Clinical correlates of cerebral diffusion tensor imaging findings in chronic traumatic spinal cord injury.

STUDY DESIGN: Prospective clinical case-control study. OBJECTIVES: The aim of this study was to use diffusion tensor imaging (DTI) to assess the state of cerebral white matter tracts after spinal cord injury (SCI). The DTI metrics were evaluated in relation to neurological deficits and to the size and level of the spinal cord lesions. SETTING: Tampere University Hospital, Tampere, Finland. METHODS: Thirty-four patients (n=34) with clinically complete and incomplete SCI were evaluated using the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI). DTI metrics (fractional anisotropy (FA) and apparent diffusion coefficient (ADC)) were calculated for multiple levels along the course of the corticospinal tract. The state of the spinal cord after injury was assessed using conventional magnetic resonance imaging (MRI). DTI parameters were compared with 40 orthopedically injured control subjects. RESULTS: Statistically significant differences in the DTI values between patients and controls were detected in the posterior area of the centrum semiovale. In this area, the FA values were lower in the patients compared with controls (P=0.008). For patients with clinically complete injury, the difference was even more significant (P=0.0005). Motor and sensory scores of the ISNCSCI correlated positively with FA and negatively with ADC values of the centrum semiovale. A moderate association was observed between the macroscopic changes in the spinal cord and the DTI abnormalities in the centrum semiovale. CONCLUSION: In patients with chronic SCI, DTI changes can be observed in the cerebral white matter. These alterations are associated with the clinical state of the patients.

Verification of palpation-guided intra-articular injections using glucocorticoid-air-saline mixture and ultrasound imaging (GAS-graphy).

OBJECTIVE: To examine a contrast medium method using a glucocorticoid-air-saline mixture and ultrasound imaging (GAS-graphy) for the verification of palpation-guided injections in different joints and to assess the inter-reader reliability of the method. METHODS: A palpation-guided injection of an air-steroid-saline mixture was given into a joint or tendon sheath of 133 consecutive patients. The dynamic ultrasound monitor images of the joints and tendons involved were videotaped before and after the injection. A rheumatologist and two radiologists analyzed separately the video clips of each patient, under blinded conditions. The readers evaluated the accuracy of the injections and the difficulty of the reading process. The inter-reader agreement was assessed by calculating the percentual values and overall kappa coefficient between the readers. RESULTS: The overall accuracy of the successful injections was 76%, 80% and 82 % evaluated by the three readers. In six out of the ten injection sites the accuracy was higher than 80%. The clarity of the method evaluated by the readers was 8, 8 and 8.5 on a scale from 0 to 10. The inter-reader agreement assessed by percentual values was 84.2%, 85.0% and 88.7%. The kappa coefficient between all readers was 0.595 showing moderate agreement. CONCLUSION: The GAS-graphy method for the verification of palpation-guided injections is a simple procedure performable to any joint site and the result can be seen immediately on the monitor after the injection. The reliability of the method is good and it can be used in developing injection techniques as well as in medical or nurse education. The method can be used as an alternative for the radiographic contrast medium method in verifying successful palpation-guided intra-articular injections.

Power Doppler ultrasonography and synovitis: correlating ultrasound imaging with histopathological findings and evaluating the performance of ultrasound equipments.

OBJECTIVES: To examine the validity of power Doppler ultrasound imaging to identify synovitis, using histopathology as gold standard, and to assess the performance of ultrasound equipments. METHODS: 44 synovial sites in small and large joints, bursae and tendon sheaths were depicted with ultrasound. A synovial biopsy was performed on the site depicted and a synovial sample was taken for histopathological evaluation. The performance of three ultrasound devices was tested using flow phantoms. RESULTS: A positive Doppler signal was detected in 29 of 35 (83%) of the patients with active histological inflammation. In eight additional samples, histological examination showed other pathological synovial findings and a Doppler signal was detected in five of them. No significant correlation was found between the amount of Doppler signal and histological synovitis score (r = 0.239, p = NS). The amount of subsynovial infiltration of polymorphonuclear leucocytes and surface fibrin correlated significantly with the amount of power Doppler signal: r = 0.397 (p<0.01) and 0.328 (p<0.05), respectively. The ultrasound devices differed in showing the smallest detectable flow. CONCLUSIONS: A negative Doppler signal does not exclude the possibility of synovitis. A positive Doppler signal in the synovium is an indicator of an active synovial inflammation in patients. A Doppler signal does not correlate with the extent of the inflammation and it can also be seen in other synovial reactions. It is important that the quality measurements of ultrasound devices are reported, because the results should be evaluated against the quality of the device used.

Assessing the intra- and inter-reader reliability of dynamic ultrasound images in power Doppler ultrasonography.

OBJECTIVE: To assess the intra-reader and inter-reader reliabilities of interpreting ultrasonography by several experts using video clips. METHOD: 99 video clips of healthy and rheumatic joints were recorded and delivered to 17 physician sonographers in two rounds. The intra-reader and inter-reader reliabilities of interpreting the ultrasound results were calculated using a dichotomous system (normal/abnormal) and a graded semiquantitative scoring system. RESULTS: The video reading method worked well. 70% of the readers could classify at least 70% of the cases correctly as normal or abnormal. The distribution of readers answering correctly was wide. The most difficult joints to assess were the elbow, wrist, metacarpophalangeal (MCP) and knee joints. The intra-reader and inter-reader agreements on interpreting dynamic ultrasound images as normal or abnormal, as well as detecting and scoring a Doppler signal were moderate to good (kappa = 0.52-0.82). CONCLUSIONS: Dynamic image assessment (video clips) can be used as an alternative method in ultrasonography reliability studies. The intra-reader and inter-reader reliabilities of ultrasonography in dynamic image reading are acceptable, but more definitions and training are needed to improve sonographic reproducibility.