Diagnostic value of non-enhanced computed tomography in identifying location of ruptured cerebral aneurysm in patients with aneurysmal subarachnoid haemorrhage.

BACKGROUND: In patients with SAH and multiple aneurysms, the ruptured lesion must be identified to prevent recurrent bleeding. AIM OF THE STUDY: To assess the diagnostic value of non-enhanced computed tomography (NECT) in identifying the rupture site in patients with subarachnoid haemorrhage (SAH) and multiple aneurysms. MATERIAL AND METHODS: We included patients with SAH revealed by NECT and multiple aneurysms detected on computed tomography angiography (CTA) in whom a ruptured aneurysm was identified during neurosurgery. Two radiologists predicted the location of the ruptured aneurysm based on the distribution of the SAH and location of intracerebral haematoma (ICH) by NECT. RESULTS: Eighty-three patients with a mean age of 55.7 ± 14.4 years were included. Ruptured aneurysms were significantly larger (mean size 7.7 ± 4.7 mm) than unruptured aneurysms (mean size 5.9 ± 4.5 mm; p = 0.014). Interobserver agreement was 0.86 (p < 0.001). Overall sensitivity and specificity of radiological prediction were 78.3% (95% CI, 68.6%-87.1%) and 96.4% (95% CI, 94.3%-97.8%) respectively. Overall PPV and NPV were 78.3% (95% CI, 67.6%-86.3%) and 96.8% (95% CI, 94.8%-98.1%) respectively. The sensitivity and PPV for aneurysms in the anterior communicating, anterior, and middle cerebral arteries appeared to be significantly higher than in other locations (p = 0.015 and 0.019 respectively). Analysis of independent predictive factors of correct radiological location revealed that ICH predisposes to a correct radiological diagnosis with an odds ratio of 8.57 (95% CI, 1.07-68.99; p = 0.03). CONCLUSIONS: NECT has a high diagnostic value in identifying the source of bleeding in patients with multiple aneurysms for anterior circulation aneurysms, especially with coexisting ICH. For other locations, NECT is not reliable enough to base treatment decisions upon.

Massive Upper Gastrointestinal Bleeding from a Splenic Artery Pseudoaneurysm Caused by a Penetrating Gastric Ulcer: Case Report and Review of Literature.

BACKGROUND: Splenic artery aneurysm and pseudoaneurysm are rare pathologies. True aneurysms are usually asymptomatic. Aneurysm rupture occurring in 2-3% of cases results in bleeding into the lesser sack, peritoneal space or adjacent organs typically presenting as abdominal pain and hemodynamic instability. In contrast, pseudoaneurysms are nearly always symptomatic carrying a high risk of rupture of 37-47% and mortality rate of 90% if untreated. Therefore, prompt diagnosis and treatment are essential in the management of patients with splenic artery pseudoaneurysm. Typical causes include pancreatitis and trauma. Rarely, the rupture of a pseudoaneurysm presents as upper gastrointestinal (UGI) bleeding. Among causes, peptic ulcer is the casuistic one. CASE REPORT: This report describes a very rare case of recurrent UGI bleeding from a splenic artery pseudoaneurysm caused by a penetrating gastric ulcer. After negative results of endoscopy and ultrasound, the diagnosis was established in CT angiography. The successful treatment consisted of surgical ligation of the bleeding vessel and suture of the ulcer with preservation of the spleen and pancreas, which is rarely tried in such situations. CONCLUSIONS: The most important factor in identifying a ruptured splenic artery pseudoaneurysm as a source of GI bleeding is considering the diagnosis. UGI hemorrhage from splenic artery pseudoaneurysm can have a relapsing course providing false negative results of endoscopy and ultrasound if performed between episodes of active bleeding. In such cases, immediate CT angiography is useful in establishing diagnosis and in application of proper therapy before possible recurrence.

Pulmonary benign metastasizing leiomyoma from the uterine leiomyoma: a case report.

BACKGROUND: Benign metastasizing leiomyoma (BML) is a rare condition described as multiple well-differentiated leiomyomas at sites distant from the uterus. Apart from lungs it has also been reported in lymph nodes, heart, brain, bone, skin, eye and spinal cord. We present a case of pulmonary benign metastasizing leiomyoma in a female patient admitted to our hospital with suspicion of left adnexal tumor. CASE REPORT: A 45-year-old woman was referred to our hospital with suspicion of left adnexal tumor. The control transvaginal ultrasound examination performed at admission to the Gynecological Department excluded adnexal neoplasm. However, a large amount of fluid within the Douglas pouch raised the oncological concern. The patient underwent myomectomy in 2005. In the same year she was diagnosed with multiple lung nodules and underwent pulmonary wedge resection with the diagnosis of pulmonary benign metastasizing leiomyoma being stated. The decision of reevaluation of the specimen, control CT and puncture of the Douglas pouch fluid was made. Computed tomography performed at the Department of Diagnostic Imaging and Interventional Radiology of the Pomeranian Medical University Hospital revealed multiple, bilateral nodules. The microscopic examination of the samples confirmed the initial diagnosis of benign metastasizing leiomyoma with no evidence of neoplastic cells within the fluid. CONCLUSIONS: Pulmonary benign metastasizing leiomyoma is a rare entity. However, it should be always taken into consideration in women with a previous or coincident history of uterine leiomyoma, especially when no evidence of other malignancy is present.

The assessment of the role of baseline low-dose CT scan in patients at high risk of lung cancer.

BACKGROUND: Despite the progress in contemporary medicine comprising diagnostic and therapeutic methods, lung cancer is still one of the biggest health concerns in many countries of the world. The main purpose of the study was to evaluate the detection rate of pulmonary nodules and lung cancer in the initial, helical low-dose CT of the chest as well as the analysis of the relationship between the size and the histopathological character of the detected nodules. MATERIAL/METHODS: We retrospectively evaluated 1999 initial, consecutive results of the CT examinations performed within the framework of early lung cancer detection program initiated in Szczecin. The project enrolled persons of both sexes, aged 55-65 years, with at least 20 pack-years of cigarette smoking or current smokers. The analysis included assessment of the number of positive results and the evaluation of the detected nodules in relationship to their size. All of the nodules were classified into I of VI groups and subsequently compared with histopathological type of the neoplastic and nonneoplastic pulmonary lesions. RESULTS: Pulmonary nodules were detected in 921 (46%) subjects. What is more, malignant lesions as well as lung cancer were significantly, more frequently discovered in the group of asymptomatic nodules of the largest dimension exceeding 15 mm. CONCLUSIONS: The initial, low-dose helical CT of the lungs performed in high risk individuals enables detection of appreciable number of indeterminate pulmonary nodules. In most of the asymptomatic patients with histopathologically proven pulmonary nodules greater than 15 mm, the mentioned lesions are malignant, what warrants further, intensified diagnostics.

New perspective on median arcuate ligament syndrome. Case reports.

A large group of patients with significant asymptomatic or low-symptomatic coeliac trunk stenosis require deeper consideration. On angiography, CT and MRI, 10-24% of examined patients are found to have their coeliac trunk compressed by the median arcuate ligament of the diaphragm. The associated median arcuate ligament syndrome, which is also called coeliac trunk compression syndrome or Dunbar syndrome, is rarely fully symptomatic. It is estimated that there are up to 7% of patients with such a clinical presentation. An asymptomatic or low-symptomatic course of the disease in patients with the syndrome is mainly explained by a developed collateral circulation, particularly involving the arterial arcades of the head of pancreas. In such cases, CT angiography detects collateral circulation in 22-69.6% of examined patients. The present authors often observed coeliac trunk blood flow to normalise in a standing position. According to them, the main causative factor for this phenomenon is the deflection of the coeliac trunk and its compression against the aorta by a lowered left lobe of the liver. The researchers observed it in many individuals; in this study, 5 cases are presented.

Ultrasonography in the diagnosis and monitoring of intra-abdominal hypertension and abdominal compartment syndrome: Ultrasonografia a nadcisnienie wewnatrzbrzuszne i zespól przedzialu brzusznego.

Despite their considerable clinical significance, intra-abdominal hypertension and abdominal compartment syndrome are rarely discussed in the context of ultrasonography. They occur in critically ill patients, usually hospitalized in intensive care units. Early diagnosis of these conditions is of key importance for prognosis as it allows for proper treatment and prevents high mortality. Although there are various methods for the assessment of intra-abdominal pressure, a measurement using a sensor-equipped catheter placed in the bladder is the gold standard. However, this technique does not allow to identify the etiology of the problem, which is usually resolved by analyzing patient's clinical data supported by imaging findings. Computed tomography is most often used for this purpose. Recent years have proved that point-of-care ultrasonography is also useful in this respect. This issue has become the basis for developing this review paper, which describes the opinion of the experts of the World Society of the Abdominal Compartment Syndrome on the nomenclature, classification and diagnosis of intra-abdominal hypertension. We also presented preliminary data on the role of ultrasound in the diagnosis and monitoring of intra-abdominal hypertension and the contribution of this modality to the choice of appropriate treatment for patients presenting with this clinical condition. A multi-center study used point-of-care ultrasonography to assess the position of a g-tube in the stomach and its contents, intraluminal content status and bowel motor function, the monitoring of gastric drainage and forced intestinal evacuation, the presence of ascites and ascitic status without and after paracentesis. Even when simplified, the method was found to be very useful.

Optimization of diagnostic ultrasonography of the gallbladder based on own experience and literature.

Although transabdominal imaging of the gallbladder has become a gold standard, new light should be shed on some aspects, which will prove useful in everyday practice. Therefore, based on our own experience and the available literature, we would like to draw attention to those elements of gallbladder ultrasound imaging which may increase its diagnostic efficacy. The paper draws attention to the difficulty in assessing certain anatomical structures, such as the inferior wall, the bottom and the region of the neck of the gallbladder, and offers ways to improve their imaging. We also emphasized the negative effects of duodenal and transverse colon (along with their contents) adhesion to the bottom of the gallbladder on the correct diagnosis. Due to the importance of size in the management strategy for detected gallbladder polyps, we suggest their measurement on an image enlarged with the zoom function. This technique also allows for an accurate assessment of the shape and echostructure of these lesions. An enlarged image of a polyp makes it possible to trace its behavior in time. We also remind that the hepatic wall of the gallbladder is the only site allowing for a reliable wall thickness measurement. We also pointed to the importance of changing patient's position when assessing the mobility and the nature of lesions. Altering patient's position during examination may help detect anomalies in the form of a floating gallbladder, which may promote its torsion. Finally, pathologies whose diagnosis may be facilitated by color-coded blood flow imaging are also presented. The issues discussed in this paper are only a fraction of problems faced by an ultrasound operator in the field of gallbladder diagnostic imaging. However, the proposed ultrasound approaches should help solve some of these problems in everyday practice.Although transabdominal imaging of the gallbladder has become a gold standard, new light should be shed on some aspects, which will prove useful in everyday practice. Therefore, based on our own experience and the available literature, we would like to draw attention to those elements of gallbladder ultrasound imaging which may increase its diagnostic efficacy. The paper draws attention to the difficulty in assessing certain anatomical structures, such as the inferior wall, the bottom and the region of the neck of the gallbladder, and offers ways to improve their imaging. We also emphasized the negative effects of duodenal and transverse colon (along with their contents) adhesion to the bottom of the gallbladder on the correct diagnosis. Due to the importance of size in the management strategy for detected gallbladder polyps, we suggest their measurement on an image enlarged with the zoom function. This technique also allows for an accurate assessment of the shape and echostructure of these lesions. An enlarged image of a polyp makes it possible to trace its behavior in time. We also remind that the hepatic wall of the gallbladder is the only site allowing for a reliable wall thickness measurement. We also pointed to the importance of changing patient's position when assessing the mobility and the nature of lesions. Altering patient's position during examination may help detect anomalies in the form of a floating gallbladder, which may promote its torsion. Finally, pathologies whose diagnosis may be facilitated by color-coded blood flow imaging are also presented. The issues discussed in this paper are only a fraction of problems faced by an ultrasound operator in the field of gallbladder diagnostic imaging. However, the proposed ultrasound approaches should help solve some of these problems in everyday practice.

Evaluation of the Accero Stent for Stent-Assisted Coiling of Unruptured Wide-Necked Intracranial Aneurysm Treatment with Short-Term Follow-Up.

BACKGROUND: Stent-assisted coiling is an effective method of treating intracranial aneurysms. The aim of the study was to assess the safety and efficacy of the new Accero stent for the treatment of intracranial aneurysms. MATERIALS AND METHODS: It was a retrospective, single-center study. Eighteen unruptured intracranial aneurysms were treated using the stent-assisted coiling method with the Accero stent. Patient demographics, aneurysm characteristics, procedural parameters, grade of occlusion, complications, and clinical results were analyzed. Follow-up magnetic resonance (MR) was performed 6 months after intervention. RESULTS: Seventeen patients with 18 incidental unruptured aneurysms were electively treated with coiling and the Accero stent. The aneurysms were located on internal carotid artery (ICA), middle cerebral artery (MCA) and basilar artery (BA). All stents were deployed successfully. Immediate complete occlusion rate Raymond-Roy occlusion classification (RROC) class I was achieved in 13 cases and class II in 4 cases. Complications occurred in 2/17 treatments and included guidewire stent perforation with subarachnoid hemorrhage (SAH) and stent deformation. Vascular spasm in the subarachnoid hemorrhage (SAH) patient subsided before discharge. Ninety days after intervention, the modified Rankin Scale (mRS) value was 0. RROC class I was observed in 88.23% of cases in follow-up. CONCLUSION: The Accero stent provides excellent support for coil mass. It constitutes an efficacious device with good initial occlusion rate for treating wide-necked unruptured intracranial aneurysms.

Differential diagnosis of fat-containing lesions in the inguinal canal using ultrasound.

Abdominal hernias are usually located in the inguinal canals. Differential diagnosis of hernias should consider other pathologies, which typically occur at this site. The aim of this review paper is to present fat-containing lesions located in the inguinal canal based on both our own experience and literature. The first part of the paper describes the embryogenesis and differences in the structure and content of male and female inguinal canal. The canal is clearly wider in men, which results from the presence of the spermatic cord and its components. The female canal contains only the narrow round ligament of the uterus. The second part of the paper discusses the incorrect use of the term "lipoma" for retroperitoneal fat, which penetrated into the lumen of the patent processus vaginalis - the authors using this term acknowledge its incorrectness. These lesions often coexist with oblique inguinal hernia and should be excised during a surgery as they may cause inguinal pain. As for other fat-containing inguinal pathologies, we discussed lipomatosis of the spermatic cord, liposarcoma and the greater omentum. Differential diagnosis of these lesions considers their echogenicity, echostructure and vascularity. Furthermore, attention was paid to the adipose tissue surrounding the lower epigastric vessels, which may be incorrectly localized in the inguinal canal. Finally, the importance of proper diagnostic methodology and knowledge of the inguinal anatomy for the correct ultrasonographic diagnosis was emphasized.

Pitfalls in ultrasound imaging of the stomach and the intestines.

The gastrointestinal tract is an extraordinary human organ in terms of its morphology and function. Its complex structure and enormous length as well as frequent presence of gas discourage many doctors performing ultrasound examination from its exploration. Moreover, there are anatomical structures in multiple locations which can mimic certain abnormalities. It is difficult to present an exhaustive account of the problem of gastrointestinal tract ultrasound imaging errors in a single work; therefore, this study focuses mainly on false positive errors which usually result from a lack of knowledge of anatomical variants of the gastrointestinal tract structure. In the case of the stomach, rugae and muscle layer thickening towards the pylorus have been mentioned, which constitute variants of the structure of this organ examined when empty. Diagnostic pitfalls in the small intestine may include the dudenojejunal flexure (ligament of Treitz), the horizontal part of the duodenum and the ileocaecal valve. The status of the apparent lesions in all of the cases mentioned will be resolved following fluid intake by the patient. In the colon, the varied structure of semilunar folds should be taken note of. Their large thickness can warrant suspicion of wall invasion or a polyp. In addition, the study emphasises the importance of appropriate preparation of a patient for gastrointestinal tract examination since it determines the accuracy of the diagnosis. The authors also take note of common 'sins' of physicians such as hasty examination and failure to comply with the stomach and appendix examination protocol.

Cartilaginous compression of the liver - clinical and ultrasonographic aspects.

INTRODUCTION: The musculocartilaginous complex is a structure composed of cartilaginous, osseous and muscular elements, which is located at the thoracoabdominal junction, at the level of the right costal arch. AIM: To determine the ultrasonographic characteristics of this complex under normal conditions as well as to demonstrate its effects on the liver depending on the constitutional body built, respiratory phase and patient's body position. MATERIALS AND METHODS: All abdominal ultrasound scans were performed between 2006 and 2015. A total of 1000 patients (566 females and 434 males aged between 35 and 82 years, mean age 52 years), who had no significant upper abdominal pathologies identified based on clinical and imaging data, were enrolled for the analysis. In addition to standard internal organ assessment, we also attempted to identify the symptoms of hepatic compression by the musculocartilaginous complex. We used 3-6 MHz convex and 7-12 MHz linear transducers. The degree of musculocartilaginous compression of the liver was assessed during breathing in supine and sitting position, as well as with trunk inclined forward. RESULTS: The study showed that musculocartilaginous compression of the liver mostly affects females (96%) with leptosomatic body build. The complex compressing the liver shows a heterogeneous echostructure. Increased hepatic compression was observed during exhalation, in a sitting position and with trunk inclined forward. CONCLUSIONS: Cartilaginous compression of the liver depends on body built and patient's body position. The musculocartilaginous complex may cause focal or segmental compression of the hepatic parenchyma, causing pain in the right upper abdomen in some patients.

[The progress in the rehabilitation of dysarthria in Parkinson disease using LSVT (Lee Silverman Voice Treatment)]. / Postepy rehabilitacji dyzartrii w chorobie Parkinsona z wykorzystaniem LSVT (Lee Silverman Voice Treatment).

Parkison's disease causes damage to the central nervous system resulting in bradykinesia, muscle rigidity, rest tremor and dysarthric speech. In clinical terms dysarthria denotes the dysfunction of articulation, phonation and respiration. It is brought about by the impairment of neural paths innervating the speech apparatus, thus causing a decreased ability to communicate. The study was conducted by the Center for Speech and Language Processing (CSLP), Adam Mickiewicz University, Poznan and the Chair and Department of Phoniatrics and Audiology, the Medical University, Poznan within the interdisciplinary research project grant called "Speech and Language Virtual Therapist for Individuals with Parkinson's Disease". Apart from traditional voice and speech therapies, one of the ways of treating speech disturbances accompanying Parkinson's disease is an innovative Lee Silverman Voice Treatment (LSVT). The purpose of this innovative method introduced by dr L. Ramig and colleagues in 1987-1988, is to teach the patient to speak loud. As a result of co-operation between CLSP and the Center for Spoken Language Research (CSLR) at the University of Colorado, Boulder, USA, a Polish version of LSVT Virtual Therapist computer programme was created (LSVTVT). The programme is based on the principles of LSVT. The positive outcomes of the therapy give hope to Parkinson's disease patients with dysarthria, as well as to speech therapists.

Detailed EFSUM recommendations on the scope of ultrasound assessment in patients with portal hypertension considering the diagnostic reference level.

An important paper describing the Standards of the Polish Ultrasound Society regarding the assessment of portal and hepatic vasculature was published in the Journal of Ultrasonography. Due to the multiplicity of morphological and hemodynamic data required, the time needed to obtain these data and the legal responsibility of doctors for the results, there seems to be a need to determine a clear range of the assessed parameters depending on the reference level of a given healthcare facility. Therefore, the aim of the paper was to present the EFSUMB recommendations on the range of the evaluated ultrasonographic parameters in portal hypertension depending on the reference level. European healthcare institutions are characterized by a clear three-level reference network. Due to the lack of a similar division in Poland, we propose our own classification of the competence of medical entities. The first reference level: ultrasound assessments in a primary health care setting (performed by GPs, emergency physicians, non-specialist private practice physicians, non-specialist practice physicians); at least one mid-class ultrasound scanner with pulsed and color Doppler options, equipped with convex 3-5 MHz and linear 7-12 MHz transducers should be available at physician's disposal. The second reference level: ultrasound assessments in the hospital setting and specialist outpatient clinics, performed by specialist private practice physicians, radiologists, gastroenterologists and hepatologists; top class (premium) digital ultrasound scanner should be available at physician's disposal. Third reference level: ultrasound assessments performed in gastroenterology, hepatology and liver surgery departments as well as their specialist outpatient clinics; physicians should use top class digital ultrasound equipment. At every reference level, physicians performing abdominal ultrasound should have the appropriate certification to perform such an assessment or specialize in gastrointestinal diagnosis.

Is it possible to differentiate between pseudopneumoperitoneum and similar pathologies ultrasonographically?

AIM: The goal of the work was comparing gas ultrasound images below the right diaphragm in two groups: in people with intestinal interposition below the diaphragm and ones with pneumoperitoneum and extracting the traits differentiating these two conditions. MATERIAL AND METHODS: Retrospectively, the documentation of 22 patients with intestinal interposition below the diaphragm (group 1) was utilized. Clinical material was used for comparison, previously published, composed of 15 cases of pneumoperitoneum following laparotomy and of 14 cases following that symptom as a result of ulcer perforation - group 2 (in total n = 29). Moreover, the distance in millimeters of the gas surface reflecting ultrasounds from the parietal peritoneum was measured, the smoothness of the surface, parietal peritoneum enhancement at the place of gas adherence, gas continuity below the diaphragm with gas in the intestine located below the liver. RESULTS: Direct adherence of the gas surface to the diaphragm was observed in 100% of the cases of emphysema, but in no cases of intestinal interposition. Yet, in the group of patients with colonic interposition (n = 21) there was always a small gap (2-3 mm) and the gas surface among those patients in 100% of the cases was uneven. CONCLUSIONS: In differentiation between pneumoperitoneum and liver-diaphragm interposition of the intestine one should take into account - apart from gas movement below the diaphragm at body position changing - the presence of protrusion and section enhancement of the diaphragmatic peritoneum as well as the distance of the gas from the diaphragm, the smoothness of its surface and the continuity with the intestine below the liver. Interpositions of small diaphragm-liver penetration may subside in erect position.

Difficulties in differentiating the nature of ascites based on ultrasound imaging.

Transabdominal ultrasound not always allows to determine the nature of ascites based solely on its characteristics. AIM: The aim of the study was to present difficulties in determining the nature of ascites using transabdominal ultrasonography solely based on extra-organ lesions as well as, after the inclusion of the overall abdominal assessment and the clinical picture. MATERIALS AND METHODS: A total of 18 patients with non-neoplastic ascites and 62 patients with neoplastic ascites whose final diagnosis was based on cytological and histopathological findings were evaluated between 2005 and 2015. Abdominal ultrasound was performed to detect the presence of fluid in all accessible spaces, and, additionally, to determine the presence of potential peritoneal tumor implants as well as to evaluate the parietal peritoneum and the greater omentum. Different digital ultrasound machines equipped with 3-6 MHz and linear 7-12 MHz transducers were used in the study. Double-sided Fisher's exact test with statistical significance at p < 0.05 was used for the analysis of the obtained results. RESULTS: Statistically significant differences between benign and neoplastic ascites were found for: anechoic peritoneal fluid (<0.0001); fluid and thickened omentum with smooth surface (<0.0001); fluid and thickened omentum with smooth surface and varices (0.01); fluid and thickened omentum with hypoechoic foci (0.049); fluid and thickened omentum with tumor implants (0.009). The inclusion of the overall assessment of abdominal organs and the clinical data allowed for an improvement in ultrasonographic diagnostic accuracy in benign and neoplastic ascites from 83.3% and 67.7% to 94.4% and 93.5%, respectively. CONCLUSIONS: When used alone, an assessment of acoustic fluid characteristics and extra-organ peritoneal lesions limits the possibility to differentiate between benign and malignant ascites. These results improve after the inclusion of sonographic assessment of all abdominal organs in combination with clinical data.

Chest wall - underappreciated structure in sonography. Part I: Examination methodology and ultrasound anatomy.

Chest wall ultrasound has been awarded little interest in the literature, with chest wall anatomy described only in limited extent. The objective of this study has been to discuss the methodology of chest wall ultrasound and the sonographic anatomy of the region to facilitate professional evaluation of this complex structure. The primarily used transducer is a 7-12 MHz linear one. A 3-5 MHz convex (curvilinear) transducer may also be helpful, especially in obese and very muscular patients. Doppler and panoramic imaging options are essential. The indications for chest wall ultrasound include localized pain or lesions found or suspected on imaging with other modalities (conventional radiography, CT, MR or scintigraphy). The investigated pathological condition should be scanned in at least two planes. Sometimes, evaluation during deep breathing permits identification of pathological mobility (e.g. in rib or sternum fractures, slipping rib syndrome). Several structures, closely associated with each other, need to be considered in the evaluation of the chest wall. The skin, which forms a hyperechoic covering, requires a high frequency transducer (20-45 MHz). The subcutaneous fat is characterized by clusters of hypoechoic lobules. Chest muscles have a very complex structure, but their appearance on ultrasound does not differ from the images of muscles located in other anatomical regions. As far as cartilaginous and bony structures of the chest are concerned, the differences in the anatomy of the ribs, sternum, scapula and sternoclavicular joints have been discussed. The rich vascular network which is only fragmentarily accessible for ultrasound assessment has been briefly discussed. A comprehensive evaluation of the chest wall should include the axillary, supraclavicular, apical and parasternal lymph nodes. Their examination requires the use of elastography and contrast-enhanced ultrasound.

Chest wall - underappreciated structure in sonography. Part II: Non-cancerous lesions.

The chest wall is a vast and complex structure, hence the wide range of pathological conditions that may affect it. The aim of this publication is to discuss the usefulness of ultrasound for the diagnosis of benign lesions involving the thoracic wall. The most commonly encountered conditions include sternal and costal injuries and thoracic lymphadenopathy. Ultrasound is very efficient in identifying the etiology of pain experienced in the anterior chest wall following CPR interventions. Both available literature and the authors' own experience prompt us to propose ultrasound evaluation as the first step in the diagnostic workup of chest trauma, as it permits far superior visualization of the examined structures compared with conventional radiography. Sonographic evaluation allows correct diagnosis in the case of various costal and chondral defects suspicious for cancer. It also facilitates diagnosis of such conditions as degenerative lesions, subluxation of sternoclavicular joints (SCJs) and inflammatory lesions of various etiology and location. US may be used as the diagnostic modality of choice in conditions following thoracoscopy or thoracotomy. It may also visualize the fairly common sternal wound infection, including bone inflammation. Slipping rib syndrome, relatively little known among clinicians, has also been discussed in the study. A whole gamut of benign lesions of thoracic soft tissues, such as enlarged lymph nodes, torn muscles, hematomas, abscesses, fissures, scars or foreign bodies, are all easily identified on ultrasound, just like in other superficially located organs.

Chest wall - a structure underestimated in ultrasonography. Part III: Neoplastic lesions.

Chest wall neoplasms mainly include malignancies, metastatic in particular. Differential diagnosis should include clinical data; tumor location, extent, delineation; the degree of homogeneity; the presence of calcifications; the nature of bone destruction and the degree of vascularization. The aim of the paper is to present both the benefits and limitations of ultrasound for the diagnosis of chest wall neoplasms. The neoplastic process may be limited to the chest wall; it may spread from the chest wall into the intrathoracic structures or spread from the inside of the chest towards the chest wall. Benign tumors basically originate from vessels, nerves, bones, cartilage and soft tissues. In this paper, we briefly discuss malformations of blood and lymphatic vessels, glomus tumor as well as neurogenic tumors originating in the thoracic branches of the spinal nerves and the autonomic visceral system. Metastases, particularly lung, breast, kidney cancer, melanoma and prostate cancer, are predominant tumors of the osteocartilaginous structures of the chest wall. Plasma cell myeloma is also relatively common. The vast majority of these lesions are osteolytic, which is reflected in ultrasound as irregular cortical defects. Osteoblastic foci result only in irregular outline of the bone surface. Lipomas are the most common neoplasms of the chest wall soft tissue. Elastofibroma is another tumor with characteristic echostructure. Desmoid fibromatosis, which is considered to be a benign lesion with local aggressivity and recurrences after surgical resection, represents an interesting tumor form the clinical point of view. Ultrasonography represents an optimal tool for the monitoring of different biopsies of pathological lesions located in the chest wall. Based on our experiences and literature data, this method should be considered as a preliminary diagnosis of patients with chest wall tumors.

Mediastinal Pancreatic Pseudocysts.

Mediastinal pseudocysts are a rare complication of acute pancreatitis. Lack of uniform treatment standards makes the management of this condition a clinical challenge. We report the case of a 43-year-old patient who presented with a left pleural effusion. Pleural fluid revealed a high amylase concentration consistent with a pancreaticopleural fistula. Endoscopic retrograde cholangiopancreatography (ERCP) revealed a disruption of the pancreatic duct with free outflow of contrast medium into the thoracic cavity. A pancreatic stent was placed. The second day after the ERCP, the patient developed septic shock and was admitted to the intensive care unit. Computed tomography (CT) revealed mediastinal pseudocysts and bilateral pleural effusions. After bilateral drainage of the pleural cavities, the patient improved clinically, and a follow-up CT scan showed that the fluid collection and pseudocysts had resolved. We discuss the optimal strategies for diagnosing and treating patients with pancreatic thoracic pseudocysts and fistulas, as well as review the management of these conditions.

Is a fatty pancreas a banal lesion?

So far, a fatty pancreas has been related to obesity and the ageing processes in the body. The current list of pathogenetic factors of the condition is clearly extended with genetically conditioned diseases (cystic fibrosis, Shwachman-Diamond syndrome and Johanson-Blizzard syndrome), pancreatitis, especially hereditary and obstructive, metabolic and hormonal disorders (hypertriglyceridemia, hypercholesterolemia, hyperinsulinemia and hypercortisolemia), alcohol overuse, taking some medicines (especially adrenal cortex hormones), disease of the liver and visceral adiposis. As regards lipomatosis of that organ resulting mainly from dyslipidemia and hyperglycemia, the term "nonalcoholic fatty pancreas disease" was introduced. Experimental studies on animals and histological preparations of the pancreatic fragments show that the lipotoxicity of the collected adipocytes collected ion the organ release a cascade of proinflammatory phenomena, and even induces the processes of carcinogenesis. Pancreas adiposis is best defined in Computed Tomography and Magnetic Resonance Imaging. However, a series of works proved the usefulness in the diagnostics of that pathology of transabdominal and endoscopic ultrasonography. In that method, the degree of adiposis was based on the comparison of echogenicity of the pancreas and the liver, renal parenchyma, spleen and/or retroperitoneal adipose. Recently, the evaluation was expanded by the evaluation of the degree of pancreatic adipose with the pancreas-to-liver index, utilizing to that end a special computer program. According to our experience, the simplest solution is the method utilized by us. On one crosssection of the body of the pancreas, its echogenicity is assessed in comparison to retroperitoneal adipose and the visibility of the splenic vein, pancreatic duct and the major retroperitoneal vessels. Depending on the visualization of these structures, it is possible to determine the degree of pancreas adiposis. Such a study applies to 250 people, in whom the adiposis was detected in 16.5%, which is close to other cohort US examinations results.