Multimodality ultrasound assessment of the spleen: Normal appearances and emergency abnormalities.

This paper summarizes the main splenic emergencies and their ultrasonographic findings to orient appropriate patient management. US requires minimal preparation time and allows to examine the parenchyma and to detect intraperitoneal fluid collections, which may be indirect evidence of solid organ injuries. In this paper, we analyze the role of B-mode, Doppler and Contrast-Enhanced Ultrasound in the diagnosis of splenic emergencies, with a particular focus on splenic infarction, infection, traumatic injuries and vascular splenic anomalies.

Multiparametric Ultrasound Diagnostic Approach to Malignancy-Mimicking Adenomatoid Tumors of the Scrotum: Is Strain Elastography Enough?

Background: Paratesticular tumors (PTs) are very uncommon, accounting for almost 5% of intrascrotal tumors. Of these, adenomatoid tumors (ATs) represent about 30% and most frequently arise in the tail of the epididymis. Ultrasound (US) examination is the first-choice imaging method employed for the evaluation of the scrotum. Unfortunately, there are no specific US-imaging features useful for distinguishing an AT from a malignant lesion. To increase diagnostic accuracy and confidence, new sonographic techniques have incorporated real-time tissue elastography (RTE) under the assumption that malignant lesions are "harder" than benign lesions. Case report: In our paper, we describe a very rare case of a 60-year-old patient with a giant paratesticular mass mimicking malignancy when examined using RTE, i.e., it was stiffer than the surrounding tissue (a hard pattern), which, upon histologic examination, was identified as an AT. Discussion: Our case underscores that there is also a significant overlap between different types of scrotal lesions when RTE is used for examination. Thus, if a PT is found, the imaging approach should always be supplemented with more definitive diagnostic methods, such as FNAC or FNAB, which are the only diagnostic methods capable of leading to a certain diagnosis. Conclusions: Alongside underlining the importance of pre-operative imaging for making correct diagnoses and selecting the correct therapy, we wish to draw our readers' attention to this report in order to demonstrate the clinical implications of a giant AT presenting as stiff lesions when examined using SE.

Successful endovascular embolization of a giant splenic artery pseudoaneurysm secondary to a huge pancreatic pseudocyst with concomitant spleen invasion.

Pseudoaneurysms of the pancreatic and peripancreatic arteries is a well-known complication of chronic or necrotizing pancreatitis due to proteolytic enzymatic digestion of the arterial wall. A major part of peripancreatic pseudoaneurysms involve the splenic artery, but any peripancreatic artery may be involved and bleed. They are potentially life threatening for patients, due to spontaneous intraperitoneal rupture, rupture and fistulization into the surrounding organs, or fistulization into the pancreatic duct. Small ones are usually asymptomatic and are often diagnosed incidentally, while giant (> 5 cm) aneurysms and pseudoaneurysms are symptomatic and may be detected as a pulsatile mass in the upper-left quadrant or epigastrium. Imaging plays a key role in the identification of splenic artery aneurysms and pseudoaneurysms, while angiography still represents the gold standard for the diagnosis, although nowadays it plays a prominent role in treatment. Treatment of splenic artery pseudoaneurysms is mandatory because of the high probability of rupture, with a mortality rate of up to 90%. The gold standard treatment is represented by surgery, with a mortality rate between 16% and 50%. In recent years the endovascular approach has proven to be an effective alternative treatment for splenic artery pseudoaneurysms, and it is currently the method of choice. In this article, we present the case of a ant pseudoaneurysm of the splenic artery due to huge pseudocysts in a young alcoholic patient with recurrent and chronic pancreatitis, complicated by fistulization and invasion of spleen parenchyma and arteriovenous fistula.

Embolization of high-flow priapism: technical aspects and clinical outcome from a single-center experience.

PURPOSE: High-flow priapism is an incomplete and painless persistent erection caused by trauma. Its diagnosis is performed thanks to clinic and imaging evaluation with detection of fistula/pseudoaneurysm in the cavernous tissue. This paper aims to retrospectively assess the efficacy and safety of superselective arterial embolization in patients with high-flow priapism. MATERIALS AND METHODS: From January 2008 to March 2017, nine patients with high-flow priapism have been treated in a single center with embolization. The main etiology was trauma in eight subjects. The patients were evaluated with laboratory examinations and clinical and imaging findings (color Doppler ultrasonography and angiography). The mean follow-up time after embolization was 24 months. RESULTS: Eleven procedures were performed in nine patients: two of them required a second treatment session because of recurrence after 1-2 weeks. Embolic agents were microcoils, microparticles (300-500 µm) and Spongostan. Restoration of erectile function was monitored by clinical and color Doppler evaluation during follow-up. CONCLUSIONS: Superselective embolization should be the procedure of choice in patients affected by high-flow priapism; this technique appears to be successful in preserving erectile function. The choice of the embolic agent is crucial, and it should be tailored for each patient.

The Role of CT-Angiography in the Acute Gastrointestinal Bleeding: A Pictorial Essay of Active and Obscure Findings.

Gastrointestinal bleeding is a potentially life-threatening abdominal emergency that remains a common cause of hospitalisation. Although 80-85% of cases of gastrointestinal bleeding resolve spontaneously, it can result in massive haemorrhage and death. The presentation of gastrointestinal bleeding can range from asymptomatic or mildly ill patients requiring only conservative treatments to severely ill patients requiring immediate intervention. Identifying the source of the bleeding can be difficult due to the wide range of potential causes, the length of the gastrointestinal tract and the intermittent nature of the bleeding. The diagnostic and therapeutic approach is fully dependent on the nature of the bleeding and the patient's haemodynamic status. Radiologists should be aware of the appropriate uses of computed tomography angiography and other imaging modalities in patients with acute gastrointestinal bleeding, as well as the semiotics of bleeding and diagnostic pitfalls in order to appropriately diagnose and manage these patients. The learning objective of this review is to illustrate the computed tomography angiography technique, including the potential role of dual-energy computed tomography angiography, also highlighting the tips and tricks to identify the most common and uncommon features of acute gastrointestinal bleeding and its obscure form.

High-flow post-traumatic priapism: diagnostic and therapeutic workup.

Priapism is a prolonged penile tumescence or erection unrelated to sexual stimulation that lasts more than 6 h. High-flow priapism is a rare condition usually due to a perineal trauma with the formation of an arterio-cavernosal fistula between a cavernosal artery and the lacunar spaces of the penis. High-flow priapism is usually diagnosed by clinical examination and color Doppler ultrasound, and the gold standard therapeutic management is represented by digital subtraction angiography. We report a case of a young patient with high-flow priapism after a motorcycle blunt perineal trauma, examining in detail the specific color Doppler ultrasound findings, the diagnostic workup and the therapeutic management.

Computed tomography imaging of septic shock. Beyond the cause: the "CT hypoperfusion complex". A pictorial essay.

Septic shock is a medical emergency that represents one of the most important underlying causes for presentation to the Emergency Department. Sepsis is defined as organ dysfunction, life-threatening event caused by a deregulated inflammatory host response to infection, with a mortality risk ranging from 10 to 40%. Early sepsis identification is the cornerstone of management and diagnostic imaging can play a pivotal role in this clinical context. The choice of imaging modality depends on several factors, associated with the clinical condition and the presence or absence of localising signs and symptoms. The diagnostic accuracy of contrast-enhanced total-body CT has been well established during septic shock, allowing for a rapid, panoramic, and detailed study of multiple body areas, simultaneously. The aim of this article is to illustrate the controversial CT hypoperfusion complex in patients with septic shock, characterised by the following imaging features: decreased enhancement of the viscera; increased mucosal enhancement; luminal dilation of the small bowel; mural thickening and fluid-filled loops of the small bowel; the halo sign and flattening of the inferior vena cava; reduced aortic diameter; peripancreatic oedema; abnormal parenchymal perfusion; and other controversial findings that are variably associated with each other and reversible during the early stages. Increasing physicians' awareness of the significance of these findings could prompt alternative approaches to the early assessment and management of septic shock. In this perspective, CT imaging represents a useful tool for a complete, rapid and detailed diagnosis of clinically suspected septic shock, which can be used to improve patient outcomes.

Ultrasound of scrotal and penile emergency: how, why and when.

High-resolution ultrasound is the most common imaging technique used to supplement the physical examination of scrotum and penis with great accuracy in assisting the diagnosis of the various pathologies of male genital system, with the highest diagnostic potential in emergency conditions. Technical advancements in real-time high-resolution, color flow Doppler sonography and contrast enhanced ultrasonography (CEUS) have led to an increase in the clinical applications of scrotal and penile sonography. In this pictorial review we focus on common and uncommon male genitalia emergency with special emphasis on the role of ultrasound assessment and its specific findings to improve diagnostic accuracy.

Corrigendum to "Combined surgical and interventional radiological treatment for biliary leakage following iatrogenic biliary obstruction" [Radiol Case Rep 13 (2018) 772-777].

[This corrects the article DOI: 10.1016/j.radcr.2018.04.029.].

Successful endovascular treatment of a spontaneous bleeding accessory spleen: A case report.

Accessory spleens are often encountered in radiologic studies and they are not usually associated with symptoms. They could arise from autotransplantation of splenic tissue after splenic trauma or splenectomy (splenosis) [1]. In this case we describe a woman treated for splenectomy 20 years before and subsequently for adhesions, that suffered sudden left upper abdominal quadrant pain, weakness, and pale color. Contrast-enhanced computed tomography revealed free spilling in the abdomen and venous bleeding of a big accessory spleen; thus the patient underwent transcatheter arterial embolization with coils. Due to the 2 previous surgical operations in the splenic loggia, endovascular treatment compared to "open surgery" was the best choice in this case because of determined less complications, a shorter period of hospitalization, and a reduction of health cost.

Combined surgical and interventional radiological treatment for biliary leakage following iatrogenic biliary obstruction.

Biliary leakage is a challenging complication when managing the bile duct strictures. The etiology of benign strictures of the biliary tree may have different etiologies but iatrogenic is the most common, with relevant increase after introduction of laparoscopic procedures. Interventional radiologist plays a key role, both in diagnosis and treatment of biliary strictures and leakage. We report on a case of a 39-year-old woman affected by abdominal pain and jaundice after laparoscopic cholecystectomy; jaundice was caused by surgical clipping of the common bile duct. The combined management by surgeon and interventional radiologist, consisting of removal of surgical clip and percutaneous management of biliary leakage, successfully resolved the leakage with clinical success.

Successful endovascular embolization of an intralobar pulmonary sequestration.

Pulmonary sequestration is a congenital malformation characterized by dysplastic pulmonary tissue which receives blood supply by arterial systemic system, not in communication with tracheobronchial tree. Although it could be asymptomatic, it can also cause recurrent infections and hemoptysis, rarely massive and fatal. The conventional treatment consists in surgical resection of the pulmonary sequestration, but in the last few years endovascular embolization has been proposed as a valid therapeutic alternative. In this paper, we report the case of a 43-year-old woman affected by recurrent hemoptysis. Computed tomography angiography of the chest, abdomen, and pelvis was performed in emergency setting. Intralobar pulmonary sequestration in the lower lobe of the right lung was found. A bulky aberrant artery originating from the thoracic aorta supplied the pulmonary sequestration. The interventional radiologist performed an endovascular embolization with coils of the vascular malformation. The technical success of the procedure was confirmed by computed tomography angiography of the chest performed on the fourth day after procedure. Further examination performed 6 months later showed no complications. The patient was completely asymptomatic during follow-up. This procedure can demonstrate that arterial embolization is a valid and effective therapeutic alternative to surgical resection in the treatment of pulmonary sequestration.

Uterine Arteriovenous Fistula with Concomitant Pelvic Varicocele: Endovascular Embolization with Onyx-18®.

Uterine arteriovenous fistulas are rare and acquired causes of life-threatening vaginal bleeding. They usually present with intermittent menometrorrhagia in young patients in childbearing age with history of gynecological procedures on uterus. Traditional management is hysterectomy; endovascular embolization represents nowadays an alternative strategy for patients wishing to preserve fertility. Here, the endovascular approach to a 29-year-old woman affected by severe menometrorrhagia caused by a uterine arteriovenous fistula with a concomitant pelvic varicocele is reported; a bilateral uterine arteries embolization with Onyx-18 (ev3, Irvine, CA, USA) has successfully resolved the fistula with clinical success.