These miRNA are predicted to regulate several genes in pathways previously identified by gene expression analyses, including toll-like receptor signaling, NF-κß signaling, leukocyte extravasation signaling, and the prothrombin activation pathway. CONCLUSIONS: Several miRNA are differentially expressed in blood cells of patients with acute ischemic stroke. These miRNA may regulate leukocyte gene expression in ischemic stroke including pathways involved in immune activation, leukocyte extravasation and thrombosis.