The European Position Paper on Rhinosinusitis and Nasal Polyps 2020 is the update of similar evidence based position papers published in 2005 and 2007 and 2012. The core objective of the EPOS2020 guideline is to provide revised, up-to-date and clear evidence-based recommendations and integrated care pathways in ARS and CRS. EPOS2020 provides an update on the literature published and studies undertaken in the eight years since the EPOS2012 position paper was published and addresses areas not extensively covered in EPOS2012 such as paediatric CRS and sinus surgery. EPOS2020 also involves new stakeholders, including pharmacists and patients, and addresses new target users who have become more involved in the management and treatment of rhinosinusitis since the publication of the last EPOS document, including pharmacists, nurses, specialised care givers and indeed patients themselves, who employ increasing self-management of their condition using over the counter treatments. The document provides suggestions for future research in this area and offers updated guidance for definitions and outcome measurements in research in different settings. EPOS2020 contains chapters on definitions and classification where we have defined a large number of terms and indicated preferred terms. A new classification of CRS into primary and secondary CRS and further division into localized and diffuse disease, based on anatomic distribution is proposed. There are extensive chapters on epidemiology and predisposing factors, inflammatory mechanisms, (differential) diagnosis of facial pain, allergic rhinitis, genetics, cystic fibrosis, aspirin exacerbated respiratory disease, immunodeficiencies, allergic fungal rhinosinusitis and the relationship between upper and lower airways. The chapters on paediatric acute and chronic rhinosinusitis are totally rewritten. All available evidence for the management of acute rhinosinusitis and chronic rhinosinusitis with or without nasal polyps in adults and children is systematically reviewed and integrated care pathways based on the evidence are proposed. Despite considerable increases in the amount of quality publications in recent years, a large number of practical clinical questions remain. It was agreed that the best way to address these was to conduct a Delphi exercise . The results have been integrated into the respective sections. Last but not least, advice for patients and pharmacists and a new list of research needs are included. The full document can be downloaded for free on the website of this journal: http://www.rhinologyjournal.com.

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European Position Paper on Rhinosinusitis and Nasal Polyps 2020

Over the past 20 years, neuroimaging has become a predominant technique in systems neuroscience. One might envisage that over the next 20 years the neuroimaging of distributed processing and connectivity will play a major role in disclosing the brain's functional architecture and operational principles. The inception of this journal has been foreshadowed by an ever-increasing number of publications on functional connectivity, causal modeling, connectomics, and multivariate analyses of distributed patterns of brain responses. I accepted the invitation to write this review with great pleasure and hope to celebrate and critique the achievements to date, while addressing the challenges ahead.

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Functional and effective connectivity: a review.

Brain imaging efforts are being increasingly devoted to decode the functioning of the human brain. Among neuroimaging techniques, resting-state fMRI (R-fMRI) is currently expanding exponentially. Beyond the general neuroimaging analysis packages (e.g., SPM, AFNI and FSL), REST and DPARSF were developed to meet the increasing need of user-friendly toolboxes for R-fMRI data processing. To address recently identified methodological challenges of R-fMRI, we introduce the newly developed toolbox, DPABI, which was evolved from REST and DPARSF. DPABI incorporates recent research advances on head motion control and measurement standardization, thus allowing users to evaluate results using stringent control strategies. DPABI also emphasizes test-retest reliability and quality control of data processing. Furthermore, DPABI provides a user-friendly pipeline analysis toolkit for rat/monkey R-fMRI data analysis to reflect the rapid advances in animal imaging. In addition, DPABI includes preprocessing modules for task-based fMRI, voxel-based morphometry analysis, statistical analysis and results viewing. DPABI is designed to make data analysis require fewer manual operations, be less time-consuming, have a lower skill requirement, a smaller risk of inadvertent mistakes, and be more comparable across studies. We anticipate this open-source toolbox will assist novices and expert users alike and continue to support advancing R-fMRI methodology and its application to clinical translational studies.

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DPABI: Data Processing & Analysis for (Resting-State) Brain Imaging.

A multidimensional image navigation and display software was designed for display and interpretation of large sets of multidimensional and multimodality images such as combined PET-CT studies. The software is developed in Objective-C on a Macintosh platform under the MacOS X operating system using the GNUstep development environment. It also benefits from the extremely fast and optimized 3D graphic capabilities of the OpenGL graphic standard widely used for computer games optimized for taking advantage of any hardware graphic accelerator boards available. In the design of the software special attention was given to adapt the user interface to the specific and complex tasks of navigating through large sets of image data. An interactive jog-wheel device widely used in the video and movie industry was implemented to allow users to navigate in the different dimensions of an image set much faster than with a traditional mouse or on-screen cursors and sliders. The program can easily be adapted for very specific tasks that require a limited number of functions, by adding and removing tools from the program’s toolbar and avoiding an overwhelming number of unnecessary tools and functions. The processing and image rendering tools of the software are based on the open-source libraries ITK and VTK. This ensures that all new developments in image processing that could emerge from other academic institutions using these libraries can be directly ported to the OsiriX program. OsiriX is provided free of charge under the GNU open-source licensing agreement at http://homepage.mac.com/rossetantoine/osirix.

OsiriX: An Open-Source Software for Navigating in Multidimensional DICOM Images

A system and method of pushing user-selected data items from a host system to a user's mobile data communication device upon detecting the occurrence of one or more user-defined event triggers is provided. The user may then move (or file) the data items to a particular folder within a folder hierarchy stored in the mobile data communication device, or may execute some other system operation on the data item. Software operating at the mobile device and the host system then synchronizes the folder hierarchy of the mobile device with a folder hierarchy of the host system, and any actions executed on the data items at the mobile device are then automatically replicated on the same data items stored at the host system, thus eliminating the need for the user to manually replicate actions at the host system that have been executed at the mobile data communication device.

System and Method for Pushing Information from a Host System to a Mobile Data Communication Device

Functional Magnetic Resonance Imaging

BACKGROUND AND PURPOSE: Occlusion of the AOP results in a characteristic pattern of ischemia: bilateral paramedian thalamus with or without midbrain involvement. Although the classic imaging findings are often recognized, only a few small case series and isolated cases of AOP infarction have been reported. The purpose of this study was to characterize the complete imaging spectrum of AOP infarction on the basis of a large series of cases obtained from multiple institutions. MATERIALS AND METHODS: Imaging and clinical data of 37 patients with AOP infarction from 2000 to 2009 were reviewed retrospectively. The primary imaging criterion for inclusion was an abnormal signal intensity on MR imaging and/or hypoattenuation on CT involving distinct arterial zones of the bilateral paramedian thalami with or without rostral midbrain involvement. Patients were excluded if there was a neoplastic, infectious, or inflammatory etiology. RESULTS: We identified 4 ischemic patterns of AOP infarction: 1) bilateral paramedian thalamic with midbrain (43%), 2) bilateral paramedian thalamic without midbrain (38%), 3) bilateral paramedian thalamic with anterior thalamus and midbrain (14%), and 4) bilateral paramedian thalamic with anterior thalamus without midbrain (5%). A previously unreported finding (the “V” sign) on FLAIR and DWI sequences was identified in 67% of cases of AOP infarction with midbrain involvement and supports the diagnosis when present. CONCLUSIONS: The 4 distinct patterns of ischemia identified in our large case series, along with the midbrain V sign, should improve recognition of AOP infarction and assist with the neurologic evaluation and management of patients with thalamic strokes. ABBREVIATIONS: AF atrial fibrillation; AICA anterior inferior cerebellar artery; angio angiography; AOP artery of Percheron; CAD coronary artery disease; CardAbn cardiac abnormalities (miscellaneous non-valvular); CE cardiac embolism; CHF congestive heart failure; CT perf CT perfusion; CTA CT angiography; CVA-P previous cerebrovascular accident; DM diabetes mellitus; DVI deep venous thrombus; DWI diffusion-weighted imaging; EtOH heavy drinking; FLAIR fluid-attenuated inversion recovery; FMD fibromuscular dysplasia; HHC hyperhomocysteinemia; HL hyperlipidemia; HTN hypertension; H/o history of; ICH intracranial hemorrhage; INO internuclear ophthalmoplegia; L left; LAA large artery atherosclerosis (includes large artery thrombosis and artery-to-artery embolism); LV left ventricular; LVAD left ventricular assist device; MCA middle cerebral artery; MRA MR angiography; MRI or MR MR imaging; OCP oral contraceptive pill; ODC stroke of other determined cause; P1 first segment of the PCA; P2 second segment of PCA; PCA posterior cerebral artery; PcomA posterior communicating artery; PFO patent foramen ovale; PICA posterior inferior cerebellar artery; R right; SCA superior cerebellar artery; S/p status post; SVO small vessel occlusion; TIA-P previous transient ischemic attack; Tob tobacco smoker; UND stroke of undetermined cause; VA vertebral artery; ValvAbn valvular abnormalities; Y yes

http://www.ajnr.org/content/ajnr/31/7/1283.full.pdf

Artery of Percheron Infarction: Imaging Patterns and Clinical Spectrum

A variety of congenital, infectious, inflammatory, vascular, and benign and malignant neoplastic pathology affects the temporal bone. Knowledge of normal temporal bone anatomy and space-specific differential diagnoses is key to imaging interpretation of temporal bone. Correlation with clinical history and physical examination is vital to making the correct diagnosis or providing an appropriate differential. Computed tomography and magnetic resonance imaging are complementary imaging modalities in the evaluation of temporal bone abnormalities.

Imaging of the Temporal Bone

BACKGROUND AND PURPOSE: The imaging appearance of facial nerve schwannomas (FNSs) has been described as an enhancing tubular mass (using T1-enhanced MR) within an enlarged facial nerve canal (using CT). The purpose of this study is to identify how often the FNS imaging findings conform to this description and determine whether there are underlying anatomic explanations for the discrepant imaging appearances identified. MATERIALS AND METHODS: The clinical, pathologic, and radiologic records of 24 FNS in 23 patients were retrospectively reviewed. Each FNS was evaluated for location along the facial nerve. The lesions were cataloged by facial nerve segment with the imaging characteristics of each segment described. RESULTS: The average age at time of first imaging was 39 years (age range, 10–70 years). Eighteen (71%) of the 24 FNSs were pathologically confirmed, while the others were determined intraoperatively or diagnostically by the presence of both enlargement of the facial nerve canal and enhancement on contrast-enhanced T1 MR examination. The most common location was in the geniculate fossa (83%), followed by the labyrinthine and tympanic segments of the facial nerve (both 54%). The most common clinical presentation was facial neuropathy (42%). CONCLUSION: The classic description of FNS on enhanced T1 MR is that of a well-circumscribed fusiform enhancing mass along the course of the intratemporal facial nerve with bone algorithm CT showing sharply defined bony canal enlargement. Modern imaging techniques, however, demonstrate the importance of the surrounding anatomic landscape, leading to various imaging appearances. Lesions traversing the labyrinthine segment can demonstrate a dumbbell appearance. When FNSs track along the greater superficial petrosal nerve, they may present as a round mass projecting up into the middle cranial fossa. FNS of the tympanic segment of the facial nerve preferentially pedunculate into the middle ear cavity, clinically presenting as a middle ear mass. When the mastoid segment of the facial nerve is involved, irregular and “invasive“ tumor margins seen on MR can be explained on CT as tumor breaking into surrounding mastoid air cells.

http://www.ajnr.org/content/ajnr/27/3/694.full.pdf

The many faces of facial nerve schwannoma.

BACKGROUND AND PURPOSE: This paper describes the CT findings that characterize the middle and inner ear anomalies in coloboma, heart defects, choanal atresia, mental retardation, genitourinary, and ear anomalies (CHARGE) syndrome. With this information, neuroradiologists will be better prepared to provide clinically relevant information to their referring physicians regarding this rare syndrome. MATERIALS AND METHODS: CT studies from 13 patients were reviewed by 2 neuroradiologists with Certificate of Additional Qualification. Each ear was counted separately for a total of 26 ears. Middle and inner ear anomalies associated with CHARGE syndrome were categorized. Investigational review board approval was obtained. RESULTS: Twenty of 26 (77%) ears demonstrated cochlear aperture atresia. Four of these ears were evaluated with MR imaging and were found to lack a cochlear nerve. Twenty-one of 26 (81%) cochlea had some form of dysplasia. Six of 26 (23%) round windows were aplastic. Three of 26 (12%) round windows were hypoplastic. Twenty-one of 26 (81%) oval windows were atretic or aplastic. Fifteen of 26 (58%) vestibules were hypoplastic or dysplastic. There were 5 of 26 (19%) enlarged vestibular aqueducts. Twelve of 26 (46%) vestibular aqueducts had an anomalous course. All cases demonstrated absent semicircular canals. Twenty-three of 26 (88%) facial nerve canals had an anomalous course. Four of 26 (15%) tympanic segments were prolapsed. Three of 26 (12%) temporal bones had an anomalous emissary vein referred to as a petrosquamosal sinus. Twenty-one of 26 (81%) middle ear cavities were small. Twenty-three of 26 (93%) ossicles were dysplastic with ankylosis. Three of 26 (12%) internal auditory canals were small. CONCLUSION: The CT findings that correlate to the anomalies of CHARGE syndrome affect conductive as well as sensorineural hearing. Stenosis of the aperture for the cochlear nerve aperture on CT is suggestive of hypoplasia or absence of the cochlear nerve, which has been demonstrated in some cases by MR. Absence of the cochlear nerve would be a contraindication to cochlear implantation.

http://www.ajnr.org/content/ajnr/27/8/1663.full.pdf

Richard H. Wiggins

Papers

Functional Magnetic Resonance Imaging

Artery of Percheron Infarction: Imaging Patterns and Clinical Spectrum

Imaging of the Temporal Bone

The many faces of facial nerve schwannoma.

Absent semicircular canals in CHARGE syndrome: radiologic spectrum of findings.