Detection of cranial meningiomas: comparison of 68Ga-DOTATOC PET/CT and contrast-enhanced MRI

Purpose

PET imaging with somatostatin receptor ligands, such as ⁶⁸Ga-DOTATOC, is a well-established method for detection and target volume definition of meningiomas prior to radiotherapy. Since DOTATOC PET delivers a higher contrast between meningiomas and surrounding tissues than MRI, we conducted a retrospective analysis to compare the diagnostic accuracy of contrast-enhanced MRI (CE-MRI) with ⁶⁸Ga-DOTATOC PET/CT in patients with cranial meningiomas prior to radiotherapy.

Methods

Over a period of 6?years, 134 patients (20–82?years of age, 107 women and 27 men) underwent cranial CE-MRI and ⁶⁸Ga-DOTATOC PET/CT. To compare the two methods, the lesions considered typical of meningiomas visually were counted and analysed with respect to their location and SUVmax.

Results

In the 134 patients investigated by both modalities, 190 meningiomas were detected by ⁶⁸Ga-DOTATOC PET/CT and 171 by CE-MRI. With knowledge of the PET/CT data, the MRI scans were reinvestigated, which led to the detection of 4 of the 19 incidental meningiomas, resulting in an overall detection rate of 92?% of the meningioma lesions that were found by PET/CT.

Conclusion

Ga-DOTATOC PET/CT demonstrated an improved sensitivity in meningioma detection when compared to CE-MRI. Tumours adjacent to the falx cerebri, located at the skull base or obscured by imaging artefacts or calcification are particularly difficult to detect by MRI. Therefore ⁶⁸Ga-DOTATOC PET/CT may provide additional information in patients with uncertain or equivocal results on MRI or could help to confirm a diagnosis of meningioma based on MRI or could help to confirm MRI-based diagnosis of meningiomas in cases of biopsy limitations. It is possible that not only radiotherapy and surgical planning, but also follow-up strategies would benefit from this imaging modality.     

Identification of skull base sutures and craniofacial anomalies in children with craniosynostosis: utility of multidetector CT

Purpose

Craniosynostosis is a condition characterised by the premature fusion of one or more of the cranial sutures. The aim of the study was to identify, by multidetector computed tomography (CT), the involvement of vault sutures as well as of the skull base sutures (named “minor” sutures). The latter ones are involved in development of craniofacial and skull base deformities.

Materials and methods

We retrospectively reviewed 27 children with complex synostosis (n = 21) and anterior synostotic plagiocephaly (n = 6). High-resolution CT images with bone definition algorithm and tridimensional volume rendering reconstructions were assessed.

Results

In 27 children we found different sutures involved in the synostotic process, including both major and minor skull suture synostosis, and synostosis of synchondroses. Superior orbital rim deformity, nasal root deviation, anterior endocranial axis deviation (ethmoidal axis) are found in children with coronal arch synostosis, while reduced size of the posterior fossa and Chiari 1 malformation are noted in children with lambdoid arch synostosis.

Conclusions

High-resolution CT allows an accurate identification of both “major” and “minor” skull base suture synostosis and it represents the gold standard for the diagnosis of craniostenosis and for planning the proper surgical approach.     

Radiological assessment of skull base changes in children with syndromic craniosynostosis: role of “minor” sutures

Introduction

This study aims to identify the premature synostosis of “major” and “minor” sutures of the four “sutural arches” of the skull and to perform a morphometric analysis in children with syndromic craniosynostosis in order to evaluate changes in the skull base linked with premature suture synostosis.

Methods

We reviewed multiplanar high-resolution CT images, implemented with 3D reconstructions, from 18 patients with complex syndromic craniosynostosis and compared them with 18 age-matched healthy subjects. We assessed the calvarial sutures and their extension to the skull base, and then we correlated specific types of synostosis with the size, shape and symmetry of the cranial fossae.

Results

We found a marked asymmetry of the skull base growth in all patients. The synostotic involvement around the coronal ring caused a reduction in the growth of the anterior and middle fossae. The size of the posterior cranial fossa was related not only to “major” but also to “minor” suture synostosis of the lambdoid and parieto-squamosal arches.

Conclusion

Changes in the skull base and craniofacial axis symmetry are due to structural and functional relationships between “major” and “minor” skull sutures, suggesting a structural and functional relationship between the neurocranium and basicranium. The early recognition of prematurely closed skull base sutures may help clinicians and neurosurgeons to establish correct therapeutic approaches.     

Proton beam radiotherapy: report of the first ten patients treated at the “Centro Nazionale di Adroterapia Oncologica (CNAO)” for skull base and spine tumours

Purpose

The Italian National Centre for Oncological Hadrontherapy (Centro Nazionale di Adroterapia Oncologica, CNAO), equipped with a proton and ion synchrotron, started clinical activity in September 2011. The clinical and technical characteristics of the first ten proton beam radiotherapy treatments are reported.

Materials and methods

Ten patients, six males and four females (age range 27–73 years, median 55.5), were treated with proton beam radiotherapy. After one to two surgical procedures, seven patients received a histological diagnosis of chordoma (of the skull base in three cases, the cervical spine in one case and the sacrum in three cases) and three of low-grade chondrosarcoma (skull base). Prescribed doses were 74 GyE for chordoma and 70 GyE for chondrosarcoma at 2 GyE/fraction delivered 5 days per week.

Results

Treatment was well tolerated without toxicity-related interruptions. The maximal acute toxicity was grade 2, with oropharyngeal mucositis, nausea and vomiting for the skull base tumours, and grade 2 dermatitis for the sacral tumours. After 6–12 months of follow-up, no patient developed tumour progression.

Conclusions

The analysis of the first ten patients treated with proton therapy at CNAO showed that this treatment was feasible and safe. Currently, patient accrual into these as well as other approved protocols is continuing, and a longer follow-up period is needed to assess tumour control and late toxicity.     

High-precision radiotherapy for meningiomas

Objective

To evaluate long-term outcome after high-precision radiotherapy (RT) of meningioma patients in terms of survival and side effects.

Methods

We analyzed 275 meningioma cases: 147 low-grade and 43 high-grade meningiomas (WHO II: n = 40, III: n = 3). In all, 85 patients had no pathologically confirmed histology but were determined as low-grade based on multimodal imaging. Surgery was performed in 183 cases. RT was delivered as either radiosurgery (RS, n = 16), fractionated stereotactic radiotherapy (FSRT, n = 241), or intensity-modulated radiation therapy (IMRT, n = 18). Of 218 patients contacted for patient-reported-outcome (PRO), 207 responded (95%).

Results

Median follow-up was 7.2 years. For low-grade meningioma the survival rate (OS) was 97% at 3 years, 85% at 10 years, and 64% at 15 years, for atypical meningioma 91% at 3 years, 62% at 10 years, and 50% at 15 years. Local control rate (PFS) for low-grade meningioma was 91% at 3 years, 87% at 5 years, and 86% at 10 years, for atypical cases 67% at 3 years and 55% at 5 years. Of all, 3.0% of patients reported worsened or new symptoms grade ≥3 during RT and the first 6 months thereafter; 17.5% reported a deterioration after more than 2 years. We found the prognostic factors tumor volume and age significantly influencing OS and PFS.

Conclusion

Complemented by PRO, we found long-term low toxicity rates in addition to excellent local control. Thus, due to the beneficial risk–benefit profile of benign and high-risk meningiomas, RT should be performed as adjuvant treatment and should not be postponed until tumor progression.

     

Head injuries in falls from a standing height: Do fractures of the orbital roof matter? A prospective autopsy study

Purpose

The aim of this study was to analyze the occurrence and characteristics of orbital roof fractures, periorbital hematoma, conjunctival hemorrhage, orbital roof discoloration, and concomitant head injuries in falls from a standing height.

Methods

A prospective autopsy study was performed over a 4-year period (from 2010 to 2013). Subjects who had died due to traumatic brain injury caused by falls from a standing height were included in the study.

Results

Fifty cases of ground level falls were recorded. This group consisted of 39 men and 11 women, with an average age of 67.3 ± 13.6 years, and median age of 70 years. Skull fractures originating in the proximity of impact site were found in 47 of 50 individuals, and 22 had isolated orbital roof fractures not connected to the fracture line. Bluish discoloration of the orbital roof was noted in 19 subjects, 14 had periorbital hematomas, and 12 had blotchy or purpura-like conjunctival hemorrhages.

Conclusions

Isolated orbital roof fractures in falls from a standing height are easily detected using a standard autopsy technique, with special regard to careful removal of the dura in the anterior cranial fossa. Our study shows that orbital roof fractures can occur in accidental falls from a standing height and may not be associated with concomitant skull fractures and brain injuries.     

High symptom improvement and local tumor control using stereotactic radiotherapy when given early after diagnosis of meningioma

Purpose

The goal of the present study was to analyze long-term results of fractionated stereotactic radiotherapy (SRT) in patients with a meningioma.

Methods and materials

A total of 72?patients treated between 1996 and 2008 in MAASTRO clinic (n?=?45) and University Hospital Zurich (n?=?27) were included. SRT was given as primary treatment (n?=?46), postoperatively (n?=?19) or at recurrence (n?=?7); 49?tumours (68%) were located in the skull base. Median total dose was 54?Gy.

Results

Median follow-up was 4.13?years (range 0.66–11?years). The 3- and 5-year overall survival were 92 and 79% for grade?0 and I meningioma. Progression-free survival for grade?0 and I was 95% at 3 and 5 years, and 40% for grade?II and III at 3?years. In 98.4% of patients, clinical symptoms were stable or improved. The majority of symptoms improved within 24?months after SRT. Local control is significantly better if patients are irradiated immediately after diagnosis compared to a watchful waiting policy (p?=?0.017). Grade?IV toxicity was low (4.2%, n?=?3)

Conclusion

SRT is an effective treatment with high local and clinical control. Early SRT resulted in better outcome than late treatment at progression.     

Associations among q-space MRI, diffusion-weighted MRI and histopathological parameters in meningiomas

Objectives

The purposes of this MR-based study were to calculate q-space imaging (QSI)–derived mean displacement (MDP) in meningiomas, to evaluate the correlation of MDP values with apparent diffusion coefficient (ADC) and to investigate the relationships among these diffusion parameters, tumour cell count (TCC) and MIB-1 labelling index (LI).

Methods

MRI, including QSI and conventional diffusion-weighted imaging (DWI), was performed in 44 meningioma patients (52 lesions). ADC and MDP maps were acquired from post-processing of the data. Quantitative analyses of these maps were performed by applying regions of interest. Pearson correlation coefficients were calculated for ADC and MDP in all lesions and for ADC and TCC, MDP and TCC, ADC and MIB-1 LI, and MDP and MIB-1 LI in 17 patients who underwent subsequent surgery.

Results

ADC and MDP values were found to have a strong correlation: r?=?0.78 (P?=?<0.0001). Both ADC and MDP values had a significant negative association with TCC: r?=?–0.53 (p?=?0.02) and –0.48 (P?=?0.04), respectively. MIB-1 LI was not, however, found to have a significant association with these diffusion parameters.

Conclusion

In meningiomas, both ADC and MDP may be representative of cell density.

Key Points

? Diffusion-weighted MRI offers possibilities to assess the aggressiveness of meningiomas. ? The q-space imaging-derived mean displacement correlates strongly with apparent diffusion coefficients. ? Both diffusion parameters showed a strong negative association with tumour cell counts. ? Derived mean displacement may help assess the aggressiveness of meningiomas preoperatively.     

PET SUV correlates with radionuclide uptake in peptide receptor therapy in meningioma

Purpose

To investigate whether the tumour uptake of radionuclide in peptide receptor radionuclide therapy (PRRT) of meningioma can be predicted by a PET scan with ⁶⁸Ga-labelled somatostatin analogue.

Methods

In this pilot trial, 11 meningioma patients with a PET scan indicating somatostatin receptor expression received PRRT with 7.4?GBq ¹⁷⁷Lu-DOTATOC or ¹⁷⁷Lu-DOTATATE, followed by external beam radiotherapy. A second PET scan was scheduled for 3?months after therapy. During PRRT, multiple whole-body scans and a SPECT/CT scan of the head and neck region were acquired and used to determine the kinetics and dose in the voxel with the highest radionuclide uptake within the tumour. Maximum voxel dose and retention of activity 1?h after administration in PRRT were compared to the maximum standardized uptake values (SUV_max) in the meningiomas from the PET scans before and after therapy.

Results

The median SUV_max in the meningiomas was 13.7 (range 4.3 to 68.7), and the maximum fractional radionuclide uptake in voxels of size 0.11?cm3 was a median of 23.4?×?10^?6 (range 0.4?×?10^?6 to 68.3?×?10^?6). A strong correlation was observed between SUV_max and the PRRT radionuclide tumour retention in the voxels with the highest uptake (Spearman’s rank test, P?max and the therapeutic uptake (r?=?0.95) and between SUV_max and the maximum voxel dose from PRRT (r?=?0.76). Observed absolute deviations from the values expected from regression were a median of 5.6?×?10^?6 (maximum 9.3?×?10^?6) for the voxel fractional radionuclide uptake and 0.40?Gy per GBq (maximum 0.85?Gy per GBq) ¹⁷⁷Lu for the voxel dose from PRRT.

Conclusion

PET with ⁶⁸Ga-labelled somatostatin analogues allows the pretherapeutic assessment of tumour radionuclide uptake in PRRT of meningioma and an estimate of the achievable dose.     

Magnetic resonance imaging following endoscopic nasopharyngectomy with a potassium-titanyl-phosphate (KTP) laser for early locally recurrent nasopharyngeal carcinoma

Introduction

This study aims to investigate the spectrum of magnetic resonance imaging (MRI) features following endoscopic potassium-titanyl-phosphate (KTP) laser nasopharyngectomy.

Methods

From January 2005 to December 2010, a total of 35 patients underwent KTP laser nasopharyngectomy for early recurrent NPC (rT1 or rT2) at our institute. Those who were lost to follow-up (N?=?2) were excluded. Among the remaining patients, ten were proved to have locally recurrent disease and the other 23 not locally recurrent within 2 years of postoperative follow-up. Their serial MRIs were evaluated.

Results

Postoperative nasopharyngeal mucosal changes were present in all of the subjects on first follow-up MRI, ranged from focal mucosal thinning (19/33, 57.6 %), focal mucosal thickening (8/33, 24.2 %) to mixed thinning and thickening (6/33, 18.2 %). Nasopharyngeal submucosal soft tissue volume loss was found in 23 (23/33, 69.7 %), and parapharyngeal soft tissue necrosis was found in 3 (3/33, 9.1 %). Postoperative bone marrow change involved the clivus in 31 (31/33, 93.9 %) and the petrous or pterygoid in 17 (17/33, 51.5 %). There were no significant differences between the two groups in the changes of mucosa, adjacent soft tissue, and skull base on the first MRI. The evaluation of serial MRIs disclosed that the patients in the recurrent group were more likely to develop new or enlarging mucosal masses (p?=?0.01) and enlarging skull base changes (p?=?0.0001).

Conclusions

KTP laser nasopharyngectomy induces mucosal and skull base changes that could be misinterpreted as tumor progression on early postoperative MRI scans. Sequential imaging is required to distinguish between postoperative changes and progressive disease.     

Fractionated external beam radiotherapy of skull base metastases with cranial nerve involvement

Background and purpose

Skull base metastases frequently appear in a late stage of various tumor entities and cause pain and neurological disorders which strongly impair patient quality of life. This study retrospectively analyzed fractionated external beam radiotherapy (EBRT) as a palliative treatment approach with special respect to neurological outcome, feasibility and acute toxicity.

Patients and methods

A total of 30 patients with skull base metastases and cranial nerve disorders underwent EBRT with a mean total dose of 31.6 Gy. Neurological status was assessed before radiotherapy, during radiotherapy and 2 weeks afterwards categorizing orbital, parasellar, middle fossa, jugular foramen and occipital condyle involvement and associated clinical syndromes. Neurological outcome was scored as persistence of symptoms, partial response, good response and complete remission. Treatment-related toxicity and overall survival were assessed.

Results

Before EBRT 37 skull base involvement syndromes were determined with 4 patients showing more than 1 syndrome. Of the patients 81.1?% responded to radiotherapy with 10.8?% in complete remission, 48.6?% with good response and 21.6?% with partial response. Grade 1 toxicity of the skin occurred in two patients and grade 1 hematological toxicity in 1 patient under concurrent chemoradiotherapy. Median overall survival was 3.9 months with a median follow-up of 45 months.

Conclusion

The use of EBRT for skull base metastases with symptomatic involvement of cranial nerves is marked by good therapeutic success in terms of neurological outcome, high feasibility and low toxicity rates. These findings underline EBRT as the standard therapeutic approach in the palliative setting.     

Assessment of tumor blood flow and its correlation with histopathologic features in skull base meningiomas and schwannomas by using pseudo-continuous arterial spin labeling images

Objective

We aimed to investigate whether pseudo-continuous arterial spin labeling (pcASL)-MRI can adequately evaluate tumor perfusion even if the tumors are located in the skull base region and evaluate the correlation between tumor blood flow (TBF) and the histopathologic features of skull base meningiomas and schwannomas.

Materials and methods

We enrolled 31 patients with skull base meningioma (n = 14) and schwannoma (n = 17) who underwent surgical resection. TBF was calculated from pcASL. Tissue sections were stained with CD34 to evaluate microvessel area (MVA). TBF and MVA ratio were compared between meningiomas and schwannomas using Mann–Whitney U-test. The correlations between MVA ratio and TBF were evaluated in each tumor by using single linear regression analysis and Spearman's rank correlation coefficients (r_s).

Results

MVA ratio and TBF were significantly higher in meningioma than in schwannoma (both p < 0.01). Correlation analyses revealed significant positive correlations between MVA ratio and both mean and max TBF for meningiomas (r_s = 0.89, 0.81, both p < 0.01). There was a weak positive correlation between MVA ratio and mean TBF for schwannomas (r_s = 0.43, p = 0.04). However, no significant correlation was found between MVA ratio and max TBF for schwannoma.

Conclusions

pcASL-MRI is useful for evaluating tumor perfusion even if the tumors are located in the skull base region. Moreover, pcASL-TBF was significantly higher in most meningiomas compared to schwannomas, which can help in the differential diagnosis of the 2 tumor types even without the use of contrast material.     

Tibial base design and patient morphology affecting tibial coverage and rotational alignment after total knee arthroplasty

Purpose

To understand interactions between total knee arthroplasty tibial base design attributes, variations in tibial morphology, and the resulting tibial coverage and rotational alignment.

Methods

Tibial anthropometric measurements, including aspect ratio (medial–lateral width/anterior–posterior length) and tibial asymmetry, were taken for 14,791 total knee arthroplasty patients and compared with the ability of four different commercial tibial base designs to cover the resected plateau. The anthropometric measurements were also compared with the resulting tibial base rotation, which occurred when rotating the base to maximize coverage.

Results

All four tibial base designs resulted in similar coverage ranging from 80.2 (4.7) % to 83.8 (4.6) %. Mean tibial base rotation when placed to maximize coverage ranged from 3.7 (4.4)° (internal) to 3.8 (4.5)° (external) relative to the medial third of the tibial tubercle. More asymmetric tibiae and tibiae with a lower aspect ratios resulted in increased internal tibial base rotation.

Conclusions

The four tibial base designs assessed provided similar levels of tibial bone coverage across the patient population, despite different design features. Rotating the tibial base to maximize coverage did not significantly increase the tibial coverage, but induced variability in tibial base alignment. Certain tibial anthropometrics may predispose particular patients to internal tibial base mal-rotation.     

Lateralized petrous internal carotid artery: imaging features and distinction from the aberrant internal carotid artery

Introduction

This study aimed to describe the lateralized petrous internal carotid artery (ICA), a rare variant of the intratemporal course of the ICA, and distinguish it from aberrant ICA.

Methods

A retrospective multi-institutional review of all patients diagnosed over a 10-year period with lateralized ICA was completed. Medical records were reviewed for demographic data as well as clinical information in all patients. Computerized tomography (CT) studies were reviewed in all patients. Magnetic resonance studies in this patient group were reviewed when available. In order to obtain normative data for the ICA, the intratemporal course of the ICA was evaluated on 50 consecutive high-resolution sinus CT scans.

Results

Sixteen cases of lateralized ICA were identified on CT scans in 12 patients. In each of these, the ICA entered the skull base in a position more lateral to the cochlea than normal and protruded into the anterior mesotympanum with dehiscent or thinned overlying bone. Magnetic resonance angiography was available in 5 of 12 patients and catheter angiography in 1 of 12.

Conclusion

Lateralized petrous ICA can be identified on CT by its more posterolateral entrance to the skull base and protrusion into the anterior mesotympanum. It can be distinguished from the aberrant ICA which enters the posterior hypotympanum through an enlarged inferior tympanic canaliculus, then courses across the inferior cochlear promontory to connect with the normal horizontal petrous ICA. Lateralized ICA is best considered an incidental petrous ICA variant. Awareness of this entity is important in the presurgical evaluation of the temporal bone to avoid vascular injury and confusion with the congenital diagnosis of aberrant ICA.     

Brain surface motion imaging to predict adhesions between meningiomas and the brain surface

Introduction

“Brain surface motion imaging” (BSMI) is the subtraction of pulse-gated, 3D, heavily T2-weighted image of two different phases of cerebrospinal fluid (CSF) pulsation, which enables the assessment of the dynamics of brain surface pulsatile motion. The purpose of this study was to evaluate the feasibility of this imaging method for providing presurgical information about adhesions between meningiomas and the brain surface.

Methods

Eighteen cases with surgically resected meningioma in whom BSMI was presurgically obtained were studied. BSMI consisted of two sets of pulse-gated, 3D, heavily T2-weighted, fast spin echo scans. Images of the systolic phase and the diastolic phase were obtained, and subtraction was performed with 3D motion correction. We analyzed the presence of band-like texture surrounding the tumor and judged the degree of motion discrepancy as “total,” “partial,” or “none.” The correlation between BSMI and surgical findings was evaluated. For cases with partial adhesions, agreements in the locations of the adhesions were also evaluated.

Results

On presurgical BSMI, no motion discrepancy was seen in eight cases, partial in six cases, and total in four cases. These presurgical predictions about adhesions and surgical findings agreed in 13 cases (72.2%). The locations of adhesions agreed in five of six cases with partial adhesions.

Conclusion

In the current study, BSMI could predict brain and meningioma adhesions correctly in 72.2% of cases, and adhesion location could also be predicted. This imaging method appears to provide presurgical information about brain/meningioma adhesions.     

CT and MRI findings of calcified spinal meningiomas: correlation with pathological findings

Objective

This study was designed to present characteristic CT and MR findings of calcified spinal meningiomas that correlate with pathological findings and to assess the efficacy of CT for the detection of calcifications within a mass in comparison to MRI.

Materials and methods

Between 1998 and 2009, 10 out of 11 patients who had pathologically confirmed psammomatous meningiomas showed gross calcifications on CT images and were included in this study. On CT scans of the 10 patients, the distribution pattern, morphology and number of calcifications within masses were evaluated. MRI was performed in seven patients and signal intensities of masses were assessed. The pathological results analyzed semi-quantitatively were compared with the density or the size of calcifications within a mass as seen on a CT scan.

Results

Seven of 10 masses were located at the thoracic spine level. Eight masses had intradural locations. The other two masses had extradural locations. Four masses were completely calcified based on standard radiographs and CT. Symptoms duration, the size of the mass and size or number of calcifications within a mass had no correlation. The location, size, and distribution pattern of calcifications within masses were variable. On MR images, signal intensity of calcified tumor varied on all imaging sequences. All the masses enhanced after injection of intravenous contrast material.

Conclusion

A calcified meningioma should be first suggested when extradural or intradural masses located in the spine contain calcifications regardless of the size or pattern as depicted on CT, especially in the presence of enhancement as seen on MR images.     

Relationship between stress ankle radiographs and injured ligaments on MRI

Objective

This study was performed to investigate the relationship between the injured lateral ankle ligaments on MRI and stress ankle radiographs.

Materials and methods

Two hundred and twenty-nine consecutive patients (mean age 35.5 years, SD 14.6 years; 136 males and 93 females) that underwent ankle stress radiographs and MRI for lateral ankle instability were included. Tibiotalar tilt angle and anterior translation of talus were measured on stress ankle radiographs. Degree of lateral ligaments (anterior talofibular, calcaneofibular, and posterior talofibular) and deltoid ligament injuries were evaluated and scored as intact (0), partial injury (1), and complete injury (2) on MR images. Effusion of ankle joint was also recorded. The effects of gender, age, injuries of ligaments, and ankle joint effusion on stress radiographs were statistically analyzed.

Results

Gender (p?=?0.010), age (p?=?0.020), and anterior talofibular ligament (ATFL) injury (p?<?0.001) were the factors significantly affecting tibiotalar tilt angle. Posterior talofibular ligament (PTFL) injury (p?=?0.014) was found to be the only significant factor affecting the anterior translation on the anterior drawer radiographs.

Conclusions

ATFL injury and PTFL injury on MRI significantly affected tibiotalar tilt angle and anterior drawer on stress radiographs. Other factors, such as age and gender, need to be considered in evaluating radiographic lateral ankle instability.     

Bevacizumab treatment in malignant meningioma with additional radiation necrosis

Background and purpose

Recently two retrospective cohort studies report efficacy of bevacizumab in patients with recurrent atypical and anaplastic meningioma. Another successful therapeutic option of bevacizumab seems to be treatment of cerebral radiation necrosis. However, the antiangiogenic effects in MRI diffusion and perfusion in meningiomas have not been previously described in detail. The objective of this research was to evaluate the clinical and MR imaging effects of bevacizumab in a malignant meningioma patient harboring additional cerebral radiation necrosis.

Case presentation

We report the case of an 80-year-old woman who underwent bevacizumab therapy (5 mg/kg every 2 weeks for 2 months) for treatment of a symptomatic radiation necrosis in malignant meningiomatosis of World Health Organization (WHO) grade III. The patient was closely monitored with MRI including diffusion and perfusion studies. Upon bevacizumab therapy, the clinical situation was well stabilized over a period of 4 months until the patient unfortunately died due to pneumonia/septicemia probably unrelated to bevacizumab therapy. Consecutive MRI demonstrated 4 important aspects: (1) considerable decrease of the contrast medium (CM)-enhanced radiation necrosis, (2) mixed response with respect to the meningiomatosis with stable and predominantly growing tumor lesions, (3) a new diffusion-weighted imaging (DWI) lesion in a CM-enhanced tumor as described in gliomas, which we did not interpret as a response to bevacizumab therapy, and (4) new thrombembolic infarcts, which are a known side-effect of bevacizumab treatment.

Conclusion

Bevacizumab is effective in the treatment of radiation necrosis. We could not confirm the potential antitumor effect of bevacizumab in this patient. However, we could describe several new radiographic effects of bevacizumab therapy in malignant meningioma.     

Analysis of the venous channel within the clivus using multidetector computed tomography digital subtraction venography

Purpose

Although neuroradiologists and skull base neurosurgeons are aware of the existence of veins within the clivus, such vessels have seldom been described in the literature. The aim of the present study is to elucidate the detailed venous structure of the clivus.

Methods

Computed tomography digital subtraction venography (CT-DSV) images of 50 unruptured aneurysm cases were examined retrospectively.

Results

Eighteen emissary veins were identified in 14 (28.0%) cases. A half of the emissary veins connected the inferior petrosal sinus with the inferior petro-occipital vein (IPOV) in the middle clivus. The clival diploic vein (CDV) was identified in 14.0% of cases, 42.9% of which had the clivus of the presellar type. The CDV was connected to the posterior intercavernous sinus or the rostral end of the basilar plexus superiorly, and was connected to the IPOV, anterior condylar vein, marginal sinus, or the anterior condylar confluence.

Conclusion

The CDV provides collateral channels between the cavernous sinus and the internal jugular vein and the inferior petrosal sinus and the IPOV. Understanding of the emissary veins in the clivus and the CDV is valuable for skull base surgery, especially for endonasal endoscopic skull base procedures.

     

Revision of anterior cruciate ligament reconstruction with allografts in patients younger than 40 years old: a 2 to 4 year results

Purpose

The purpose of this study is first to report the outcomes, at 4 years follow-up, in revision ACL surgery using allografts in patients younger than 40 years old, and then compared soft tissue allografts to bone tendon allografts.

Methods

This retrospective study included 47 patients who underwent ACL revision surgery with fresh-frozen allografts. Patellar tendon allograft or tibialis anterior allograft was used. Twenty-seven patients undergoing ACL revision with patellar tendon allograft were compared retrospectively with twenty-two patients undergoing the same procedure with soft tissue tibialis anterior allograft. Lysholm, IKDC, and KT-1000 values were obtained preoperatively and postoperatively.

Results

The average patient follow-up was 4.6 years (±2.5). The mean age at time of the revision was 34 years old (±6.3). Overall, patients reported the overall condition of their knee as excellent or good in 85 % of the patients (10 excellent, 33 good). Based on their experience, 85 % would have the surgery again if they had the same problem in the other knee. Both subgroups experienced significant improvement in Lysholm, IKDC, and KT-1000 values, with no difference found between groups at final follow-up.

Conclusion

Revision ACL with allografts has excellent and good results in 85 % of patients younger than 40 years old. No statistical difference was seen between soft tissue (tibialis anterior) and patellar tendon allograft.

Level of evidence

IV.