Adnexal incidentalomas on multidetector CT: how to manage and characterise.

Although CT is not considered the examination of choice for the detection and characterisation of adnexal diseases, adnexal masses may be incidentally detected during CT examination performed for other clinical indications. Most adnexal incidentalomas are benign, and therefore may not require further investigation, follow-up or intervention; however, few of them may prove malignant. Multidetector CT has improved the diagnostic performance of the technique in the detection and differentiation of adnexal mass lesions. Radiologists should be able to recognise the normal CT appearance of the ovaries and the CT characteristics of various adnexal incidentalomas. This may obviate unnecessary imaging evaluation and allow optimal treatment planning. Regarding the management of adnexal lesions incidentally found on CT, recommendations based on the collective experience of the members of the American College of Radiology Incidental Findings Committee II have recently been presented.

Early-stage cervical carcinoma: the role of multidetector CT in correlation with histopathological findings.

The objective of this retrospective study was to assess the diagnostic performance of multidetector CT (MDCT) in staging patients with surgical-pathological proven early-stage cervical carcinoma. A total of 22 women were referred for preoperative staging by MDCT, on a 16-row CT scanner. The protocol included scanning of the abdomen during the portal phase using a detector collimation of 16 × 0.75 mm and a pitch of 1.2. The evaluated parameters were: tumour detection, tumour maximal diameter, tumour extension to the uterine body and/or the vagina, parametrial invasion and presence of pelvic lymph node metastases. CT stage was assigned for each cervical carcinoma. The surgical-pathological stage was assigned on the basis of the operative findings and the histology report. The overall accuracy of MDCT in detecting and staging primary cervical carcinoma was 86% and 86%, respectively. Our results showed good diagnostic performance of MDCT in the detection and local staging of early-stage cervical carcinoma.

Effect of very early treatment in rheumatoid arthritis on bone oedema and synovitis, using magnetic resonance imaging.

OBJECTIVE: To evaluate the magnetic resonance imaging (MRI) findings of hand involvement before and 1 year after treatment in patients with early rheumatoid arthritis (RA). METHOD: MRI of the dominant hand was performed in 22 patients fulfilling the new criteria for early RA. The patients were divided into three groups. Nine had very early RA (VERA; disease duration < 3 months), seven had early RA (ERA; disease duration < 6 months), and six had established RA (ESTRA; disease duration > 12 months). The MRI protocol consisted of fat-suppressed T2, and plain and contrast-enhanced T1-weighted sequences. Assessment of bone marrow oedema, synovitis, and bone erosions was performed by the OMERACT RA MRI scoring system. Patients were treated with methotrexate (MTX) 0.2 mg/kg/body weight/week and prednisone 7.5 mg/day. Clinical assessment was evaluated using the Disease Activity Score for 28 joint indices (DAS28). RESULTS: After treatment, a significant decrease was observed: (a) in DAS28 of VERA (6.2 ± 0.9 vs. 2.4 ± 1.2), ERA (5.3 ± 0.8 vs. 2.8 ± 1.0), and ESTRA patients (5.7 ± 8.0 vs. 2.7 ± 0.7; p < 0.05); (b) in bone oedema (16.77 ± 13.78 vs. 5.88 ± 6.31) and synovitis (12.44 ± 6.44 vs. 2.88 ± 3.25) of VERA patients; and (c) in synovitis (7.57 ± 6.32 vs. 1.42 ± 1.81) of ERA patients (p < 0.05). No significant difference was found in erosions in any group. CONCLUSION: Bone marrow oedema and synovitis decrease significantly when RA is diagnosed and treated early. MRI is useful in the early detection of these changes. MTX treatment resulted in a significant decrease in DAS28 score and significant improvement in bone oedema and synovitis.

Primary diffuse large B-cell testicular lymphoma: magnetic resonance imaging findings.

Testicular lymphoma represents the commonest testicular malignancy in men older than 50 years. MR imaging of the scrotum is an efficient supplemental diagnostic tool in the evaluation of scrotal diseases. We report two cases of primary diffuse large B-cell testicular lymphoma, presented in men over the age of 50 years. MR imaging revealed the presence of a hypointense intratesticular mass lesion on T2-weighted images, strongly and heterogeneously enhancing after gadolinium administration.

Subclinical atherosclerosis in scleroderma patients.

OBJECTIVE: To investigate subclinical atherosclerosis in patients with systemic sclerosis (SSc). METHODS: Sixty-six patients with SSc who met the American College of Rheumatology criteria for the disease were included. The serum levels of total cholesterol (TC), triglycerides, high density lipoprotein cholesterol (HDL-C), and low density lipoprotein cholesterol (LDL-C) were determined in all patients. Carotid artery intima-media thickness (IMT) and carotid plaques were measured. Patients with a history of atherosclerosis, hypertension, smokers, or patients suffering from conditions that affect the lipid profile, such as diabetes mellitus, hypothyroidism, liver or kidney diseases, Cushing's syndrome, obesity, and a history of familial dyslipidaemia, were excluded. Patients receiving medication affecting lipid metabolism were also excluded from the study. Fifty-one age- and sex-matched non-smoking volunteers were used as controls. RESULTS: Sixty patients were investigated. Six were excluded. Of these, two were smokers, two had diabetes mellitus, one hypothyroidism, and one had hypertension treated with diuretics. Patients with SSc exhibited mild dyslipidaemia expressed mainly by low serum levels of HDL-C and high TC (p < 0.001 and p < 0.021, respectively) compared to controls. In addition, the atherogenic ratio LDL-C/HDL-C was significantly higher among SSc patients (p < 0.0001). Common carotid artery IMTs were higher in SSc compared to controls (0.77 +/- 0.2 vs. 0.59 +/- 0.14, p < 0.0001). No correlation between IMTs and any SSc features were found. Logistic regression analysis showed an independent association of scleroderma with IMTs and TC. CONCLUSION: The scleroderma patients exhibited an atherogenic lipid profile and subclinical atherosclerosis and have an increased risk for cardiovascular events.

Is Low-Grade Intraventricular Hemorrhage in Very Preterm Infants an Innocent Condition? Structural and Functional Evaluation of the Brain Reveals Regional Neurodevelopmental Abnormalities.

BACKGROUND AND PURPOSE: There is increasing evidence of abnormal neurodevelopmental outcomes in very preterm infants with low-grade intraventricular hemorrhage grades I and II. Our purpose was to evaluate the effects of low-grade intraventricular hemorrhage on gray and white matter integrity. MATERIALS AND METHODS: MR imaging at around term-equivalent age was performed in 16 very preterm infants (mean gestational age, 28.8 ± 5.3 weeks) with mild intraventricular hemorrhage on brain sonography and 13 control subjects (mean gestational age, 29.6 ± 4.1 weeks) without intraventricular hemorrhage. Structural and functional evaluation of the cortex was performed using regional measurements of surface area, thickness and volume, and resting-state fMRI, respectively, and of WM microstructural integrity, applying Tract-Based Spatial Statistics to diffusion tensor imaging data. RESULTS: Compared with the control infants, the infants with low-grade intraventricular hemorrhage had decreases in the following: 1) GM surface area in Brodmann areas 19 left and 9 and 45 right, and GM volume in Brodmann areas 9 and 10 right; 2) fractional anisotropy bilaterally in major WM tracts; and 3) brain activity in the left lower lateral and in the right higher medial somatosensory cortex. CONCLUSIONS: Very premature infants with low-grade intraventricular hemorrhage at around term-equivalent age may present with regional abnormalities, appearing on imaging studies as cortical underdevelopment, functional impairment, and microstructural immaturity of major WM tracts.

Age-related grey matter changes in preterm infants: an MRI study.

Grey matter (GM) maturation has not been previously studied in healthy preterm children. The purpose of this study was to evaluate the age dependency of GM development in 116 GM areas in preterm subjects. Sixty one preterm infants (corrected age: 13.7+/-9.92 months, gestational age: 33.4+/-1.9 weeks) with normal structural appearance on MRI were included in the study. Using a T1-weighted high resolution 3D spoiled gradient echo sequence, volumes of 116 GM areas were calculated after their segmentation using the Voxel Based Morphometry Toolboxes and the Individual Brain Atlas Statistical Parametric Mapping (IBASPM) software packages. Non linear regression analysis assessed age dependency of volume data for every GM area using the monoexponential function y=A-Bexp(-x/C). All supratentorial GM areas followed the monoexponential function model reasonably well. Cerebellar structures had a poor goodness of fit. Volume increase of the individual GM areas followed an inferior to superior and a posterior to anterior pattern. The putamen, thalamus, and caudate nucleus reached 99% of the final volume earlier than most cortical GM areas. The visual cortex and the postcentral and precentral cortices matured earlier than the parietal, frontal and temporal cortices. The fronto-occipital asymmetry or torque seen in adults was observed in the preterm infants; the left occipital areas reached maturation earlier than the right, while the right prefrontal and frontal areas matured earlier than the left. To conclude, GM development progresses in a region-specific manner coinciding with functional, phylogenetical and regional white matter (WM) maturation.

Heterotopic ossification in systemic sclerosis.

Although myopathy or myositis may occur in systemic sclerosis (SSc) as well as soft tissue calcification, ossification is not a feature of the disease. Here we present an unusual case of extended calcification and, to a lesser degree, ossification of the right gluteal region, lateral thigh, and knee, with associated myopathy and functional impairment. Heterotopic ossification (HO), or myositis ossificans, has not been reported so far in scleroderma patients, making this case, in our opinion, unique and interesting. However, differential diagnosis from other causes of extraskeletal ossification, such as tumours or tumour-like conditions, is required.

A case of Brucella spondylitis in a patient with psoriatic arthritis receiving infliximab.

A 69-year-old woman with psoriatic arthritis treated with infliximab presented with low back pain of recent onset and fever. Serological, microbiological and imaging studies revealed Brucella spondylitis at the L5-S1 level. Immunosuppressive therapy was suspended and antibiotic therapy including doxycycline and rifampicin was administered for six months. The patient responded adequately with clinical and laboratory improvement and a considerable remission of spondylitis on repeat magnetic resonance imaging scan. The pathophysiology of tumor necrosis factor (TNF) alpha in Brucellosis and the role of anti-TNFalpha therapy are discussed.

Magnetic resonance imaging findings of the cervical spine in patients with rheumatoid arthritis. A cross-sectional study.

OBJECTIVES: To investigate by magnetic resonance (MR) imaging the occurrence of cervical spine (CS) involvement in rheumatoid arthritis (RA) patients. METHODS: Fifty-one consecutive unselected patients, who fulfilled the revised American College of Rheumatology criteria for RA, were investigated. All patients had a complete physical and laboratory evaluation. Radiological evaluation included hand and wrist x-rays, as well as CS radiographs in anteroposterior, lateral and lateral in full flexion views. In addition, MR (Spin Echo T2-weighted sagittal scans [neutral and flexion position], plain and contrast enhanced T1-weighted sagittal and axial scans) was performed in all patients. Hand x-rays were evaluated according to the Larsen's criteria, while CS radiographs were evaluated according to Winfield classification. Disease activity was assessed by disease activity score for 28 joint indices (DAS-28). RESULTS: There were 42 females and 9 males with a mean age of 56.5 +/- 10.4 years and mean disease duration 12.4 +/- 8.5 years. Thirty-three patients (64.7%) had positive IgM rheumatoid factor (RF). Thirty patients presented clinical findings, mainly cervical pain and stiffness of CS (25 with positive and 5 with negative MR), while, radiological findings of CS involvement were found in 40 patients. Forty-four patients (86.2%) presented MR findings of CS involvement (peridental pannus 88%; dens erosion 23.5%; atlantoaxial subluxation 13.7%; subaxial subluxations 10%; brainstem compression 5.9%). Peridental pannus correlated with high DAS-28, positive IgM RF and advanced erosive changes of the wrist and hand (p < 0.05) in the univariate analysis. However, multivariate logistic regression analysis did not confirm such correlation. CONCLUSIONS: We conclude that the frequency of CS involvement in Greek RA patients is high but the destructive changes are mild. However, in patients with active erosive peripheral disease it is very probable to also have some changes in CS. These may be clinically important and in such cases, MR may offer valuable information.

Astrocytoma-like multiple sclerosis.

Multiple sclerosis (MS) may sometimes mimic clinically and radiologically a brain tumor. The initial recognition of such cases is essential as it might avoid a surgical intervention and supplementary treatment. However, even in patients who underwent surgery, the appropriate preparation of the specimen is of crucial importance for the correct pathological diagnosis since tumors and non-neoplastic demyelinating lesions share some common histopathological features. We present such a case of multiple sclerosis presenting with features of an astrocytoma and was treated with surgery and additional radiotherapy.

Predictors of clinical outcome and radiologic progression in patients with neuropsychiatric manifestations of systemic lupus erythematosus.

PURPOSE: We sought to identify the predictors of clinical outcome and of the evolution of cerebral abnormalities in patients with neuropsychiatric systemic lupus erythematosus (SLE). SUBJECTS AND METHODS: Thirty-two patients with SLE (including 14 with the antiphospholipid syndrome) who had been hospitalized with primary neuropsychiatric disease were observed prospectively for at least 2 years. Laboratory and clinical characteristics and data from magnetic resonance imaging (MRI) studies obtained during the hospitalization and 2 years later were evaluated. We ascertained nonreversible or new MRI changes and clinical outcomes, including neuropsychiatric events, during follow-up. RESULTS: Cranial MRI scans on admission were abnormal in 26 (81%) of the 32 patients. Patients with the antiphospholipid syndrome were more likely to have focal cerebral white matter lesions (odds ratio [OR] = 12, 95% confidence interval [CI]: 2.0 to 72). After 2 years, neuropsychiatric deficits substantially improved in 22 (69%) of the patients, stabilized in 6 (19%), and deteriorated in 4 (12%). The number of prior neuropsychiatric events was associated with persistent MRI lesions (OR = 4.8 per each event, 95% CI: 1.1 to 21) and unfavorable clinical outcome (OR = 4.3 per each event, 95% CI: 1.4 to 13) at 2 years. The antiphospholipid syndrome also predicted an unfavorable clinical outcome at 2 years (OR = 11, 95% CI: 1.7 to 65). CONCLUSIONS: Among patients with SLE who have neuropsychiatric disease, prior neuropsychiatric events and the antiphospholipid syndrome increase the risk of adverse outcomes.

Distensibility and pulse wave velocity of the thoracic aorta in patients with juvenile idiopathic arthritis: an MRI study.

OBJECTIVE: An increased incidence of cardiovascular disease has been found in rheumatic disorders. Changes in the variables of aortic elasticity in patients with juvenile idiopathic arthritis (JIA) were evaluated and their relationship to inflammation, anti-rheumatic drugs and traditional cardiovascular risk factors were investigated in this study. METHODS: Phase contrast MR was performed in 31 patients with JIA and 28 age and sex matched controls to evaluate the aortic distensibility and pulse wave velocity (PWV). Disease activity variables, plasma lipid profile, homocysteine, thyroid hormones, glucose and insulin were assessed in the patients. RESULTS: Eighteen patients had oligoarticular, 6 polyarticular and 7 systemic disease. Distensibility was lower (mean: 10.25; SD: 4.18) and PWV was higher (mean: 3.68; SD: 1.59) in the patients compared to the controls (mean: 13.4; SD: 4.99), (mean: 1.38; SD: 0.54) respectively (p < 0.01). A positive correlation between PWV and age was observed in the patients (rs = 0.47, p < 0.01) and controls (rs = 0.72, p < 0.01), and a negative correlation between distensibility and age in the patients (rs = -0.59, p < 0.01) and controls (rs = -0.63, p < 0.01). No statistically significant correlations were found between distensibility and PWV and metabolic and disease activity parameters. When distensibility and PWV were adjusted for age no significant differences were found between the three subtypes of JIA. CONCLUSION: JIA is associated with increased aortic stiffness that might suggest subclinical atherosclerosis. Early detection and follow-up by non-invasive methods may be useful in the prevention of future cardiovascular disease.

The role of MRI in the evaluation of hip joint disease in clinical subtypes of juvenile idiopathic arthritis.

The purpose of this study was to evaluate the role of MRI in the assessment of hip joint involvement in clinical subtypes of juvenile idiopathic arthritis (JIA). 28 patients (mean age 12.5 years) with JIA (oligoarthritis 8, polyarthritis 13, systemic arthritis 7) were examined with T(2) weighted turbo spin echo and T(1) weighted spin echo (plain and contrast enhanced) sequences. The severity of joint involvement was evaluated using an MR grading score: grade 1=no contrast enhancement; grade 2=focal synovial contrast enhancement; grade 3=diffuse synovial contrast enhancement; grade 4=grade 3+diffuse synovial thickening; grade 5=grade 4+villonodular synovial thickening; and grade 6=grade 5+cartilage and subchondral bone erosions. MRI was abnormal in 57.1% of cases (25% of oligoarthritis, 53.8% of polyarthritis and 100% of systemic arthritis). Clinical examination was positive in 32.1% of cases and was associated with higher MR grades (mean 4.6, SD 1.34) compared with a negative clinical examination, which was associated with lower MR grades (mean 1.78, SD 1.13) (p<0.001). Patients with active disease (mean grade 3.9, SD 2) had higher MR grades than those with inactive disease (mean grade 2.1, SD 1.4) (p<0.01). The MR grades were different in the three clinical subtypes: oligoarticular (mean 1.5, SD 1.06); polyarticular (mean 2.38, SD 1.55); and systemic (mean 4.85, SD 1.21) (F:12.3, p<0.001), with a significant difference between systemic arthritis and oligoarthritis, and between systemic arthritis and polyarthritis (p<0.001). MRI of the hip might be considered for inclusion in the study protocol of patients with JIA since it reveals joint involvement at early stages and provides a detailed evaluation of the extent of joint disease.

Malignant haemangiopericytoma of the knee joint: MR findings.

The imaging findings of intra-articular haemangiopericytomas have not been described previously. We report on a 35-year-old man with a primary malignant haemangiopericytoma of the left knee joint. MRI demonstrated joint effusion and a heterogeneous mass with haemorrhagic components and multiple peripheral serpentine signal voids, suggesting the presence of vascular channels. Multiple pulmonary metastases were seen on chest CT. These imaging findings, although not pathognomonic, might be useful in suggesting the diagnosis of intra-articular haemangiopericytoma.

T(2) relaxation rate of basal ganglia and cortex in patients with beta-thalassaemia major.

In thalassaemic patients, neurophysiological disturbances have been associated with high serum ferritin levels and desferrioxamine therapy. In the presence of a magnetic field, ferritin, the main iron storage protein, induces a preferential decrease of the T(2) relaxation time. The purpose of this study was to evaluate thalassaemic patients for brain iron deposition by assessing the T(2) relaxation rate (1/T(2)) of the grey matter. 41 thalassaemic patients (age range 8.5-44 years, mean 24 years) and 58 age- and sex-matched controls were included in the study. Current serum ferritin levels were obtained. The 1/T(2) values of the cortex (motor and temporal) (mean 0.0122 ms(-1), SD 0.0004), putamen (mean 0.0137 ms(-1), SD 0.0004) and caudate nucleus (mean 0.0132 ms(-1), SD 0.0003) were higher in patients compared with the controls (mean 0.0110 ms(-1), SD 0.0004; mean 0.0120 ms(-1), SD 0.0005; mean 0.0117 ms(-1), SD 0.0003, respectively) (p<0.001 for all parameters). No statistically significant differences were found in the globus pallidus. No correlation was found between 1/T(2) and serum ferritin. The higher values of 1/T(2) in the cortex, putamen and caudate nucleus of thalassaemic patients probably reflect a higher iron deposition. The lack of differences in 1/T(2) of the globus pallidus might suggest that even in thalassaemic patients iron cannot exceed a saturation level.

White matter water diffusion changes in primary Sjögren syndrome.

BACKGROUND AND PURPOSE: Histopathologic studies have demonstrated WM damage in primary Sjögren syndrome. The purpose of this study was to evaluate WM microstructural changes by use of DTI-derived parameters in patients with primary Sjögren syndrome. MATERIALS AND METHODS: DTI was performed in 19 patients with primary Sjögren syndrome (age, 64.73 ± 9.1 years; disease duration, 11.5 ± 7.56 years) and 16 age-matched control subjects. Exclusion criteria were a history of major metabolic, neurologic, or psychiatric disorder and high risk for cardiovascular disease. Data were analyzed by use of tract-based spatial statistics, for which the WM skeleton was created, and a permutation-based inference with 5000 permutations was used with a threshold of P < .01, corrected for multiple comparisons to enable identification of abnormalities in fractional anisotropy, mean diffusivity, radial diffusivity, and axial diffusivity. RESULTS: Tract-based spatial statistics showed decreased fractional anisotropy in multiple areas in patients with primary Sjögren syndrome compared with control subjects, located mainly in the corticospinal tract, superior longitudinal fasciculus, anterior thalamic radiation, inferior fronto-occipital fasciculus, uncinate fasciculus, and inferior longitudinal fasciculus. Increased mean diffusivity and radial diffusivity and decreased axial diffusivity were observed in most of the fiber tracts of the brain in patients with primary Sjögren syndrome, compared with control subjects. CONCLUSIONS: Patients with primary Sjögren syndrome show loss of WM microstructural integrity, probably related to both Wallerian degeneration and demyelination.