Pulmonary congenital cystic disease in adults. Spiral computed tomography findings with pathologic correlation and management.

PURPOSE: The aim of this study was to assess the computed tomography (CT) features of intrapulmonary congenital cystic diseases in adults and to correlate the imaging features with the pathological findings, with emphasis on the oncogenic potential of the lesions. MATERIALS AND METHODS: We retrospectively reviewed the CT scans in three institutions from August 1996 to December 2008, of nine patients (six men, three women; mean age 48.6 years; range 26-75 years) who had histological diagnosis of pulmonary cystic disease after surgery. Six patients had a diagnosis of intrapulmonary bronchogenic cyst (IBC), and three had a type-I cystic adenomatoid malformation (CAM). In one case, intralobar sequestration (ILS) was associated with type-I CAM. RESULTS: Three patients were symptomatic and six were asymptomatic. On CT scans, IBCs showed homogeneous fluid attenuation (n=2), air-fluid level (n=2), air attenuation (n=1) or soft-tissue attenuation (n=1). The surrounding lung tissue showed areas of band-like linear attenuation in three IBCs, atelectasia in two and mucocele-like areas in one. On CT, type-I CAM appeared as a unilocular cystic lesion with air-fluid level (n=1) or air content (n=1). Both cases had thin walls surrounded by normal lung parenchyma. ILS appeared as a fluid-filled cyst with afferent and efferent vessels. Of the six IBCs, one occurred in the upper right lobe, two in the middle lobe and three in the lower right lobe. Of the three type-I CAMs, one was in the upper left lobe and one in the middle lobe. The type-I CAM associated with ILS was located in the left lower lobe. CONCLUSIONS: The similar CT patterns preclude differentiation between IBC and type-I CAM. Surgical resection of all intrapulmonary cystic lesions detected in adults is mandatory because type-I CAM is a precursor of mucinous bronchioloalveolar carcinoma.

Small (< or = 2 cm) atypical hepatic haemangiomas in the non-cirrhotic patient: pattern-based classification scheme for enhancement at triple-phase helical CT.

PURPOSE: The aim of this study was to determine by triplephase helical computed tomography (CT) the appearance of atypical small (< or = 2 cm) hepatic haemangiomas (HHs) in the non-cirrhotic patient. MATERIALS AND METHODS: We retrospectively reviewed the hepatic arterial-dominant phase (HAP), portal venous phase (PVP) and delayed-phase (DP) helical CT images of 47 patients with 52 atypical small (< or = 2 cm) HHs associated with 34 typical small HHs. Images were assessed to identify the patterns of enhancement of atypical HHs and correlate their appearance with that of typical small HHs in the delayed phase. Interobserver variability and kappa value were calculated. Statistical significance was calculated by the Fisher exact test. RESULTS: The 52 atypical small HHs were categorised as follows: type 1a (hyperattenuating in the HAP, n=17), type 1b [hyperattenuating with transient hepatic attenuation difference (THAD) around the lesion in the HAP, n=12], type 2a (homogeneously hypoattenuating in the HAP or PVP, n=9), type 2b (hypoattenuating with "bright-dot" sign in the HAP or PVP, n=13) and type 3 (hypoattenuating with central enhancing area, n=1). Interobserver agreement was perfect for HHs of types 1a, 1b, 2a and 3. On DP images, the appearance of atypical small HHs was identical to that of typical small HHs in all cases (p<0.0001), with lesions showing homogeneous isoattenuation to the aorta or liver parenchyma without peripheral capsule. CONCLUSIONS: Triple-phase helical CT scans can distinguish several types of atypical small HHs. The demonstration of patterns similar to those of typical forms on DP CT is fundamental for the diagnosis.

Impedance plethysmography in the diagnosis of asymptomatic deep vein thrombosis in hip surgery. A venography-controlled study.

We prospectively evaluated the accuracy of computerized impedance plethysmography (CIP) in the diagnosis of asymptomatic deep vein thrombosis (DVT) in 246 consecutive high-risk patients scheduled for hip surgery, with bilateral venography used for comparison. The CIP was performed as a surveillance program every third day. If the CIP remained negative, bilateral venography was performed on postoperative day 10 +/- 1 or on day of treatment 14 +/- 1 in nonoperated-on patients. If the CIP became positive, venography was performed within 24 hours. The sensitivity and specificity of CIP for proximal and distal DVT were 19% (confidence interval [CI], 13% to 24%) and 91% (CI, 87% to 94%), respectively. The positive and negative predictive values were 52% (CI, 38% to 65%) and 70% (CI, 65% to 74%), respectively. The sensitivity and specificity of CIP for proximal DVT were 24% (CI, 13% to 34%) and 90% (CI, 87% to 94%), respectively; the positive and negative predictive values were 31% (CI, 20% to 51%) and 87% (CI, 83% to 90%), respectively. We conclude that, because of its low sensitivity, CIP cannot be used in the surveillance of DVT in high-risk patients or for outcome measurements in clinical trials on DVT prophylaxis.

Detection of asymptomatic deep vein thrombosis by real-time B-mode ultrasonography in hip surgery patients.

The aim of this study was to prospectively evaluate the accuracy of real-time B-mode ultrasonography in the diagnosis of asymptomatic proximal deep vein thrombosis (DVT) in hip surgery patients. Venography was adopted as the gold standard. We studied 100 consecutive patients undergoing hip surgery: 60 patients for hip fracture and 40 patients for elective hip replacement. Bilateral real-time B-mode ultrasonography was performed prior to bilateral venography. The two diagnostic procedures were performed on the same day by different investigators unaware of the assigned prophylatic regimen for DVT. Compressibility of the vein segment was adopted as the single criterion for DVT. Venography was performed and judged by radiologists unaware of the ultrasonography results. In 13 limbs venography was either impossible to perform or not adequate for judgement. Ultrasonography and an adequate venography was obtained in 187 limbs. A venography proven DVT was observed in 49 limbs (26.2%) and a proximal DVT in 21 limbs (11.2%). All the patients were asymptomatic for DVT. The sensitivity and specificity of real time B-mode ultrasonography for proximal DVT were 57% (95% confidence interval: C.I. 36-80) and 99% (C.I. 99-100), respectively and the positive and negative predictive values were 93% (C.I. 73-100) and 95% (C.I. 91-97), respectively. The sensitivity and specificity for overall DVT were 25% (C.I. 11-38) and 99% (C.I. 97-100), respectively and the positive and negative predictive values were 92% (C.I. 73-100) and 79% (C.I. 76-85), respectively. Our data indicate that real-time B-mode ultrasonography for its high specificity could make venography unnecessary in patients with positive results.(ABSTRACT TRUNCATED AT 250 WORDS)

Clinical outcome of orthopaedic patients with negative lower limb venography at discharge.

Pharmacological prophylaxis for postoperative venous thromboembolism is generally restricted to the hospital stay. A high incidence of deep vein thrombosis (DVT) and pulmonary embolism presenting after hospital discharge has been reported and thus it has been claimed that pharmacological prophylaxis should be continued after discharge. The aim of this study was to perform a prospective survey to assess the prevalence of clinically overt thromboembolic events in hip surgery patients discharged with a negative venography without further pharmacological prophylaxis. We followed-up 213 patients with negative venography at discharge (105 elective hip replacement and 108 hip fracture patients). 186 patients (87.3%) were re-examined as outpatients one to two months after discharge. Five patients reported symptoms of DVT but the diagnosis was not confirmed by objective testing. The remaining 27 patients (12.7%) were followed up through their family doctor or by telephone call; in these patients the follow-up period ranged from 60 days to 2 years. Twenty-two patients (10.3%) were still alive and reported no signs or symptoms of venous thromboembolism. Three patients (1.4%) died for reasons not correlated with venous thromboembolism. Two patients could not be traced due to geographical inaccessibility; they were still alive after 1 year according to the records of their health care district. The results of our study suggest that in hip surgery patients with negative venography the prevalence of clinically overt thromboembolic events after hospital discharge ranges from 0 to 2.2% (95% C.I.). It is conceivable that the majority of late presenting postoperative DVT actually develop during the hospital stay and become symptomatic after hospital discharge.

A randomised, double-blind, placebo-controlled trial of dermatan sulphate for prevention of deep vein thrombosis in hip fracture.

Dermatan sulphate (MF 701) is a natural glycosaminoglycan that catalyses thrombin inhibition by heparin cofactor II. The aim of the study was to evaluate the efficacy and safety of MF 701 for prevention of deep vein thrombosis (DVT) in patients with hip fracture. A randomised, double-blind, placebo-controlled design was used to assess two dose regimens of MF 701 in two consecutive study phases. Treatment was started within 48 h from the trauma and continued for 14 days for non-operated patients or until the 10th postoperative day. Bilateral mandatory venography was used to assess the end-point. Eighty patients were included in the first phase (40 MF 701, 40 placebo). MF 701, 100 mg IM b.i.d., did not reduce incidence of DVT from that on placebo and did not induce any bleeding. In the second phase 126 patients were included, with a randomisation ratio of 2:1 (84 MF 701, 300 mg IM b.i.d., 42 placebo). Bilateral venography was obtained for 110 patients. The incidence of DVT was 64% (23/36) in the placebo group and 38% (28/74) in the MF 701 group (p = 0.01; odds ratio [OR] = 0.34, 95% confidence limits [CL] = 0.15-0.80p; proximal DVTs were 42% (15/36) and 20% (15/74), respectively (p = 0.02; OR = 0.36, CL = 0.15-0.89). No significant differences were found in haemorrhagic complications (2.4% in each group), blood loss from drains, blood transfusions, haemoglobin and haematocrit values. This study is the first demonstration that dermatan sulphate is a clinically effective antithrombotic agent without bleeding effects. It also provides evidence of the biological role of heparin cofactor II.

Features of thrombi and diagnostic accuracy of impedance plethysmography in symptomatic and asymptomatic deep vein thrombosis.

Impedance plethysmography (IPG) has high sensitivity and specificity in patients with symptomatic deep vein thrombosis (DVT) while it fails to detect asymptomatic DVT. The aim of this study was to determine whether the features of thrombi such as location, size and occlusiveness could explain the different accuracy of IPG in symptomatic and asymptomatic DVT patients. One-hundred and seventeen consecutive outpatients with a clinical suspicion of DVT and 246 consecutive patients undergoing hip surgery were admitted to the study. In symptomatic patients IPG was performed on the day of referral, followed by venography, while in asymptomatic patients IPG was performed as a surveillance programme, followed by bilateral venography. A venography proved DVT was observed in 37% of the symptomatic patients and 34% of the asymptomatic limbs. A significantly higher proportion of proximal DVTs was found in symptomatic patients than in asymptomatic patients (78% vs 46%; p = 0.001). The mean Marder score, taken as an index of thrombus size, was significantly higher in symptomatic patients than in asymptomatic patients (19.0 vs 9.6; p = 0.0001). A significantly higher proportion of occlusive DVTs was observed in symptomatic than in asymptomatic patients (69% vs 36%; p = 0.001). We conclude that the unsatisfactory diagnostic accuracy of IPG in asymptomatic DVT is due to the high prevalence of distal, small and non occlusive thrombi. Such thrombi are unlikely to cause a critical obstruction of the venous outflow and therefore to produce a positive IPG.

MRI postoperative monitoring in patients surgically treated for aortic dissection.

In most cases, surgery of aortic dissections repairs only the ascending portion of the aorta, leaving a residual dissection in the arch and descending aorta. We studied 17 patients operated upon for type A aortic dissection. A total of 42 magnetic resonance imaging (MRI) examinations were performed, with two to five studies per patient (mean 2.47). The studies were done between 5 weeks and 47 months (mean 17.5 months) after surgery. The patients were evaluated by MRI using gated spin-echo and gradient-echo sequences on axial and oblique sagittal views, and in selected cases, coronal views. A high incidence of abnormalities was observed. Pericardial hematoma was observed in 11% of cases, aortic and branch involvement in 41%, abdominal aortic branch involvement in 47%, dilatation of native aorta in 58%, and extension of dissection in 10%. New complications were detected during follow-up in 53% of patients. MRI was helpful in the follow-up of patients operated upon for aortic dissections, owing to its noninvasiveness and multiplanarity. By means of this technique, it was possible to obtain information about the natural history of the disease, as well as information useful for subsequent treatment.

MR study of N2 disease in lung cancer: contrast-enhanced method using gadolinium-DTPA.

OBJECTIVE: In several previous studies, including one of our own, CT and MRI provided similar information on N2 detection in the staging of lung cancer. Both imaging techniques can be considered effective in detecting enlarged mediastinal lymph nodes but the results are often inaccurate when confronted with pathological findings. The purpose of this study was to assess the diagnostic accuracy of gadolinium-DTPA enhanced MRI in the detection of mediastinal lymph nodes in lung cancer. METHODS: A prospective study to compare standard unenhanced MRI and Gd-DTPA enhanced MRI was carried out in patients with diagnosed lung cancer. The study focused on the status of mediastinal lymph nodes. Gd-DTPA was administered at a dosage of 0.2 mmol2/KG before T1 weighted sequences. Qualitative visual analyses of both standard and contrast enhanced MRI images were performed on each patient by 2 independent radiologists. The imaging results were then compared to pathological findings obtained after surgical operation. RESULTS: In the identification of mediastinal lymph node metastases standard MRI was 62% sensitive, 100% specific and 74% accurate whereas Gd-DTPA enhanced MRI was 100% sensitive, 91% specific and 97% accurate. CONCLUSIONS: Gd-DPTA enhanced MRI was more accurate than standard MRI in the detection of metastatic lymph nodes in patients with lung cancer. These initial results can be considered encouraging especially with regards to the reduction of false negative findings although further confirmation is, understandably, required.

Chronic iliac artery occlusion: treatment with the Strecker stent after PTA.

The purpose of this retrospective study was to evaluate the use of percutaneous transluminal angioplasty (PTA) and subsequent. Strecker stent implantation for the treatment of chronic iliac artery occlusions. A total of 39 patients were subjected to this procedure. The occluded vessels were catheterized, dilated and subjected to stenting in all patients: the length of occlusion varied from 4.5 to 10.5 cm (mean 5.9), lesions were located in common iliac arteries (25), external iliac arteries (10) and in combinations of both (4). Twenty-five patients presented stage II according to Fontaine classification, nine patients stage III and five patients stage IV. The stent was mounted on balloon catheter and introduced through a 9 French sheet (for 8-10 mm stent diameter). After this procedure, 37 out of 39 patients showed a statistically significant increase in the Doppler sonographic ankle-arm index (AAI) (P = 0.001) and improvement of clinical symptoms, while in two patients a complete occlusion resulted due to long dissection not covered by the stent in one case and to stent misplacement in the other case. After stenting, 27 patients improved to stage I, ten patients to stage IIa and two patients showed no changes. Two complications were observed: one groin hematoma and one distal embolization. At a 6-month follow-up, a 89.7% of patency was observed. This study shows that Strecker stent can be successfully employed in addition to PTA to treat occlusions of the iliac arteries.

Emergencies in the retroperitoneum: assessment of spread of disease by helical CT.

Acute pancreatitis, leaking abdominal aortic aneurysm, and renal trauma frequently occur in the setting of patients with abdominal nontraumatic and traumatic injury; it represents the most urgent conditions that may determine the presence of fluid collections or haematoma in the retroperitoneum. Single spiral CT and multidetector-row CT (MDCT) play an important role in diagnosis of retroperitoneal emergencies, providing useful informations on the type, site, extent and management of the fluid collections. An accurate CT assessment requires the awareness of the existence of dissectable retroperitoneal fascial planes. Fluid collections or haematoma tends to escape the retroperitoneal site of origin into planes extend from the diaphragm to the pelvic floor. We assess the multicompartimental anatomy of the retroperitoneum and the pathway of spread of the most frequent retroperitoneal fluid collections or haematoma by helical CT.

Low-field magnetic resonance imaging in the evaluation of mechanical and biological heart valve function.

Magnetic resonance imaging (MRI) has been frequently considered unsafe for patients with ferromagnetic implants: risks to be considered include induction of electric current, heating and dislocation of the prosthesis. Previous in vitro and in vivo studies have indicated the possibility of performing MRI examinations on patients with prosthetic heart valves. The aim of our study was to verify the presence of artifacts at the level of the prosthetic heart valve in vivo using a low-field MR unit (0.2 T) and to define the possibility of a functional analysis of the valve in patients with biomedical or mechanical prostheses. We evaluated 14 patients surgically treated for implantation of nine biological and seven mechanical aortic and mitral valves. A low-field MR unit (0.2 T) was employed using cine-MR technique on long- and short-axis view. The images were acquired on planes parallel and perpendicular to the valvular plane. Semiquantitative analysis with double-blind evaluation for definition of the extent of the artifact was performed. Three classes of artifacts were distinguished from minimal to significant. The examinations showed the presence of minimal artifacts in all biological heart valves and moderate artifacts in mechanical valves giving good qualitative data on blood flow near the valve. Analysis of the flow behind the valve showed signs of normal function in 13 prostheses and pathological findings in the remaining three. In these latter cases, MRI was able to define the presence of a pathologic aortic pressure gradient, mitral insufficiency and malpositioning of the mitral valve causing subvalvular turbulence. Nevertheless, we believe that the application of velocity-encoding cine-MR is more promising than semiquantitative analysis of artifacts.

Diagnostic accuracy of computerized impedance plethysmography in the diagnosis of symptomatic deep vein thrombosis: a controlled venographic study.

The aim of our study was to evaluate the sensitivity, the specificity, and the positive and negative predictive values of a recently developed computerized impedance plethysmography (CIP) in the diagnosis of deep vein thrombosis (DVT); 117 consecutive outpatients with a clinical suspicion of DVT were evaluated. After informed consent was obtained, a CIP and, within twenty-four hours, a venography of the symptomatic lower limb were performed in each patient. The results of CIP were compared with the results of contrast venography, which was considered as the gold standard. As far as the diagnosis of both proximal and distal DVT was concerned, the accuracy of CIP was 88.5%; the sensitivity and specificity were 95.1% and 83.6%, respectively; the positive and negative predictive values were 81.2% and 95.8%, respectively. When the diagnosis of only proximal deep vein thrombosis was considered, the accuracy of CIP was 88.8%; the sensitivity and specificity were 97.1% and 83.6%, respectively; the positive and negative predictive values were 79.0% and 97.8%, respectively. The authors conclude that the newly developed CIP has a diagnostic accuracy similar to that of traditional impedance plethysmography. Moreover, being completely automated and portable, CIP can play an important role in the bedside diagnosis of DVT.

[Importance of lymphangiography in the diagnosis of recto-sigmoid tumors]. / Importanza della linfoangiografia nella diagnosi dei tumori del retto-sigma.

Preoperative lymphangiography was performed in 25 cases of rectosigmoid neoplasia. Comparison between the angiographic picture and the anatomopathological findings permitted statistical assessment of the incidence of lymph node metastasis in this form, and substantiated the reliability and significance of this examination in its early diagnosis.

Duplex-sonography and color-Doppler evaluation of renal artery stenosis--angiographic correlation.

Echo Doppler has been used in 22 patients with suspected renovascular hypertension (RVH) to detect stenosis or occlusion of the renal artery. In 12 cases duplex Doppler technique was used and in 10 color Doppler. The Doppler examination was always performed before angiography which was considered the reference gold-standard. Using duplex Doppler the diagnosis of RVH was based on qualitative (spectral analysis of the waveform) and semi quantitative parameters (resistive index). With color Doppler two other quantitative parameters were used, peak systolic frequency shift at the level of the stenosis and stenosis index. The color Doppler has shown a better specificity and a better PPV. The sensitivity of the color Doppler was comparable to that of the duplex scanner (89% and 90%, respectively). Further studies are necessary in order to define the diagnostic parameters, the reproducibility and the intra- and interobserver reproducibility. The technological progress may in the future reduce the difficulty and the time of examination.