Case 225: Leiomyoma.

A 33-year-old pregnant woman (gravida 11, para 8) presented with increasing severe abdominal pain during the first trimester of pregnancy and increasing abdominal distention out of proportion to her prior pregnancies. Ultrasonography (US) without Doppler performed at another hospital had revealed a pelvic mass; therefore, this patient had been referred to our institution for further evaluation. Unenhanced magnetic resonance (MR) imaging was then performed at 8 weeks of gestation. The main portion of the gravid uterus and the ovaries was not seen on these images, but the parts that were seen appeared normal. Diagnostic laparoscopic biopsy was performed during the first trimester, but complete removal of the mass was deferred because of fears the pregnancy would be lost. The patient was closely observed throughout the pregnancy with serial US until the 37th week of gestation, at which time the patient underwent Caesarian section. At the time of Caesarian section, the mass was noted to extend from the spleen downward deep into the pelvis. A biopsy was performed at the time of Caesarian section. Definitive removal of the mass was deferred at the time of Caesarian section to minimize postpartum blood loss and to further delineate the mass with imaging for future surgery. Intravenous contrast material-enhanced (120 mL of Omnipaque 350; Nycomed Amersham, Princeton, NJ) computed tomography (CT) was performed 3 days after Caesarian section. The cystic component measured approximately 15 HU. Repeat MR imaging 1.5 months after Caesarian section was then performed. No loss of signal intensity in the mass was seen on fat-saturated images. There was no evidence of local or distant metastatic disease. The mass abutted and displaced the uterus and the ovaries but did not distort either of these organs. Vascular anatomy was not useful in determining the origin of the mass. The comprehensive metabolic panel and complete blood count were normal throughout and after the pregnancy.

A dental nightmare, resolved: what a radiologist needs to know when consulted about ingestion of dental foreign body material.

Ingestion of dental foreign bodies, while relatively rare, may cause serious, and occasionally fatal, injuries to the airways and gastrointestinal tract. Numerous case reports are available describing the clinical course of such ingestions. The aim of this paper is to develop concise, practical recommendations to aid radiologists in providing clinically relevant diagnostic information, thereby accelerating detection and management of acute ingestion of dental material.

Effects of varying serum glucose levels on 18F-FDG biodistribution.

OBJECTIVE: Hyperglycemia has been shown to influence fluorine-18 fluorodeoxyglucose ((18)F-FDG) uptake in tumor cells. Therefore, patients are instructed to fast for 6 h, while maintaining serum glucose levels at an acceptable range. The study was performed to evaluate the effect of fasting blood glucose levels on the biodistribution of (18)F-FDG in various tissues including the liver, heart, bone marrow, skeletal muscle, and tumors. MATERIALS AND METHODS: Fingerstick fasting blood glucose is routinely measured on the morning of the procedure. The maximum standardized uptake value (SUV(max)) in the right and left hepatic lobes, left ventricle, sacrum, thigh, and tumor was measured in 229 consecutive patients undergoing (18)F-FDG PET/computed tomography for tumor. Patients were divided into three groups depending on their serum glucose levels: low (<100; n = 53), medium (100-160; n = 149), and high (160-201; n = 27). A retrospective analysis of the relationship between glucose levels and standardized uptake value was performed. RESULTS: There was a statistically significant increase in the average SUV(max) in the right and left hepatic lobes as glucose levels increased (right lobe P=0.00144; left lobe P = 0.03889). Subsequently, pairwise analysis was performed, revealing a statistically significant increase in SUV(max) in the right hepatic lobe between low-glucose and medium-glucose groups and in both hepatic lobes between low and high groups (P < 0.017). No significant difference was observed in any of the other measured tissues. CONCLUSION: This study shows a directly proportional relationship between blood glucose levels and nonpathologic (18)F-FDG biodistribution in the right and left hepatic lobes. The influence of blood glucose on expected biodistribution patterns, particularly in the liver, should be considered during interpretation.

Historical perspective: eponyms of vascular radiology.

Eponyms are ubiquitous throughout the medical literature, especially the radiology lexicon. In particular, vascular radiology is replete with dozens of eponyms named after pathologic and anatomic features and various medical devices. Several disease processes are known exclusively by their eponyms or by both their eponyms and their descriptive names. Although some authors advocate abandoning eponyms in favor of more descriptive terms, the established history and common use of eponyms make it unlikely that they will disappear from the vocabulary. Radiologists should be familiar with both the eponymous and descriptive names of disease processes to ensure effective communication and prevent erroneous identification. Study of these eponyms provides information about these disease processes and other medical knowledge for use in daily practice. In addition, biographic information about the pertinent physicians can yield insights into the sometimes surprising origins of these eponyms. The authors provide biographic sketches of these physicians and discuss the clinical relevance of the anatomic features, malformations, and syndromes that bear their names.

Clinical guidelines for imaging and reporting ingested foreign bodies.

OBJECTIVE: The purpose of this article is to familiarize radiologists with the specific characteristics of foreign bodies, obtained from image interpretation, to guide further management. Details of object morphologic characteristics and location in the body gained through imaging form the backbone of the classification used in the treatment of ingested foreign bodies. CONCLUSION: The characteristics of foreign bodies and predisposing bowel abnormalities affect the decision to follow ingested objects radiographically, perform additional imaging, or proceed with endoscopic or surgical removal.

Perforation in a patient with stercoral colitis and diverticulosis: who did it?

Stercoral colitis with perforation of the colon is an uncommon, yet life-threatening cause of the acute abdomen. No one defining symptom exists for stercoral colitis; it may present asymptomatically or with vague symptoms. Diagnostic delay may result in perforation of the colon resulting in complications, even death. Moreover, stercoral perforation of the colon can also present with localized left lower quadrant abdominal pain masquerading as diverticulitis. Diverticular diseases and stercoral colitis share similar pathophysiology; furthermore, they may coexist, further complicating the diagnostic dilemma. The ability to decide the cause of perforation in a patient with both stercoral colitis and diverticulosis has not been discussed. We, therefore, report this case of stercoral perforation in a patient with diverticulosis and include a discussion of the epidemiology, clinical presentation, and a review of helpful diagnostic clues for a rapid differentiation to allow for accurate diagnosis and treatment.

Radiologic findings in cases of attempted suicide and other self-injurious behavior.

Suicide is one of the leading causes of death in multiple age groups. Therefore, it is important that radiologists be aware of this commonly encountered entity. Attempted suicide may take a variety of forms; those discussed by the authors include sharp force injury, immolation and inhalation, ingestion, hanging, firearm use, jumping from a height, and drowning. Certain radiologic findings are commonly seen in cases of attempted suicide and other self-injurious behaviors. In some cases, especially when the patient is unconscious or is unwilling to provide a history, it may not be apparent that suicide has been attempted until characteristic imaging findings are recognized. Correct identification of suicide attempts on the basis of such findings will ensure that these patients receive appropriate psychiatric treatment. When a suicide attempt is unsuccessful, it is important to be familiar with the complications that may contribute to delayed mortality and morbidity. The radiologist plays an integral role in the acute medical or surgical management of patients who have attempted suicide. In addition, imaging examinations may provide useful forensic information.

Imaging of mechanical tubal occlusion devices and potential complications.

The increasing use of permanent mechanical contraceptive devices has placed growing demands on radiologists. Hysteroscopically placed tubal occlusion devices, in particular, must be evaluated promptly and carefully to verify that they are in a satisfactory location and are functioning effectively. Hysterosalpingography, radiography, ultrasonography, computed tomography, and magnetic resonance imaging all may be useful for this purpose; however, the acquisition and interpretation of images of these devices can be challenging and requires specific knowledge. Verification of tubal occlusion with a hysteroscopically placed device depends heavily on the adequacy of cornual distention with the contrast medium at hysterosalpingography. Some complications of coil (Essure device) placement, such as tubal perforation and device migration, may be clinically occult and their imaging appearances subtle; a high degree of suspicion is needed to detect them at postprocedural imaging. The position of another tubal occlusion device, a radiolucent silicone matrix (Adiana device), is not directly depicted at imaging with x-rays. By contrast, laparoscopically placed locking tubal clips are well depicted at radiography; however, their dislodgement and migration are seldom symptomatic and thus unlikely to be discovered in time to avert pregnancy. The use of any tubal occlusion device is associated with low albeit finite risks of unwanted intrauterine pregnancy, ectopic pregnancy, tubal and uterine perforation, and device migration into the peritoneal cavity. Results of multiple trials show that a substantial percentage of such complications occurred because of image misinterpretation and consequent patient reliance on tubal occlusion alone for contraception. Accurate description and classification of abnormalities in device position or function seen at imaging performed postprocedurally or for other clinical indications will enhance the value of radiologists' contributions to patient care.

Pediatric osteomyelitis: a scintigraphic case-based review.

This review presents techniques to optimize bone scintigraphy for evaluation of the spectrum of abnormalities associated with pediatric osteomyelitis, with an emphasis on the approaches to patient preparation and positioning and to interpretation. The diagnosis of pediatric osteomyelitis can be challenging for several different reasons. Bone scintigraphy is especially useful when the site of osteomyelitis is unclear. Other imaging modalities, including radiography, ultrasonography, and magnetic resonance imaging, all have advantages and may have a role in evaluating the condition of the child with osteomyelitis. Pathophysiologic considerations unique to children contribute to a different clinical presentation of osteomyelitis in the pediatric population than that seen in adults. In addition, patient movement degrades image quality substantially, which is an important consideration for imaging children. Neonates have a higher incidence of multifocal osteomyelitis, and they represent a unique subset of the pediatric population with separate considerations. Several examples illustrate techniques to optimize imaging, as well as show the spectrum of abnormalities associated with pediatric osteomyelitis. Careful attention to bone scintigraphic technique ensures that high-quality images can be obtained, which will allow confident diagnosis of pediatric osteomyelitis.

The bone scan.

Bone imaging continues to be the second greatest-volume nuclear imaging procedure, offering the advantage of total body examination, low cost, and high sensitivity. Its power rests in the physiological uptake and pathophysiologic behavior of 99m technetium (99m-Tc) diphosphonates. The diagnostic utility, sensitivity, specificity, and predictive value of 99m-Tc bone imaging for benign conditions and tumors was established when only planar imaging was available. Currently, nearly all bone scans are performed as a planar study (whole-body, 3-phase, or regional), with the radiologist often adding single-photon emission computed tomography (SPECT) imaging. Here we review many current indications for planar bone imaging, highlighting indications in which the planar data are often diagnostically sufficient, although diagnosis may be enhanced by SPECT. (18)F sodium fluoride positron emission tomography (PET) is also re-emerging as a bone agent, and had been considered interchangeable with 99m-Tc diphosphonates in the past. In addition to SPECT, new imaging modalities, including (18)F fluorodeoxyglucose, PET/CT, CT, magnetic resonance, and SPECT/CT, have been developed and can aid in evaluating benign and malignant bone disease. Because (18)F fluorodeoxyglucose is taken up by tumor cells and Tc diphosphonates are taken up in osteoblastic activity or osteoblastic healing reaction, both modalities are complementary. CT and magnetic resonance may supplement, but do not replace, bone imaging, which often detects pathology before anatomic changes are appreciated. We also stress the importance of dose reduction by reducing the dose of 99m-Tc diphosphonates and avoiding unnecessary CT acquisitions. In addition, we describe an approach to image interpretation that emphasizes communication with referring colleagues and correlation with appropriate history to significantly improve our impact on patient care.