Regorafenib in Glioblastoma Recurrence: How to Deal With MR Imaging Treatments Changes.

The treatment of recurrent high-grade gliomas remains a major challenge of daily neuro-oncology practice, and imaging findings of new therapies may be challenging. Regorafenib is a multi-kinase inhibitor that has recently been introduced into clinical practice to treat recurrent glioblastoma, bringing with it a novel panel of MRI imaging findings. On the basis of the few data in the literature and on our personal experience, we have identified the main MRI changes during regorafenib therapy, and then, we defined two different patterns, trying to create a simple summary line of the main changes of pathological tissue during therapy. We named these patterns, respectively, pattern A (less frequent, similar to classical progression disease) and pattern B (more frequent, with decreased diffusivity and decrease contrast-enhancement). We have also reported MR changes concerning signal intensity on T1-weighted and T2-weighted images, SWI, and perfusion imaging, derived from the literature (small series or case reports) and from our clinical experience. The clinical implication of these imaging modifications remains to be defined, taking into account that we are still at the dawn in the evaluation of such imaging modifications.

ColorViz, a New and Rapid Tool for Assessing Collateral Circulation during Stroke.

Prognosis of patients with acute ischemic stroke is strictly related to the patency and prominence of the collateral leptomeningeal pathways distal to the arterial occlusion. The gold standard for assessment of collateral circulation is conventional angiography, but it is invasive and used in selected cases. To date, the most reliable technique is multiphase CTA; currently, the available classifications of collateral circles are often complex, time-consuming, and require a trained observer. The purpose of our work is to establish the effectiveness of a new semi-automatic post-processing software (ColorViz FastStroke, GE Healthcare, Milwaukee, Wisconsin) in evaluation of collateral circulation compared to the six-point classifications of multiphase CTA already validated in literature. We selected 86 patients with anterior ischemic stroke symptoms who underwent multiphasic CTA in our emergency department. Two radiologists separately evaluated the collateral leptomeningeal vessels, analyzing respectively, the multiphase CTA (using the six-point scale and its trichotomized form) and ColorViz (using a three-point scale). Then the results were matched. We found a good correlation between the two different analyses; the main advantage of ColorViz is that, while maintaining fast diagnostic times, it allows a simpler and more immediate evaluation of collateral circulation, especially for less experienced radiologists.

Soft-tissue mineralization in Werner syndrome.

Werner syndrome is a rare autosomal recessive disorder characterized by clinical signs of premature aging, short stature, scleroderma-like skin changes, endocrine abnormalities, cataracts, and an increased incidence of malignancies. We report on a 48-year-old woman with Werner syndrome associated with intracranial meningiomas who had extensive musculoskeletal manifestations including osteoporosis of the extremities, extensive tendinopathy about the ankles, osteomyelitis of the phalanges of the first left toe, abundant soft-tissue calcification, and two dense ossified soft-tissue masses, with cortical bone and trabeculae arising from the posterosuperior aspect of the calcanei and extending into Kager fat pads. A review of previous descriptions of the radiological abnormalities of Werner syndrome indicates that the presence of soft-tissue calcifications has either not been noted or been mentioned only briefly. Moreover, there is no mention of bony masses associated with Werner syndrome in the world literature, and this would appear to be the first report of this kind.

Combined diagnostic imaging in a patient with Forestier disease and dysphagia.

The case of a patient with dysphonia and ingravescent dysphagia, associated with crises of lipothymia "ab ingestis" is discussed. ENT examination with videolaryngoscopy evidenced a swelling of the posterior hypopharyngeal wall. X-ray study of the upper digestive tract was discontinued for inhalation. The scintigraphic study of swalling documented marked alteration of the oropharyngeal phase with phenomena of post-deglutitory aspiration. CT of the cervical vertebral column documented anterior diffuse vertebral hyperostosis of C3-C6: this finding was suggestive of Forestier disease.

Reasoned approach to multiple osteosclerotic lesions. Combined diagnostic imaging in a case of osteopoikilosis.

The case of a female patient who had undergone mastectomy for infiltrating ductal carcinoma and come to the Orthopedics Division for lumbosacral pain unresponsive to conventional treatment is discussed. Pelvic X-ray, CT and scintigraphy were performed. The presence of multiple areas of selerosis of the pelvis and proximal femurs were documented. The differential range could be limited to osteoblastic metastasis and osteopoikilosis. The diagnosis of osteopoikilosis was established based on scintigraphy which proved the absence of uptake of the radiotracer.

CT and functional respiratory tests. Evaluation of efficacy of bronchodilator therapy in chronic obstructive pulmonary disease (COPD).

PURPOSE: To evaluate changes in qualitative and quantitative parameters at high resolution CT (HRCT) and in respiratory function indexes (RFI) after bronchodilator administration in COPD patients. MATERIALS AND METHODS: Fifteen former smokers (9 male and 6 female, mean age 65 years), with COPD were studied. Patients with asthmatic or pulmonary diseases were excluded. After informed consent, the patients underwent blood gas analysis, baseline RFI (respiratory function index), inspiratory/expiratory HRCT, administration of salbutamol and bromide (by metered-dose inhaler), RFI after 45 minutes, and inspiratory/expiratory HRCT. First, we performed a visual qualitative analysis (by means of a preformed questionnaire), and then a quantitative analysis by "density mask" programme at three levels: aortic arch, carina, and supradiaphragmatic level. By using this diagnostic approach we were able to determined the global area of each lung, dependent and independent of density, bronchus-artery ratio, emphysema extension, air trapping, morphologic distortion of the airways. RESULTS: Data correlation analysed through linear regression statistical test. Outstanding correlations were found between the RFI (Raw, SVC, IC, RV, FEV1, VP70) and, respectively, density, global lung areas, and bronchus-artery ratio changes before and after bronchodilators administration. CONCLUSIONS: Our study confirmed the usefulness of bronchodilators and the need for a multiparametric and comparative (radiological and functional) approach to COPD, as well as the usefulness of HRCT in evaluating the response to visible airway physiologic stimulus and extension, and reversibility of air trapping.

Post-processing of digital images.

Post-processing of bi- and three-dimensional images plays a major role for clinicians and surgeons in both diagnosis and therapy. The new spiral (single and multislice) CT and MRI machines have allowed better quality of images. With the associated development of hardware and software, post-processing has become indispensable in many radiologic applications in order to address precise clinical questions. In particular, in CT the acquisition technique is fundamental and should be targeted and optimized to obtain good image reconstruction. Multiplanar reconstructions ensure simple, immediate display of sections along different planes. Three-dimensional reconstructions include numerous procedures: multiplanar techniques as maximum intensity projections (MIP); surface rendering techniques as the Shaded Surface Display (SSD); volume techniques as the Volume Rendering Technique; techniques of virtual endoscopy. In surgery computer-aided techniques as the neuronavigator, which with information provided by neuroimaging helps the neurosurgeon in simulating and performing the operation, are extremely interesting.

Combined diagnostic imaging of transitional cell carcinoma of the upper urinary tract.

The case of a female patient with recurrent macroscopic hematuria and negative vesical and renal ultrasonography, is discussed. On urography a gross pyelocaliceal filling defect was visualized. Urographic findings were suggestive of the diagnosis of transitional cell carcinoma of the upper urinary. CT was performed to confirm the diagnosis and stage the tumor: it showed the presence of an advanced lesion. At histology the diagnosis of transitional cell carcinoma of the upper urinary tract was confirmed.