Utility of vaginal and rectal contrast medium in MRI for the detection of deep pelvic endometriosis.

OBJECTIVE: To study the sensitivity of MRI performed utilising vaginal and rectal opacification with ultrasound gel in the detection of deep pelvic endometriosis. MATERIAL AND METHODS: This was a prospective monocentric study. All patients evaluated by the gynaecologist for pelvic pain, endometriosis or infertility were included. Axial and sagittal T2-weighted images were performed both with and without vaginal and rectal opacification with ultrasound gel. Three radiologists, all blinded, interpreted the images with a minimum of 15 days between the two readings. MRI performance with and without vaginal and rectal opacification was evaluated by calculating sensitivity, specificity and both positive and negative predictive values. RESULTS: Seventy-eight patients were included. Among these, 31 patients had deep pelvic endometriosis of which 24 were confirmed by laparoscopy. Seventy-six locations of deep pelvic endometriosis were discovered on MRI. For the three reviewers there was a significant improvement in sensitivity between pre- and post-contrast MRI (p < 0.0002). CONCLUSION: Opacification of the vagina and rectum significantly improved the sensitivity of MRI for the detection of deep pelvic endometriosis by expanding the vagina and rectum, thus allowing better delineation of the pelvic organs. This was especially apparent for lesions localised to the vagina and rectovaginal septum.

Anterior pelvic endometriosis: MRI features.

Many atypical locations for deep endometriosis exist that are not well known to both the radiologist and gynecologist. This work explores these unusual localizations, which we have arbitrarily grouped under the term "anterior endometriosis" in contrast to the more common posterior presentation of deep endometriosis that has been so well described in the literature. Parietal and inguinal involvement is first detailed, followed by a description of deep endometriosis involving the urinary system and anterior supporting ligaments of the uterus. A necessary adaptation to the MRI protocol in order to accurately diagnosis deep anterior endometriosis as well as specific diagnostic criteria for each type of lesion is reviewed.

[Splenic artery aneurysm: diagnosis and endovascular therapy]. / Anévrisme de l'artère splénique: diagnostic et thérapeutique endovasculaire.

Splenic artery aneurysms are now diagnosed more frequently thanks to the increase and improvement in different imaging techniques. In case of rupture they are potentially life threatening and thus in certain cases may require appropriate preventive treatment. This treatment should be offered to patients with suspected pseudoaneurysms, with an aneurysm larger than 20mm in diameter, or which is progressing. The development of interventional endovascular radiology has provided new therapeutic options for the management of aneurysms, by excluding the sac from the arterial circulation with coil embolisation or with a covered stent. The success rate of these treatments is between 75 and 100% with significantly less morbidity and mortality than with surgical techniques.

[CT imaging features and significance of gas in the pancreatic bed]. / Aspects tomodensitométriques et signification du gaz dans l'aire pancréatique.

The pancreas is an organ that normally does not contain gas. The purpose of this article is to reaffirm the value of CT to detect gas in abnormal locations and illustrate the different causes of gas collections in the pancreatic bed. Abscesses and infected pseudocysts are the most frequent causes of gas in the pancreatic bed followed by malignant and inflammatory fistulae. Iatrogenic etiologies should be considered along with the rare emphysematous pancreatitis associated with very poor prognosis. All of these entities shows multiple imaging findings, including the presence of gas in the pancreatic bed.

[Anatomy of the female pelvis on MRI: value of intravaginal contrast]. / Anatomie pelvienne en IRM: apport du contraste vaginal.

PURPOSE: Prospective monocentric study to determine the feasibility, tolerability and diagnostic value of intravaginal contrast to assess female pelvic anatomy on MRI. MATERIALS AND METHODS: Forty-nine consecutive women referred for MRI evaluation of the pelvis, irrespective of the indication, were included in this study. The MR imaging protocol consisted of axial and sagittal T2W images before and after intravaginal instillation of sterile US gel. Eight anatomical regions were analyzed and their visibility graded from 1 to 4 (1=excellent; 4=non-visualized) by 3 radiologists without and with intravaginal gel. The value of intravaginal gel was determined by calculating the difference in the visibility index for each anatomical region by the Wilcoxon and khi2 tests. Inter-observer agreement was also determined using the kappa test. RESULTS: Two women declined vaginal opacification resulting in an acceptance rate of 96%. The gel instillation procedure had a duration of less than 3 minutes on average and was well tolerated by all patients. Intravaginal gel allowed significantly improved visualization of all anatomical regions (p<0.001); improvement between 0.5 and 2.5 points on average per anatomical region. Inter-observer agreement significantly improved after gel instillation increasing from 72% to 92%. CONCLUSION: Intravaginal instillation of US gel is simple, noninvasive, well-accepted and well-tolerated by patients. It increases visibility of pelvic anatomical structures with improved inter-observer agreement.

[Evaluation of two classifications systems for pelvic prolapse on dynamic MRI]. / Evaluation de deux systèmes de cotation des prolapsus pelviens en IRM dynamique.

PURPOSE: To determine the usefulness of two classification systems for pelvic prolapse on MRI. MATERIALS AND METHODS: Prospective study of 30 patients with symptoms of pelvic prolapse performed in a single center. All patients underwent clinical evaluation followed by dynamic pelvic MRI within 15 days. All MR examinations were reviewed by three readers using both classification systems based on different anatomical landmarks. The first used the pubococcygeal line and the second used the midpubic line. RESULTS: For prolapse detection, the correlation between clinical examination and MRI was good to very good, ranging between 74 and 89%. For prolapse staging, the correlation was poor to moderate. Inter-observer agreement was good to very good (kappa between 0.67 and 0.95). It was slightly better at the mid stage, with both systems (kappa between 0.83 and 0.97). Comparison of the inter-observer agreement between both MRI classification systems showed better results for the system using the pubococcygeal line (p<0.005). CONCLUSION: The classification system based on the pubococcygeal line appeared more reliable and simple for th eevaluation of pelvic prolapse on MRI.

[Deep pelvic endometriosis: MRI features]. / Endométriose pelvienne profonde en IRM.

Endometriosis is a frequent pathology of adult women. Clinical examination and US are poorly sensitive for detection of deep pelvic implants and MRI is superior for presurgical mapping of disease extent. This is important to optimize complete surgical excision, the only proven treatment to achieve symptomatic relief. The purpose of this pictorial essay is to describe the imaging features of deep pelvic endometriosis and the technical means to optimize its detection.

[MR imaging evaluation of endometrial carcinoma]. / Evaluation en imagerie par résonance magnétique des carcinomes de l'endomètre.

Prognosis for endometrial carcinoma is closely related to cell type and tumor grade but also to local staging using the FIGO classification. MRI, under specific technical conditions, allows excellent depiction of the degree of myometrial tumor extension. It also has an excellent specificity for the detection of cervical extension. In addition, it allows evaluation of regional nodes, but with sensitivity values that are not perfect. The purpose of this paper is to review the MR imaging features of endometrial carcinoma along with its limitations and pitfalls.

Pelvic prolapse: static and dynamic MRI.

Pelvic magnetic resonance is a simple and non-invasive imaging technique for dynamic and static assessment of the pelvic floor. The morphology of the support system is assessed by T2-weighted images. Dynamic sequences are used to assess pelvic prolapse. In this study we illustrate the normal and pathologic features of the levator ani muscle which represents the main active support of pelvic organs. Furthermore we describe the different types of prolapses, floor by floor, and the different staging techniques.

[Transcatheter embolization for endoscopically unmanageable acute nonvariceal upper gastrointestinal hemorrhage]. / Traitement par embolisation endovasculaire d'hémorragies gastro-intestinales hautes non variqueuses et aiguës après échec du traitement endoscopique.

OBJECTIVES: Evaluate the efficacy of endovascular embolization for patients with endoscopically unmanageable acute nonvariceal upper gastrointestinal hemorrhage as well as the factors that may influence mortality. MATERIALS AND METHODS. Retrospective study over a 4-year period including a historical cohort of 37 consecutive patients (22 men), with a mean age of 69.2 years (range, 22-93 years). In most cases (54%), the hemorrhage stemmed from a gastrointestinal ulcer. Technical, primary clinical, and secondary clinical success rates, as well as complication rates, were calculated. Several clinical and angiographic parameters were compared to the early mortality rate using Kruskal-Wallis or Fisher tests. RESULTS: Technical, primary clinical, secondary clinical success rates, and complication rates were, respectively, 89.2%, 83.8%, 88.9%, and 10.8%. The early mortality rate was 32.4%. The APACHE II and IGS II scores were strongly correlated with mortality (p=0.001 and p=0.003, respectively). CONCLUSION: Endovascular embolization in patients with endoscopically unmanageable acute nonvariceal upper gastrointestinal hemorrhage is effective. However, the mortality rate remains high because of the changes in the clinical condition of these patients.

[Percutaneous vertebroplasty in symptomatic osteoporotic vertebral compression fractures: review of 50 patients]. / Résultats de la vertébroplastie percutanée dans le traitement des fractures vertébrales ostéoporotiques hyperalgiques (50 cas).

PURPOSE: Evaluation of percutaneous vertebroplasty (PVP) in symptomatic osteoporotic vertebral compression fractures after failure of conservative management. MATERIALS AND METHODS: Retrospective study of cases performed between 2002 and 2005 in a single institution. Outcome was measured using Huskisson's visual analogue scale. RESULTS: A total of 77 vertebrae in 50 patients were treated. Mean follow-up was 12.9 months (1-36 months). Significant symptomatic improvement (p<0.001) was noted with pre PVP pain score of 7.4 (+/-0.99), 24 hour and 1 month post PVP score of 2.31 (+/-2.65), 6 month post PVP score of 2.4 (+/-2.7) and 18 month post PVP score of 2.91 (+/-2.91). Seven patients presented with a new symptomatic vertebral compression fracture, with 5 cases adjacent to the treated level. CONCLUSION: Percutaneous vertebroplasty is reliable and effective in the treatment of symptomatic osteoporotic vertebral compression fractures.

[Imaging of inflammatory pseudotumors of the liver]. / Imagerie des pseudo-tumeurs inflammatoires hépatiques.

PURPOSE: To describe the imaging features of inflammatory pseudotumors of the liver. INTRODUCTION: Inflammatory pseudotumors of the liver are rare benign lesions that may simulate malignancy on imaging studies. Diagnosis is most frequently confirmed after surgical resection of the lesion. MATERIALS AND METHODS: Retrospective study from 1998 to 2006 of histologically proven cases of inflammatory pseudotumors of the liver. A combination of the following imaging modalities were utilized: US, contrast enhanced US, helical CT and MRI. RESULTS: A total of seven lesions (mean diameter of 61.4 mm) were detected in 6 patients (mean age of 66 years). Clinical and laboratory results were non-specific. The following imaging studies were available: US in 5 cases, including one with contrast material, CT in 5 cases and MRI in 3 cases. All tumors were hypoechoic on US, with no enhancement after injection of Levovist. The tumors were generally hypodense on noncontrast CT and enhancement, when present, was delayed and moderate. On MRI, the tumors were iso- or slightly hyperintense on T2W images and iso- or slightly hypointense on T1W images with subtle peripheral enhancement on delayed imaging. CONCLUSION: The differential diagnosis of inflammatory pseudotumor of the liver should be known to radiologists and could be suggested in a clinical context of chronic inflammatory process in patients with non-specific liver mass showing imaging features of partial fibrosis with delayed enhancement.

[MR Features of hepatic macronodular mycobacteriosis]. / IRM des atteintes macronodulaires hépatiques à mycobactéries.

Hepatic macronodular mycobacteriosis is rare. Its diagnosis is challenging and is most often proposed on the basis of histological analysis. Final diagnosis, except for germ-proven cases, is made in conjunction with clinical, biological, and radiological arguments. We retrospectively report the MR features of ten hepatic lesions discovered on five patients. MRI is sensitive but has a low specificity in demonstrating pseudotumoral lesions most often exhibiting hypointensity on the T1-weighted sequence, hyperintensity on the T2-weighted sequence, and a slight rim enhancement after gadolinium-enhanced T1-weighted sequences.

Descending necrotizing mediastinitis: a rare pathology to keep in mind.

The spreading of a cervical infection to the mediastinum is a complication rarely observed, and its prognosis is still very severe. The infectious spreading follows known anatomical tracts, leading to the invasion of definite mediastinal spaces. The cervicothoracic scanning is the ideal procedure leading to the diagnosis, the localization of the infectious sites, and to the demonstration of an abscess and the presence of air in the mediastinum. We report a case of a patient in whom the early use of specific imaging and of proper aggressive surgical intervention did not allow the elimination of a fatal outcome.

MRI features of a pancreatic schwannoma.

A case of a pancreatic schwannoma is presented. The patient, a previously healthy woman, is hospitalized with the diagnosis of purulent pleuritis. Ultrasonography (US) of the abdomen shows a 3-cm mass in the head of the pancreas. Magnetic resonance imaging (MRI) reveals, in T1-weighted sequences, the mass to be hypointense, and an early and persistent enhanced signal is noted following the administration of gadolinium. In T2-weighted fat saturation sequences, the lesion appears markedly hyperintense. A duodenopancreatotomy is performed, and the pathologic specimen demonstrates a schwannoma of the pancreas with Antoni A pattern.

Rare localization of a portal cavernoma in the wall of the common bile duct.

The first communication on biliary complications secondary to a portal cavernoma was published in 1965 [Br. J. Surg. 52 (1965) 636.], and since then several cases have been reported in the medical literature. These biliary complications, studied initially by anterograde or retrograde cholangiography, and later MR cholangiography [Van Hoe L, Van Beckevoort D, Van Steenbergen W. Atlas of across-sectional and projective MR cholangiography. Berlin: Springer; 1999. p. 166-7.], appear to be secondary to a double mechanism which produces a compression of the common bile duct (CBD) and ischemic changes. The biliary abnormalities most frequently found are a dilatation of the intrahepatic biliary ducts associated with extrinsic strictures and segmental dilatation of the CBD [J. Radiol. 83 (2001) 341.]. We report a rare type of portal cavernoma characterized by a thickening of the walls of the CBD and by a dilatation of the intrahepatic biliary ducts. The thickened walls of the CBD were evaluated by ultrasound and by magnetic resonance imaging.

[Value of CT in small-bowel obstruction]. / Valeur du scanner dans l'occlusion mécanique de l'intestin grêle.

Small bowel obstruction is a leading cause of admission in surgical and emergency units. During the last two decades, the classical philosophy of "never let the sun set or rise on small-bowel obstruction" has been succeeded by a new management based especially on the cause and the severity of the obstruction. It most often allows a correct choice between medical therapy and surgery using laparotomy or laparoscopy. This changing attitude is still in progress and is mainly related to the high accuracy of computed tomography. This review will discuss the semiology and value of computed tomography compared with clinical examination and other imaging modalities.

[Conservative treatment of a compressive adenomyosis: report of a case]. / Traitement conservateur d'une adénomyose compressive: à propos d'un cas.

Adenomyosis is frequent, mostly asymptomatic. A hypertrophy of the smooth muscular cells around ectopic endometrial glands might induce a compressive syndrome. We report the case of an embolization of a voluminous adenomyosic uterus which has triggered venous iliac's compression in patient refusing surgery. This treatment was efficient in reduction of uterin volume, without recurrence after three years. MR imaging is the exam of choice particularly when diagnosis is still uncertain and allows a non-invasive and good evaluation, and follow-up. Embolization is not actually recommended. But, it appears to be efficient, relatively safe and contributes to the conservation of fertility.