Diagnosis, Prognosticators, and Management of Acute Invasive Fungal Rhinosinusitis: Multidisciplinary Consensus Statement and Evidence-Based Review with Recommendations.

BACKGROUND: Acute invasive fungal sinusitis (AIFS) is an aggressive disease that requires prompt diagnosis and multidisciplinary treatment given its rapid progression. However, there is currently no consensus on diagnosis, prognosis, and management strategies for AIFS, with multiple modalities routinely employed. The purpose of this multi-institutional and multidisciplinary evidence-based review with recommendations (EBRR) is to thoroughly review the literature on AIFS, summarize the existing evidence, and provide recommendations on the management of AIFS. METHODS: The PubMed, EMBASE, and Cochrane databases were systematically reviewed from inception through January 2022. Studies evaluating management for orbital, non-sinonasal head and neck, and intracranial manifestations of AIFS were included. An iterative review process was utilized in accordance with EBRR guidelines. Levels of evidence and recommendations on management principles for AIFS were generated. RESULTS: A review and evaluation of published literature was performed on 12 topics surrounding AIFS (signs and symptoms, laboratory and microbiology diagnostics, endoscopy, imaging, pathology, surgery, medical therapy, management of extrasinus extension, reversing immunosuppression, and outcomes and survival). The aggregate quality of evidence was varied across reviewed domains. CONCLUSION: Based on the currently available evidence, judicious utilization of a combination of history and physical examination, laboratory and histopathologic techniques, and endoscopy provide the cornerstone for accurate diagnosis of AIFS. In addition, AIFS is optimally managed by a multidisciplinary team via a combination of surgery (including resection whenever possible), antifungal therapy, and correcting sources of immunosuppression. Higher quality (i.e., prospective) studies are needed to better define the roles of each modality and determine diagnosis and treatment algorithms.

Imaging of Painful Ophthalmologic Disorders.

Cross-sectional imaging with computed tomography (CT) and MRI are diagnostic examinations useful in the diagnosis of painful ophthalmologic disorders and their potential complications. CT is a first-line imaging study for suspected orbital infections, particularly useful in differentiating preseptal cellulitis and orbital cellulitis and detecting complications such as orbital abscess. When compared with CT, MRI is better for orbital soft tissue evaluation, particularly useful for optic neuritis, ocular diseases such as endophthalmitis, and invasive fungal rhinosinusitis with orbital involvement. CT angiography is the preferred noninvasive imaging modality for the detection and classification of carotid cavernous fistula.

Ipilimumab-related orbitopathy: a case report.

Ipilimumab, an immune checkpoint inhibitor used in the treatment of metastatic melanoma, can cause immune-related adverse events including rare ocular-related inflammation. This is a case of a 54-year-old man with metastatic melanoma and bilateral orbital inflammation associated with ipilimumab that occurred after drug rechallenge 6 years after initial orbital inflammation with ipilimumab use. Imaging revealed tendon-involving myositis. He was managed with intravenous corticosteroid and intravenous immunoglobulin therapy with improvement in his orbital inflammation. This case demonstrates the potential ocular effects of ipilimumab use, differentiation of ipilimumab-associated orbital inflammation from thyroid orbitopathy and management considerations to effectively reduce orbital inflammation.

Magnetic resonance imaging of musculoskeletal infections.

Magnetic resonance imaging (MRI) is a powerful imaging modality in the evaluation of musculoskeletal (MSK) soft tissue, joint, and bone infections. It allows prompt diagnosis and assessment of the extent of disease, which permits timely treatment to optimize long-term clinical outcomes. MRI is highly sensitive and specific in detecting the common findings of MSK infections, such as superficial and deep soft tissue oedema, joint, bursal and tendon sheath effusions, lymphadenopathy, bone marrow oedema, erosive bone changes and periostitis, and bone and cartilage destruction and sequestration. Contrast-enhanced MRI allows detection of non-enhancing fluid collections and necrotic tissues, rim-enhancing abscesses, heterogeneously or diffusely enhancing phlegmons, and enhancing active synovitis. Diffusion-weighted imaging (DWI) is useful in detecting soft-tissue abscesses, particularly in patients who cannot receive gadolinium-based intravenous contrast. MRI is less sensitive than computed tomography (CT) in detecting soft-tissue gas. This article describes the pathophysiology of pyogenic MSK infections, including the route of contamination and common causative organisms, typical MR imaging findings of various soft tissue infections including cellulitis, superficial and deep fasciitis and necrotizing fasciitis, pyomyositis, infectious bursitis, infectious tenosynovitis, and infectious lymphadenitis, and of joint and bone infections including septic arthritis and osteomyelitis (acute, subacute, and chronic). The authors also discuss MRI findings and pitfalls related to infected hardware and diabetic foot infections, and briefly review standards of treatment of various pyogenic MSK infections.

99mTc-Sestamibi Scintigraphy Reveals Parathyroid Adenoma Masquerading as Esophageal Diverticulum.

ABSTRACT: A 74-year-old woman with primary hyperparathyroidism diagnosed from routine laboratory tests described symptoms of fatigue and difficulty with concentration. During surgical consultation, the cervical and thoracic spine MRI scans from the preceding 10-year period, performed for relapsing-remitting multiple sclerosis, were reviewed. In this clinical context, the slowly enlarging left upper paraesophageal lesion, reported as a lateral proximal esophageal (Killian-Jamieson) diverticulum, was reevaluated for a potential parathyroid adenoma. 99mTc-sestamibi SPECT/CT demonstrated focal uptake in the paraesophageal lesion with surgical resection, confirming it to be a large parathyroid adenoma.

Magnetic resonance imaging of the spine.

Low back and neck pain are common and result in significant patient disability and health care expenditure. When conservative treatment fails or worrisome clinical findings are present, magnetic resonance imaging (MRI) is the imaging modality of choice to assess the cause and complicating features of spine pain. There are many potential aetiologies of spine pain with similar clinical presentation, including degenerative changes, infection, and insufficiency and pathologic fractures. MRI allows for the differentiation of these sources of spine pain and potential complicating features, permitting the appropriate direction of therapy.

Extracranial Metastases From Glioblastoma With Primitive Neuronal Components on FDG PET/CT.

A 17-year-old girl with World Health Organization grade IV glioblastoma with primitive neuronal components (histone H3 G34-mutant and IDH1 wild type) underwent whole-body FDG PET/CT staging due to vertebral metastases on initial MRI. PET/CT revealed extracranial metastatic disease with spinal leptomeningeal dissemination, osseous metastases, and peritoneal seeding via a ventriculoperitoneal shunt. Glioblastoma is uncommon in pediatric patients and particularly those with primitive neuronal components. Extracranial metastases from glioblastoma are more common in those with primitive neuronal components. This case demonstrates the utility of FDG PET/CT for revealing distant metastases from glioblastoma.

Primary Nasolacrimal Duct Obstruction Visualized on 123I Preablation Scan for Papillary Thyroid Carcinoma.

A 56-y-old man underwent total thyroidectomy and bilateral central and right lateral neck dissection for papillary thyroid carcinoma with lymph nodes metastases. Before radioiodine ablation, a 123I scan established the diagnosis of primary nasolacrimal duct obstruction (dacryostenosis).

A systematic approach in the diagnosis of paediatric skull lesions: what radiologists need to know.

Paediatric skull lesions are commonly identified on imaging. They can be challenging to image, given their location and size, and often require several imaging modalities to narrow down the differential diagnosis. Accurate diagnosis of these lesions is paramount because the clinical therapy can vary tremendously. In this review, we provide a simple and systematic approach to clinical-radiological features of primary skull lesions. We highlight the imaging characteristics and differentiate pathologies based on imaging appearances. We also accentuate the role of cross-sectional imaging in lesion identification and management implications.

Update on Imaging of Spinal Fixation Hardware.

This article discusses instrumented spinal surgeries, the radiologic assessment of spinal fixation hardware, and the potential complications of spinal hardware. Radiography is the standard for the postoperative assessment of spinal hardware. Computed tomography and magnetic resonance imaging play a valuable role in the detection of hardware and postsurgical-related complications such as infection, pseudarthrosis, and malpositioned instrumentation. Familiarity with the normal imaging appearance of implanted spinal hardware along with the expected progression of normal postoperative osseous arthrodesis enables recognition of potential complications and helps facilitate appropriate clinical management.

Physics for clinicians: Fluid-attenuated inversion recovery (FLAIR) and double inversion recovery (DIR) Imaging.

A pedagogical review of fluid-attenuated inversion recovery (FLAIR) and double inversion recovery (DIR) imaging is conducted in this article. The basics of the two pulse sequences are first described, including the details of the inversion preparation and imaging sequences with accompanying mathematical formulae for choosing the inversion time in a variety of scenarios for use on clinical MRI scanners. Magnetization preparation (or T2prep), a strategy for improving image signal-to-noise ratio and contrast and reducing T1 weighting at high field strengths, is also described. Lastly, image artifacts commonly associated with FLAIR and DIR are described with clinical examples, to help avoid misdiagnosis. LEVEL OF EVIDENCE: 5 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2017;46:1590-1600.

An outcomes-based grading scale for the evaluation of cerebral aneurysms treated with flow diversion.

OBJECT: Despite the popularity of flow-diverting stents for the treatment of cerebral aneurysms, there is no widely accepted scale for the characterization of results. We present an outcomes-based grading scale that considers factors related to failure of flow diversion. METHODS: The grading scale was developed using the results from consecutive patients at two institutions who were treated with flow diversion for a cerebral aneurysm. The initial treatment results were graded on patient, aneurysm, and treatment characteristics. A 6-point grading scale was developed based on these data. RESULTS: One hundred and seventy-one patients were included in the patient cohort. When compared by multivariate analysis with patients without residuals, patients with aneurysm residuals were found to be older (age ≥60 years, p=0.01, OR 1.17, 95% CI 1.03 to 1.33), to have larger aneurysms (size ≥15 mm, p<0.01, OR 1.38, 95% CI 1.17 to 1.62), to have aneurysms with associated side branches (p=0.02, OR 1.17, 95% CI 1.03 to 1.33), and to have a post-treatment Raymond score of 2 or 3 (p=0.01, OR 1.28, 95% CI 1.06 to 1.56). Using the Raymond score (1-3) as the foundation for the grading scale, additional points (0 or 1) were given for the other three identified factors, creating a 6-point scale. We found that patients with residual aneurysms had statistically higher final tabulated scores (p<0.01). CONCLUSIONS: We propose a novel straightforward outcomes-based scale to characterize results after flow diversion treatment of cerebral aneurysms. This scale may provide the basis for the common reporting of results in future studies.

Inter-rater reliability of published flow diversion occlusion scales.

BACKGROUND: With increasing use of flow-diverting stents for the treatment of intracranial aneurysms, standardized methods and a common language to evaluate angiographic outcomes are needed. Multiple grading scales have been developed for this purpose but none has been widely adopted. OBJECTIVE: To analyze these scales to determine interobserver reliability. METHODS: Four independent assessors scored the intraprocedural angiograms of patients who underwent flow-diverting stent deployment for an intracranial saccular or fusiform aneurysm at our institution between October 2012 and June 2015. Angiographic outcome immediately after flow-diverting stent deployment was scored using three grading scales (Kamran-Byrne (KB), Simple Measurement of Aneurysm Residual after Treatment (SMART), and O'Kelley, Krings, Marotta (OKM)). Statistical analysis was performed using Light's κ for multiple raters (κ), Kendall's coefficient of concordance (W), and intraclass correlation (ICC). RESULTS: We included the angiograms of 50 consecutive patients (mean age 58 years, range 30-79) who underwent flow-diverting stent deployment for an intracranial aneurysm (40 saccular, 10 fusiform). Six aneurysms were located in the posterior circulation. The inter-rater reliability was typically poor or fair: SMART aneurysm filling (κ=0.30, W=0.36, ICC=0.12), SMART parent vessel stenosis (κ=0.07, W=0.33, ICC=0.12), KB axis I (κ=0.24, W=0.50, ICC=0.25), KB axis II (κ=0.07, W=0.30, ICC=0.06), OKM aneurysm filling (κ=0.23, W=0.45, ICC=0.13), OKM contrast stasis (κ=0.36,W=0.71, ICC=0.54). CONCLUSIONS: Existing flow-diverting stent grading scales have low inter-rater reliability for most categories.

Ocular dysmotility after intra-arterial chemotherapy for retinoblastoma.

We report the case of a 15-month-old boy with retinoblastoma who developed exotropia secondary to a right medial rectus infarct after intra-arterial chemotherapy. He had unilateral sporadic group C tumor (International Classification of Retinoblastoma) and was treated with intra-arterial melphalan. One week after the first session of intra-ophthalmic arterial melphalan chemotherapy, he was noted to have orbital congestion, exotropia, and right adduction limitation. Magnetic resonance imaging was suggestive of a right medial rectus infarct. The tumor showed a good response to intra-arterial chemotherapy but the exotropia persisted.

Imaging of Orbital Trauma and Emergent Non-traumatic Conditions.

Diagnostic imaging has become critical in the care of patients suffering from traumatic or nontraumatic emergent orbital conditions. Multidetector computed tomography (MDCT) has become the standard imaging modality for assessing orbital trauma because of its accurate assessment of orbital skeletal and soft tissues injuries. Contrast-enhanced MR imaging is the first-line examination in the assessment of nontraumatic orbital conditions given its excellent evaluation of the orbital soft tissues. Conventional angiography is necessary in some vascular orbital complications and allows for endovascular treatment. This article discusses the spectrum of orbital pathology encountered in the imaging of orbital trauma and nontraumatic orbital emergencies.

Spectrum of critical imaging findings in complex facial skeletal trauma.

Multidetector computed tomography (CT) is the modality of choice for the evaluation of facial trauma because it helps accurately identify and characterize fractures and associated complications, thereby aiding timely clinical management and surgical planning. In particular, CT clearly depicts clinically relevant fractures in the eight osseous struts or buttresses that function as an underlying scaffold for facial structures. Information about the involvement of specific facial buttresses in a complex fracture is helpful for determining the type of fracture present and for identifying associated soft-tissue injuries that may require urgent care or surgery. Various kinds of complications can be expected to occur in Le Fort fractures, which affect the full thickness of the pterygoid plates, with resultant dissociation of part or all of the maxilla from the skull base; naso-orbitoethmoid complex fractures, which involve the medial orbital wall, nasal bone, ethmoid sinuses, and, often, the attachment site of the medial canthal tendon; zygomaticomaxillary complex fractures, which disrupt all four zygomatic sutures and may lead to enophthalmos due to increased orbital volume because of angulation of the lateral orbital wall; orbital "blowout" fractures, which may result in extraocular muscle herniation or entrapment and injuries to the globe or the infraorbital nerve; and fractures of the alveolar process, which are treated as open fractures because of their extension through the gingiva to the oral cavity and their resultant vulnerability to infection. Similarly, extension of a frontal sinus fracture through the posterior sinus wall creates a portal to the anterior cranial fossa and may lead to cerebrospinal fluid leakage, intracranial hemorrhage, or intracranial infection.