Feedback from Dr. Robert C McKinstry, MD, PhD

Robert C McKinstry, MD, PhD
ASNR International Outreach Professor to South Africa
Reflections on My Experience with the Program

Travel to South Africa

I left Thursday midday on a flight from St. Louis to Dulles. After a 4-hour layover, I flew from Dulles to Ghana (10 hours) on South African Airways. I had a 1 hour layover on the plane before I flew from Ghana to Johannesburg (5.5 hours) arriving in the early evening on Friday. I met Gordon the driver from FreeFlight Africa by calling his mobile. This worked very well from a safety perspective because it established a positive ID for my driver. He was waiting for me by passenger arrivals. He drove me to the CityLodge in Pretoria.

Lodging and Sightseeing in Pretoria

This CityLodge location was great. The hotel gave dinner vouchers that I could use in the adjacent mall each night for dinner. I had 6 choices (Steak, Eclectic, Casual, Pizza, Fish, Burgers. This was very convenient. On Saturday, I worked in my room all day catching up on email and recovering from my travels. On Sunday, I went sightseeing around Pretoria with Gordon from FreeFlight as my guide. We went to the Union Buildings, the Paul Kruger House and to the Vorrstrekker Monument. I got a better appreciation for the history of South Africa from the perspective of the Afrikaners.

University of Pretoria, Steve Biko Hospital (Professor Zarina Lockhat)

Each day I ate the breakfast at the hotel that was included with my room. FreeFligh picked me up and drove me to Steve Biko hospital. I arrived at 9am. I generally spent the morning in the radiology department taking tours (MR, CT, General Diagnostic), reviewing difficult cases with the consultants and registrars, helping to refine MR protocols (diffusion, perfusion, MR spectroscopy, cranial nerves) and giving impromptu lectures on various topics that would arise. Every day I had a very nice and tasty catered lunch in the radiology conference room. On Wednesday evening, one of the consultants and her husband took me out to dinner at the Pretoria Golf Club for a traditional South African meal (Springbok carpaccio and medallions of impala).

The afternoons were the busiest time. I gave lectures to the consultants, registrars and neurologists. The curriculum included:

Advanced MR Imaging of the Developing Brain
MR Imaging of Preterm Brain Development
Imaging of Brain Injury in Newborns
Approach to Neuro MRI Contrast
Registrar Brain Case Conference
Registrar Head and Neck Case Conference
MR Physics – Image Optimization
Differential Diagnosis of Pediatric White Matter Disease
Imaging of Infarct Evolution
Pineal & Intraventricular Case Review
4^th year registrar case tutorial (oral boards preparation). Some of Steve Biko consultants (front row) and senior registrars (back row) are pictured below.

I also attended and participated in

Pediatric neurology conference
Neurosurgery conference and
Endocrine conference.

Finally, I held consultation hours when clinicians could bring by difficult cases for review and discussion. These cases were focused on pediatric white matter and metabolic brain diseases. Cases that were particularly memorable from the week were

The largest pilocytic astrocytoma of the cerebellum I’ve ever seen.
The largest medulloblastoma of the cerebellum I’ve ever seen.
The largest anaplastic thyroid carcinoma I’ve ever seen.
The largest dermatofibrosarcoma of the chest wall I have ever seen.
The first case of 68-Ga DOTATATE PET I’ve seen. In this case to work up a suspected pheochromocytomatous.
A case of suspected mitochondrial white matter disease.

On Friday, Professor Lockhat felt it was best to send me to Johannesburg midday to avoid the traffic.

Lodging and sightseeing in Johannesburg

I checked into the Crowne Plaza Rosebank and worked for 10 hours catching up on email. I ate room service. On Saturday, I was escorted to the Apartheid museum where I met up with Reff Ngqobe and her brother. We toured the museum together, ate lunch and they then took me to Constitution Hill where we saw the prison and the constitutional court. This was a great opportunity to learn about the liberation of black South Africa and we were able to talk for hours about black African culture. This was an amazing opportunity.

On Saturday night, I went out to dinner at Moyo Melrose Arch for traditional African cuisine and music. Professor Mngomezulu, and 4 consultants from the Johannesburg circuit joined me. This was a great social event.

On Sunday, I was picked up at the hotel by consultants Thandi Buthelezi and Kate Mohongo. We drove to the Cradle of Human Kind where we toured the Sterkfontein caves and the Meropeng exhibition. We also had a nice lunch.

At the end of the day, they drove me back to my hotel and I prepared for the next day. I ate dinner most nights in the hotel restaurant with the exception of the one day I walked up to the Rosebank mall to get take away.

The Johannesburg Hospital Circuit

Each day started with an amazing breakfast at the Crowne Plaza. My driver picked me up at the hotel at 7AM so that I could make it to Wits University/ CMFAH to give lectures from 7:30 to 9 AM. The curriculum included:

Approach to Neuro MRI Contrast
Imaging of Infarct Evolution
Advanced MR Imaging of the Developing Brain
MR Imaging of Preterm Brain Development
Differential Diagnosis of Parasailer Masses
Differential Diagnosis of Pediatric White Matter Disease
Imaging of Brain Injury in Newborns
Cranial Nerve Review
MRI of Cortical Malformations
Pineal & Intraventricular Case Review
Registrar Brain Case Conference
Registrar Head and Neck Case Conference

Consultants and registrars attending my morning lectures.

Monday – CMFAH

After my lectures, I met with Professor Victor Mngomezulu in his office to discuss the plan for the week. Then I joined Doctor Thandi Buthelezi in the reading room. I was shown a number of cases in consultation. I sat with the registrars and read out neuroradiology cases (informally). I was taken to lunch by Dr. Halvani Moodley to a local restaurant. In the afternoon, I attended a pediatric neurology conference. We went through about 5 cases in consultation. Of note, we saw 2 hemispheric malformations of cortical development and a congenital muscular dystrophy case. At 4pm, I was taken by an escort back to the Crowne Plaza. I ate dinner and prepared for the next day.

Tuesday – Chris Hani Baragwanath Academic Hospital

After my lectures at CMFAH, I was escorted to Bara by Dr. Marianne Kuehnast. Upon arrival took a tour Mammography, CT and MRI.

In MRI, we set up protocols for

Fetal MRI: We scanned a fetus with corpus callosum dysgenesis and cysts in the pineal region.
MR Spectroscopy and DSC Perfusion: We scanned an HIV+ patient (CD4 >500) with bifrontal cortical/subcortical signal abnormality on T2 and post contrast T1W imaging. We were able to show that the lesion had low CBV and a benign MRS metabolite pattern.
Cranial Nerves: We were able to compare CISS and T2SPACE for SNR and CNR in a case of suspected cholesteatoma.

I also had lunch with the registrars and a few consultants in the department. We had a lively discussion of the differences in training and clinical service delivery between the 3^rd largest hospital in the world and my hospital in the US. I also had the chance to meet with neurologists to consult on some of their difficult cases.

On the way back to the hotel, we drove along the edge of Soweto. My driver was able to share what life in the township was like.

Wednesday – Nelson Mandela Children’s Hospital

After my morning lectures, I was escorted to NMCH by Dr. Jaishree Naidoo. Upon arrival, I took a tour of the radiology department. We then had tea. We next took a tour of the hospital and then had lunch.

After lunch, we reviewed MR protocols and reviewed some recent challenging cases. The MR protocols we reviewed included

MR spectroscopy
MAGIC (plural contrast imaging) versus standard T1, T2, FLAIR and SWI acquisitions.

The consultants and radiographers and staff at NMCH

In the late afternoon, I was taken back to CMFAH for an additional lecture. Upon special request, I gave the lecture “Imaging of Brain Injury in Newborns”. Following this lecture, my driver took me back to the hotel. I ate dinner and prepared for the next day.

Thursday – Rahima Moosa Mother and Child Hospital

After my morning lectures, I was escorted to the RMMCH by Dr. Nasreen Mahomed. Upon arrival, I took a tour of the facility, met the consultants, staff and registrars and then had tea. We reviewed challenging cases together. I also gave a lecture to the consultants in radiology, neurology and neonatology “Imaging of Brain Injury in Newborns.” Following my lecture, they showed me unknown cases for an hour to ask for my opinion. This was done as a conference with about 25 doctors in attendance.

The consultants, registrars, radiographers and staff at Ramima Moosa

Following the conference, I was escorted back to the CMFAH. I gave a 90 minted 4^th year registrar case tutorial (oral boards preparation).

The 4th year registrars after the oral board review session

After the review session, my driver took me back to the hotel. I made it in time to welcome my spouse Kelly who flew in that day.

Friday – CMFAH

After my registrar case conference in the morning, I spent the rest of the day in MRI with Drs. Thandi Butelezi and Kate Mahongo. We reviewed challenging cases including a diagnosis of a Dandy Walker malformation with a tethered cord. I read cases (informally) with the registrars and we worked on MR protocols. The major accomplishments were that we set up single voxel and multivoxel MRS protocols. As chance would have it, the second patient we performed MRS upon had an inborn error of metabolism Glutaric aciduria Type 1 confirmed by the MRS.