Beyond the bowel: Wernicke's encephalopathy as a neurological complication of Crohn's disease: A case report.

Wernicke encephalopathy (WE) is a rare but severe neurological syndrome characterized, in its classic form, by the acute onset of ocular disturbances, ataxia, and cognitive impairment. It is caused by a deficiency of thiamine (vitamin B1) and mainly affects chronic alcoholics, although it can also affect patients with pathologies that lead to malnutrition. We present a case of a 58-year-old woman, who presented with significant weight loss over the past 6 months and who came to the emergency department for episodes of repetitive vomiting and a sleepy state. The patient underwent blood chemistry tests and a brain CT scan, which revealed symmetrical and bilateral hypodensity of the medial portion of the thalamus, tectal plate, and periaqueductal gray matte, suggestive of WE. She was subsequently referred to the Department of Neurology and underwent a brain MRI, which confirmed the clinical suspicion. She also had an abdominal CT scan and ileo-colonoscopy and was diagnosed with Crohn's disease. Immediately after the clinical diagnosis of WE, a replacement therapy based on intravenous thiamine at high doses was promptly set up, and the patient improved from a clinical point of view. Wernicke encephalopathy can be difficult to diagnose when it occurs in non-alcoholic patients; WE associated with IBD is a rare condition, and it can present with atypical and more subtle symptoms. Radiologists and physicians must be aware of this condition and imaging findings for rapid diagnosis and treatment.

Suppurative thyroiditis, a sign of branchiogenic fistula? Lesson based on a case report.

Branchiogenic fistulas are congenital alterations that affect the cervical compartments. Those of the fourth branchial cleft are rarest and can begin late with very serious complications. The suppurative thyroiditis can be a complication of these alterations. We describe a case of 3-year-old girl with high fever, left cervical swelling and increased inflammation indices. The neck ultrasound showed an abscess of the left thyroid lobe and a fluid mass with aerial content in laterocervical region. On MRI, the fluid mass extended from the left piriform sinus to the mediastinum. Fluoroscopy also highlighted a fistolose trait that extended from the left side wall of the esophagus, anteriorly towards the trachea. Treatment of these pathologies must be early and a late diagnosis can put patients' lives at risk.

Prostate Artery Embolization as Minimally Invasive Treatment for Benign Prostatic Hyperplasia: An Updated Systematic Review.

Background/Objectives: Benign prostatic hyperplasia (BPH) has a significant impact on the quality of life of symptomatic patients. In patients manifesting lower urinary tract symptoms (LUTS), prostatic arterial embolization (PAE) has become a topic of interest in recent years. The purpose of this systematic review is to analyze and review techniques and clinical outcomes of patients who underwent endovascular treatment of BPH, with a special focus on the comparison of surgical and endovascular procedures. Methods: Through the major scientific databases, 1225 articles were selected from the initial research utilizing specific keywords and medical subject headings. Based on the inclusion and exclusion criteria established for selecting relevant studies for our purposes, the systematic analysis of the literature was conducted on a total of seven articles. Results: We collected data on 718 male patients (408 patients underwent PAE and 310 received TURP). The technical success rate varied from 86% to 100% for TAE and was 100% for TURP. During a 12-month follow-up period, both PAE and TURP were comparable on the reduction in IPSS and QoL questionnaire, while TURP showed significant improvements in Qmax and in the reduction in prostate volume. Length and cost of hospitalization were lower for PAE. Complication and adverse events rates were higher in the TURP group rather than in the PAE group (60.6% vs. 35.5%). Conclusions: Prostatic artery embolization represents an emerging minimally invasive procedure for BPH. According to previously released clinical studies, quality-of-life and urological symptom scores of the PAE group were comparable to those of the TURP group. Our research strengthens the evidence supporting the effectiveness and safety of PAE as a therapy for LUTS related to BPH.

Renal extramedullary hematopoiesis as an epiphenomenon of bone marrow dysfunction in a patient with primary myelofibrosis: A rare case report.

Extramedullary hematopoiesis represents a clinical compensatory condition characterized by the growth of hematopoietic tissue outside the bone marrow. It can mainly occur in patient with myeloproliferative disorders where alteration or neoplastic invasion of the bone marrow causes ineffective production of blood cells with the recruitment of progenitrix blood cells in non-hematopoietic organs, including kidneys. Renal extramedullary hematopoiesis is a rare condition manifesting as parenchymal or perirenal soft tissue masses with different patterns mimicking neoplasms, infectious or vascular diseases. We describe a unique case of a patient affected by primary myelofibrosis underwent ultrasound and magnetic resonance examinations showing bilateral perirenal alterations to be related to hemopoietic tissue. We also focused on the pathophysiology of this condition with imaging correlation. The case we present emphasises the importance of recognising the main radiological features of renal extramedullary hematopoiesis. MR examination should become part of the diagnostic pathway of the patient with primary myelofibrosis.

Quantitative Diffusion-Weighted MR Imaging: Is There a Prognostic Role in Noninvasively Predicting the Histopathologic Type of Uveal Melanomas?

Histopathologically, uveal melanomas (UMs) can be classified as spindle cell, mixed cell and epithelioid cell type, with the latter having a more severe prognosis. The aim of our study was to assess the correlation between the apparent diffusion coefficient (ADC) and the histologic type of UMs in order to verify the role of diffusion-weighted magnetic resonance imaging (DWI) as a noninvasive prognostic marker. A total of 26 patients with UMs who had undergone MRI and subsequent primary enucleation were retrospectively selected. The ADC of the tumor was compared with the histologic type. The data were compared using both one-way analysis of variance (ANOVA) (assessing the three histologic types separately) and the independent t-test (dichotomizing histologic subtypes as epithelioid versus non-epithelioid). Histologic type was present as follows: the epithelioid cell was n = 4, and the spindle cell was n = 11, the mixed cell type was n = 11. The mean ADC was 1.06 ± 0.24 × 10-3 mm2/s in the epithelioid cells, 0.98 ± 0.19 × 10-3 mm2/s in the spindle cells and 0.96 ± 0.26 × 10-3 mm2/s in the mixed cell type. No significant difference in the mean ADC value of the histopathologic subtypes was found, either when assessing the three histologic types separately (p = 0.76) or after dichotomizing the histologic subtypes as epithelioid and non-epithelioid (p = 0.82). DWI-ADC is not accurate enough to distinguish histologic types of UMs.

Acute Colonic Diverticulitis: CT Findings, Classifications, and a Proposal of a Structured Reporting Template.

Acute colonic diverticulitis (ACD) is the most common complication of diverticular disease and represents an abdominal emergency. It includes a variety of conditions, extending from localized diverticular inflammation to fecal peritonitis, hence the importance of an accurate diagnosis. Contrast-enhanced computed tomography (CE-CT) plays a pivotal role in the diagnosis due to its high sensitivity, specificity, accuracy, and interobserver agreement. In fact, CE-CT allows alternative diagnoses to be excluded, the inflamed diverticulum to be localized, and complications to be identified. Imaging findings have been reviewed, dividing them into bowel and extra-intestinal wall findings. Moreover, CE-CT allows staging of the disease; the most used classifications of ACD severity are Hinchey's modified and WSES classifications. Differential diagnoses include colon carcinoma, epiploic appendagitis, ischemic colitis, appendicitis, infectious enterocolitis, and inflammatory bowel disease. We propose a structured reporting template to standardize the terminology and improve communication between specialists involved in patient care.

Spontaneous Abdominal Wall Hematoma Treated with Percutaneous Transarterial Embolization: Diagnostic Findings, Procedural Outcome, and Efficacy-A Multicenter Study.

Endovascular management of abdominal wall hematomas (AWHs) is now the primary treatment option in hemodynamically stable patients, and it is often preferred to surgical interventions. The purpose of this multicentric study was to assess the safety, technical, and clinical success of percutaneous transarterial embolization (PTAE) of spontaneous AWHs to evaluate the efficacy of blind or empiric embolization compared to targeted embolization and to compare the outcome of the endovascular treatment approach in patients affected by COVID-19 and non-COVID-19 patients. We retrospectively enrolled 112 patients with spontaneous AWHs who underwent PTAE, focusing on signs of bleeding at pre-procedural CTA and DSA. Patients were separated into two groups depending on whether a blind or targeted embolization approach was used. We also divided patients into COVID-19 and non-COVID-19 groups. The mean age of the study population was 68.6 ± 15.8 years. CTA and DSA revealed signs of active bleeding in 99 and 88 patients, respectively. In 21 patients, blind embolization was performed. The overall technical success rate was 99%. Clinical success was obtained in 96 patients (86%), while 16 (14%) re-bled within 96 h. One patient reported a major peri-procedural complication. The comparison between blind and targeted embolization approaches showed no statistically significant differences in the characteristics of groups and technical and clinical success rates. No significant differences were found in the procedural outcome between COVID-19 and non-COVID-19 groups. Our study confirmed that PTAE is effective for treating spontaneous AWHs, even in COVID-19 patients. It suggests that the efficacy and safety of blind embolization are comparable to targeted embolization.

Embolization for acute nonvariceal bleeding of upper and lower gastrointestinal tract: a systematic review.

BACKGROUND: Acute non-variceal gastrointestinal bleedings (GIBs) are pathological conditions associated with significant morbidity and mortality. Embolization without angiographic evidence of contrast media extravasation is proposed as an effective procedure in patients with clinical and/or laboratory signs of bleeding. The purpose of this systematic review is to define common clinical practice and clinical and technical outcomes of blind and preventive embolization for upper and lower gastrointestinal bleeding. MAIN BODY: Through the PubMed, Embase and Google Scholar database, an extensive search was performed in the fields of empiric and preventive embolization for the treatment of upper and lower gastrointestinal bleedings (UGIB and LGIB). Inclusion criteria were: articles in English for which it has been possible to access the entire content; adults patients treated with empiric or blind transcatheter arterial embolization (TAE) for UGIB and/or LGIB. Only studies that analysed clinical and technical success rate of blind and empiric TAE for UGIB and/or LGIB were considered for our research. Exclusion criteria were: recurrent articles from the same authors, articles written in other languages, those in which the entire content could not be accessed and that articles were not consistent to the purposes of our research. We collected pooled data on 1019 patients from 32 separate articles selected according to the inclusion and exclusion criteria. 22 studies focused on UGIB (total 773 patients), one articles focused on LGIB (total 6 patients) and 9 studies enrolled patients with both UGIB and LGIB (total 240 patients). Technical success rate varied from 62% to 100%, with a mean value of 97.7%; clinical success rate varied from 51% to 100% with a mean value of 80%. The total number of complications was 57 events out of 1019 procedures analysed. CONCLUSION: TAE is an effective procedure in the treatment of UGIB patients in which angiography does not demonstrate direct sign of ongoing bleeding. The attitude in the treatment of LGIBs must be more prudent in relation to poor vascular anastomoses and the high risk of intestinal ischemia. Blind and preventive procedures cumulatively present a relatively low risk of complications, compared to a relatively high technical and clinical success.

Radiological stent placement of post sleeve gastrectomy leak: efficacy, imaging features and post-procedure complications.

Laparoscopic sleeve gastrectomy (SG) is the most commonly performed bariatric procedure. The primary and insidious early post-SG complication is the gastric leak (GL). In literature, there are many studies describing the endoscopic stent placement as treatment of GL and few studies about stent placement performed by interventional radiology under fluoroscopic guide. Our aims were to describe the radiological stent placement technique, to compare endoscopic and radiological stent placement, to illustrate normal diagnostic features and summarise the incidence of complications after stent placement, removal, and their imaging features. This was a single centre retrospective study of 595 patients who underwent SG between 2011 and 2019. Inclusion criteria: patients who developed GL after SG and treated with gastro-oesophageal stent placement by endoscopy or interventional radiology; availability of medical history and imaging studies; follow-up time after stent removal (1 year). The rates of technical success, clinical success and complications after stent placement and removal were collected and compared between the two methods of stent positioning. A total of 17/595 (2.8%) patients developed a radiologically diagnosed GL after SG. The type II-III GLs (15/17) were treated with endoscopic or radiological stent placement. 9/15 (60%/Group A) patients underwent gastro-oesophageal stenting by interventional radiology and 6/15 (40%/Group B) were treated with endoscopic stent placement. The technical and clinical success rate was 100% for both groups. Stent migration occurred in 22% and 27% for Group A and B respectively. Post-extraction stenosis was the main late complication, occurring in 22% in Group A and 0% in Group B. Gastro-esophageal stent placement performed by interventional radiologists is a valid "mini-invasive" treatment for GL. This procedure is not inferior to endoscopic positioning regarding efficacy, periprocedural and postprocedural complication rate. It's necessary to be familiar with radiological findings after stent placement and removal. Computed tomography (CT) scan is the main radiological technique to identify stent placement complications. Upper gastrointestinal (UGI) series are the first radiological procedures used to detect late complications after stent removal.

Histopathologic and MR Imaging Appearance of Spontaneous and Radiation-Induced Necrosis in Uveal Melanomas: Initial Results.

Necrosis in uveal melanomas can be spontaneous or induced by radiotherapy. The purpose of our study was to compare the histopathologic and MRI findings of radiation-induced necrosis of a group of proton beam-irradiated uveal melanomas with those of spontaneous necrosis of a control group of patients undergoing primary enucleation. 11 uveal melanomas who had undergone proton beam radiotherapy, MRI and secondary enucleation, and a control group of 15 untreated uveal melanomas who had undergone MRI and primary enucleation were retrospectively identified. Within the irradiated and nonirradiated group, 7 and 6 eyes with histological evidence of necrosis respectively, were furtherly selected for the final analysis; the appearance of necrosis was assessed at histopathologic examination and MRI. Irradiated melanomas showed a higher degree of necrosis as compared with nonirradiated tumors. Irradiated and nonirradiated lesions differed based on the appearance and distribution of necrosis. Irradiated tumors showed large necrotic foci, sharply demarcated from the viable neoplastic tissue; nonirradiated tumors demonstrated small, distinct foci of necrosis. Radiation-induced necrosis, more pigmented than surrounding viable tumor, displayed high signal intensity on T1-weighted and low signal intensity on T2-weighted images. The hemorrhagic/coagulative necrosis, more prevalent in nonirradiated tumors (4 out of 6 vs. 1 out of 7 cases), appeared hyperintense on T2-weighted and hypointense on T1-weighted images. Our study boosts the capability to recognize radiation-induced alterations in uveal melanomas at MRI and may improve the accuracy of radiologists in the evaluation of follow-up MR examination after radiotherapy.

Pulmonary Vasculitides: A Radiological Review Emphasizing Parenchymal HRCT Features.

Vasculitides represent a heterogeneous group of immune-mediated disorders, characterized by a systemic inflammatory destructive process of the blood vessels resulting either in ischemia or hemorrhage. The organ involved and vessel size influence the pattern of presentation of the pathology. The lung is commonly involved in systemic vasculitides, with heterogeneous clinical, radiological, and histopathological presentations. Primary vasculitides most commonly associated with lung parenchymal involvement include small-vessel antineutrophil cytoplasmic autoantibody (ANCA)-associated vasculitides, such as granulomatosis with polyangiitis (GPA), eosinophilic granulomatosis with polyangiitis (EGPA), and microscopic polyangiitis (MPA). Several studies have reported cases of interstitial lung diseases (ILDs) associated with systemic vasculitis, particularly those positive for ANCA associated vasculitis/vasculitidis: AAV. We have selected from our case series different radiological features of pulmonary vasculitis (i.e., solitary or multiple nodules, cavitary lesions, nodules with centrilobular or peribronchial distribution, airspace consolidations, "crazy paving" appearance, interstitial disease), including cases with interstitial lung alterations. Therefore, the aim of this review is to describe the typical clinical manifestations of vasculitides and their main radiologic features (especially AAV).

Non traumatic intrathoracic liver herniation mimicking a pulmonary metastasis in patient with breast cancer: A case report.

Non-traumatic hepatic hernia is defined as hepatic protrusion through acquired or congenital defects on diaphragm without prior trauma. This event is rare among adults and infrequently reported in literature. 52-year-old Caucasian woman with surgically treated breast cancer with suspected lung metastasis detected during a routine Multidetector Computed Tomography lung exam. Ultrasound and subsequently Magnetic Resonance Imaging (MRI) was performed which revealed an overdiaphragmatic mass in contiguity with liver parenchyma compatible with overdiaphragmatic hepatic hernia. Differential diagnosis should be made with diaphragmatic or pulmonary nodule. Correct diagnosis can avoid further diagnostic investigations or invasive procedures such as biopsy. Magnetic Resonance Imaging is a non-risky method and can clarify interpretative doubts. Currently there are still controversies about traumatic or idiopathic nature of this hernia.

Stylo-Jugular Venous Compression Syndrome: Lessons Based on a Case Report.

BACKGROUND Eagle syndrome is a vascular compression syndrome that is caused by a very elongated styloid process and/or calcification of the stylohyoid ligament compressing the vascular or nerve structures of the neck, resulting in vascular congestion, thrombosis, or neurological symptoms (eg, dysphagia, neck pain, ear pain). Stylo-jugular venous compression syndrome is a subtype of Eagle syndrome and is caused by compression of the internal jugular vein. Treatment varies according to the symptoms and the severity of the compression, and it can be pharmacological or surgical, with vascular stenting and/or removal of the styloid process. We describe a rare case of left cerebral venous sinus thrombosis and ipsilateral internal jugular vein stenosis sustained by excessive length of the left styloid process. CASE REPORT A 36-year-old woman presented with recurrent episodes of drug-resistant headache and recent memory disturbances. She underwent cerebral and neck multidetector computed tomography-angiography and Doppler ultrasound of the epiaortic vessels that respectively revealed thrombosis of the left cerebral venous sinus and left internal jugular vein stenosis due to a very long styloid process. The patient was treated with anticoagulant drugs and experienced a gradual remission of symptoms. CONCLUSIONS Compression of the jugular vein by the styloid process is a rare entity, and it often goes undiagnosed when it is asymptomatic. Doppler ultrasound is a sensitive method for identifying jugular vein stenosis and can provide an estimated degree of stenosis, which is useful for treatment planning. Doppler ultrasound should be combined with multidetector computed tomography-angiography to rule out compression of other vascular structures and other causes of compression. Failure to treat these patients could have serious health consequences for them.

Imaging features in management of laparoscopic mini/one anastomosis gastric bypass post-surgical complications.

Obesity is a widespread pathology among the population related to an increase in mortality and morbidity of patients. Bariatric surgery provides several forms of treatment for obese patients. Laparoscopic mini/one anastomosis gastric bypass (MGB/OAGB) is a recent low risk bariatric surgical procedure common in a large number of countries in the treatment of severe obesity. MGB/OAGB, compared to other bariatric surgery techniques, offers the significant technical improvement of requiring only one anastomosis in place of two. In this scenario, diagnostic imaging takes a significant role in the postoperative period, to evaluate the outcomes of surgical treatment and to detect possible complications both in early and late postoperative period. The prevalent radiological procedure to investigate suspicions of clinical post-operative complications is Computed tomography (CT) with oral and intravenous contrast administration. This pictorial essay aims to illustrate and identify normal radiological aspects of MGB/OAGB and post-surgery complication imaging features. We think that this article will serve to familiarize all the specialists with the diagnostic imaging of MGB/OAGB.

Clinically Suspected Segmental Arterial Mediolysis of the Splanchnic Arteries: A Report of 2 Rare Cases.

BACKGROUND Segmental arterial mediolysis (SAM) is an uncommon vascular pathology characterized by arteriopathy, mainly of medium-sized abdominal splanchnic vessels, without an atherosclerotic, inflammatory, infectious, or autoimmune underlying etiology. Segmental arterial mediolysis is clinically heterogeneous and symptoms may be completely nonspecific. The knowledge of radiological features of segmental arterial mediolysis and the exclusion of other pathologies should direct early diagnosis and refer patients for correct treatment. CASE REPORT In the last 2 years, we treated 2 different adult patients (an 89-year-old woman and a 52-year-old man) with spontaneous visceral bleeding, admitted to the Emergency Department due to acute onset of abdominal pain, anemia, and computed tomographic angiography (CTA) evidence of aneurysmatic, and stenotic alterations of splanchnic arteries. Based on clinical, laboratory, and radiological features, segmental arterial mediolysis was suspected. These 2 patients were referred to our Interventional Radiology Department and treated with super-selective transcatheter arterial embolization (TAE), performed by a minimally invasive approach, allowing an immediate clinical improvement with regression of symptoms and avoiding major surgical treatment. CONCLUSIONS In patients with clinical, laboratory, and radiological signs of acute and/or chronic abdominal bleeding and radiological findings suggesting segmental arterial mediolysis, mini-invasive endovascular treatment is a safe, extremely reliable, and secure procedure and appears to be the first-choice treatment when available. Since abdominal bleeding could have fatal consequences in these patients, timely diagnosis and endovascular therapy are essential to treat visceral vascular alterations due to segmental arterial mediolysis.

The role of ultrasound imaging in vascular compression syndromes.

Vascular compression syndromes are rare alterations that have in common the compression of an arterial and/or venous vessel by contiguous structures and can be congenital or acquired. The best known are the Thoracic Outlet Syndrome, Nutcracker Syndrome, May-Thurner Syndrome, and Dunbar Syndrome. The incidence of these pathologies is certainly underestimated due to the non-specific clinical signs and their frequent asymptomaticity. Being a first-level method, Ultrasound plays a very important role in identifying these alterations, almost always allowing a complete diagnostic classification. If in expert hands, this method can significantly contribute to the reduction of false negatives, especially in the asymptomatic population, where the finding of the aforementioned pathologies often happens randomly following routine checks. In this review, we briefly discuss the best known vascular changes, the corresponding ultrasound anatomy, and typical ultrasound patterns.

HRCT Patterns of Drug-Induced Interstitial Lung Diseases: A Review.

Interstitial Lung Diseases (ILDs) represent a heterogeneous group of pathologies, which may be related to different causes. A low percentage of these lung diseases may be secondary to the administration of drugs or substances. Through the PubMed database, an extensive search was performed in the fields of drug toxicity and interstitial lung disease. We have evaluated the different classes of drugs associated with pulmonary toxicity. Several different high resolution computed tomography (HRCT) patterns related to pulmonary drug toxicity have been reported in literature, and the most frequent ILDs patterns reported include Nonspecific Interstitial Pneumonia (NSIP), Usual Interstitial Pneumonia (UIP), Hypersensitivity Pneumonitis (HP), Organizing Pneumonia (OP), Acute Respiratory Distress Syndrome (ARDS), and Diffuse Alveolar Damage (DAD). Finally, from the electronic database of our Institute we have selected and commented on some cases of drug-induced lung diseases related to the administration of common drugs. As the imaging patterns are rarely specific, an accurate evaluation of the clinical history is required and a multidisciplinary approach-involving pneumologists, cardiologists, radiologists, pathologists, and rheumatologists-is recommended.

A Case of Nutcracker Syndrome Combined with Wilkie Syndrome with Unusual Clinical Presentation.

BACKGROUND Nutcracker syndrome and Wilkie's syndrome are rare vascular diseases due to the abnormal course of the superior mesenteric artery originating from the abdominal aorta with reduced angle (<22°) and consequent compression of the left renal vein (nutcracker) and duodenum (Wilkie). Here, we report the case of a patient with a rare combination of these 2 syndromes and with unusual clinical manifestation of post-prandial pain. CASE REPORT We describe the case of a young male patient with rapid weight loss, coupled with post-prandial abdominal pain, with sub-acute onset, not associated with other symptoms. The ultrasound examination found an aorto-mesenteric angle of 18° and compression of the left renal vein and left varicocele. A CT study was performed to exclude oncological diseases and/or other pathologies responsible for the pain and weight loss, which confirmed the ultrasound findings and showed compression of the third part of the duodenum. The patient underwent endovascular treatment, with stent placement in the left renal vein, which resolved the vascular compression and of the duodenum, with regression of symptoms. CONCLUSIONS The ultrasound scan promptly highlighted the reduction of the aorto-mesenteric angle and the signs of venous congestion of the left renal vein. Based on this experience, in patients with weight loss and post-prandial pain, in our opinion, diagnostic investigations should also be extended to the study of the aorto-mesenteric angle to confirm or exclude any vascular and/or duodenal compression.