Efficacy and safety of magnetic resonance-guided focused ultrasound for the treatment of painful bone metastases: a systematic review and meta-analysis.

OBJECTIVE: To report the safety and efficacy of magnetic resonance-guided focused ultrasound (MRgFUS) in the treatment of painful bone metastases through a systematic review and meta-analysis of pain scores before and after MRgFUS treatment and post-treatment adverse events. MATERIALS AND METHODS: A comprehensive literature search of PubMed and Embase databases was performed for studies evaluating the efficacy and/or safety of MRgFUS. The mean difference of pain scores (10-point visual analogue scale or numerical rating scale) between baseline and 1-month/3-month pain scores was collected and analyzed in a pooled meta-analysis. Post-treatment adverse events based on the Common Terminology Criteria for Adverse Events (CTCAE) grading were recorded and the pooled prevalence was calculated. RESULTS: A total of 33 studies published between 2007 and 2019 were collected, resulting in a total sample size of 1082 patients. The majority of the studies were prospective with a reported follow-up period of 3 months. The pooled proportion of patients that achieved pain relief from MRgFUS (complete response or partial response [≥ 2-point improvement of pain score]) was 79% (95% CI 73-83%). The pooled 1-month and 3-month mean difference in pain score were - 3.8 (95% CI - 4.3; - 3.3) and - 4.4 (95% CI - 5.0; - 3.7), respectively. The overall rate of high-grade (CTCAE grade 3 or higher) and low-grade (CTCAE grade 2 or lower) MRgFUS-related adverse events were 0.9% and 5.9%, respectively. CONCLUSION: MRgFUS is an effective procedure that is able to provide significant pain palliation for patients with symptomatic bone metastases with a favorable safety profile.

Role of ultrasound-guided perineural injection of the posterior antebrachial cutaneous nerve for diagnosis and potential treatment of chronic lateral elbow pain.

OBJECTIVE: To examine diagnostic and therapeutic utility of novel ultrasound-guided perineural injection of posterior antebrachial cutaneous nerve in chronic lateral elbow pain. MATERIALS AND METHODS: We performed a retrospective analysis of ultrasound-guided perineural injection of the posterior antebrachial cutaneous nerve with local anesthetic with or without corticosteroid in patients with chronic lateral elbow pain. Data variables collected included patient demographics, illness course, diagnostic ultrasound findings, immediate pre- and post-injection pain using numeric rating pain scale between 0 and 10, injection complications, and post-injection outcomes. RESULTS: Fifteen patients (9 females and 6 males) with average age 46.9 (range 16-69 years) underwent 20 perineural injections between 2009 and 2019. Patients had on average 84% reduction in pain immediately after the injection (median pre- and post-procedure numeric rating pain scale of 6 and 0, respectively, p < 0.001). Patients had pain relief for an average of 15 h (range 2-48 h) when only local anesthetic was injected, compared with average pain relief of 26.5 days (range 2 h-43 days) when local anesthetic was combined with corticosteroid, p = 0.01. CONCLUSION: Novel ultrasound-guided perineural anesthetic injections around the posterior antebrachial cutaneous nerve can be performed safely and have diagnostic and potentially therapeutic utility in select patients with chronic refractory lateral elbow pain.

Value of dedicated small-field-of-view sacroiliac versus large-field-of-view pelvic magnetic resonance imaging for evaluating pediatric sacroiliitis.

BACKGROUND: Optimized MRI parameters can be leveraged to improve signal intensity, accelerate imaging acquisition and increase resolution. Higher-resolution imaging with a small field of view (FOV) has been proposed as standard practice for investigating sacroiliac (SI) joints, but the improvement in disease detection and characterization over pelvic imaging with large FOV has not been established. OBJECTIVE: The purpose of this study was to compare dedicated MR images of the SI joints with survey imaging (large-FOV pelvic MRI) for detecting sacroiliitis. MATERIALS AND METHODS: Fifty-eight pediatric patients suspected of having sacroiliitis underwent dedicated sacroiliac joint and survey pelvic imaging at the same imaging session. We independently evaluated the small- and large-FOV image data sets for presence or absence of sacroiliitis, e.g., bone marrow edema, erosions and synovitis. We used nonparametric statistical tests to compare lesion scores for severity of inflammation. We created test characteristics for the survey pelvic images (low-resolution images of the sacroiliac joints) using dedicated sacroiliac images (small-FOV, high-resolution images) as the gold standard. RESULTS: Dedicated sacroiliac small-FOV MRI detected more sacroiliitis compared to survey pelvic imaging with large FOV (χ2=6.125, P=0.013). Readers detected significantly more features of inflammation on small- compared to large-FOV images, e.g., erosions (P=0.039), synovitis (P=0.009), sclerosis (P=0.017) and osteitis (P=0.001). Test characteristics for pelvic large-FOV imaging were sensitivity=0.76, specificity=1.00, positive predictive value = 1.00 and negative predictive value = 0.75. CONCLUSION: This study provides test characteristics for survey pelvic MRI with lower-resolution large-field-of-view images as a screening tool for detecting sacroiliitis. Pelvic screening studies with large FOV have lower sensitivity, and dedicated sacroiliac MRI with small FOV is superior in detecting sacroiliitis when compared to pelvic screening MRI.

Temporal lobe contusions on computed tomography are associated with impaired 6-month functional recovery after mild traumatic brain injury: a TRACK-TBI study.

INTRODUCTION: Mild traumatic brain injury (MTBI) can cause persistent functional deficits and healthcare burden. Understanding the association between intracranial contusions and outcome may aid in MTBI treatment and prognosis. METHODS: MTBI patients with Glasgow Coma Scale 13-15 and 6-month outcomes [Glasgow Outcome Scale-Extended (GOSE)], without polytrauma from the prospective TRACK-TBI Pilot study were analyzed. Intracranial contusions on computed tomography (CT) were coded by location. Multivariable regression evaluated associations between intracranial injury type (temporal contusion [TC], frontal contusion, extraaxial [epidural/subdural/subarachnoid], other-intraaxial [intracerebral/intraventricular hemorrhage, axonal injury]) and GOSE. Odds ratios (OR) are reported. RESULTS: Overall, 260 MTBI subjects were aged 44.4 ± 18.1-years; 67.7% were male. Ninety-seven subjects were CT-positive and 46 had contusions (41.3%-frontal, 30.4%-temporal, 21.7%-frontal + temporal, 2.2% each-parietal/occipital/brainstem); 95.7% had concurrent extraaxial hemorrhage. Mortality was 0% at discharge and 2.3% by 6-months. GOSE distribution was 2.3%-death, 1.5%-severe disability, 27.7%-moderate disability, 68.5%-good recovery. Forty-six percent of TC-positive subjects suffered moderate disability or worse (GOSE ≤6) and 41.7% were unable to return to baseline work capacity (RTBWC), compared to 29.1%/20.4% for CT-negative and 26.1%/20.9% for CT-positive subjects without TC. On multivariable regression, TC associated with OR = 3.33 (95% CI [1.16-9.60], p = 0.026) for GOSE ≤6, and OR = 4.48 ([1.49-13.51], p = 0.008) for inability to RTBWC. CONCLUSIONS: Parenchymal contusions in MTBI are often accompanied by extraaxial hemorrhage. TCs may be associated with 6-month functional impairment. Their presence on imaging should alert the clinician to the need for heightened surveillance of sequelae complicating RTBWC, with low threshold for referral to services.

Factors Associated With Pre- and Postoperative Seizures in 1033 Patients Undergoing Supratentorial Meningioma Resection.

BACKGROUND: Risk factors for pre- and postoperative seizures in supratentorial meningiomas are understudied compared to other brain tumors. OBJECTIVE: To report seizure frequency and identify factors associated with pre- and postoperative seizures in a large single-center population study of patients undergoing resection of supratentorial meningioma. METHODS: Retrospective chart review of 1033 subjects undergoing resection of supratentorial meningioma at the author's institution (1991-2014). Multivariate regression was used to identify variables significantly associated with pre- and postoperative seizures. RESULTS: Preoperative seizures occurred in 234 (22.7%) subjects. At 5 years postoperative, probability of seizure freedom was 89.9% among subjects without preoperative seizures and 62.2% with preoperative seizures. Multivariate analysis identified the following predictors of preoperative seizures: presence of ≥1 cm peritumoral edema (odds ratio [OR]: 4.45, 2.55-8.50), nonskull base tumor location (OR: 2.13, 1.26-3.67), greater age (OR per unit increase: 1.03, 1.01-1.05), while presenting symptom of headache (OR: 0.50, 0.29-0.84) or cranial nerve deficit (OR: 0.36, 0.17-0.71) decreased odds of preoperative seizures. Postoperative seizures after discharge were associated with preoperative seizures (OR: 5.70, 2.57-13.13), in-hospital seizure (OR: 4.31, 1.28-13.67), and among patients without preoperative seizure, occurrence of medical or surgical complications (OR 3.39, 1.09-9.48). Perioperative anti-epileptic drug use was not associated with decreased incidence of postoperative seizures. CONCLUSIONS: Nonskull base supratentorial meningiomas with surrounding edema have the highest risk for preoperative seizure. Long-term follow-up showing persistent seizures in meningioma patients with preoperative seizures raises the possibility that these patients may benefit from electrocorticographic mapping of adjacent cortex and resection of noneloquent, epileptically active cortex.