Assessment of radiation and chemotherapy efficacy for brain cancer patients is traditionally accomplished by measuring changes in tumor size several months after therapy has been administered. The ability to use noninvasive imaging during the early stages of fractionated therapy to determine whether a particular treatment will be effective would provide an opportunity to optimize individual patient management and avoid unnecessary systemic toxicity, expense, and treatment delays. We investigated whether changes in the Brownian motion of water within tumor tissue as quantified by using diffusion MRI could be used as a biomarker for early prediction of treatment response in brain cancer patients. Twenty brain tumor patients were examined by standard and diffusion MRI before initiation of treatment. Additional images were acquired 3 weeks after initiation of chemo-and͞or radiotherapy. Images were coregistered to pretreatment scans, and changes in tumor water diffusion values were calculated and displayed as a functional diffusion map (fDM) for correlation with clinical response. Of the 20 patients imaged during the course of therapy, 6 were classified as having a partial response, 6 as stable disease, and 8 as progressive disease. The fDMs were found to predict patient response at 3 weeks from the start of treatment, revealing that early changes in tumor diffusion values could be used as a prognostic indicator of subsequent volumetric tumor response. Overall, fDM analysis provided an early biomarker for predicting treatment response in brain tumor patients. diffusion MRI ͉ therapeutic response

We review the theoretical background to diffusion tensor imaging (DTI) and some of its commoner clinical applications, such as cerebral ischemia, brain maturation and traumatic brain injury. We also review its potential use in diseases such as epilepsy, multiple sclerosis, and Alzheimer's disease. The value of DTI in the investigation of brain tumors and metabolic disorders is assessed.

SUMMARY: Conebeam x-ray CT (CBCT) is a developing imaging technique designed to provide relatively low-dose high-spatial-resolution visualization of high-contrast structures in the head and neck and other anatomic areas. This first installment in a 2-part review will address the physical principles underlying CBCT imaging as it is used in dedicated head and neck scanners. Concepts related to CBCT acquisition geometry, flat panel detection, and image quality will be explored in detail. Particular emphasis will be placed on technical limitations to low-contrast detectability and radiation dose. Proposed methods of x-ray scatter reduction will also be discussed.C onebeam x-ray CT (CBCT) is a relatively recent installment in the growing inventory of clinical CT technologies. Although the first prototype clinical CBCT scanner was adapted for angiographic applications in 1982, the emergence of commercial CBCT scanners was delayed for more than a decade. 1 The arrival of marketable scanners in the last 10 years has been, in part, facilitated by parallel advancements in flat panel detector (FPD) technology, improved computing power, and the relatively low power requirements of the x-ray tubes used in CBCT. These advancements have allowed CBCT scanners to be sufficiently inexpensive and compact for operation in office-based head and neck as well as dental imaging applications. These systems are distinguished by a conical x-ray beam geometry and the use of 3D reconstruction algorithms; most recent models are also fit with FPDs. As they are employed for specific imaging tasks in restricted anatomic regions such as the head and neck, preliminary research suggests that they can produce images with high isotropic spatial resolution while delivering a relatively low patient dose. This first part in a series of 2 articles will review the physical principles underlying CBCT as it is employed in head and neck diagnostic imaging. C-arm CBCT systems used in the interventional suite and CBCT systems used in radiation therapy have been the subject of other reviews.2-4 Although there are numerous differences between CBCT and conventional fan-beam CT techniques, many of the fundamental physical concepts are the same. Fundamental Principles of CTThe original clinical CT scanner was introduced by Sir Godfrey N. Hounsfield in 1967. Data acquisition was based on a translaterotate parallel-beam geometry wherein pencil beams of x-rays were directed at a detector opposite the source and the transmitted intensity of photons incident on the detector was measured. The gantry would then both translate and rotate to capture x-ray attenuation data systematically from multiple points and angles.5 Although x-ray sources, acquisition geometries, and detectors have rapidly evolved since Hounsfield's original scanner, the theory behind CT has not changed.The attenuation of a monochromatic x-ray beam through a homogeneous object is described by the Lambert-Beer law:where I is the transmitted photon intensity, I o is the original intensity, x is the lengt...

SUMMARY: Conebeam x-ray CT (CBCT) is being increasingly used for point-of-service head and neck and dentomaxillofacial imaging. This technique provides relatively high isotropic spatial resolution of osseous structures with a reduced radiation dose compared with conventional CT scans. In this second installment in a 2-part review, the clinical applications in the dentomaxillofacial and head and neck regions will be explored, with particular emphasis on diagnostic imaging of the sinuses, temporal bone, and craniofacial structures. Several controversies surrounding the emergence of CBCT technology will also be addressed. C onebeam CT (CBCT) is an advancement in CT imagingthat has begun to emerge as a potentially low-dose crosssectional technique for visualizing bony structures in the head and neck. The physical principles, image quality parameters, and technical limitations relevant to CBCT imaging were discussed in Part 1 of this 2-part series. The second part presented here will highlight the evidence related to CBCT applications in head and neck as well as dentomaxillofacial imaging. Controversial aspects of this technology will also be addressed, including limitations in image quality and its often officebased operational model.CBCT was first adapted for potential clinical use in 1982 at the Mayo Clinic Biodynamics Research Laboratory. 1 Initial interest focused primarily on applications in angiography in which soft-tissue resolution could be sacrificed in favor of high temporal and spatial-resolving capabilities. Since that time, several CBCT systems have been developed for use both in the interventional suite and for general applications in CT angiography. 2,3 Exploration of CBCT technologies for use in radiation therapy guidance began in 1992, 4,5 followed by integration of the first CBCT imaging system into the gantry of a linear accelerator in 1999. 6 The first CBCT system became commercially available for dentomaxillofacial imaging in 2001 (NewTom QR DVT 9000; Quantitative Radiology, Verona, Italy). Comparatively low dosing requirements and a relatively compact design have also led to intense interest in surgical planning and intraoperative CBCT applications, particularly in the head and neck but also in spinal, thoracic, abdominal, and orthopedic procedures. [7][8][9][10][11] Diagnostic applications in CT mammography and head and neck imaging are also under evaluation. 12-14 The technical and clinical considerations pertaining to CBCT imaging in many of these applications have been the subjects of several recent reviews. [15][16][17][18][19] The recent review by Dörfler et al 16 of the neurointerventional applications of CBCT is of particular interest to the field of neuroradiology.The discussion below will focus on the diagnostic and treatment-planning applications of CBCT in dentomaxillofacial and head and neck imaging. Commercially available CBCT systems for dentomaxillofacial imaging include the CB MercuRay and CB Throne (Hitachi Medical, Kashiwi-shi, Chiba-ken, Japan), 3D Accuitomo products (J. Mor...

Diffuse malignant gliomas, the most common type of brain tumor, carry a dire prognosis and are poorly responsive to initial treatment. The response to treatment is typically evaluated by measurements obtained from radiographic images several months after the start of treatment; therefore, an early biomarker of tumor response would be useful for making early treatment decisions and for prognostic information. Thirty-four patients with malignant glioma were examined by diffusion MRI before treatment and 3 weeks later. These images were coregistered, and differences in tumor-water diffusion values were calculated as functional diffusion maps (fDM), which were correlated with the radiographic response, time-to-progression (TTP), and overall survival (OS). Changes in fDM at 3 weeks were closely associated with the radiographic response at 10 weeks. The percentage of the tumor undergoing a significant change in the diffusion of water (V T ) was different between patients with progressive disease (PD) vs. stable disease (SD) (P < 0.001). Patients classified as PD by fDM analysis at 3 weeks were found to have a shorter TTP compared with SD (median TTP, 4.3 vs. 7.3 months; P < 0.04). By using fDM, early patient stratification also was correlated with shorter OS in the PD group compared with SD patients (median survival, 8.0 vs. 18.2 months; P < 0.01). On the basis of fDM, tumor assessment provided an early biomarker for response, TTP, and OS in patients with malignant glioma. Further evaluation of this technique is warranted to determine whether it may be useful in the individualization of treatment or evaluation of the response in clinical protocols.diffusion MRI ͉ human glioma ͉ treatment assessment ͉ surrogate marker

Perfusion computed tomography (CT) is a relatively new technique that allows rapid qualitative and quantitative evaluation of cerebral perfusion by generating maps of cerebral blood flow (CBF), cerebral blood volume (CBV), and mean transit time (MTT). The technique is based on the central volume principle (CBF = CBV/MTT) and requires the use of commercially available software employing complex deconvolution algorithms to produce the perfusion maps. Some controversies exist regarding this technique, including which artery to use as input vessel, the accuracy of quantitative results, and the reproducibility of results. Despite these controversies, perfusion CT has been found to be useful for noninvasive diagnosis of cerebral ischemia and infarction and for evaluation of vasospasm after subarachnoid hemorrhage. Perfusion CT has also been used for assessment of cerebrovascular reserve by using acetazolamide challenge in patients with intracranial vascular stenoses who are potential candidates for bypass surgery or neuroendovascular treatment, for the evaluation of patients undergoing temporary balloon occlusion to assess collateral flow and cerebrovascular reserve, and for the assessment of microvascular permeability in patients with intracranial neoplasms. This article is a review of the technique, clinical applications, and controversies surrounding perfusion CT.

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Allergic fungal sinusitis is a distinct clinical entity with nonspecific symptoms that may be initially suggested by the CT findings. These findings should alert the clinician to the possibility of allergic fungal sinusitis and prompt other diagnostic studies to establish the diagnosis and treatment plan.