Characterization of the Physiological Displacement of the Aortic Arch Using Non-Rigid Registration and MR Imaging.

OBJECTIVES: The aim of this work was to study physiological aortic arch three-dimensional displacement using non-rigid registration methods and magnetic resonance imaging (MRI). MATERIALS AND METHODS: Ten healthy volunteers underwent thoracic MRI. Prospective cardiac gating was performed with a 3D turbo field echo sequence to obtain end-systolic and end-diastolic MR images. The rigid and elastic behavior between these two cardiac phases was detected and compared using either an affine or an elastic registration method. To assess reproducibility, a second MRI acquisition was performed 14 days later. RESULTS: Affine registration between the end-systolic and end-diastolic MR images showed significant global translations of the aortic arch and the supra-aortic vessels in the x, y, and z directions (2.02 ± 1.6, -0.71 ± 1.1, and -1.21 ± 1.4 mm, respectively). Corresponding elastic registration indicated significant local displacement with a vector magnitude of 5.1 ± 0.89 mm for the brachiocephalic artery (BCA), of 4.26 ± 0.83 mm for the left common carotid artery (LCCA), and of 4.8 ± 0.86 mm for the left subclavian artery (LSCA). There was a difference in displacement between the supra-aortic trunks of the order of 2 mm. Vector displacement was not statistically different between the repeated acquisitions. CONCLUSIONS: The present results showed important deformations in the ostia of supra-aortic vessels during the cardiac cycle. It seems that aortic arch motions should be taken into account when designing and manufacturing fenestrated endografts. The elastic registration method provides more precise results, but is more complex and time-consuming than other methods.

Clinical-radiological correlation after functional endoscopic sinus surgery in patients with chronic rhinosinusitis: interest of a sinonasal aerial volumetry.

BACKGROUND: Although a CT scan is often performed after functional endoscopic sinonasal surgery (FESS) in patients with chronic rhinosinusitis, its role hasn`t been firmly established. The goal of this study is to investigate the correlation between symptoms and CT findings before and after FESS for chronic rhinosinusitis. In addition, the interobserver agreement for both sinonasal aerial volumetry and CT score is assessed. METHODS: Thirty-three patients surgically treated for chronic rhinosinusitis were included in this prospective study. Conventional and modified Lund-Mackay scores and sinonasal volumetry were determined by two radiologists before (M0), at 3 months (M3) and 1 year (M12) after surgery. The symptoms were evaluated by the 22-item SinoNasal Outcome Test (SNOT-22). RESULTS: Change of SNOT-22 and air volume were significantly correlated between M0 and M12, but not between M0 and M3, for both readers. Compared to other scores, volume had the best intraclass correlation coefficient and reproducibility, according to the Bland-Altman analysis. No correlation was found between SNOT-22 and CT scores before and after surgery, except between M12 and M0 for one reader. CONCLUSION: The correlation between CT scan and symptoms is low or absent. The measurement of sinonasal air volume is best correlated with the symptoms after surgery, with the best inter-observer agreement.

[Assessment of the transobturator male sling by a pelvic MRI]. / Évaluation du positionnement de la bandelette rétro-urétrale transobturatrice par IRM pelvienne statique et dynamique.

PURPOSE: To evaluate the usefulness of MRI to assess the anatomical and functional relationships between the transobturator male sling Advance(®) and the uretral sphincter, in patients treated for postprostatectomy urinary incontinence. PATIENTS: For 12 patients treated for postprostatectomy urinary incontinence using the transobturator male sling Advance(®), a pelvic real-time MRI was performed between 1 and 3 months postoperatively. A comparison between pre- and postoperative MRI was performed in eight patients. The static sequences studied the anatomical relationships between the sling and the uretral sphincter, as well as the impact on the location of the vesico-uretral anastomosis. The dynamic sequences by coughing looked for the existence of an uretral sphincter mobility. Finally, the voiding sequences studied the impact of the sling on the uretral lumen during the micturition. RESULTS: The position of the sling was always visible, located at a median distance of 5mm from the posterior wall of the uretra. On transverse sections, the angles between the transobturator arms and the horizontal line between the ischial tuberosities varied from 28 to 59 degrees. The vesico-uretral anastomosis location was not modificated between pre and postoperative MRI. On the preop sequences by coughing, four patients had uretral mobility, which didn't exist on postop sequences. To finish, the seven patients who were able to void during MRI, had micturition without uretral stenosis. CONCLUSION: Pelvic MRI was a useful tool to assess the positioning of the sling and the relationships with the uretral sphincter. When correctly positioned, the sling was retro-uretrally and no urethral stenosis was visible during the micturition.

Overestimation of moderate carotid stenosis assessed by both Doppler US and contrast enhanced 3D-MR angiography in the CARMEDAS study.

PURPOSE: To evaluate the agreement and diagnostic accuracy of Contrast enhanced magnetic resonance angiography (CE-MRA), Doppler ultrasound (DUS) and Digital subtraction angiography (DSA) in the assessment of carotid stenosis. METHODS: DUS, CE-MRA and DSA were performed in 56 patients included in the Carotide-angiographie par résonance magnétique-échographie-doppler-angioscanner (CARMEDAS) multicenter study with a carotid stenosis ≥ 50%. Three readers evaluated stenoses on CE-MRA and DSA (NASCET criteria). Velocities criteria were used for stenosis estimation on DUS. RESULTS: CE-MRA had a sensitivity and specificity of 96-98% and 66-83% respectively for carotid stenoses ≥ 50% and a sensitivity and specificity of 94% and 76-84% respectively for carotid stenoses ≥ 70%. The interobserver agreement of CE-MRA was excellent, except for moderate stenoses (50-69%). DUS had a sensitivity and specificity of 88 and 75% respectively for carotid stenoses ≥ 50% and a sensitivity and specificity of 83 and 86% respectively for carotid stenoses ≥ 70%. Combined concordant CE-MRA and DUS had a sensitivity and specificity of 100 and 85-90% respectively for carotid stenoses ≥ 50% and a sensitivity and specificity of 96-100% and 80-87% respectively for carotid stenoses ≥ 70%. The positive predictive value of the association CE-MRA and DUS for carotid stenoses ≥ 70% is calculated between 77 and 82% while the negative predictive value is calculated between 97 and 100%. CE-MRA and DUS have concordant findings in 63-72%, and the overestimations cases were recorded only for carotid stenosis ≤ 69%. CONCLUSION: Combined DUS-CE-MRA is excellent for evaluation of severe stenosis but remains debatable in moderate stenosis (50-69%) due to the risk of overestimations.

[Anatomic study and CT angiography with 3D reconstructions of the pulmonary arterial tree]. / Etude anatomique et angioscanographique avec reconstructions 3D de l'arbre artériel pulmonaire.

AIM OF THE STUDY: To prove in vivo and on cadaveric lungs, the constancy of the collateral type of distribution for the right and left pulmonary arteries as described in classical books and modern studies; to estimate the frequency of the main branches observed and define an arterial tree of reference set up with the most common branches for reading the CT pulmonary angiographies. PATIENTS AND METHODS: Sixty three-dimensional reconstructions of pulmonary arterial trees (right: 30; left: 30) using the Volume Rendering Technique (VRT) performed from CT angiographic studies of 30 patients without bronchial, arterial or pulmonary pathology. Dissection of 16 pulmonary arteries from eight fresh cadavers injected with latex. Finally, 76 pulmonary arteries (right: 38; left: 38) were examined. RESULTS: The most common division of the pulmonary artery is a collateral distribution but in seven cases from 38 (18.4%) at right and one case from 38 (2.6%) at left the artery ended in two or three terminal lobar trunks which provided the segmental arteries. The mediastinal artery for the upper right lobe was always found, with a complementary scissural artery in 89.5% of cases; a middle lobar trunk was observed in 22 of the 38 right lungs (57.9%). On the left tree, four different but usually not coexisting mediastinal arteries were identified for the upper lobe, three for the culmen and one for the lingula; six various scissural arteries were noted, three for the culmen and three for the lingula; the segment 6 received one or two segmental arteries, exceptionally three. An arterial tree of reference could be defined for both sides. CONCLUSION: The division in terminal lobar trunks of the pulmonary arteries is a variation demonstrated for the first time. The data obtained from 3D reconstruction imaging in vivo are in conformity with the results of studies performed on injected cadaveric lungs for this point and to define the arterial tree of reference.

[MR angiography of peripheral arterial disease of the distal legs: is time resolved MRA (TRICKS) necessary?]. / Angiographie par Résonance Magnétique dans l'artériopathie distale des membres inférieurs: peut-on se passer d'une séquence multiphase (TRICKS)?

PURPOSE: To demonstrate the added diagnostic value of time-resolved imaging of contrast kinetics (TRICKS) in the evaluation of lower limb arteries compared to standard 3 level MRA with stepping table method. PATIENTS AND METHODS: Forty patients (30% diabetics) with lower extremity peripheral arterial disease (87.5% with chronic ischemia) underwent standard contrast MRA including TRICKS of the distal arteries. Five arterial segments were defined per leg, and 395 arterial segments were compared (one patient with amputation). Two reviewers evaluated the quality of arterial imaging, presence of venous return and degree of stenosis per segment. The degree of interobserver agreement for arterial stenosis measurement was calculated. RESULTS: More arterial segments could be analyzed on the TRICKS sequence (good or excellent analysis in 63.03%-66.32% of arterial segments compared to 41.51%-47.08% on routine MRA). There was less venous contamination on TRICKS images (25.57% to 27.60% gain). The degree of interobserver agreement was superior with TRICKS compared to standard MRA (kappa 0.85 vs 0.69). CONCLUSION: The TRICKS sequence can be added to standard MRA for pre-therapeutic evaluation of distal arteries in patients with peripheral arterial disease, especially with chronic ischemic with rest pain and/or trophic changes.

Multi-detector row computed tomography angiography: an alternative imaging method for surgical strategy in lower extremity arterial occlusive disease.

In order to show the value of CT angiography in the pretherapeutic assessment of lower leg ischemia, we studied 93 CT angiographies in 85 patients. Two groups were defined according to the level of revascularization: 52 angioscanner were made prior to suprainguinal revascularization and 41 prior to infrainguinal reconstruction. Two decision attitudes were chosen by two different physicians, a radiologist and vascular surgeon, members of the same team. The attitudes where then compared in order to evaluate the value of CT angiography. The first attitude was a pragmatic strategy based on the images as interpreted by the first physician and on the intraoperative information including surgical treatment and, if necessary, angiography. This indicates that the results of this attitude cover the performed revascularizations. The second attitude determined a virtual strategy and was chosen by the second physician a posteriori, based solely on the medical file with the same CT angiography images. These two strategies were compared in order to assess the agreement on the level of the lesion and the choice of revascularization. In 84 CT angiographies (90.3%), the analysis of the lesions and the choice of lesions to be treated were identical. In 9.6% of scans the strategies were not comparable because the lesions were interpreted differently or the scans were difficult to read. The sensitivity of CT angiography in detecting lesions and guiding the therapeutic strategy was 96% and its positive predictive value was 93%. Follow-up was reported according to the life-table method to assess the overall outcome and the results in both groups. The overall survival rate at 12 months for 85 patients was 90%. Secondary patency rates at 12 months in the group of patients who underwent a suprainguinal and infrainguinal revascularization were 98% and 71% respectively. Overall limb salvage at 12 months was 94%. In this setting, CT angiography allowed us to select adequate treatment in the majority of cases. These results obtained after a strategy based on CT angiography images are comparable with the results as published in the literature after the strategy based on conventional angiography.

Diagnostic accuracy of compression ultrasonography for the detection of asymptomatic deep venous thrombosis in medical patients--the TADEUS project.

We assessed the accuracy of venous compression ultrasonography (CUS) for the detection of asymptomatic deep vein thrombosis in 122 consecutive patients, with a mean age of 69 years, who were hospitalised in an internal medicine unit. All included patients had CUS within 48 h of admission. Twelve out of 17 patients with a positive CUS underwent phlebography, as the others withdrew their consent, whereas the remaining 105 patients with a negative serial CUS testing were clinically followed-up at 3 months. We found that CUS had a sensitivity and a specificity of respectively 1 (95% CI, 0.73 to 1) and 1 (95% CI, 0.96 to 1) for the detection of asymptomatic deep vein thrombosis. Kappa-coefficients for intra-observer and inter-observer agreements were respectively 0.88 and 0.56. We concluded that venous compression ultrasonography, performed as described, fulfils requirements of a screening test that could be available for prophylactic clinical trials or epidemiological researches.

Evaluation of a new rapid D-dimer assay for clinically suspected deep venous thrombosis (Liatest D-dimer).

In previous studies, enzyme-linked immunosorbent assays (ELISA) for plasma D-dimer analysis have demonstrated high sensitivity, suggesting their potential usefulness in excluding deep venous thrombosis (DVT). We evaluated the usefulness of a new D-dimer test (Liatest D-dimer) for suspected DVT in a prospective study of patients admitted to the hospital because of recent (not exceeding 1 week before admission) clinical signs. Contrast venography or compression ultrasonography or both were performed within 24 hours of admission. A new quantitative determination of D-dimer concentration using a suspension of microlatex particles coated with specific antibodies was tested. A standard plasma D-dimer ELISA measurement was also performed. Of 464 patients, 276 had a proven DVT (distal, 74; proximal, 202). For a cutoff level of 400 ng/mL, sensitivity of the Liatest method in the diagnosis of overall DVT was 94.6% (95% confidence interval, 92.0%-97.0%), and the specificity was 35% (95% confidence interval, 28%-42%). The sensitivity and negative predictive value were 98.5% and 95.6%, respectively, in the diagnosis of proximal DVT, but only 83.8% and 84.6%, respectively, in the diagnosis of distal DVT. This new rapid Liatest D-dimer assay seems to be highly sensitive and could replace the ELISA method in excluding patients with proximal DVT. Both methods provide lower sensitivity for distal DVT.

Successful surgical treatment of intraorbital arteriovenous malformations: case report.

OBJECTIVE AND IMPORTANCE: Cases of intraorbital arteriovenous malformations are rare, and their management presents a challenge for multidisciplinary teams. CLINICAL PRESENTATION: A 39-year-old woman developed a pulsating exophathalmos, visual loss, and ocular pain within 1 month, revealing the presence of intraorbital arteriovenous malformations. She underwent only surgical treatment. INTERVENTION: A fronto-orbital approach with removal of the orbital rim was performed. A CO2 laser facilitated all the surgical steps. CONCLUSION: Full recovery of vision and correction of the proptosis have been achieved, and postoperative magnetic resonance imaging and angiography confirmed the total removal of the malformations. The literature is reviewed regarding the management of such lesions. Surgery remains the treatment of choice. The role of embolization is discussed.

Concurrent spinal dural and intradural arteriovenous fistulas. Case report.

Among spinal arteriovenous malformations (AVMs), dural arteriovenous fistulas (DAVFs) should be distinguished from intradural AVMs. The authors report the unusual and well-documented case of a 49-year-old man who suffered from a rapidly progressive myelopathy. Two concurrent spinal AVMs (one DAVF and one intradural direct AVF [Anson-Spetzler Type IV-B AVM]) were found located in the midthoracic region and in the conus medullaris, respectively. Both AVMs were successfully treated by surgery. To the authors' knowledge, the association of these two pathological entities has not been previously described. Clinically, if the patient fails to improve or deteriorates after the treatment of a spinal AVM, the presence of another AVM should be investigated by repeated angiography, especially if a complete spinal angiography study was not initially performed.

[Calf muscle venous thrombosis and pulmonary embolism]. / Thrombose veineuse musculaire du mollet et embolie pulmonaire.

INTRODUCTION: The clinical significance of calf muscle venous thrombosis (CMVT) still remains a matter of debate. Detected by ultrasonography, they are overlooked by venography. This prompted us to evaluate the frequency of such localizations and their association to pulmonary embolism (PE). METHODS: Retrospective review of our database over a three-year period. All patients with an isolated CMVT were included. RESULTS: Isolated CMVT were detected in 106 patients (mean age 68.6 years; 65% women), that is 12.5% of all venous thromboses diagnosed in the vascular sonography unit over the study period Sixteen associated PE were detected (15%). CONCLUSIONS: Association of CMVT and PE is not infrequent. Whether or not such thromboses have the potential to extend into deep veins and/or to migrate into pulmonary circulation requires further studies.

[Pulmonary embolism and unusual deep venous thrombosis. Report of two cases]. / Embolies pulmonaires et thromboses veineuses profondes inhabituelles. A propos de deux observations.

Contrast venography is the gold standard for the diagnosis of deep vein thrombosis in the lower limb extremities, but it fails to visualize deep veins like deep femoral vein and internal iliac vein. The internal iliac can be examined with duplex scanning if the technique and the examination conditions are correct. As reported in these two cases, thrombosis of these deep veins may lead to pulmonary embolism. The first case is a young female with venous thromboembolic disease in whom internal iliac vein thrombosis was documented only at the second examination. In the second case, deep femoral vein thrombosis appeared early in a comatose young male. This thrombosis may be classified as proximal muscular vein thrombosis. These two cases emphasize the importance of a duplex scanning examination performed with rigorous technique, whose the main limitation being examination conditions.

[Vascular deficit is the major cause of fistula in esophageal surgery]. / Le déficit vasculaire est la cause majeure des fistules en chirurgie oesophagienne.

AIM OF THE STUDY: The aim of this retrospective study was to find a link between vascularization failure and fistula in esophageal surgery. The originality of this study was to be based on hyperselective arteriogaphy of the artery vascularizing the gastric plasty, showing all vascular network of the plasty. PATIENTS AND METHODS: Hyperselective arteriography was carried out in 14 patients operated for esophagus cancer with a gastric plasty replacement. All these patients had a postoperative leakage or a bad vascularization of the gastric plasty during the operation. RESULTS: The vascularization of the gastric plasty was organized from the gastro-epiploic artery by anastomotic transversal network, depending on the left gastro-epiploic artery and left gastric artery. For the 14 patients, a constant link between leakage and vascularization failure could be proved. CONCLUSION: Esophageal surgery is dependent on the vascular status of the patient. The type of gastric plasty with large or narrow tubulization does not interfere with the quality of vascularization at the top of the plasty due to the preservation of a corporeal low branch.

[3-dimensional reconstruction of x-ray computed tomographic views in fractures of the acetabulum]. / Reconstructions tridimensionnelles à partir de coupes tomodensitométriques dans les fractures du cotyle.

In 21 cases of acetabulum fractures of 19 patients, the authors compare the findings given by three dimensional reconstructions of axial CT scan cuts with the plain films. The number of CT scan cuts is reasonable for each patient. Working time is about 20 to 30 minutes for the technician. In the cases of complex and displaced fractures, three dimensional imaging brings often decisive informations for the therapeutic management of these patients. Unusual views are often allowed but completely adapted to each type of fracture.

[Congenital aneurysm of the trunk of the pulmonary artery]. / Anévrisme congénital du tronc de l'artère pulmonaire.

A case of congenital aneurysm of the main pulmonary artery incidentally discovered following blunt chest trauma is reported. This anormaly is rare and the authors will emphasize the plain radiographic and MRI findings. The etiology and evolution of this entity are not well known.

[Ultrasonic features of congenital anomalies of the gallbladder]. / Aspects échographiques des anomalies congénitales de la vésicule biliaire.

Congenital anomalies of the gallbladder (GB) correspond to the ultimate manifestation of the wide range of anatomical variations that may affect the GB. Anomalies may be numerical: duplication, accessory GB, and, rarely, agenesis. Anomalies of position are more common: ectopic GB, floating or wandering GB. Morphological anomalies (septations) are the most common GB anomalies. Most of these anomalies may result in pitfalls at US imaging.

[Pulmonary embolism and the level of thrombosis. A prospective study of 155 patients]. / Embolie pulmonaire et niveau de thrombose. Une étude prospective de 155 patients.

This study was designed to assess the risk of associated pulmonary embolism according to the level of deep venous thrombosis. From March 1992 to March 1994, 328 patients were referred to medical units for suspected deep venous thrombosis, with recent clinical signs, less than a week. Each patient underwent contrast venography and/or duplex ultrasounds of lower extremities, ventilation and perfusion lung scan within 48 hours and angiography in case of low or intermediate pulmonary embolism probability. Diagnosis of deep venous thrombosis was confirmed in 155 patients; location was distal in 41, proximal in 114; an associated pulmonary embolism was found in 66 patients (10 with distal, 56 with proximal deep venous thrombosis); odds ratio was 2.99 (95% Cl: 1.2-3.13). Significantly higher risk of associated pulmonary embolism when deep venous thrombosis involves proximal veins is confirmed, but as many as 10 out of 41 patients with distal thrombosis also had an associated embolism. Management of both distal and proximal deep venous thromboses appears identical.

[Persistence of the stapedial artery: three cases]. / Persistance de l'artère stapédienne: à propos de trois observations.

The authors report three cases of persistence of the stapedial artery, discovered by computed tomography examination. For two cases, a clinical symptomatology was present but probably related to the association with an aberrant carotid artery in the middle ear; the only case of isolated persistence of the stapedial artery was asymptomatic. Direct visualisation of the abnormal artery was possible on the C. T. scans in two cases and a collateral sign as a larger tympanic part of the facial canal was found in the third case inducing a MRI. The incidence of this anomaly is 0.48 per cent from 1,045 dissections of temporal bones but it is generally clinically unrecognized. The hyoïdo-stapedial artery appears and develops at the 7-18 mm embryonic stages. Partial or complete persistence have been described associated with no regression or no division of the ventral pharyngeal artery.

[Right-sided duplication of the inferior vena cava]. / Duplication droite de la veine cave inférieure.

An infrarenal duplication of the inferior vena cava with both channels lying on the right side of the aorta was fortuitously found during an abdominal Computed Tomography performed on a 52 year-old woman. Only two same cases seem to be reported in the literature. This very uncommon abnormality probably results from persistence of the infra-renal part of the right subcardinal vein. Radiologists have to be aware of this right-sided ipsilateral duplication for it may be a trap in abdominal imaging as well as "classical" inferior vena cava duplication located on both sides of the abdominal aorta.