Percutaneous Sclerotherapy for Budd-Chiari Syndrome Secondary to Giant Hepatic Venous Malformations (Hemangiomas).

This prospective study evaluated the safety and effectiveness of percutaneous sclerotherapy in the treatment of secondary Budd-Chiari syndrome due to hepatic venous malformations (HVMs). Four patients (mean age, 40 years; 3 women) with 5 HVMs underwent 7 sessions of percutaneous sclerotherapy with a mixture of bleomycin and lipiodol. All patients had chronic Budd-Chiari syndrome, determined based on imaging findings, with the main symptom being abdominal discomfort and distention. On physical examination, 2 patients had ascites and the other 2 had an epigastric mass. The indication for treatment was intractable abdominal symptoms due to hepatic and/or inferior vena cava (IVC) outflow compression. All procedures were technically successful, with no major complications. Three patients underwent a second session because of incomplete IVC decompression. The patients' symptoms completely resolved at 6 and 12 months of follow-up. There was a significant reduction in lesion volume (P = .007) and an increase in IVC luminal area (P = .018) at 12 months of follow-up.

Percutaneous Sclerotherapy with Bleomycin and Ethiodized Oil: A Promising Treatment in Symptomatic Giant Liver Hemangioma.

Background Percutaneous sclerotherapy with bleomycin has been proven to have a potential benefit in the management of low-flow venous malformations. Liver hemangiomas are considered low-flow venous malformations. Thus, percutaneous sclerotherapy could potentially have a promising result in their management. Purpose To investigate the feasibility, efficacy, and safety of percutaneous sclerotherapy with bleomycin in the management of symptomatic giant liver hemangioma (GLH). Materials and Methods This single-institute prospective study was conducted between September 2018 and July 2020. Percutaneous sclerotherapy was performed using a mixture of bleomycin and ethiodized oil under guidance of US and fluoroscopy in participants with GLH who were experiencing related abdominal pain or fullness. Technical success was recorded. Change in symptom severity, according to visual analog scale (VAS), was considered the primary outcome of the study. Volume change, based on the lesion volume at CT, and complications, based on the classification of the Society of Interventional Radiology, were regarded as secondary outcomes. The primary and secondary outcomes were recorded 6 and 12 months after the procedure. Comparison was performed by using the Wilcoxon signed-rank test or paired t test. Results Twenty-eight participants (mean age, 45 years ± 9; 25 women) were evaluated. Technical success was 100%. The mean VAS score was 8.3 before the procedure, which decreased to 1.4 (84.7% reduction) and 1.5 (83.5% reduction) at 6- and 12-month follow-ups, respectively (P < .001 for both). All participants reported relief of symptoms (17 of 28 participants [61%] with complete relief; 11 [39%] with partial relief) at 12-month follow-up. Mean GLH volumes dropped from 856.3 cm3 to 309.8 cm3 (65.7% reduction) and 206.0 cm3 (76% reduction) at 6- and 12-month follow-ups, respectively (P < .001 for both). No major complications were detected. Conclusion Percutaneous sclerotherapy is a safe and feasible method with promising results in the treatment of patients with symptomatic giant liver hemangioma. Clinical trial registration no. NCT03649113 © RSNA, 2021 See also the editorial by McGahan and Goldman in this issue.

Association between pulmonary arterial obstruction index and right lateral ventricular wall thickness with in-hospital mortality in patients with acute pulmonary embolism.

PURPOSE: To retrospectively assess the correlation between pulmonary arterial obstruction index (PAOI) and right lateral ventricular wall thickness with in-hospital mortality in patients with acute pulmonary embolism. METHODS: CT angiography (CTA) of 55 consecutive patients (30 males; 25 females; mean age ± SD, 59 ± 11 years) with proven acute pulmonary embolism was investigated. PAOI was determined according to the Qanadli score on CTA. Right ventricular lateral wall thickness was also measured, and patients' in-hospital mortality was recorded. The correlation between PAOI and mortality, right ventricular lateral wall thickness and mortality, and PAOI and right ventricular lateral wall thickness was evaluated. RESULTS: PAOI was 23.6 and 10.4 in patients with and without in-hospital mortality, respectively (P < 0.001). Right ventricular lateral wall thickness was 8.7 mm and 7.5 mm in patients with and without in-hospital mortality, respectively (P < 0.001). PAOI more than 21.5 and right ventricular lateral wall thickness more than 8.75 were predictive of in-hospital mortality with a high accuracy. Also, PAOI and right ventricular lateral wall thickness had a significant correlation with each other (P < 0.001; r = 0.695). CONCLUSION: PAOI and right ventricular lateral wall thickness on CTA were highly predictive of in-hospital mortality in patients with pulmonary embolism. Right ventricular lateral wall thickness and PAOI had a significant correlation with each other as well.

Added value of lung window in detecting drug mules on non-contrast abdominal computed tomography.

We evaluated the added value of lung window in non-contrast computed tomography (CT) of suspected body packers or stuffers. Forty suspected drug mules who were referred to our tertiary toxicology center were included. The final diagnosis of drug mule was based on the detection of packs in stool examination or surgery. Non-contrast CT scans were retrospectively interpreted by two blinded radiologists in consensus before and after reviewing the lung window images. The diagnostic performance of abdominal window scans alone and scans in both abdominal and lung windows were subsequently compared. Seven body packers and 21 body stuffers were identified. The sensitivity, negative predictive value (NPV), and diagnostic accuracy of scans in detection of drug mules (either drug packers or stuffers) raised from 60.7, 52.1, and 72.5 to 64.2, 54.5, and 75.0 %, respectively, with a more number of packs being detected (114 vs. 105 packs). In the body packers group, the diagnostic performance of both abdominal windows scans and combined abdominal and lung windows scans were 100 %. In the body stuffers group, the sensitivity, NPV, and diagnostic accuracy of scans increased from 47.6, 52.1, and 55.0 to 52.3, 54.5, and 57.5 %, respectively, after the addition of lung windows. Reviewing the lung window on non-contrast abdominal CT can be helpful in detection of drug mules.

Real-time scrotal ultrasound of patients with varicoceles: correlation with impaired semen analysis.

OBJECTIVES: To evaluate the potential relationship between scrotal ultrasound findings and abnormal semen analysis. METHODS: Eighty-seven patients with varicoceles underwent semen analysis and scrotal sonography. On ultrasound, estimated testes volume and the largest pampiniform vein diameters on the affected side at rest and with Valsalva manoeuvre in both the supine and upright positions were examined. In addition, the differences between the largest venous diameters at rest and during the Valsalva manoeuvre in each position (supine and upright) and also the differences between the largest venous diameter in the supine position and the upright position in each condition (at rest and during the Valsalva manoeuvre) were calculated. The relationship between various ultrasound parameters and impaired semen analysis was evaluated using receiver operating characteristic curves. RESULTS: Seventy-one patients had spermatogenesis impairment, and the remaining 16 had normal semen analysis. The difference in the mean spermatic vein diameter at rest between the supine and upright positions (cut-off point, 0.25 mm) had the highest diagnostic accuracy in differentiating the patients with abnormal sperm analysis from those with normal spermatogenesis with an area under the curve of 0.86. CONCLUSIONS: Real-time scrotal ultrasound can be helpful in predicting abnormal sperm analysis in patients with varicoceles. KEY POINTS: Scrotal ultrasound is a non-invasive method to evaluate spermatic veins in varicoceles. Ultrasound can evaluate venous dimension change at rest after upright position (ΔD(R) ). ΔD( R) > 2.5 mm distinguishes patients with abnormal semen analysis. ΔD( R) has the most accuracy in predicting abnormal spermatogenesis. Ultrasound findings improve differentiation between patients with abnormal and normal spermatogeneses.

Evaluation of hemodynamic properties of cerebral venous drainage in patients with multiple sclerosis: a case-control study.

BACKGROUND: The purpose of this study was to compare patients with multiple sclerosis and healthy control subjects as regards hemodynamics of cerebral venous drainage. MATERIAL/METHODS: Between December 2012 and May 2013, 44 consecutive patients with multiple sclerosis and 44 age- and sex-matched healthy subjects underwent the B-mode, color Doppler, and duplex Doppler evaluations of the internal jugular vein (IJV) and vertebral vein. The following four parameters were investigated: IJV stenosis, reversal of postural control of the cerebral venous outflow pathways, absence of detectable blood flow in the IJVs and/or vertebral veins, and reflux in the IJVs and/or vertebral veins in the sitting or supine position. RESULTS: In the study group, IJV stenosis, postural control reversal of the cerebral venous outflow pathways, and absence of flow in the IJVs and/or vertebral veins were found in 3 (6.8%), 2 (4.5%), and 3 (6.8%) patients, respectively. In the control group, IJV stenosis (P=0.12), postural control reversal of the cerebral venous outflow pathways (P=0.50), and absence of flow (P=0.12) were not detected. Abnormal reflux was found neither in multiple sclerosis patients nor in healthy subjects. CONCLUSIONS: No significant difference in the cerebral venous drainage through the IJV or vertebral vein was found between patients with multiple sclerosis and healthy subjects within any of the investigated ultrasonographic parameters.

Multidetector computed tomography findings of abdominal aortic aneurysm and its complications: a pictorial review.

Abdominal aortic aneurysms (AAAs) are defined as abnormal dilatation of the abdominal aorta and are potential to catastrophic complications. With the advent of multidetector computed tomography (MDCT), this diagnostic modality has virtually replaced conventional angiography in many circumstances and has become an integral part of the evaluation of AAA. Its ability to assess the peri-aortic soft tissue and the exact extension of aneurysm as well as its excellent vascular opacification and multiplanar reconstruction make computed tomography angiography the best suited imaging modality for not only detecting AAA but also evaluating its various complications. In this pictorial essay, we intend to demonstrate the spectrum of MDCT findings in AAA and its various consequences including impending rupture, contained rupture, rupture, aorto-caval fistula, aorto-left renal vein fistula, aorto-enteric fistula, and infection. Familiarity with the characteristic imaging features of AAA is essential for clinical radiologists and also referring physicians for the prompt diagnosis of life-threatening complications.

Not-to-tap cystic lesions: spectrum of hydatid disease.

Hydatid disease (HD) may occur almost anywhere in the body. Despite their characteristic radiologic manifestations at times, they may enlarge and produce bizarre imaging features which make diagnosis challenging, particularly for those radiologists working in areas of low incidence. Plain radiography, ultrasonography, computed tomography, and magnetic resonance imaging may demonstrate some of the typical imaging manifestations of HD as well as its exact extension. On the other hand, particular caution is required before any kind of interventions to be done in that biopsy or aspiration of such lesions may cause devastating consequences, in particular anaphylactic shock. Hence, being familiar with various radiologic features of HD is essential in improving diagnostic accuracy and also preventing adverse reactions in these patients. The purpose of this pictorial review is to illustrate the different radiological features of HD in various organs.

A technical review of percutaneous sclerotherapy with bleomycin for giant hepatic venous malformation.

BACKGROUND: Hepatic venous malformation (HVM), traditionally called liver haemangioma, is considered the most common benign hepatic lesion. Treatment might be indicated in large and symptomatic HVMs. We aim to describe stepwise technical aspects of trans-hepatic percutaneous sclerotherapy of hepatic venous malformation (HVM). MAIN TEXT: Patients with symptomatic HVM larger than 5 cm are selected after discussion in hepatobiliary multidisciplinary team. After prophylactic antibiotic and corticosteroid administration, local anaesthesia and conscious sedation are applied. A 22-gauge spinal or Chiba needle is used to obtain percutaneous access to the HVM through normal liver parenchyma under ultrasound guidance. To ensure proper needle placement and to prevent accidental delivery of sclerosant into unintended areas, about 5-10 mL iodine contrast is injected under fluoroscopy. Then, 45-60 IU bleomycin is mixed with 10 mL distilled water and 10 mL lipiodol and is slowly injected under fluoroscopy over a period of 20-30 s. After the needle is removed, manual pressure is applied over the puncture site for a period of 5 min followed by placement of a sandbag. Patients are monitored for 6-8 h post-procedure. CONCLUSION: In this technical review, we described our institutional technique of percutaneous sclerotherapy, which could be regarded as an alternative to TAE in the management of HVM.

Computed tomographic imaging features of sudden cardiac arrest and impending cardiogenic shock.

We intend to describe the imaging findings of sudden cardiac arrest occurring during computed tomographic (CT) examination and also of impending cardiogenic shock in 4 patients. Despite rare reports of acute cardiac arrest occurring during or shortly after CT scan, CT features are quite characteristic. Familiarity with CT findings of these patients is essential for accurate interpretation of images, immediate initiation of resuscitation, as well as informing clinical physician in these conditions.

Partial Splenic Embolization for the Management of Severe Refractory Thrombocytopenia in Antiphospholipid Syndrome: A Case Report and Literature Review.

Antiphospholipid syndrome is an autoimmune condition characterized by arteriovenous thromboembolic events. Thrombocytopenia is a common finding among these patients and is typically of mild severity not requiring any treatment. However, severe cases of thrombocytopenia should be treated. Steroids, intravenous immune globulin (IVIG), and immunomodulatory agents are the first-line treatment options, and surgical splenectomy is usually reserved for more severe and refractory cases of thrombocytopenia. Herein, we report the case of a 30-year-old man with primary antiphospholipid syndrome and severe thrombocytopenia. The patient's thrombocytopenia had been refractory to almost all the medical managements, and surgical splenectomy could not be an option due to the patient's high-risk condition for surgery. The patient was successfully managed by partial splenic embolization (PSE) which was a unique application of this technique.

A Randomised Clinical Trial to Compare Coaxial and Noncoaxial Techniques in Percutaneous Core Needle Biopsy of Renal Parenchyma.

PURPOSE: To compare the coaxial and noncoaxial techniques of renal parenchymal core needle biopsy. MATERIALS AND METHODS: This is an institutional review board-approved randomised controlled trial comparing 83 patients (male, n = 49) who underwent renal parenchymal core biopsy with coaxial method and 83 patients (male, n = 40) with noncoaxial method. The rate of complications, the number of glomerular profiles, and the procedural time were evaluated in a comparison of the two methods. Correlation between the presence of renal parenchymal disease and the rate of complication was also evaluated. RESULTS: The procedural time was significantly shorter in the coaxial technique (coaxial group, 5 ± 1 min; noncoaxial group, 14 ± 2 min; p < 0.001). The rates of complications for the coaxial method was significantly lower than the noncoaxial method (coaxial group, 10.8 %; noncoaxial group, 24.1 %; p = 0.025). There was no significant correlation between gender and the rate of complication. The number of glomerular profiles was significantly higher in patents who underwent renal biopsy with the coaxial method (coaxial group, 18.2 ± 9.1; noncoaxial group, 8.6 ± 5.5; p < 0.001). In the whole study population, the rate of complications was significantly higher in patients with a pathologic renal parenchyma compared to those with a normal parenchyma (19/71 vs. 10/95; p = 0.006). CONCLUSIONS: Renal parenchymal biopsy using a coaxial needle is a faster and safer method with a lower rate of complications.

Unique Imaging Features of Renal Arteriopelvic Fistula on Contrast-enhanced Multidetector Computed Tomography.

The development of renal arteriopelvic fistula after percutaneous renal interventions is an extremely rare complication. We report a case of iatrogenic left renal arteriopelvic fistula in a 78-year-old man with unique imaging features on contrast-enhanced multidetector computed tomography.

Transperineal Prostate Core Needle Biopsy: A Comparison of Coaxial Versus Noncoaxial Method in a Randomised Trial.

PURPOSE: To compare the procedural time and complication rate of coaxial technique with those of noncoaxial technique in transperineal prostate biopsy. MATERIALS AND METHODS: Transperineal prostate biopsy with coaxial (first group, n = 120) and noncoaxial (second group, n = 120) methods was performed randomly in 240 patients. The procedural time was recorded. The level of pain experienced during the procedure was assessed on a visual analogue scale (VAS), and the rate of complications was evaluated in comparison of the two methods. RESULTS: The procedural time was significantly shorter in the first group (p < 0.001). In the first group, pain occurred less frequently (p = 0.002), with a significantly lower VAS score being experienced (p < 0.002). No patient had post procedural fever. Haematuria (p = 0.029) and haemorrhage from the site of biopsy (p < 0.001) were seen less frequently in the first group. There was no significant difference in the rate of urethral haemorrhage between the two groups (p = 0.059). Urinary retention occurred less commonly in the first group (p = 0.029). No significant difference was seen in the rate of dysuria between the two groups (p = 0.078). CONCLUSIONS: Transperineal prostate biopsy using a coaxial needle is a faster and less painful method with a lower rate of complications compared with conventional noncoaxial technique.

Idiopathic inferior mesenteric arteriovenous fistula: a rare cause of pulsatile abdominal mass.

Inferior mesenteric arteriovenous fistula (AVF) is an extremely rare vascular abnormality which may be idiopathic or secondary to previous trauma or surgery, and it may result in portal hypertension or ischemic colitis if left untreated. Imaging can help accurately diagnose visceral AVFs and create a vascular map to display the feeding artery and draining vein before the surgery; however, multidetector computed tomography (MDCT) angiography of inferior mesenteric AVF is not well documented in the literature. In this article, the authors report a case of inferior mesenteric AVF in a 48-year-old woman evaluated for left-sided abdominal pain and diagnosed preoperatively by MDCT angiography. Surgical excision of the AVF was successfully performed, and the postoperative course was uneventful.

Congenital external carotid-external jugular arteriovenous fistula: diagnosis with contrast-enhanced computed tomography.

Arteriovenous fistula (AVF) between the external carotid artery and external jugular vein is extremely rare, with only few cases reported in the literature so far. Most of these AVFs have been either iatrogenic or secondary to previous trauma. Herein, we report a 42-year-old woman with congenital AVF between the external carotid artery and external jugular vein, presenting with palpitation and dyspnea. The patient was suffering from mitral and tricuspid regurgitation. On physical examination, a thrill on the left side of the neck and an audible bruit over the left mandibular angle were detected. The possibility of abnormal AVF was considered and it was confirmed on contrast-enhanced computed tomography (CT), inferring that this modality is not only fast and non-invasive, but also accurate in detecting vascular abnormalities.

Multifocal Skeletal Tuberculosis Mimicking Langerhans Cell Histiocytosis in a Child: a Case Report With a Long-Term Follow-Up.

INTRODUCTION: Multifocal skeletal tuberculosis is a rare condition that may masquerade as Langerhans cell histiocytosis, especially in children. CASE PRESENTATION: We report a case of multifocal osseous tuberculosis in a 5-year-old female patient admitted to our hospital with a complaint of low back pain but no history of respiratory symptoms or malaise. Radiological findings included vertebra plana and multiple lytic lesions in both the frontal and pelvic bones. An initial diagnosis of Langerhans cell histiocytosis was made based on imaging findings; however, the patient underwent further evaluation for Mycobacterium tuberculosis, and histopathologic findings confirmed the diagnosis of tuberculosis. The patient showed a nearly complete response after receiving a course of anti-tuberculosis drugs. CONCLUSIONS: A high index of suspicion is required for the early diagnosis and prompt treatment of patients with osseous tuberculosis. Given the high prevalence of tuberculosis in developing countries, tuberculosis should be considered in the differential diagnosis of multifocal lytic lesions and vertebra plana, especially in children.

Central nervous system tuberculosis: an imaging-focused review of a reemerging disease.

Central nervous system (CNS) tuberculosis is a potentially life threatening condition which is curable if the correct diagnosis is made in the early stages. Its clinical and radiologic manifestations may mimic other infectious and noninfectious neurological conditions. Hence, familiarity with the imaging presentations of various forms of CNS tuberculosis is essential in timely diagnosis, and thereby reducing the morbidity and mortality of this disease. In this review, we describe the imaging characteristics of the different forms of CNS tuberculosis, including meningitis, tuberculoma, miliary tuberculosis, abscess, cerebritis, and encephalopathy.

Imaging Findings of Isolated Bronchial Anthracofibrosis: A Computed Tomography Analysis of Patients With Bronchoscopic and Histologic Confirmation.

BACKGROUND: To evaluate the chest computed tomography (CT) findings of patients with isolated bronchial anthracofibrosis confirmed by bronchoscopy and histopathology. METHODOLOGY: Fifty-eight patients with isolated bronchial anthracofibrosis (29 females; mean age, 70 years) were enrolled in this study. The diagnosis of bronchial anthracofibrosis was made based on both bronchoscopy and pathology findings in all patients. The various chest CT images were retrospectively reviewed by two chest radiologists who reached decisions in consensus. RESULTS: Central peribronchial soft tissue thickening (n=37, 63.8%) causing bronchial narrowing (n=37, 63.8%) or obstruction (n=11, 19%) was identified as an important finding on imaging. Multiple bronchial stenoses with concurrent involvement of 2, 3, and 5 bronchi were seen in 12 (21%), 9 (15%), and 2 (3.4%) patients, respectively. Segmental atelectasis and lobar or multilobar collapse were detected. These findings mostly occurred in the right lung, predominantly in the right middle lobe. Mosaic attenuation patterns, scattered parenchymal nodules, nodular patterns, and calcified or non-calcified lymph nodes were also observed. CONCLUSIONS: On chest CT, isolated bronchial anthracofibrosis appeared as peribronchial soft tissue thickening, bronchial narrowing or obstruction, segmental atelectasis, and lobar or multilobar collapse. The findings were more common in the right side, with simultaneous involvement of multiple bronchi in some patients.

Diagnostic accuracy of secondary ultrasound exam in blunt abdominal trauma.

BACKGROUND: In stable patients with blunt abdominal trauma, accurate diagnosis of visceral injuries is crucial. OBJECTIVES: To determine whether repeating ultrasound exam will increase the sensitivity of focused abdominal sonography for trauma (FAST) through revealing additional free intraperitoneal fluid in patients with blunt abdominal trauma. PATIENTS AND METHODS: We performed a prospective observational study by performing primary and secondary ultrasound exams in blunt abdominal trauma patients. All ultrasound exams were performed by four radiology residents who had the experience of more than 400 FAST exams. Five routine intraperitoneal spaces as well as the interloop space were examined by ultrasound in order to find free fluid. All patients who expired or were transferred to the operating room before the second exam were excluded from the study. All positive ultrasound results were compared with intra-operative and computed tomography (CT) findings and/or the clinical status of the patients. RESULTS: Primary ultrasound was performed in 372 patients; 61 of them did not undergo secondary ultrasound exam; thus, were excluded from the study.Three hundred eleven patients underwent both primary and secondary ultrasound exams. One hundred and two of all patients were evaluated by contrast enhanced CT scan and 31 underwent laparotomy. The sensitivity of ultrasound exam in detecting intraperitoneal fluid significantly increased from 70.7% for the primary exam to 92.7% for the secondary exam. Examining the interloop space significantly improved the sensitivity of ultrasonography in both primary (from 36.6% to 70.7%) and secondary (from 65.9% to 92.7%) exams. CONCLUSIONS: Performing a secondary ultrasound exam in stable blunt abdominal trauma patients and adding interloop space scan to the routine FAST exam significantly increases the sensitivity of ultrasound in detecting intraperitoneal free fluid.