4D SPECT/CT: A Hybrid Approach to Primary Hyperparathyroidism.

Our rationale was to review the imaging options for patients with primary hyperparathyroidism and to advocate for judicious use of 4-dimensional (4D) SPECT/CT to visualize diseased parathyroid glands in patients with complex medical profiles or in whom other imaging modalities fail. We review the advantages and disadvantages of traditional imaging modalities used in preoperative assessment of patients with primary hyperparathyroidism: ultrasound, SPECT, and 4D CT. We describe a scheme for optimizing and individualizing preoperative imaging of patients with hyperfunctioning parathyroid glands using traditional modalities in tandem with 4D SPECT/CT. Using the input from radiologists, endocrinologists, and surgeons, we apply patient criteria such as large body habitus, concomitant multiglandular disease, multinodular thyroid disease, confusing previous imaging, and unsuccessful previous surgery to create an imaging paradigm that uses 4D SPECT/CT yet is cost-effective, accurate, and limits extraneous radiation exposure. 4D SPECT/CT capitalizes on the strengths of SPECT and 4D CT and addresses limitations that exist when these modalities are used in isolation. In select patients with complicated clinical parameters, preoperative imaging with 4D SPECT/CT can improve accuracy yet remain cost-effective.

Posttraumatic Headaches and Postcraniotomy Syndromes.

Headaches following head trauma or craniotomy have multiple causes, each of which has characteristic imaging features. Posttraumatic headaches may relate to intracranial hemorrhage, fracture, shear injury, mass effect, or vascular injury. Various complications of craniotomy and craniectomy may manifest with headache. CT and MRI of the brain play important roles in diagnosing these causes of headache.

Postoperative Imaging Findings Associated with Transpalpebral Craniotomy Approach to Anterior Cranial Fossa.

Background and Purpose The transpalpebral "eyelid" approach is a novel alternative to the traditional ciliary or supraciliary incision for supraorbital frontal craniotomy and access to the anterior cranial fossa. Though a prior publication from our institution has described the surgical approach in detail along with cosmetic and clinical outcomes, postoperative imaging findings have not yet been described. As this surgical technique becomes more widely practiced, it is essential for neuroradiologists, oculoplastic surgeons, and skull base neurosurgeons to be familiar with the expected postoperative imaging findings, especially those that prompt subsequent intervention. Materials and Methods A retrospective, institutional review board approved review was performed of 102 patients who underwent transpalpebral surgical approach at Allegheny General Hospital from June 2007 through May 2015. Operative reports, pathology reports, preoperative imaging, postoperative imaging, and postoperative clinical documentation were reviewed. Results Forty-nine percent of patients had solely benign expected postoperative imaging findings, 37% had various atypical findings not requiring further intervention (most commonly asymmetric globe protrusion and bone cement in a paranasal sinus), 6% had findings prompting minimally invasive bedside procedures (most commonly pseudomeningocele), and 8% had findings requiring surgical intervention. Conclusion The majority of imaging following the transpalpebral approach showed typical, benign findings, such as minimal pneumocephalus and asymmetric globe protrusion. Nonetheless, members of the clinical team should be aware of the small number of findings requiring intervention, especially pseudomeningocele.