Prostatic artery embolization using three-dimensional cone-beam computed tomography.

PURPOSE: The purpose of this study was to report the use of three-dimensional (3D) cone-beam computed tomography (CBCT) for prostatic artery embolization (PAE) in patients with benign prostatic hypertrophy (BPH). MATERIALS AND METHODS: Twenty-three consecutive men who underwent PAE using 3D CBCT from June 2016 to September 2018, were retrospectively included in this observational single-center study. There were 23 men with a mean age of 73±12 (SD) years (range: 52-94years) with moderate to severe lower urinary tract symptoms (mean international prostate symptom score, 21±5.7 [SD]; range: 9-30) due to BPH (mean prostate weight, 100g±63 [SD]; range: 30-250g). PAEs were analyzed with respect to procedure time, fluoroscopy time, technical success, complications and dosimetric indices. RESULTS: The mean catheterization time of the prostatic artery from the internal iliac artery was 17.3±12.5 (SD) min (range: 8-57min) on the right side and 23.6±14.9 (SD) min (range: 6-54min) on the left side. A technical success was achieved in 21 patients (21/23; 91%). PAE was bilateral in 14 patients (14/21; 66%) and unilateral in 7 patients (7/21; 33%). No occurrence of non-target embolization was reported. The mean dose area product was 146.7±47.9 (SD) Gy.cm2 (range: 54-254Gy.cm2) and mean cumulative air kerma was 771.4±333.3 (SD) mGy; range: 280-1560 mGy. The mean fluoroscopy time was 42.3±23.1 (SD) min (range: 19.4-118.2min). CONCLUSION: 3D CBCT is a useful tool to identify the prostatic arteries and facilitates catheterization of prostatic arteries with an acceptable level of radiation exposure.

Improved Assessment of Middle Ear Recurrent Cholesteatomas Using a Fusion of Conventional CT and Non-EPI-DWI MRI.

BACKGROUND AND PURPOSE: Recurrent middle ear cholesteatomas are commonly preoperatively assessed using MR imaging (non-EPI-DWI) and CT. Both modalities are used with the aim of distinguishing scar tissue from cholesteatoma and determining the extent of bone erosions. Inflammation and scar tissue associated with the lesions might hamper a proper delineation of the corresponding extensions on CT images. Using surgical findings as the criterion standard, we assessed the recurrent middle ear cholesteatoma extent using either uncoregistered or fused CT-MR imaging datasets and determined the corresponding accuracy and repeatability. MATERIALS AND METHODS: Twenty consecutive patients with suspected recurrent middle ear cholesteatoma and preoperative CT-MR imaging datasets were prospectively included. A double-blind assessment and coregistration of the recurrent middle ear cholesteatoma extent and manual delineation of 18 presumed recurrent middle ear cholesteatomas were performed by 2 radiologists and compared with the criterion standard. "Reliability score" was defined to qualify radiologists' confidence. For each volume, segmentation repeatability was assessed on the basis of intraclass correlation coefficient and overlap indices. RESULTS: For the whole set of patients, recurrent middle ear cholesteatoma was further supported by surgical results. Two lesions were excluded from the analysis, given that MR imaging did not show a restricted diffusion. Lesions were accurately localized using the fused datasets, whereas significantly fewer lesions (85%) were correctly localized using uncoregistered images. Reliability scores were larger for fused datasets. Segmentation repeatability showed an almost perfect intraclass correlation coefficient regarding volumes, while overlaps were significantly lower in uncoregistered (52%) compared with fused (60%, P < .001) datasets. CONCLUSIONS: The use of coregistered CT-MR images significantly improved the assessment of recurrent middle ear cholesteatoma with a greater accuracy and better reliability and repeatability.

Image fusion-guided portal vein puncture during transjugular intrahepatic portosystemic shunt placement.

PURPOSE: The purpose of this study was to assess the feasibility and utility of image fusion (Easy-TIPS) obtained from pre-procedure CT angiography and per-procedure real-time fluoroscopy for portal vein puncture during transjugular intrahepatic portosystemic shunt (TIPS) placement. MATERIALS AND METHODS: Eighteen patients (15 men, 3 women) with a mean age of 63 years (range: 48-81 years; median age, 65 years) were included in the study. All patients underwent TIPS placement by two groups of radiologists (one group with radiologists of an experience<3 years and one with an experience≥3 years) using fusion imaging obtained from three-dimensional computed tomography angiography of the portal vein and real-time fluoroscopic images of the portal vein. Image fusion was used to guide the portal vein puncture during TIPS placement. At the end of the procedure, the interventional radiologists evaluated the utility of fusion imaging for portal vein puncture during TIPS placement. Mismatch between three-dimensional computed tomography angiography and real-time fluoroscopic images of the portal vein on image fusion was quantitatively analyzed. Posttreatment CT time, number of the puncture attempts, total radiation exposure and radiation from the retrograde portography were also recorded. RESULTS: Image fusion was considered useful for portal vein puncture in 13/18 TIPS procedures (72%). The mean posttreatment time to obtain fusion images was 16.4minutes. 3D volume rendered CT angiography images was strictly superimposed on direct portography in 10/18 procedures (56%). The mismatch mean value was 0.69cm in height and 0.28cm laterally. A mean number of 4.6 portal vein puncture attempts was made. Eight patients required less than three attempts. The mean radiation dose from retrograde portography was 421.2dGy.cm2, corresponding to a mean additional exposure of 19%. CONCLUSION: Fusion imaging resulting from image fusion from pre-procedural CT angiography is feasible, safe and makes portal puncture easier during TIPS placement.

Epistaxis: The role of arterial embolization.

Epistaxis is defined as flow of blood from the nasal fossae and is a common and benign disorder in the great majority of cases which does not require medical care. It may however become a genuine medical or surgical emergency because of the amount, repeated episodes or patient's medical vulnerability (such as coronary artery disease patients). Epistaxis may be either primary or a symptom of an underlying disease. Four levels of problems need to be answered faced with epistaxis: recognizing it, and in particular not missing "epistaxis" due to swallowed blood or venous hemorrhage, which falls outside of the scope of interventional radiology; establishing the amount and its repercussions, particularly as a decompensating factor in another disease; investigating its cause and in particular never missing a tumor (male adolescents); obtaining hemostasis. Epistaxis varies not only in type and cause but must be considered in its clinical context. Arterial embolization is a treatment of choice for severe refractory epistaxis and some hemorrhages. When carried out by trained operators, it is an effective method with few risks of complications and is increasingly being used in reference centers (Brinjikji et al.). It remains, however, a method which is less widely used than surgery, particularly in the United States where in a series of 69,410 patients treated over the last 10 years for refractory epistaxis, 92.6% underwent surgical ligation, 6.4% embolization and 1% combined treatments (Brinjikji et al.). Epistaxis is occasionally catastrophic and requires extremely urgent management. In each case, close collaboration with the surgeon, the presence of an intensive care anesthetist and at least sedation are all factors which improve management and therefore the results of embolization. All patients and/or their friends/close family should have given "reliable, clear and appropriate" information.

MR imaging of arrhythmogenic right ventricular dysplasia: What the radiologist needs to know.

Arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C) is an inherited heart muscle disease that predominantly affects the right ventricle. Clinical manifestations are related to severe ventricular arrhythmia that may lead to sudden death, mostly in young patients. Magnetic resonance imaging (MRI), included in the new diagnostic criteria since 2010, aims to detect segmental and global wall motion abnormalities, reduced ejection fraction, right ventricular dilatation and right ventricular diastolic/systolic dysfunction. An MRI assessment of the right ventricle is often challenging, partly because the MRI diagnostic criteria have some limitations, and also because it requires a significant learning curve due to the low prevalence of the disease. Therefore, this article aims to review the pathophysiology of the disease, the cardiac MRI protocol, images of the various stages of this affection as well as the differential diagnosis.

Ethylene vinyl alcohol copolymer (Onyx®) in peripheral interventional radiology: indications, advantages and limitations.

Onyx(®) is a remarkable liquid embolizing agent that may allow a well-trained operator to undertake challenging embolization procedures. In multiple interventional radiology indications, the physico-chemical properties of Onyx(®) allow safe embolization. The purpose of this article is to review the advantages and disadvantages of Onyx(®) and identify its main indications.

Lithotripsy for salivary stones with prospective US assessment on our first 25 consecutive patients.

OBJECTIVES: To evaluate the predictive value of sonographic fragmentation in the successful treatment of sialolithiasis. The main objective was to streamline the management by treating the patients with three sessions of ultrasonic lithotripsy, and to compare the success rate and complications with data from the literature. A second objective was to analyse the predictive value of data from the post procedure and follow-up sonography related to therapeutic success with regard to size, site and location of stones. MATERIAL AND METHODS: Prospective follow-up of 25 patients (mean age of 43 ± 17.2 years old 11-68; 13 women, 10 men) over a period of 31 months (October 2009-April 2012) with one or more salivary calculi (19 parotid, submandibular 6) treated with extracorporeal lithotripsy (electromagnetic MINILITH SL 1, Storz Medical, Switzerland). No anaesthesia or analgesia was used. Each session of lithotripsy lasted on average 30 min. Minor complications were collected on an anonymised sheet. RESULTS: Complete success (absence of clinical symptoms 3 months after the end of treatment (or the last session) and residual stones <2 mm) was observed in 36% of patients, partial success (persistence of symptoms least 3 months (lower intensity and lower frequency) or size of residual stones>2 mm) in 48% and failure (persistence of same or increased symptoms at 3 months or no change in size of the calculi) in 17% of patients. Sonographic fragmentation of the stone (p = 0.004), total energy delivered (p = 0.008) and the total number of shock waves (n = 0.045) are predictive factors of complete success. Size, salivary topography, ductal topography, mobilization of the stones, occurrence of minor side effects and total duration of treatment had no predictive value of complete success (p > 0.05). There was no significant difference between the first 5 and the last 20 patients (p = 0.367). In agreement with the literature data, the efficacy of treatment was greater for parotid than submandibular calculi. CONCLUSION: Extracorporeal lithotripsy is an alternative to conventional surgery with no major complications. Sonographic fragmentation of calculi, total energy and total number of shock waves are predictive factors of successful treatment.

Cardiac MRI in the diagnosis of complications of myocardial infarction.

The improvement in revascularization techniques and medicine treatment during infarction has substantially reduced mortality during the acute phase of this condition. Since the advent of kinetic sequences and the concomitant development of gadolinium chelates and delayed enhancement sequences, cardiac MRI has become the second-line reference examination for ischemic heart disease. The technique of delayed enhancement with the inversion recovery sequence performed after injection has been validated for numerous indications in ischemic disease. Delayed enhancement sequences make it possible in particular to look for "no-reflow" areas (microvascular obstructions), to quantify the infarction area, and to assess prognosis. MRI also allows us to define the area at risk, that is, the area with edema, and to look for and assess the mechanical complications of the infarction. The aim of this review is to summarize current knowledge about: the pharmacokinetic principles that regulate myocardial enhancement; the different sequences available to acquire delayed enhancement images, and; the value of cardiac MRI in the diagnosis of complications of myocardial infarction.

[Imaging of mediastinal tumors]. / Imagerie des tumeurs du médiastin.

Imaging of mediastinal tumors is an important part of the diagnostic workup in patients presenting symptoms suggestive of compression of one or more of the mediastinal components. In other cases, lesions growing within the mediastinum remain asymptomatic and are diagnosed when chest X-ray or CT are routinely performed for other indications. CT remains the most available and reliable tool among the different imaging methods. Due to its permanent technical improvements, it can be used as the one-step answer to all the requirements of the pretherapeutic evaluation of a mediastinal mass. Chest plain film is still needed as the first line examination in order to carefully select the acquisition protocol for CT. MR did not demonstrate any superiority to CT except for the preoperative workup of lesions arising in the posterior part of the mediastinum. MR remains an interesting tool for tissue characterisation. Topography of mediastinal lesions (based upon the definition of mediastinal compartments) is one of the guides through the diagnostic pathway in imaging these tumors. The other one is their main tissue component, so that cystic, fatty and soft tissue masses can be differentiated.

[Nasopharyngeal carcinoma]. / Cancer du nasopharynx.

Nasopharyngeal carcinoma is relatively common. Undifferentiated Carcinomas of Nasopharyngeal Type (UNCT) are endemic Epstein-Barr virus (EBV)-related tumors. They are mainly radiosensitive. The role of imaging is to assess locoregional extension, TNM classification and adjust the radiation fields. MRI is essential to determine the initial extension. CT is useful to confirm the presence of bone involvement and evaluate nodal status. MRI and CT are necessary for the post-treatment follow-up.

[Cervical lymph nodes]. / Adénopathies cervicales.

Imaging plays a chief role in the care and monitoring of patients in cervico-facial oncology. The radiologist must know the anatomy of different lymph nodes as well as signs of malignancy (hypertrophy, enhancement, necrosis, capsular rupture, etc.). CT is still the first-line examination because of its high reliability, its accessibility and its ability to make an assessment of the upper aero digestive ways at the same time. Ultrasound is very accuracy, and allows the realization of cytoponction, but does not provide a complete exploration of the neck. MRI does not appear to be indicated for the first intention, but the new rapid sequences (STIR, diffusion) seem interesting. The PET-CT is useful in post-therapeutic management of patients, and probably in the initial staging, but its accessibility is poor.

[Prospective evaluation of PICC line related complications]. / Evaluation prospective des complications des PICCs.

PURPOSE: To report the occurrence of complications following placement of peripherally inserted central catheters (PICC). Materials and methods. A total of 127 PICC lines were placed in 115 patients for TPN (n=54), long-term antibiotics (n=29), chemotherapy (n=14) or miscellaneous intravenous therapy (n=18). RESULTS: All PICC lines were successfully inserted. PICC lines were used for a mean duration of 16 days (1-166 days). The following complications were recorded: occlusion (7%), rupture (1.6%), accidental withdrawal (2.4%), infection (3.1%) and venous thrombosis (2.4%). CONCLUSION: PICC lines are a simple, safe and effective alternative to conventional central venous catheters. The occurrence of complications, typically "mechanical", must be reduced and prevented by strict management of this type of central line by the treating team.

[Anatomic variants of the biliary tree with MR Cholangiography: feasibility and surgical applications]. / Variations anatomiques des voies biliaires en cholangio-IRM: faisabilité et intérêt chirurgical.

PURPOSE: To assess the usefulness of MR Cholangiography for evaluation of anatomic variants of the biliary tree before biliary surgery. MATERIALS AND METHODS: Our study group consisted of 45 consecutive patients (29 males, 16 females; mean age 57 years), who were referred for MR evaluation of malignant (n=26) and benign (n=19) cholangiopancreatic diseases. MR Cholangiography studies were independently reviewed by two radiologists. RESULTS: Anatomic variants of the biliary tree were observed in 9 patients (20%); 6 variants involved the biliary confluence and 4 the cystic duct (one patient had both). Anatomic variants involved principally the right posterior duct: 1 (2,2%) drainage of right posterior duct into left hepatic duct; 2 (4,4%) triple confluence of right posterior duct, right anterior duct, and left hepatic duct, and 3 (6,6%) aberrant drainage of right posterior duct into common hepatic duct. Observed cystic duct anomalies included: 2 (7,44%) low insertion of the cystic duct into the common hepatic duct and 3 (11,1%) medial insertion of the cystic duct into the common hepatic duct. CONCLUSION: MR Cholangiography accurately shows anatomic variants of the biliary tree. Noninvasive preoperative evaluation of the biliary anatomy may be important for the detection of anatomic variants that may increase the complexity of hepatic surgical procedures and biliary interventions.

Cavernous sinus thrombosis secondary to non-invasive sphenoid aspergillosis.

The sphenoid localization of aspergillosis is a rare sinusal disease, often latent or asymptomatic. The neurological complications are the result of invasive forms occurring in most cases for the immunocompromised or diabetic patients. Nevertheless, non-invasive sphenoid aspergillosis may cause also several complications and affect the vital prognosis of nonimmunocompromised patients. This report is about two cases of cavernous sinus thrombosis secondary to a non-invasive sphenoid aspergillosis. The authors refer to the clinical and radiological findings and therapeutic approach of this rare complication.

Preoperative diagnostic values of fine-needle cytology and MRI in parotid gland tumors.

The aim of this retrospective study was to assess and compare the diagnostic value of fine-needle cytology and MRI for the prediction of malignancy in parotid tumors. During an 11-year period, 148 patients underwent preoperative fine-needle aspiration cytology in our institution. Eighty-seven patients underwent a preoperative MRI study, and 54 had both MRI and cytology. The study compares results of cytology and MRI with histological reports. The sensitivity, specificity and accuracy for detecting malignant lesions were 87, 94 and 93% respectively for MRI, 81, 95 and 92% respectively for cytology and 100, 88 and 91% respectively for both studies combined. Fine-needle cytology provided better information than MRI concerning precise histological diagnoses. Conversely, the proportion of non-diagnostic smears reached 10%. Fine-needle cytology and MRI are simple, well-tolerated diagnostic means with an impact on the management of salivary gland tumors. The associated anatomic information obtained by MRI imaging makes it the test of first choice in an optimal medical environment.

[MR imaging and arrhythmogenic right ventricular dysplasia (ARVD)]. / IRM et dysplasie arythmogène du ventricule droit (DAVD).

Arrhythmogenic right ventricular dysplasia (ARVD) is a cardiomyopathy of unknown etiology responsible for 20% of cases of sudden death in young adults secondary to arrhythmia. It is characterized histologically by fatty or fibro-fatty infiltration of the right ventricular myocardium. Diagnostic criteria have been proposed for diagnosing ARVD. Imaging, especially MRI, plays an important role. MR imaging must be performed using cardiac gating, and should include both cine-MR sequences for evaluation of segmental and global right ventricular function or any morphological change of the right ventricular shape, and anatomic sequences to detect fatty or fibro-fatty infiltration of the right ventricular myocardium.

[A case of nasal septum schwannoma: endoscopic resection]. / Le schwannome du septum nasal. A propos d'un cas.

OBJECTIVES: To define clinical and radiological characteristics of nasal septal schwannoma, and to propose endoscopic surgery. PATIENT AND METHODS: We report a case of an isolated schwannoma of the anterior part of the nasal septum, without involvement of any local structure. The only preoperative symptom was nasal obstruction. Imaging study included a CT scan and an MRI study. RESULTS: Schwannoma is a sheath tumor originating from Schwann cells of peripheral nerves. It rarely occurs in nasal and paranasal sinuses and its development on the nasal septum is extremely rare. Complete removal of the tumor was performed by endoscopic sinus surgery technique. Limits of the excision were free of tumor and the histological type was Antoni type A Schwannoma. After a year of follow up, the patient is free of recurrence. CONCLUSION: The Schwannoma of the nasal septum is a rare tumour whose clinical and radiological diagnosis by CT scan and IRM is relatively easy. Its treatment is surgical and the endoscopic surgery can be proposed in the forms slightly extensive.

Endovascular treatment of anastomotic false aneurysms of the abdominal aorta.

Conventional surgical treatment of anastomotic false abdominal aortic aneurysms (AFAA) is technically difficult. Morbidity-mortality rates are higher than those for surgery of infrarenal abdominal aortic aneurysm (AAA). Endovascular management without laparotomy or aortic clamping represents an attractive alternative. The purpose of this study was to determine the immediate and middle-term outcome of endovascular management of AFAA. Between 1998 and 2001, 10 patients were treated for AFAA by placement of an endograft. The initial procedure was aortobifemoral bypass for occlusive artery disease in eight cases and resection and grafting for AAA in two cases. Mean age was 70 years. Seven patients were classified ASA 3 or 4. Three patients presented cardiac insufficiency with left ventricular ejection fraction <40%. Eight patients were treated using an aortounilateral iliac artery endograft in association with crossover femorofemoral bypass (3 AneuRx, 2 Endologix, 1 Talent, 1 Zenith, 1 surgeon-made stent). Two patients were treated with an aortoaortic endograft (1 Talent, 1 surgeon-made stent). In two patients extraperitoneal exposure of the common iliac artery was required for introduction of the stent in one case and for surgical closure of the iliac artery in the other case. A total of nine patients underwent another surgical procedure in association with stenting. Four endografts were custom-made. Endograft deployment was successful in all cases. No patient died during the postoperative period. Postoperative computed tomography (CT) scan confirmed exclusion of the aneurysmal sac in all cases. The mean duration of hospitalization was 13 days (range, 5-28 days). During follow-up (mean duration, 17.7 months; range, 5-42 months), one patient died from heart-related causes. No direct or indirect endoleak was detected by CT scan follow-up and a significant reduction in AFAA diameter was noted in the eight patients with follow-up periods lasting 6 months or more. One patient developed occlusion of an aortounilateral iliac artery endograft and was treated by axillobifemoral bypass. In one patient stenosis of the distal end of an aortounilateral iliac endograft was discovered by duplex scan and successfully treated by dilatation. Endovascular treatment of AFAA is technically feasible but requires more complex procedures involving associated surgical procedures and use of custom-made endografts. The morbidity-mortality rate in this small series of high-risk patients was low. Immediate and middleterm exclusion of AFAA was good.

[Sphenoid sinusitis]. / Sinusites sphénoïdales.

Sphenoid sinusitis is uncommon, with an incidence of about 2.7%. Failure to diagnose and treat sphenoid sinus disease has been shown to lead to serious neurologic sequellae. Plain radiographs play a limited role in the management of sinusitis. CT scan can provide a positive diagnosis by the visualization of mucosal thickening, air-fluid level and complete opacification of the sinusal cavities. In addition, CT can provide more information about the anatomy and abnormalities of the sphenoid sinus. MRI is used in cases of suspected tumors or neurologic involvement. The most common presenting symptom is headache that arise characteristically, but rarely, from the vertex. Sphenoiditis has a high risk of severe neurologic involvement, cavernous sinus thrombosis being one of the most serious complications.