American College of Radiology Appropriateness Criteria: Advancing Evidence-Based Imaging Practice.

ACR Appropriateness Criteria (ACR AC) are evidence-based guidelines to assist referring physicians, other providers, and patients in making the most appropriate imaging or treatment decision for a specific clinical condition. The ACR AC are created by expert panels consisting of multidisciplinary physicians, using principles outlined by the Agency for Healthcare Research and Quality as designed by the Institute of Medicine. The ACR AC are qualified appropriate use criteria as designated under the Protecting Access to Medicare Act legislation of 2014. The ACR AC development process includes topic selection, literature search, evidence table development, appropriateness (risk-benefit) assessment, patient and public input, document publication and ACR AC content dissemination through clinical decision support mechanisms, and periodic review. These criteria benchmark the selection of the most appropriate imaging or treatments, as well as educating radiology, nuclear medicine, and other clinical discipline trainees.

Transformation of Face Transplants: Volumetric and Morphologic Graft Changes Resemble Aging After Facial Allotransplantation.

Facial allotransplantation restores normal anatomy to severely disfigured faces. Although >30 such operations performed worldwide have yielded promising short-term results, data on long-term outcomes remain scarce. Three full-face transplant recipients were followed for 40 months. Severe changes in volume and composition of the facial allografts were noted. Data from computed tomography performed 6, 18 and 36 months after transplantation were processed to separate allograft from recipient tissues and further into bone, fat and nonfat soft tissues. Skin and muscle biopsies underwent diagnostic evaluation. All three facial allografts sustained significant volume loss (mean 19.55%) between 6 and 36 months after transplant. Bone and nonfat soft tissue volumes decreased significantly over time (17.22% between months 6 and 18 and 25.56% between months 6 and 36, respectively), whereas fat did not. Histological evaluations showed atrophy of muscle fibers. Volumetric and morphometric changes in facial allografts have not been reported previously. The transformation of facial allografts in this study resembled aging through volume loss but differed substantially from regular aging. These findings have implications for risk-benefit assessment, donor selection and measures counteracting muscle and bone atrophy. Superior long-term outcomes of facial allotransplantation will be crucial to advance toward future clinical routine.

Vascular communications between donor and recipient tissues after successful full face transplantation.

The vascular reorganization after facial transplantation has important implications on future surgical planning. The purpose of this study was to evaluate blood flow (BF) after full face transplantation using wide area-detector computed tomography (CT) techniques. Three subjects with severe craniofacial injury who underwent full face transplantation were included. All subjects underwent a single anastomosis bilaterally of the artery and vein, and the recipient tongue was preserved. Before and after surgery, dynamic volume CT studies were analyzed for vascular anatomy and blood perfusion. Postsurgical CT showed extensive vascular reorganization for external carotid artery (ECA) angiosome; collateral flows from vertebral, ascending pharyngeal or maxillary arteries supplied the branches from the recipient ECAs distal to the ligation. While allograft tissue was slightly less perfused when the facial artery was the only donor artery when compared to an ECA-ECA anastomosis (4.4 ± 0.4% vs. 5.7 ± 0.7%), allograft perfusion was higher than the recipient normal neck tissue. BF for the recipient tongue was maintained from contralateral/donor arteries when the lingual artery was sacrificed. Venous drainage was adequate for all subjects, even when the recipient internal jugular vein was anastomosed in end-to-end fashion on one side. In conclusion, dynamic CT identified adequate BF for facial allografts via extensive vascular reorganization.

CT angiography for surgical planning in face transplantation candidates.

SUMMARY: Facial allotransplantation replaces missing facial structures with anatomically identical tissues, providing desired functional, esthetic, and psychosocial benefits far superior to those of conventional methods. On the basis of very encouraging initial results, it is likely that more procedures will be performed in the near future. Typical candidates have extremely complex vascular anatomy due to severe injury and/or multiple prior reconstructive attempts; thus, each procedure is uniquely determined by the defects and vascular anatomy of the candidate. We detail CT angiography vascular mapping, noting the clinical relevance of the imaging, the angiosome concept and noninvasive delineation of the key vessels, and current controversies related to the vascular anastomoses.

Steroid-responsive large vessel vasculitis: application of whole-brain 320-detector row dynamic volume CT angiography and perfusion.

SUMMARY: A patient with suspected giant cell arteritis and prior negative findings on superficial temporal artery biopsy was evaluated with 320-detector row CT angiography (CTA) and whole-brain perfusion. Corticosteroid treatment was initiated on the basis of CT angiography findings of arteritis and a cortical perfusion deficit. The patient's symptoms and perfusion imaging findings resolved following therapy. Whole-brain CTA and imaging was helpful in the diagnosis and monitoring this patient with suspected vasculitis.

Glomerulocystic kidney disease: MRI findings.

Glomerulocystic kidney disease (GCKD) is a rare form of renal cystic disease characterized by cystic dilation of Bowman's capsule. The imaging findings of small renal cysts with a predominant cortical and subcapsular distribution allows for distinction from other, more common, polycystic kidney diseases. The appearance and distribution of the renal cysts by magnetic resonance imaging allow for a definitive diagnosis of GCKD.

Fast three-point Dixon MR imaging of the retrobulbar space with low-resolution images for phase correction: comparison with fast spin-echo inversion recovery imaging.

A new phase-correction algorithm for three-point Dixon (3PD) MR imaging allows on-line image reconstruction of three images per section: pure water, pure fat, and water plus fat. When combined with fast spin-echo acquisition, the sequence is suitable for routine MR imaging of the retrobulbar space. The 3PD pure water images have double the image signal-to-noise ratio of fast spin-echo inversion recovery images. The dramatic contrast-to-noise ratio of the 3PD pure fat images may offer improved lesion detection.

Fast three-point dixon MR imaging using low-resolution images for phase correction: a comparison with chemical shift selective fat suppression for pediatric musculoskeletal imaging.

OBJECTIVE: The purpose of this study is to describe and to implement a new fast three-point Dixon MR imaging sequence with online image reconstruction, and to compare this sequence with conventional chemical shift selective (CHESS) suppression of fat in pediatric musculoskeletal imaging. SUBJECTS AND METHODS: A three-point Dixon technique using a fast spin-echo sequence with a new phase-correction algorithm providing online image reconstruction was implemented on a 1.5-T scanner. Twelve pediatric patients and young adults were imaged with both the new three-point Dixon and conventional CHESS sequences. Three radiologists un-aware of imaging parameters and clinical information independently scored the homogeneity of fat suppression and conspicuity of abnormality using a four-point system. An additional comparison between the two techniques was made using a phantom. RESULTS: The three-point Dixon method showed superior fat suppression and lesion conspicuity (p < 0.001), particularly in the hands and feet, where CHESS is prone to inconsistent fat suppression. The phantom study showed no significant difference in the ratio of suppressed fat signal to background noise and more homogeneous fat suppression using the three-point Dixon method. CONCLUSION: Compared with CHESS, the new fast three-point Dixon sequence with online image reconstruction provides superior fat suppression and lesion conspicuity and can be routinely used in pediatric musculoskeletal imaging.

Analytic reconstruction of magnetic resonance imaging signal obtained from a periodic encoding field.

We have proposed a two-dimensional PERiodic-Linear (PERL) magnetic encoding field geometry B(x,y) = g(y)y cos(q(x)x) and a magnetic resonance imaging pulse sequence which incorporates two fields to image a two-dimensional spin density: a standard linear gradient in the x dimension, and the PERL field. Because of its periodicity, the PERL field produces a signal where the phase of the two dimensions is functionally different. The x dimension is encoded linearly, but the y dimension appears as the argument of a sinusoidal phase term. Thus, the time-domain signal and image spin density are not related by a two-dimensional Fourier transform. They are related by a one-dimensional Fourier transform in the x dimension and a new Bessel function integral transform (the PERL transform) in the y dimension. The inverse of the PERL transform provides a reconstruction algorithm for the y dimension of the spin density from the signal space. To date, the inverse transform has been computed numerically by a Bessel function expansion over its basis functions. This numerical solution used a finite sum to approximate an infinite summation and thus introduced a truncation error. This work analytically determines the basis functions for the PERL transform and incorporates them into the reconstruction algorithm. The improved algorithm is demonstrated by (1) direct comparison between the numerically and analytically computed basis functions, and (2) reconstruction of a known spin density. The new solution for the basis functions also lends proof of the system function for the PERL transform under specific conditions.

A method for approximating the density of maximum-likelihood and maximum a posteriori estimates under a Gaussian noise model.

The performance of maximum-likelihood (ML) and maximum a posteriori (MAP) estimates in non-linear problems at low data SNR is not well predicted by the Cramér-Rao or other lower bounds on variance. In order to better characterize the distribution of ML and MAP estimates under these conditions, we derive a point approximation to density values of the conditional distribution of such estimates. In an example problem, this approximate distribution captures the essential features of the distribution of ML estimates in the presence of Gaussian-distributed noise.