Digital pair-matching of iliac bones: pilot study on a three-dimensional approach with models acquired through stereophotogrammetry.

Three-dimensional (3D) pair-matching has brought about an innovative approach for the analysis of commingled skeletal remains, and it has been tested on bone models acquired through CT and laser scans. Here, 3D models of 40 innominate bones (20 left and 20 right) of 20 documented male individuals from a cemeterial skeletal collection were acquired through a stereophotogrammetric device (VECTRA M3, Canfield Scientific, Inc.). The ventral iliac surface was chosen as the anatomical region of interest (ROI) for the analysis. Each left ROI was mirrored and superimposed on the matching right ROI (contralateral element from the same individual) and mismatching ROIs (contralateral elements from different individuals). The point-to-point distance between models was calculated through the Vectra Analysis Module (VAM) software and the root mean square (RMS) point-to-point distance value was used to evaluate the sorting performance of the method, in terms of sensitivity and specificity rates. Differences in RMS between matches and mismatches were investigated through a Student's t test (p < 0.05). The state of preservation of the remains was assessed following an index of anatomical completeness and differences in RMS distances of true matches according to different anatomical completeness were assessed through the Mann-Whitney test (p < 0.05). RMS point-to-point distances of matches and mismatches were significantly different (p < 0.01), being the matches lower than mismatches. The RMS threshold of 2.9 mm identified all the true pairs; the test was 100% sensitive and 51% specific. The RMS of matches with a better state of preservation are significantly lower than the less preserved matches (p < 0.05). In general, a low RMS distance value may indicate a true match, being it to be further verified. The 3D approach for sorting innominate bones provides a valid screening test that could complete subjective and osteometric methods with numerical evidence of the match. Preliminary data suggest a possible relation between RMS distance values and taphonomic condition, which would benefit from further research.

Lesion or Pseudolesion? A Comprehensive Description of Perfusion-Based Liver Alterations on Contrast-Enhanced Computed Tomography and Literature Review.

ABSTRACT: Pseudolesions on contrast-enhanced computed tomography represent a diagnostic challenge for radiologists because they could be difficult to distinguish from true space-occupying lesions. This article aims to provide a detailed overview of these entities based on radiological criteria (hyperattenuation or hypoattenuation, localization, morphology), as well as a brief review of the hepatic vascular anatomy and pathophysiological process. Relevant examples from hospital case series are reported as helpful hints to assist radiologists in recognizing and correctly diagnosing these abnormalities.

Morphological and Metrical Relationships Between Sphenoid Sinus and Sella Turcica: Possible Applications in Transnasal Transsphenoidal Surgery.

INTRODUCTION: Transsphenoidal surgeries imply the risk of intraoperative lesions to the neurovascular structures surrounding the sphenoid sinus (SS). Aim of the present study is to assess the metrical and morphologic relationships existing between SS and sella turcica (ST). MATERIALS AND METHODS: Two hundred computed tomography-scans of patients were selected. For each patient volumes of SS were calculated from their 3-dimensional models segmented through ITK-SNAP program. Variants of SS in pneumatisation and sellar diameters [antero-posterior (AP) diameter, depth, and length] were evaluated on each computed tomography-scan. Correlations among different measurements were assessed through Spearman test ( P <0.01), whereas associations between sellar parameters and presence of pneumatisation variants were assessed through Mann-Whitney test ( P <0.01). RESULTS: In males, pneumatization of the greater wings was related to smaller AP diameter ( P <0.01) and depth of ST ( P <0.01), whereas in females lower values of depth were found in patients with pneumatization of the pterygoid processes ( P <0.01). In both sexes, a positive correlation was found between AP diameter and, respectively, length and depth of ST ( P <0.01), together with a negative correlation between volume of SS and depth of ST ( P <0.01). Lastly, in females a positive correlation was found between age and, respectively, length and depth of ST ( P <0.01). CONCLUSIONS: The present study highlighted new metrical and morphologic relationships between volume and pneumatisation of SS and diameters of ST. Knowledge of these correlations allows to understand more clearly, in the preoperative setting, the surgical working space. Further studies are needed, especially for what concerns the relationship between sellar measurements and age in females.

Taphonomic study on drowned victims in a non-sequestered aquatic environment in the Mediterranean Sea.

Human decomposition in sea water poses several challenges to forensic practitioners tasked with the analysis of drowned bodies. Postmortem changes in the marine environment have not been extensively investigated and the current literature is mainly based on bodies retrieved from shallow waters or on limited samples. On 18 April 2015, a fishing boat carrying allegedly 1,000 migrants sank in the Mediterranean Sea. In a fifteen-month time span, humanitarian missions were carried out to recover the bodies from the sea. The present study investigates postmortem changes on the drowned victims in a non-sequestered environment in the Mediterranean Sea. A retrospective study was performed by two observers on the autopsy photographic records in the series of bodies recovered from the open sea. For 184 bodies, the postmortem changes were evaluated according to facial, body, limb, and total aquatic decomposition score (FADS, BADS, LADS, TADS, respectively). Furthermore, a modification to the current scoring system that divides upper and lower limbs was suggested. The interobserver agreement was assessed using Krippendorff's alpha coefficient. Possible relations between the decomposition scores and PMSI were investigated with Pearson correlation analysis. According to the sequence of the recovery missions, increasing FADS, BADS, LADS, and TADS were observed. The modified scoring system showed a strong agreement between observers, allowing a more accurate description of the actual extent of decomposition. The scores showed a significant relation with the PMSI (p < 0.01). Prolonged submersion in the open marine environment was confirmed to show increasing decomposition rates, from moderate decay to full disarticulation. This study provides a descriptive unicum of the postmortem changes in the open sea, which may contribute to strengthen the discipline and aid description of bodies recovered in similar circumstances, especially if a body needs to be associated to a disaster or period with respect to another, thus facilitating families or authorities in the search for specific victims.

Anatomical Variations of Anterior Ethmoidal Foramen and Cribriform Plate: Relations With Sex.

ABSTRACT: Position of anterior ethmoidal artery and height of lateral lamella of cribriform plate (LLCP) represent critical variants in endoscopy.In 200 maxillofacial computed tomography scans of patients the position of anterior ethmoidal foramen (AEF) in relation to ethmoid roof was recorded. The height of LLCP was measured and classified according to Keros classification.Differences in AEF position and distribution of Keros types, and LLCP height according to sex were assessed through chi-square test (P < 0.05) and 1-way analysis of covariance (ANCOVA) test, respectively (P < 0.05). Differences in LLCP height according to different AEF position were assessed through Mann-Whitney test (P < 0.05).No differences were observed in prevalence of AEF exposure according to sex (P > 0.05); LLCP height was higher in males than in females, with a higher frequency of Keros type 3 (P < 0.05). Moreover, subjects with AEF exposure had a significantly higher LLCP height (P < 0.01).Results highlighted innovative data useful for improving the knowledge of these sensitive variants.

Three-Dimensional Facial Anthropometric Analysis With and Without Landmark Labelling: Is There a Real Difference?

INTRODUCTION: The actual role of landmarks labeling before three-dimensional (3D) facial acquisition is still debated. In this study, several measurements were compared among textured labeled (TL), unlabeled (NL), and untextured (NTL) 3D facial models. MATERIALS AND METHODS: The face of 50 subjects was acquired through stereophotogrammetry. Landmark coordinates were extracted from TL, NL, and NTL facial models, and 33 linear and angular measurements were calculated, together with surface area and volume. Accuracy of measurements among TL, NL, and NTL models was assessed through calculation of relative technical error of measurement (rTEM). The intra- and inter-observer errors for each type of facial model were calculated. RESULTS: Intra- and inter-observer error of measurements increased passing from textured to NTL and NL 3D models. Average rTEMs between TL models, and NTL and NL models were 4.5 ±â€Š2.6% and 4.7 ±â€Š2.8%, respectively, almost all measurements being classified as "very good" or "good." Only for orbital height and its inclination, mandibular ramus length, nasal convexity, alar slope angle, and facial divergence, rTEM was classified as "moderate" or "poor." CONCLUSIONS: Accuracy and precision of measurements decrease when landmarks are not previously labeled; attention must be taken when measurements have a low magnitude or involve landmarks requiring palpation.

Distinctive facial features in Andersen-Tawil syndrome: A three-dimensional stereophotogrammetric analysis.

Andersen-Tawil syndrome (ATS) is a rare potassium channelopathy causing periodic paralysis, cardiac arrhythmias, and dysmorphic features. A detailed analysis of the face could facilitate diagnosis of ATS, as approximately 30% of patients do not show variants in KCNJ2 gene, and diagnosis is established by clinical findings. We aimed to characterize the face in ATS through a quantitative approach, as facial anomalies may be unnoticed on visual inspection. Facial images of 12 subjects with genetically confirmed ATS (six males, six females, age 5-67 years) were acquired through stereophotogrammetry. Using 38 soft-tissue landmarks, linear distances, angles, and ratios were calculated and expressed as z-score values, with reference to 477 healthy subjects matched for sex and age. All patients showed decreased lower facial height with shortening of philtrum (mean z-score ± SD: -1.5 ± 0.9), smaller mid and lower facial depths (-1.9 ± 0.7; -2.3 ± 0.9), short palpebral fissures (right -1.2 ± 0.4; left -1.6 ± 0.6), smaller mandibular ramus length (-2.1 ± 0.4), and increased nasal width/length ratio (1.4 ± 0.5) with smaller nostril axis length (right -1.8 ± 0.8, left -1.6 ± 0.7). Hypertelorism and low-set ears were detected in two-thirds of patients. The study quantified facial dysmorphysm in ATS, extending information about known features, and detecting unrecorded philtrum and nostril characteristics, which may be distinctive traits of the disorder.

Does the choice of the reference model affect the results of 3D-3D superimposition procedure? A comparison of different protocols for personal identification.

In literature, 3D-3D superimposition has been widely recognized as a valid method for personal identification. However, very little information is available about possible variability due to differences in protocols of registration of 3D models and calculation of RMS (root mean square) point-to-point distance. Frontal sinuses from 50 CT scans were segmented twice through the ITK-SNAP software and grouped in two samples (1 and 2). Maximum breadth, height and volume were measured. 3D models belonging to the same subject were then superimposed one on each other in 50 matches. In addition, superimposition of 50 random mismatches was performed. For each superimposition, the procedure was repeated four times choosing different reference models both for registration and calculation of RMS. Differences in RMS value among protocols of registration and RMS calculation were assessed through paired Student's t-test (p < 0.05). Possible correlations between differences in RMS among groups and differences in frontal sinus size between the superimposed models were analysed through calculation of Pearson's correlation coefficient (p < 0.05). Results showed that RMS calculation did not yield significant differences according to which 3D model is used as reference; on the other hand, RMS values from registration procedure significantly differ according to which model is chosen as reference, but only in the mismatch group (p < 0.001). Differences in RMS value according to RMS calculation are dependent upon all the three measurements, whereas differences according to registration protocols were significantly related only with the breadth of frontal sinuses but only in mismatches (p < 0.001). In no case, superimpositions of RMS values were found between matches and mismatches. This article for the first time proves that the protocol of registration and calculation of RMS significantly influences the results of 3D-3D superimposition only in case of mismatches.

Exploring the potential of cranial non-metric traits as a tool for personal identification: the never-ending dilemma.

Forensic anthropologists tasked with identification of skeletal remains often have to set up new strategies to overcome the limitations of conventional individualizing markers. A sound acquaintance with non-metric traits is essential for a reliable distinction between normal variations and pathological or traumatic conditions, yet the role of cranial variants in the identification process is still somehow ill-defined. One hundred crania (50 males and 50 females) of known sex and age were selected from the Collezione Antropologica LABANOF (a documented contemporary skeletal collection) and non-metric traits were scored as present or absent and by side. The frequencies of 13 traits were used to calculate the compound probabilities to find an individual with an exact combination of cranial features in the worldwide population. The probabilities of the majority of the individuals (53%) are within the 1 out of 10 million-1 out of 1 million interval. However, a fair number of subjects (25%) of the sample have the probabilities falling into the 1 out of 1 billion-1 out of 100 million interval, while the probabilities of a small portion of the sample (10%) are less than 1 out of 1 billion. This pilot study illustrates that some combinations of cranial variants are quite rare and may represent potential evidence to discern presumptive identifications, when an appropriate set of traits is selected and antemortem data are available for comparison. However, further research on larger and various samples is needed to confirm or discard the use of combinations of cranial non-metric traits as individualizing markers.

Improving 3D-3D facial registration methods: potential role of three-dimensional models in personal identification of the living.

Personal identification of the living from video surveillance systems usually involves 2D images. However, the potentiality of three-dimensional facial models in gaining personal identification through 3D-3D comparison still needs to be verified. This study aims at testing the reliability of a protocol for 3D-3D registration of facial models, potentially useful for personal identification. Fifty male subjects aged between 18 and 45 years were randomly chosen from a database of 3D facial models acquired through stereophotogrammetry. For each subject, two acquisitions were available; the 3D models of faces were then registered onto other models belonging to the same and different individuals according to the least point-to-point distance on the entire facial surface, for a total of 50 matches and 50 mismatches. RMS value (root mean square) of point-to-point distance between the two models was then calculated through the VAM® software. Intra- and inter-observer errors were assessed through calculation of relative technical error of measurement (rTEM). Possible statistically significant differences between matches and mismatches were assessed through Mann-Whitney test (p < 0.05). Both for intra- and inter-observer repeatability rTEM was between 2.2 and 5.2%. Average RMS point-to-point distance was 0.50 ± 0.28 mm in matches, 2.62 ± 0.56 mm in mismatches (p < 0.01). An RMS threshold of 1.50 mm could distinguish matches and mismatches in 100% of cases. This study provides an improvement to existing 3D-3D superimposition methods and confirms the great advantages which may derive to personal identification of the living from 3D facial analysis.

Relationship between lateral angle and shape of internal acoustic canal: cautionary note for diagnosis of sex.

Lateral angle (LA) of the internal acoustic canal (IAC) at its opening at the surface of the petrous portion of the temporal bone is known in literature as a dimorphic measurement useful for sex assessment. However, its reliability is still debated. Moreover, no information is available about the possible relationship between LA and shape and size of the IAC. This study aims at assessing breadth, length and lateral angle of IAC on 100 CT scans belonging to subjects aged between 20 and 70 years, equally divided between males and females. Possible differences in the three measurements according to side and sex were assessed through two-way ANCOVA test, using three cranial measurements (distance between anterior and posterior nasal spine, upper facial height, bizygomatic breadth) as covariates (p < 0.05). Possible correlations among IAC measurements and with age were assessed through Pearson's test (p < 0.05). Results showed a significantly greater IAC breadth on the left side than on the right side; moreover, LA was significantly wider in females than in males and was positively correlated with IAC breadth in both males and females. In addition, LA was negatively correlated with age only in the female group. The study first showed that LA is strictly related to IAC morphology; moreover, it is significantly affected by masculinization of skeletal traits in females. Therefore, caution is suggested in using this measurement for sex assessment.

Localization of Foramen Ovale According to Bone Landmarks of the Splanchnocranium: Help for Transforaminal Surgical Approach to Trigeminal Neuralgia.

ABSTRACT: Trigeminal neuralgia is a painful condition, usually treated through surgical procedures focusing on the foramen ovale (FO). A detailed localization of FO relative to reference landmarks is therefore crucial to avoid possible complications.The present study aims at assessing the position of FO according to the surrounding bone structures: 100 CT-scans of patients, equally divided between sexes, aged between 18 and 86 years were examined. From each subject, the 3D models of FO and the maxillary bones, the zygomatic bones and the zygomatic process of the temporal bones were segmented through ITK-SNAP software. The distance between the center of the FO and subnasale, zygion, and the upper edge of the zygomatic bone at the origin of the frontal process were measured on 3D models. On CT-scans three cranial measurements were taken as well (distance between anterior and posterior nasal spine, upper facial height and bizygomatic breadth).Statistically significant differences in the three distances according to side and sex were assessed through two-way ANCOVA test, using the three cranial measurements (ANS-PNS, NP, ZZ) as covariates (P < 0.05).Distances between the centre of FO and subnasale, zygion and the upper edge of the zygomatic bone were on average 82.3 ±â€Š3.4 mm, 41.9 ±â€Š2.6 mm and 48.8 ±â€Š3.5 mm in males, 77.3 ±â€Š3.9 mm, 38.2 ±â€Š2.5 mm and 45.5 ±â€Š3.1 mm in females, with a significant difference according to sex (P < 0.05).Results provide innovative data for the localization of FO and will be useful for the management of transforaminal procedures in case of trigeminal neuralgia.

Temporal Bone Pneumatization: Relationship With Sex and Variants of the Ethmoid and Sphenoid Bone.

ABSTRACT: Pneumatization variants of the temporal bone have a crucial importance in several surgical interventions. However, very few data are known about possible correlation with other pneumatization variants.Pneumatization of glenoid fossa, petrous apex, and infralabyrinthine portion of temporal bone was assessed in 200 computed tomography scans, equally divided between males and females (18-92 years). Pneumatization variants of the ethmoid (concha bullosa, agger nasi, pneumatized crista galli) and the sphenoid sinuses (pneumatized pterygoid processes, anterior clinoid processes, dorsum sellae, volume) were recorded as well.Differences in prevalence of each pneumatization type according to sex and side, among different portions of the temporal bone, and between temporal bone and the pneumatized variants of the ethmoid bone and sphenoid sinuses, were assessed through chi-square test (P < 0.05). Differences in sphenoid volume among different pneumatization degrees of the temporal bone were assessed through 1-way analysis of covariance test (P < 0.05).Pneumatization of the petrous apex and the infralabyrinthine portion was significantly more frequent in males than in females, whereas pneumatization of the glenoid fossa was more often observed on the right side (P < 0.05). Variants of the temporal bone are all related one with each other in males, whereas in females only the relationship between pneumatized petrous apex and infralabyrinthine portion was found. Moreover, in females the pneumatized petrous apex was related with pneumatized anterior clinoid process, and the pneumatized infralabyrinthine portion was related with the sphenoid sinus volume.Results may be useful for predicting these important variants in planning surgical interventions of the cranial base.

Radiomic analysis of the optic nerve at the first episode of acute optic neuritis: an indicator of optic nerve pathology and a predictor of visual recovery?

OBJECTIVE: Retinal nerve fiber layer thickness (RNFL) is a biomarker of neuroaxonal loss and index of visual function in multiple sclerosis (MS). We aimed to assess the correlation between radiomic features and RNFL, visual acuity (VA) at patients' presentation, visual outcome (VO), and clinical diagnosis. METHODS: We reviewed imaging and clinical data of 25 patients with a first episode of optic neuritis (ON) (14 females, 11 males; 5 bilateral ON; 7 left ON; 13 right ON). All patients underwent a complete ophthalmological assessment, including visual acuity and RNFL, neurological evaluation, orbits MRI. Segmentation of the optic nerves was performed through 3D slicer open software to get radiomics analysis. All patients underwent a complete neuro-ophthalmological follow-up at 6 months to assess the VO, classified as: complete recovery, partial recovery, deficit persistence/relapse, or visual worsening and were diagnosed as MS or clinically isolated syndrome. RESULTS: We observed significant correlations between radiomic features and RNFL and between radiomic features and VA. Regression model analysis identified 1 radiomic feature with significant association with VO (Gray Level non-uniformity Normalized, p = 0.004) and 6 radiomic features with significant correlation with diagnosis (High Gray Level Zone Emphasis, p < 0.001; Entropy, p < 0.001, for T1 segmentation; Mean Absolute Deviation, p < 0.001; Coarseness < 0.001; Small Area Low Gray Level Emphasis, p < 0.001; Contrast, p = 0.008, for STIR segmentation). CONCLUSION: Orbits MRI analysis at the first episode of ON has the potential to assess the visual function and VO in ON patients, and predict MS development.

Non-contrast magnetic resonance lymphography (NCMRL) in cancer-related secondary lymphedema: acquisition technique and imaging findings.

Cancer-related secondary lymphedema (LE) is a widespread issue, which markedly affects patients' quality of life. Its diagnosis is mainly clinical since there is no consensus on the best imaging technique that should be used to assess this pathology. Even if lymphedema treatment has been traditionally conservative and mainly based on compressive bandages and decongestive therapy, new surgical techniques are proving their effectiveness in the management of the disease and made proper assessment and characterization of lymphedema necessary. In this scenario, non-contrast magnetic resonance lymphography (NCMRL) is acquiring an increasing role, as a non-invasive imaging technique, useful for the analysis of LE. NCMRL is an effective tool in diagnosis confirmation, in providing information about the structural changes of the affected limbs, in grading this disorder, and provides a guide for LE management and treatment planning. This article aims to provide an overview of the literature regarding this examination, analyzing the acquisition technique, the interpretation of the imaging findings and their usefulness, the advantages and limits of this technique, to help the radiologist approach this relatively new investigation in cases of cancer-related LE.

Reported and Unreported Potentially Important Incidental Findings in Urgent Nonenhanced Abdominal CT for Renal Colic.

OBJECTIVE: The aim of the study was to retrospectively evaluate the prevalence of reported and unreported potentially important incidental findings (PIFs) in consecutive nonenhanced abdominal CTs performed specifically for renal colic in the urgent setting. METHODS: One radiologist, blinded to the finalized report, retrospectively re-evaluated nonenhanced abdominal CTs performed from January to December 2017 on adult patients from the emergency department with the specific request of urgent evaluation for renal colic, searching for PIFs. RESULTS: The CTs of 312 patients were included in the study. Thirty-eight findings were reported in 38 different CTs, whereas the re-evaluation added 47 unreported findings in 47 different CTs, adding to total of 85 findings (27%). The difference in the proportion of reported and unreported PIFs between the original report and re-evaluation was significant (p < 0.001). No significant difference was found between the age of patients with and without reported findings. The proportion of potentially important findings did not vary significantly among the 3 shifts in the original report and in re-evaluation. The most frequent findings, both reported and unreported, were pleural effusion, lymphadenopathies, and liver nodules. CONCLUSIONS: Potentially important additional findings are frequently present in urgent nonenhanced abdominal CTs performed for renal colic, and many are not described in the finalized reports. Radiologists should take care not to underreport PIFs even in the urgent setting because of the possible consequences on the patient's health and in order to avoid legal issues, while at the same time satisfying the need for timely and efficient reporting.

3D facial morphometry in Italian patients affected by Aicardi syndrome.

Aicardi syndrome (AIC) is a rare congenital neurodevelopmental disorder of unknown etiology, that affects almost exclusively females, originally characterized by corpus callosum agenesis, chorioretinal lacunae, and infantile spasms. The current diagnostic criteria also include qualitative facial features (prominent premaxilla, upturned nasal tip, decreased nasal bridge angle, sparse lateral eyebrows, and microphthalmia) that still need quantification. A three-dimensional (3D) photogrammetric assessment of 11 Italian females, age 7-32 years, who satisfied AIC criteria, was performed. Linear distances and angles were computed from soft-tissue facial landmarks coordinates. The z-score values were calculated using data of 850 healthy reference females matched for age and compared by Mann-Whitney test (p < .01). Patients showed a shorter philtrum and right side orbital height (mean z-scores: -1.7, -0.9), shorter superior, middle, and inferior facial depths (mean z-scores: -1.3, -2.2, -2.3), and a smaller length of mandibular ramus (mean z-score: -2.1); conversely, they showed larger nasal and lower facial widths, and lower facial convexity (mean z-scores: 1.7, 1.4, 2.4). The inclinations of the orbit versus the true horizontal were increased bilaterally (mean z-scores: 1.8, 1.1). Some common facial abnormalities were quantified in AIC patients using a noninvasive instrument. They may help clinicians in performing a definite AIC diagnosis in atypical or doubt cases.

Are coding systems of frontal sinuses anatomically reliable? A study of correlation among morphological and metrical features.

Frontal sinuses are of special interest for personal identification thanks to their high variability. A common procedure for comparing ante-mortem and post-mortem material is based on coding systems classifying frontal sinuses according to their morphological and metrical characteristics. However, the calculation of possible combinations is performed on the hypothesis that all the classified features are independent one from each other. This study aims at analysing the correlation among morphological and metrical characteristics of frontal sinuses. Two hundred CT scans of patients equally divided between males and females were segmented through the ITK-SNAP software. Number of accessory septations, scalloping and supra-orbital cells, side asymmetry and superiority, breadth, height, length and volume were extracted from the frontal sinuses of each subject. A possible relationship among morphological and metrical features was analysed through Pearson's correlation test, Mann-Whitney test or chi-square test according to the type of compared data (p < 0.05). In general, a positive correlation was found for all comparisons among metrical measurements (breadth, height, depth and volume) and number of septations, scalloping and supra-orbital cells (p < 0.05), but not between the number of scalloping and supra-orbital cells. In addition, side of asymmetry was positively related with side of superiority of the upper profile of frontal sinuses (p < 0.05). This study proved that morphological and metrical characteristics of frontal sinuses are strictly related one with each other: therefore, the coding systems based on these features should be applied with caution for personal identification, as the number of possible combinations is lower than reported by literature.

Noncontrast Magnetic Resonance Lymphangiography in a Rare Case of Everolimus-Related Lymphedema.

Everolimus is a mammalian target of rapamycin (mTOR) inhibitor, which is used in immunosuppressive treatment regimens in solid-organ transplant recipients. Although mTOR inhibitors are usually well tolerated, their adverse effects have been reported: sirolimus treatment in transplant patients has been rarely reported to be associated with lymphedema of the skin and subcutaneous tissues, whereas the use of everolimus seemed to be less burdened by this type of adverse effect. We report the case of a 58-year-old man with a history of end-stage renal disease of unknown etiology who had undergone right renal transplantation 11 years before. After the transplant, the patient soon developed bilateral progressive swelling involving feet and legs. The symptoms of the left limb improved markedly after discontinuing everolimus. This condition has been classified as everolimus-induced lymphedema. The patient was referred to our department for the execution of a noncontrast magnetic resonance lymphangiography, that is, a noninvasive magnetic resonance imaging technique that has recently proposed for the study of lymphedema. Noncontrast magnetic resonance lymphangiography showed asymmetry between the lower extremities with signs of advanced lymphedema located in the right lower limb and dilated peripheral lymphatic vessels.Drug withdrawal is currently the only effective solution for treating this type of secondary lymphedema; however, with the prolonged use of the drug, lymphedema tends to persist even after mTOR inhibitor suspension, with only partial clinical improvement, as in this case.This case report describes the imaging characteristics of such condition at noncontrast magnetic resonance lymphangiography and discusses the rare adverse effects of everolimus. Immediate suspension of the drug is the only effective strategy to avoid the persistence of this disorder.

Secondary Lymphedema Following Radical Prostatectomy: Noncontrast Magnetic Resonance Lymphangiography Assessment and Vascularized Lymph Node Transfer.

Lymphedema (LE) is a progressive chronic disorder, frequently related to malignancies and their treatment in Western countries. It markedly affected patients' quality of life, and its management is challenging, mainly based on conservative therapy, as bandages and manual lymphatic drainage, with limited results.Recent advances in imaging technology and microsurgical techniques have changed the approach to this disorder, particularly the recent application of magnetic resonance for the study of LE and the increasingly widespread use of surgical interventions, such as vascularized lymph node transfer. As secondary LE due to radical prostatectomy and/or radiation treatment is a frequent cause of chronic disability in the male population, and few data are available in literature about which imaging technique can be applied to diagnose it and about the surgical modalities to treat this condition, we want to propose an overview on the lymphatic vessels anatomy and function, on the applications of noncontrast magnetic resonance lymphangiography and about the pieces of information this examination can provide, and on the technique of vascularized lymph node transfer and the rationale of this surgical procedure in secondary LE related to prostatic malignancy treatment.