Consensus report from the 7th International Forum for Liver Magnetic Resonance Imaging.

OBJECTIVES: Liver-specific MRI is a fast-growing field, with technological and protocol advancements providing more robust imaging and allowing a greater depth of information per examination. This article reports the evidence for, and expert thinking on, current challenges in liver-specific MRI, as discussed at the 7th International Forum for Liver MRI, which was held in Shanghai, China, in October 2013. METHODS: Topics discussed included the role of gadoxetic acid-enhanced MRI in the differentiation of focal nodular hyperplasia from hepatocellular adenoma and small hepatocellular carcinoma (HCC) from small intrahepatic cholangiocarcinoma (in patients with chronic liver disease), the differentiation of low-grade dysplastic nodule (DN) from pre-malignant high-grade DN and early HCC, and treatment planning and assessment of treatment response for patients with HCC and colorectal liver metastasis. Optimization of the gadoxetic acid-enhanced MRI protocol to gain robust arterial and hepatobiliary phase images was also discussed. RESULTS AND CONCLUSIONS: Gadoxetic acid-enhanced MRI demonstrates added value for the detection and characterization of focal liver lesions and shows promise in a number of new indications, including regional liver functional assessment and patient monitoring after therapy; however, more data are needed in some areas, and further developments are needed to translate cutting-edge techniques into clinical practice. KEY POINTS: Liver-specific MRI is a fast-growing field, with many technological and protocol advancements. Gadoxetic acid-enhanced MRI demonstrates value for detecting and characterizing focal liver lesions. Gadoxetic acid-enhanced MRI shows promise in regional functional assessment and patient monitoring. Further developments are needed to translate cutting-edge techniques into clinical practice.

Contrast enhancement pattern on multidetector CT predicts malignancy in pancreatic endocrine tumours.

OBJECTIVES: Preoperative suspicion of malignancy in pancreatic neuroendocrine tumours (pNETs) is mostly based on tumour size. We retrospectively reviewed the contrast enhancement pattern (CEP) of a series of pNETs on multiphasic multidetector computed tomography (MDCT), to identify further imaging features predictive of lesion aggressiveness. METHODS: Sixty pNETs, diagnosed in 52 patients, were classified based on CEP as: type A showing early contrast enhancement and rapid wash-out; type B presenting even (B1) or only (B2) late enhancement. All tumours were resected allowing pathologic correlations. RESULTS: Nineteen pNETs showed type A CEP (5-20 mm), 29 type B1 CEP (5-80 mm) and 12 type B2 (15-100 mm). All tumours were classified as well differentiated tumours, 19 were benign (WDt-b), 15 with uncertain behaviour (WDt-u) and 26 carcinomas (WDC). None of A lesions were malignant (12 WDt-b; 7 WDt-u), all B2 lesions were WDC, 7 B1 lesions were WDt-b, 8 WDt-u and 14 WDC; 4/34 (12 %) lesions ≤2cm were WDC. CEP showed correlation with all histological prognostic indicators. CONCLUSIONS: Correlating with the lesion grading and other histological prognostic predictors, CEP may preoperatively suggest the behaviour of pNETs, assisting decisions about treatment. Moreover CEP allows recognition of malignant small tumours, incorrectly classified on the basis of their dimension.

Identification of responders to sorafenib in hepatocellular carcinoma: is tumor volume measurement the way forward?

OBJECTIVES: Early assessment of hepatocellular carcinoma (HCC) response during sorafenib (SO) treatment is challenging, since tumor necrosis, extension and radiological appearance can be inhomogeneous. We evaluated the predictive value of different imaging criteria - such as Response Evaluation Criteria in Solid Tumors (RECIST) 1.1, European Association for the Study of the Liver (EASL), modified RECIST (mRECIST), tumor density and volume variations - in the early follow-up of SO treatment. METHODS: The study included 22 patients. CT images from baseline and 2 months were reviewed to assess response according to RECIST 1.1, mRECIST, EASL, Choi's criteria (decreased tumor density by ≥15%) and arterial-enhancing tumor volume ratio; α-fetoprotein (AFP) variations were expressed as AFP ratio. RESULTS: The response criteria and volume measurements were reproducible (k > 0.80). The overall disease control rate was 40.9% by EASL and mRECIST, and 27.3% by RECIST 1.1; a ≥15% decrease in tumor density was observed in 9 patients (40.9%). The mean volume ratio was 1.73 ± 2.12, the mean AFP ratio 14 ± 37. The 1-year survival rate was 65.9%. Volume ratio was the only predictive factor for survival, with 1-year cumulative survival rates of 90% for volume ratios ≤1.1 and of 45.4% for volume ratios >1.1 (p = 0.04). CONCLUSIONS: Tumor volume measurements are reproducible and might provide an early predictive marker of response in HCC patients treated with SO.

Optimizing the balance between radiation dose and image quality in pediatric head CT: findings before and after intensive radiologic staff training.

OBJECTIVE: The purpose of this study was to assess the radiation dose and image quality of pediatric head CT examinations before and after radiologic staff training. MATERIALS AND METHODS: Outpatients 1 month to 14 years old underwent 215 unenhanced head CT examinations before and after intensive training of staff radiologists and technologists in optimization of CT technique. Patients were divided into three age groups (0-4, 5-9, and 10-14 years), and CT dose index, dose-length product, tube voltage, and tube current-rotation time product values before and after training were retrieved from the hospital PACS. Gray matter conspicuity and contrast-to-noise ratio before and after training were calculated, and subjective image quality in terms of artifacts, gray-white matter differentiation, noise, visualization of posterior fossa structures, and need for repeat CT examination was visually evaluated by three neuroradiologists. RESULTS: The median CT dose index and dose-length product values were significantly lower after than before training in all age groups (27 mGy and 338 mGy ∙ cm vs 107 mGy and 1444 mGy ∙ cm in the 0- to 4-year-old group, 41 mGy and 483 mGy ∙ cm vs 68 mGy and 976 mGy ∙ cm in the 5- to 9-year-old group, and 51 mGy and 679 mGy ∙ cm vs 107 mGy and 1480 mGy ∙ cm in the 10- to 14-year-old group; p < 0.001). The tube voltage and tube current-time values after training were significantly lower than the levels before training (p < 0.001). Subjective posttraining image quality was not inferior to pretraining levels for any item except noise (p < 0.05), which, however, was never diagnostically unacceptable. CONCLUSION: Radiologic staff training can be effective in reducing radiation dose while preserving diagnostic image quality in pediatric head CT examinations.

A great enigma of the Italian Renaissance: paleopathological study on the death of Giovanni dalle Bande Nere (1498-1526) and historical relevance of a leg amputation.

BACKGROUND: The Medici project consisted in archeological and paleopathological researches on some members of the great dynasty of the Italian Renaissance. The remains of Giovanni de' Medici, so-called "dalle Bande Nere" (Forlì 1498- Mantua 1526) have not been investigated yet. The enigma of the fatal injury and leg amputation of the famous Captain excited curiosity of paleopathologists, medical scientists and Italian Society of Orthopedic and Traumatology which contributed to realize the project of exhumation and study of his skeletal remains. The aim of the study is to report the first anthropological and paleopathological results. CASE PRESENTATION: The tomb of Giovanni and his wife Maria Salviati was explored and the skeletal remains were investigated. Anthropological and paleopathological examination defined: age at death, physical constitution and activity, skeletal diseases. The bones of the leg were studied macroscopically, under stereoscopic microscope, at X-ray and CT scans to detect type of injury and level of amputation. CONCLUSIONS: The skeleton and muscular insertions of Giovanni revealed a young-adult and vigorous man, subjected to stresses of military activity since adolescence. Right tibia was amputated below the proximal half of diaphysis leaving long tibio-fibular stumps with a horizontal cut only at the lateral portion. Thus, the surgeon limited to complete the traumatic hemi-amputation. Amputation in the Sixteenth Century technically consisted in guillotine incisions below the knee using crescent shaped knife and bony saw, usually leaving a quite long tibial stump. Amputations in the Sixteenth Century were contaminated and grossly performed not providing vascular binding nor wound closure. The surgeon performed the procedure in conformity with surgical knowledge of that period.

Consensus report of the Fifth International Forum for Liver MRI.

OBJECTIVE: This article reviews topics discussed during the Fifth International Forum for Liver MRI (with a focus on gadoxetic acid-enhanced MRI), which was held in Munich, Germany, in September 2011. CONCLUSION: Growing evidence shows that gadoxetic acid-enhanced MRI has high sensitivity and specificity for diagnosing liver tumors. Hepatobiliary phase imaging adds new information for the characterization of borderline lesions. However, there is a need to develop standardized criteria for interpretation of gadoxetic acid-enhanced MRI in patients with cirrhosis or other risk factors for hepatocellular carcinoma.

3-T magnetic resonance angiography in primary angiitis of the central nervous system.

OBJECTIVE: Primary angiitis of the central nervous system (PACNS) is a rare disease characterized by an inflammatory process of intracranial vessels. Magnetic resonance angiography (MRA) (3 T) offers increased signal-to-noise ratio and background suppression, leading to better depiction of the intracranial vessels. The aim of our work was to compare the sensitivity of 3-T MRA to that of 1.5-T MRA in the diagnosis of PACNS. METHODS: Eight patients with PACNS and signs of angiitis at digital subtraction angiography (DSA) underwent MRA at 1.5 and 3 T. Magnetic resonance angiograms obtained with time-of-flight (TOF) technique were evaluated for the presence of stenosis with respect to DSA. RESULTS: In PACNS patients, DSA identified 827 intracranial stenoses. Sensitivity for vessel stenosis of 3-T TOF MRA was 47% and 14% for 1.5-T TOF. CONCLUSIONS: Time-of-flight MRA at 3 T improved the sensitivity of MRA in the noninvasive preliminary evaluation of patients with PACNS.

Contrast-enhanced magnetic resonance imaging of 102 nodules in cirrhosis: correlation with histological findings on explanted livers.

PURPOSE: To analyze Gd-EOB-DTPA-enhanced magnetic resonance (MR) findings of nodules (low-grade dysplastic nodules-LGDNs; high-grade dysplastic nodules-HGDN, and hepatocellular carcinoma-HCC), histologically identified on cirrhotic, explanted livers. METHODS: IRB approval was obtained for this study. Thirty-four patients underwent Gd-EOB-DTPA-enhanced MR examinations (1.5T system), that included 20-min delayed hepatobiliary (HB) phase imaging, before undergoing orthotopic liver transplantation (OLT; mean time MR-OLT: 2.7 months). A total of 102 hepatic nodules were identified and analyzed at histopathological examination, and classified as LGDN, HGDN, and HCC. Two radiologists by consensus performed a quantitative (enhancement ratios, ERs) and a qualitative analyses of signal intensities of identified nodules on vascular dynamic phases (30-35 s after injection-arterial phase; 180-190 s after injection late phase) and on HB phases. Correlation between nodules MR patterns and histological classification was analyzed by means of dedicated statistical software. RESULTS: No differences were appreciable among ERs of HGDN and HCCs on HB phase (P > 0.001). Lesions' enhancement on vascular dynamic and on HB phases significantly correlated to histological classification of nodules (P < 0.0001). Nodular hyperintensity on arterial phase and hypointensity on late phase were highly predictive for HCC (PPV 100%), with a moderate sensitivity (72.5%). Nodular hypointensity on HB phase was detected on 39/40 HCCs (sensitivity 97.5%) and in 21/30 HGDNs, whereas no LGDN showed it. CONCLUSIONS: Hyperenhancement on arterial phase and hypointensity on late phase are the most specific clues for the diagnosis of HCC. Hypointensity on HB phase shows a PPV of 100% in suggesting nodular premalignancy/malignancy, independently from nodular dynamic vascular enhancement.

80-kV pulmonary CT angiography with 40 mL of iodinated contrast material in lean patients: comparison of vascular enhancement with iodixanol (320 mg I/mL)and iomeprol (400 mg I/mL).

OBJECTIVE: The purpose of this article is to compare the vascular enhancement obtained with a low-kilovoltage pulmonary CT angiography (CTA) protocol in lean patients, using 40 mL of a moderate-concentration isoosmolar (iodixanol, 320 mg I/mL) and a high-concentration low-osmolar (iomeprol, 400 mg I/mL) iodinated contrast medium injected at the same iodine delivery rate. SUBJECTS AND METHODS: Forty-two lean patients (31 men and 11 women; body mass index, ≤ 23 kg/m(2)) with suspected pulmonary embolism and non-small cell lung carcinoma underwent pulmonary CTA with a 64-MDCT scanner using a tube voltage of 80 kV. Twenty-three patients (54.8%) received 40 mL of iodixanol (320 mg I/mL) injected at a rate of 5 mL/s, and the remaining 19 patients (45.2%) were administered an equal volume of iomeprol (400 mg I/mL) at a flow rate of 4 mL/s. Intraarterial density was measured in the common pulmonary artery trunk, the main right and left pulmonary arteries, lobar arteries, and at the segmental level, for a total of 15 regions of interest per patient. Intravascular enhancement homogeneity from central to subsegmental level was also assessed visually using a semiquantitative score (1 = poor, 2 = good, and 3 = excellent). RESULTS: The overall vascular density of pulmonary arteries down to the segmental level was significantly higher with iodixanol (320 mg I/mL) than with iomeprol (400 mg I/mL) (p = 0.036). Enhancement homogeneity was good with both contrast agents, with no statistically significant difference between them (p = 0.8966). CONCLUSION: In 80-kV pulmonary CTA of lean patients, higher intravascular enhancement can be achieved with 40 mL of iodixanol (320 mg I/mL) than with the same volume of iomeprol (400 mg I/mL), with good vessel conspicuity down to the subsegmental level.

Giant fibrovascular polyp of the esophagus-imaging techniques for proper treatment planning: report of two cases.

Giant fibrovascular polyps of the esophagus are rare, benign mesenchymal intraluminal lesions that arise from the cervical esophagus and can reach a very large size. Surgical excision is the treatment of choice, since endoscopic removal alone is not always feasible due to the presence of a very much vascularized stalk in most cases. We present two archetypal cases emphasizing the fact that these lesions can grow to huge masses with various and bizarre clinical presentation and they can arise (although rarely) at the level of the hypopharynx. We also aim to point out the role of imaging in defining the exact origin and characteristics of the stalk (width, vascularization) and the polyp structure (tissue components), thus providing useful information for planning the most appropriate surgical approach.

Anatomical localization of deep infiltrating endometriosis: 3D MRI reconstructions.

PURPOSE: The goal of this study was to determine the accuracy of three-dimensional (3D) MRI reconstructions obtained with segmentation technique in the preoperative assessment of deep infiltrating endometriosis (DIE) and in particular to evaluate rectosigmoid and bladder wall involvement. MATERIALS AND METHODS: Institutional review board approval for this study was obtained, and each patient gave written informed consent. Fifty-seven consecutive patients with diagnosis of DIE who had undergone pelvic MRI at 1.5 T before surgery between 2007 and 2011, were retrospectively evaluated and 3D post-processed in order to obtain a detailed mapping of DIE. A blinded reader interpreted images. MRI results were compared with surgical findings and were scored by using a four-point scale (0_3 score). RESULTS: 36/57 patients with symptomatic DIE underwent surgery: 18/36 had endometriotic nodules infiltrating the rectouterine pouch, 12/36 the vesicouterine pouch, and 6/36 the rectovaginal pouch. The sensitivity of MRI and 3D MRI vs. surgery was, respectively, 64% vs. 83%; diagnostic accuracy of 3D MRI respect to MRI alone was 86% vs. 67% for localization; 86% vs. 67% for dimension; 79% vs. 58% for rectosigmoid infiltration; 92% vs. 75% for bladder infiltration. CONCLUSIONS: In this preliminary study, 3D MRI reconstructions obtained with semi-automatic method of segmentation provided encouraging results for staging DIE preoperatively. In fact, the addition of 3D MRI reconstructions improved diagnostic accuracy and staging of DIE providing the exact volume of the lesions and enabling a precise mapping of these before surgery.

Rotational thromboelastometry for diagnosis of fibrinolysis induced by urokinase in an in-vitro model.

Fibrinolysis can be abnormally activated in several critical care settings but it's often misdiagnosed by standard laboratory tests. Although rotational thromboelastometry can assess the whole coagulative process, its ability to detect fibrinolysis has been questioned. Aim of this study was to investigate the ability of thromboelastometry in detecting induced fibrinolysis in an in-vitro model. Whole blood samples were taken from 18 healthy volunteers. Each sample was split and added with increasing urokinase concentrations till to reach 0, 50, 75 and 100 IU/ml. Thromboelastometry tests, extem and aptem, were performed on the obtained samples. If significant lysis at 50 IU/ml was recorded, also 10, 25 and 35 IU/ml drug concentrations were tested. No lytic effects were detected in 10 IU/ml samples. Lysis variables were the most sensitive in detecting fibrinolysis even at 25 IU/ml (P < 0.05). Clot firmness parameters were also affected by urokinase, but only at the two highest drug concentrations (P < 0.05). Extem/aptem ratio enhanced the sensitivity of these parameters only if lysis was more marked. Analysing groups of different lysis severity, the time to achieve maximum clot firmness could anticipate an ongoing fulminant or intermediate lysis with 100% sensitivity and 100% specificity (P < 0.05) when lower than 1341.5 s. Rotational thromboelastometry could detect fibrinolysis when it was induced in vitro by 25 IU/ml urokinase or more. Apart from the parameters specific for lysis, time to achieve maximum clot firmness appeared as the earliest indicator of fibrinolysis with high sensitivity and specificity especially if a more intense lysis was going on.

64-row MDCT perfusion of head and neck squamous cell carcinoma: technical feasibility and quantitative analysis of perfusion parameters.

OBJECTIVES: To evaluate the technical feasibility of 64-row computed tomography (CT) quantitative perfusion imaging of head and neck squamous cell carcinoma (SCC). METHODS: Twenty-nine patients with a total of 29 pathologically proven SCC underwent a cine-mode CT perfusion acquisition covering the lesion site. The acquisition started 10 s after intravenous injection of iodinated contrast material and lasted 50 s. On a dedicated workstation, regions of interest (ROI) were traced within the SCC, on a healthy portion of tissue (H), and on the ipsilateral sternocleidomastoid muscle (M). Blood flow (BF), blood volume (BV), mean transit time (MTT) and permeability-surface product (PS) were calculated. RESULTS: In SCC, BF, BV and PS were higher compared with H (p<0.0001, p=0.002 and p=0.004, respectively) and M (p<0.0001). Conversely, MTT was lower in SCC than in H (p=0.0009) and M (p=0.0003). All datasets were free from substantial motion artefacts and ROI misregistration phenomena. No substantial discomfort or adverse events were experienced by any of the patients. CONCLUSION: 64-row CT quantitative perfusion imaging allows head and neck SCC to be distinguished from normal tissues.

Technical note: DTI measurements of fractional anisotropy and mean diffusivity at 1.5 T: comparison of two radiofrequency head coils with different functional designs and sensitivities.

PURPOSE: Diffusion tensor imaging (DTI) is highly sensitive to noise and improvement of radiofrequency coil technology represents a straightforward way for augmenting signal-to-noise ratio (SNR) performance in magnetic resonance imaging (MRI) scanners. The aim of this study was to characterize the dependence of DTI measurements of fractional anisotropy (FA) and mean diffusivity (MD) on the choice of head coil, comparing two head coils with different functional designs and sensitivities. METHODS: Fourteen healthy subjects underwent DTI acquisitions at 1.5 T. Every subject was scanned twice, using a standard quadrature birdcage head coil (coil-A) and an eight-channel array head coil (coil-B). FA and MD maps, estimated using both the linear least squares (LLS) and nonlinear least squares (NLLS) methods, were nonlinearly normalized into a standard space. Then, volumetric regions of interest encompassing typical white and gray matter structures [splenium of the corpus callosum (SCC), internal capsule (IC), cerebral peduncles (CP), middle cerebellar peduncles (MCP), globus pallidus (GP), thalamus (TH), caudate (CA), and putamen (PU)] were analyzed. Significant differences and trends of variation in DTI measurements were assessed by the Wilcoxon test for paired samples with and without Bonferroni correction for multiple comparisons, respectively. RESULTS: The overall SNR of coil-B was 30% higher than that of coil-A. When comparing DTI measurements (coil-B versus coil-A), mean FA values (SCC, IC, and TH), mean MD values (IC, CP, GP, and TH), FA standard deviation (CP, MCP, GP, and CA), and MD standard deviation (IC, CP, TH, and PU) resulted decreased (significant difference, p(cor) < 0.05, or trend of variation, P(uncor) < 0.05) in several gray and white matter regions of the human brain. With the exception of CP, the results in terms of revealed significant difference or trend of variation were independent of the method (LLS and NLLS) used for estimating the diffusion tensor. CONCLUSIONS: In various gray and white matter structures, the eight-channel array head coil yielded more precise and accurate measurements of DTI derived indices compared to the standard quadrature birdcage head coil.

Conventional versus doxorubicin-eluting bead transarterial chemoembolization for hepatocellular carcinoma.

PURPOSE: To compare short- and long-term clinical outcomes after conventional transarterial chemoembolization and drug-eluting bead (DEB) transarterial chemoembolization in hepatocellular carcinoma (HCC). MATERIALS AND METHODS: Patients with unresectable HCC unsuitable for ablative therapies were randomly assigned to undergo conventional or DEB chemoembolization. The primary endpoints of the study were safety, toxicity, and tumor response at 1 month. Secondary endpoints were number of repeated chemoembolization cycles, time to recurrence and local recurrence, time to radiologic progression, and survival. RESULTS: In total, 67 patients (mean age, 70 y ± 7.7) were evaluated. Mean follow-up was 816 days ± 361. Two periprocedural major complications occurred (2.9%) that were treated by medical therapy without the need for other interventions. A significant increase in alanine aminotransferase levels 24 hours after treatment was reported, which was significantly greater after conventional chemoembolization (n = 34) than after DEB chemoembolization (n = 33; preprocedure, 60 IU ± 44 vs 74 IU ± 62, respectively; at 24 h, 216 IU ± 201 vs 101 IU ± 89, respectively; P = 0.007). No other differences were observed in liver toxicity between groups. At 1 month, complete and partial tumor response rates were 70.6% and 29.4%, respectively, in the conventional chemoembolization group and 51.5% and 48.5%, respectively, in the DEB chemoembolization group. No differences were observed between groups in time to recurrence and local recurrence, radiologic progression, and survival. CONCLUSIONS: Conventional chemoembolization and DEB chemoembolization have a limited impact on liver function on short- and long-term follow-up and are associated with favorable clinical outcomes.

Complete response for advanced liver cancer during sorafenib therapy: case report.

BACKGROUND: Hepatocellular carcinoma (HCC) is the fifth most common neoplasia in the world. In the past, treatment of advanced HCC with conventional antineoplastic drugs did not result in satisfactory outcomes: recently, in this patient population the oral multikinase inhibitor sorafenib has been able to induce a statistically significant improvement of overall survival. Similarly to other anti-angiogenic drugs employed in other tumour types, also sorafenib seldom induces the dimensional tumour shrinking usually observed with conventional cytotoxic drugs: data gathered from studies carried out with sorafenib and other competitors under development do not report any complete response in HCV-induced HCC. CASE PRESENTATION: An 84-year old man with a long-lasting history of chronic HCV hepatitis was referred to our Institution for an ultrasonography investigation of a focal hepatic lesion. To better characterize the liver disease and clearly define the diagnosis of the focal hepatic lesion, the patient was hospitalized in our department. Laboratory and instrumental investigations confirmed the clinical picture of HCV-related liver cirrhosis and identified a hepatic lesion of about 6 cm featuring infiltrating HCC with thrombosis of the portal trunk. Due to the advanced stage of the disease, therapy with sorafenib 400 mg bid was started. Right from one month after the treatment was started, a reduction of alpha-fetoprotein level was observed which, by the third month, turned down within the normal limits. In addition the CT scan showed 50% reduction of the neoplastic lesion along with canalization of the portal trunk. At the sixth month the normalization of the alpha-fetoprotein level at the lower limit of normality was confirmed and the MRI showed complete disappearance of the neoplasia. In addition a reduction of a metallo-proteinase serum level was observed. At the twelfth month a further MRI confirmed complete response had been maintained. At present the patient is in a follow-up program to evaluate the duration of the complete response. CONCLUSIONS: This case is worth mentioning since, to the best of our knowledge, it represents the first evidence of complete response to sorafenib in an elderly patient with advanced HCV-related HCC.

Reproducibility of BOLD localization of interictal activity in patients with focal epilepsy: intrasession and intersession comparisons.

OBJECT: Simultaneous EEG-fMRI recordings allow the identification of haemodynamic changes induced by neuronal activity during ictal or interictal epileptiform events (IEDs). We evaluated the reproducibility of continuous EEG-fMRI (cEEG-fMRI) in patients with focal epilepsy. MATERIALS AND METHODS: We studied 15 patients with focal epilepsy (8 cryptogenic and 7 symptomatic) and frequent interictal abnormalities. Each patient underwent two cEEG-fMRI acquisitions (runs) in the same day (session) and 8 patients repeated the examination after one month. cEEG-fMRI reproducibility was defined by the existence of partially overlapping clusters between activation maps obtained from different runs. RESULTS: We detected IEDs in 40 out of 46 EEG-fMRI runs and a related significant BOLD-response in all 40 runs. A prevalent positive BOLD response was detected in 12 patients and a prevalent negative response in 3 subjects. Statistical maps included a mean of 10 significant clusters. Nearly 30% of clusters were reproducible in both intrasession and intersession comparisons, with a mean overlap of 30%. Reproducibility did not differ between positive and negative BOLD-responses. DISCUSSION: Among the reproducible clusters, those with the highest percentage of overlap were concordant with the EEG electric field in all patients and they were localized in the same lobe as the brain lesion in patients with symptomatic epilepsy. We hypothesize that reproducible clusters could be more consistently related to the irritative zone than non-reproducible ones. CONCLUSION: The evaluation of cluster reproducibility could improve our knowledge of IED-related BOLD response. Moreover, it could enhance the reliability of cEEG-fMRI to identify the irritative zone in focal epileptic patients.

Hepatocellular nodules in liver cirrhosis: contrast-enhanced MR.

Nowadays, the diagnosis of hepatocellular carcinoma (HCC) is increasingly demanded to imaging techniques. Anyway, imaging cirrhotic patients still remains a challenging issue, since pre-neoplastic hepatocellular lesions, as dysplastic nodules (DNs), may frequently mimic small neoplasms. Differently from other imaging modalities, magnetic resonance (MR) can give an accurate evaluation of both intracellular and vascular changes occurring during the carcinogenetic pathway from dysplasia to full malignancy. Both DNs and HCC may in fact show a large variety of signal intensities, strictly reflecting nodules' characteristics, such as lesion architecture, grading, stromal components, as well as intracellular contents. In these last years, the introduction of dedicated contrast media has increased MR diagnostic efficacy, permitting to explore both vascular as well as the pathological changes occurring in the biliary and reticuloendothelial systems during the carcinogenetic process. MR performed with tissue specific contrast agents (hepatobiliary and reticulo-endothelial) may thus give an insight on this "gray area", in whom significant histological changes are already present without an evident nodule arterial supply. This peculiar MR prerogative permits to give predictive information about the evolution trend in a cirrhotic parenchyma and to identify patients at high risk for developing carcinoma who would benefit from well-timed treatments.

Diagnosis of a variant of Mayer-Rokitansky-Kuster-Hauser syndrome: useful MRI findings.

Mayer-Rokitansky-Kuster-Hauser (MRKH) syndrome consists of vaginal aplasia associated with other müllerian duct abnormalities. Its penetrance varies, as does the involvement of other organ systems. Type I MRKU syndrome is characterized by an isolated absence of the proximal two thirds of the vagina, whereas type II is marked by other malformations which include vertebral, cardiac, urologic (upper tract), and otologic anomalies. In both types, the extent of vaginal aplasia varies, ranging from virtually absent to a length much more inferior than the normal one (2-5 cm). MRKU syndrome usually remains undetected until the patient presents with primary amenorrhea despite normal female sexual development. It is important to underline the fact that this syndrome is the second most common cause of primary amenorrhea. Although this condition has psychologically devastating consequences, its anatomical defects can be surgically treated. In fact, following diagnosis, surgery allows patients to have normal sexual function while reproduction may be possible if assisted techniques are performed.

CT colonography: patient tolerance of laxative free fecal tagging regimen versus traditional cathartic cleansing.

PURPOSE: The aim of our prospective study was to compare patient tolerance of laxative free fecal tagging regimen (LFT) versus traditional cathartic cleansing (TC). MATERIALS AND METHODS: 264 patients, at average risk for development of colorectal cancer (105 men and 159 women; mean age 62 years ± 5 SD), underwent 32 rows CT colonography. Patients were alternatively placed into 2 study groups: Group 1 (n = 132) followed TC and Group 2 (n = 132) LFT. TC protocol consisted of no fiber diet and Phospho-lax(®) 80 mL in 2 L of water the day before imaging. LFT protocol consisted of no fiber diet and ingestion with meals of 30 mL of water-soluble iodinated contrast agent (Gastrografin(®)) for 2 days before imaging. No frank laxative drugs were administered. All studies were reviewed in a combined fashion, primary 2D followed by 3D endoluminal and dissected views. After the examination all patients were asked to provide a feedback about tolerance to the each bowel preparation. The first 30 patients of each group were also investigated with optical colonoscopy (OC) used as gold standard to confirm our diagnosis (Group 1* and Group 2*). CONCLUSIONS: LFT reduces discomfort and seems to improve diagnostic accuracy of CTC.