Statin-Induced Necrotizing Autoimmune Myopathy: Case Report of a Patient under Chronic Treatment.

Introduction: 3-Hydroxy-3-methylglutaryl coenzyme A reductase (HMGCR) inhibitors are widely used worldwide to treat dyslipidaemia and prevent cardiovascular events. Statins can cause a wide variety of muscle injuries ranging from myalgia to severe rhabdomyolysis. In most cases, these symptoms are mild and self-limiting and do not require specific treatment besides drug withdrawal. Statin-induced autoimmune necrotizing myopathy (SINAM) is a rare but potentially fatal complication, characterized by the subacute onset of progressive proximal muscle weakness and considerably high creatine phosphokinase (CK) levels in patients exposed to statins. The diagnosis is supported by the presence of antibodies HMGCR, which allows the differentiation from other forms of necrotizing autoimmune myopathies. Symptoms usually progress even after statin discontinuation and can determine severe muscle damage. Summary. We describe the case of a 77-year-old man who developed SINAM after 5 years of statin use. He suffered from muscle functional impairment mainly involving proximal lower limb muscles which progressed to the point that he almost became bedridden. Initial treatment with prednisone alone was not effective, and he required a combination therapy with steroids, methotrexate, and intravenous immunoglobulins. After 5 months of therapy and rehabilitation, he showed complete laboratory response and muscle strength recovery. Conclusion: Recognizing SINAM is paramount in order to promptly start treatment and avoid permanent muscle damage. Using a combination therapy from the beginning could contribute to a better outcome. Prompt statin cessation, categorization of the muscle disease by autoantibody testing, imaging, and histology, exclusion of malignancy, and anti-inflammatory therapy with corticosteroids, antimetabolites, immunoglobulins, and in some cases rituximab are currently accepted approaches to this entity.

High-resolution ultrasound and magnetic resonance imaging of ulnar nerve neuropathy in the distal Guyon tunnel.

OBJECTIVE: The aim of the present study is to describe the ultrasound (US) and magnetic resonance imaging (MRI) findings in patients with neuropathies affecting the deep (DB) and superficial (SB) branches of the Ulnar nerve (UN) and to investigate the potential role of imaging modalities in the diagnostic workup of these conditions. MATERIALS AND METHODS: We screened our institutional imaging database to identify patients with a diagnosis of UN mononeuropathy, and among them, we reviewed the cases where US disclosed pathological findings affecting the UN terminal divisions. In this latter subgroup, we retrieved available data on MRI and electrodiagnostic tests performed by the patients during the diagnostic workup. All the patients were evaluated with US machines equipped with 17-5-MHz, 18-4-MHz, 24-8-MHz, or 22-8-MHz probes. MRI exams were performed on a 3-T unit equipped with a 64-channel head RF coil. RESULTS: Among 166 patients with UN mononeuropathy, we retrieved 15 patients (9%) for which US detected pathological findings affecting the UN terminal divisions, consisting of 7 cases of DB neuropathy, 4 cases of SB neuropathy, and 4 cases of combined neuropathy involving both nerves. Seven (46.7%) patients were submitted to MRI to integrate US findings. Among patients with SB and DB neuropathies, imaging allowed the identification of 7 traumatic nerve injuries, 2 nerve tumors, and 6 entrapment neuropathies, including 4 cases of nerve compression by a ganglion cyst. CONCLUSION: High-resolution US and MRI are accurate modalities for the investigation of patients with SB/DB neuropathy, can provide critical information on the cause of nerve damage, and guide therapeutic decisions. CRITICAL RELEVANCE STATEMENT: High-resolution US and MRI are accurate modalities for the investigation of patients with superficial/deep branch of the ulnar nerve neuropathy. In the proper setting, US may be regarded as a first-line approach in patients with suspected neuropathies affecting these small branches. KEY POINTS: • Neuropathies affecting the distal ulnar nerve often require multimodal investigations. • US and MRI can provide detailed morphological information about the terminal branches of the ulnar nerve. • US may be considered as a first-line approach in suspected distal ulnar nerve neuropathies.

High-resolution US of the facial vessels with new facial vein landmarks for reconstructive surgery and dermal injection.

BACKGROUND: Accurate knowledge of vessel anatomy is essential in facial reconstructive surgery. The technological advances of ultrasound (US) equipment with the introduction of new high-resolution probes improved the evaluation of facial anatomical structures. Our study had these objectives: the primary objective was to identify new surgical landmarks for the facial vein and to verify their precision with US, the secondary objective was to evaluate the potential of high-resolution US examination in the study of both the facial artery and vein. METHODS: Two radiologists examined a prospective series of adult volunteers with a 22-8 MHz hockey-stick probe. Two predictive lines of the facial artery and vein with respective measurement points were defined. The distance between the facial vein and its predictive line (named mandibular-orbital line) was determined at each measurement point. The distance from the skin and the area of the two vessels were assessed at every established measurement point. RESULTS: Forty-one volunteers were examined. The median distance of the facial vein from its predictive line did not exceed 2 mm. The facial vein was visible at every measurement point in all volunteers on the right side, and in 40 volunteers on the left. The facial artery was visible at every measurement point in all volunteers on the right and in 37 volunteers on the left. CONCLUSIONS: The facial vein demonstrated a constant course concerning the mandibular-orbital line, which seems a promising clinical and imaging-based method for its identification. High-resolution US is valuable in studying the facial artery and vein. RELEVANCE STATEMENT: High-resolution US is valuable for examining facial vessels and can be a useful tool for pre-operative assessment, especially when combined with the mandibular-orbital line, a new promising imaging and clinical technique to identify the facial vein. KEY POINTS: • High-resolution US is valuable in studying the facial artery and vein. • The facial vein demonstrated a constant course concerning its predictive mandibular-orbital line. • The clinical application of the mandibular-orbital line could help reduce facial surgical and cosmetic procedure complications.

Ultrasound of the palmar aspect of the hand: normal anatomy and clinical applications of intrinsic muscles imaging.

Intrinsic hand muscles play a fundamental role in tuning the fine motricity of the hand and may be affected by several pathologic conditions, including traumatic injuries, atrophic changes induced by denervation, and space-occupying masses. Modern hand surgery techniques allow to target several hand muscle pathologies and, as a direct consequence, requests for hand imaging now carry increasingly complex diagnostic questions. The progressive refinement of ultrasound technology and the current availability of high and ultra-high frequency linear transducers that allow the investigation of intrinsic hand muscles and tendons with incomparable resolution have made this modality an essential tool for the evaluation of pathological processes involving these tiny structures. Indeed, intrinsic hand muscles lie in a superficial position and are amenable to investigation by means of transducers with frequency bands superior to 20 MHz, offering clear advantages in terms of resolution and costs compared to magnetic resonance imaging. In addition, ultrasound allows to perform dynamic maneuvers that can critically enhance its diagnostic power, by examining the questioned structure during stress tests that simulate the conditions eliciting clinical symptoms. The present article aims to review the anatomy, the ultrasound scanning technique, and the clinical application of thenar, hypothenar, lumbricals and interossei muscles imaging, also showing some examples of pathology involving these structures.

Clinical indications for image-guided interventional procedures in the musculoskeletal system: a Delphi-based consensus paper from the European Society of Musculoskeletal Radiology (ESSR)-part VII, nerves of the lower limb.

OBJECTIVES: To perform a Delphi-based consensus on published evidence on image-guided interventional procedures for peripheral nerves of the lower limb (excluding Morton's neuroma) and provide clinical indications. METHODS: We report the results of a Delphi-based consensus of 53 experts from the European Society of Musculoskeletal Radiology who reviewed the published literature for evidence on image-guided interventional procedures offered around peripheral nerves in the lower limb (excluding Morton's neuroma) to derive their clinical indications. Experts drafted a list of statements and graded them according to the Oxford Centre for evidence-based medicine levels of evidence. Consensus was considered strong when > 95% of experts agreed with the statement or broad when > 80% but < 95% agreed. The results of the Delphi-based consensus were used to write the paper. RESULTS: Nine statements on image-guided interventional procedures for peripheral nerves of the lower limb have been drafted. All of them received strong consensus. Image-guided pudendal nerve block is safe, effective, and well tolerated with few complications. US-guided perisciatic injection of anesthetic provides good symptom relief in patients with piriformis syndrome; however, the addition of corticosteroids to local anesthetics still has an unclear role. US-guided lateral femoral cutaneous nerve block can be used to provide effective post-operative regional analgesia. CONCLUSION: Despite the promising results reported by published papers on image-guided interventional procedures for peripheral nerves of the lower limb, there is still a lack of evidence on the efficacy of most procedures. KEY POINTS: • Image-guided pudendal nerve block is safe, effective, and well tolerated with few complications. • US-guided perisciatic injection of anesthetic provides good symptom relief in patients with piriformis syndrome; however, the addition of corticosteroids to local anesthetics still has an unclear role. • US-guided lateral femoral cutaneous nerve block can be used to provide effective post-operative regional analgesia. The volume of local anesthetic affects the size of the blocked sensory area.

Hand and Wrist Neuropathies: High-resolution Ultrasonography and MR Neurography.

High-resolution ultrasonography (US) and magnetic resonance neurography (MRN) have followed parallel paths for peripheral nerve imaging with little comparison of the two modalities. They seem equally effective to study a variety of neuropathies affecting large and small nerves in the wrist and hand. This article outlines the technical considerations of US and MRN and discusses normal and abnormal imaging appearances of hand and wrist nerves from etiologies such as entrapment, injury, tumor, and proximal and diffuse neuropathy, with specific case illustrations.

Endovascular Versus Open Surgical Repair for Ruptured Descending Aortic Pathologies: A Systematic Review and Meta-Analysis of Observational Studies.

PURPOSE: Ruptured descending thoracic aorta (rDTA) is an harmful condition requiring emergent treatment. Thoracic endovascular aortic repair (TEVAR) is replacing the traditional open repair in the majority of descending thoracic aortic disease. An unanimous agreement regarding the optimal approach to treat rDTA has not been reached yet due to the lack of evidences supporting the improvement of long-term survival. The present meta-analysis of observational cohort studies aims to estimate the outcome of endovascular (TEVAR) versus surgical (OR) approach in the treatment of rDTA. METHODS: Prisma Statement for performing and reporting meta-analysis has been used. MEDLINE, Scopus and the Cochrane Library databases were searched. A meta-analysis of observational cohort studies that examined the outcomes after OR and TEVAR for the management of rDTA was performed. RESULTS: A total of 10,466 patients with rDTA were screened. Endovascular therapy was associated with a lower risk of in-hospital mortality compared with open repair (Risk Ratio[RR] 0.63; 95% CI0.57-0.70). The risk of stroke rate was not statistically different between endovascular versus open approach (RR0.86; 95% CI0.62-1.19). Endovascular treatment had benefits on paraplegia (RR0.70; 95% CI0.55-0.91) and other neurological complications (RR0.24; 95% CI0.10-0.56). TEVAR was associated with lower renal failure, cardiac complications and vascular injuries. Late mortality (Hazard Ratio[HR] 0.84; 95% CI0.63-1.13) and re-intervention rate (RR1.48; 95% CI0.80-2.74) were not significantly different between TEVAR and OR. CONCLUSIONS: TEVAR seems to offer advantages in terms of early mortality and complications rate. Moreover, data on late mortality and re-intervention are encouraging to consider endovascular treatment comparable to open repair for acute thoracic aorta emergency on long-term follow-up.

Clinical indications for image-guided interventional procedures in the musculoskeletal system: a Delphi-based consensus paper from the European Society of Musculoskeletal Radiology (ESSR)-part I, shoulder.

BACKGROUND: Image-guided interventional procedures around the shoulder are commonly performed in clinical practice, although evidence regarding their effectiveness is scarce. We report the results of a Delphi method review of evidence on literature published on image-guided interventional procedures around the shoulder with a list of clinical indications. METHODS: Forty-five experts in image-guided musculoskeletal procedures from the ESSR participated in a consensus study using the Delphic method. Peer-reviewed papers regarding interventional procedures around the shoulder up to September 2018 were scored according to the Oxford Centre for Evidence-based Medicine levels of evidence. Statements on clinical indications were constructed. Consensus was considered as strong if more than 95% of experts agreed and as broad if more than 80% agreed. RESULTS: A total of 20 statements were drafted, and 5 reached the highest level of evidence. There were 10 statements about tendon procedures, 6 about intra-articular procedures, and 4 about intrabursal injections. Strong consensus was obtained in 16 of them (80%), while 4 received broad consensus (20%). CONCLUSIONS: Literature evidence on image-guided interventional procedures around the shoulder is limited. A strong consensus has been reached for 80% of statements. The ESSR recommends further research to potentially influence treatment options, patient outcomes, and social impact. KEY POINTS: • Expert consensus produced a list of 20 evidence-based statements on clinical indications of image-guided interventional procedures around the shoulder. • The highest level of evidence was reached for five statements. • Strong consensus was obtained for 16 statements (80%), while 4 received broad consensus (20%).

Primary and Secondary Breast Lymphoma: Focus on Epidemiology and Imaging Features.

Aim of this study was to select all the cases of Primary (PBL) and Secondary (SBL) Breast Lymphoma from our breast unit since 01/01/2000, to obtain up-to-date data on the prevalence of this rare pathology and to analyze imaging features, with a special focus on CT. All pathological reports of breast biopsies performed from 01/01/2000 to 01/01/2019 were at first screened. Among them, we performed two different researches, looking for key words suggesting either a diagnosis of lymphoma or any other malignant disease. Using the Wiseman criteria, we identify PBL and SBL. All imaging features of PBL and SBL were analyzed. Prevalence of lymphoma amongst suspicious breast masses and amongst all breast malignancies were calculated. Out of 42,505 histopathology reports from mammary nodule biopsies, we found 19,354 malignancies. We were able to identify 11 patients affected by PBL (0,03% of suspicious breast lesions, 0.06% of breast malignancies), and 23 cases of SBL (0,05% of suspicious breast lesions, 0,12% of breast malignancies). Most common isotype in PBL was DLBC lymphoma, whereas in SBL that resulted Follicular lymphoma. In PBL group, we were able to retrieve images 7 CT or CT-PET study performed at diagnosis 7 US, 1 mammography and and 1 MR. In SBL group, we analyzed 14 CT/CT-PET examinations, 11 US studies and 3 mammography. PBL and SBL are rarer than considered until now. There is no definite imaging characteristic able to distinguish between these two pathologies and among them and breast cancer.

Clinical indications for image guided interventional procedures in the musculoskeletal system: a Delphi-based consensus paper from the European Society of Musculoskeletal Radiology (ESSR)-part III, nerves of the upper limb.

BACKGROUND: Image-guided interventional procedures of the nerves are commonly performed by physicians from different medical specialties, although there is a lack of clinical indications for these types of procedures. This Delphi-based consensus provided a list of indications on image-guided interventional procedures for nerves of the upper limb based on updated published evidence. METHODS: An expert panel of 45 members of the Ultrasound and Interventional Subcommittees of the ESSR participated in this Delphi-based consensus study. After revision of the published papers on image-guided interventional procedures for nerves of the upper limb updated to September 2018, the experts drafted a list of statements according to the Oxford Centre for evidence-based medicine levels of evidence. Consensus on statements regarding clinical indications was considered as strong when more than 95% of experts agreed, and broad if more than 80% agreed. RESULTS: Ten statements were drafted on procedures for nerves of the upper limb. Only two statements reached the highest level of evidence (ultrasound guidance is a safe and effective method for brachial plexus block; ultrasound-guided non-surgical approaches are safe and effective methods to treat carpal tunnel syndrome in the short term, but there is sparse evidence on the mid- and long-term effectiveness of these interventions). Strong consensus was obtained on 6/10 statements (60%), while 4/10 statements reached broad consensus (40%). CONCLUSIONS: This Delphi-based consensus study reported poor evidence on image-guided interventional procedures for nerves of the upper limb. Sixty percent of statements on clinical indications provided by the expert board reached a strong consensus. KEY POINTS: • An expert panel of the ESSR provided 10 evidence-based statements on clinical indications for image-guided interventional procedures for nerves of the upper limb • Two statements reached the highest level of evidence • Strong consensus was obtained on 6/10 statements (60%), while 4/10 statements reached broad consensus (40%).

Breast Metastases: Updates on Epidemiology and Radiologic Findings.

Purpose The aim of this study was to report the prevalence of secondary breast malignancies and analyze their radiological characteristics. Materials and methods We collected 42,505 pathological reports of mammary biopsies performed from January 2000 to January 2019 in our hospital database, from which we screened reports of secondary cancer of the breast. We collected and analyzed imaging data from computed tomography (CT), ultrasound (US), and mammography. Mammograms, CT scans, and US images were reviewed by two breast radiologists. Prevalence of secondary breast malignancy among suspicious breast masses and all breast malignancies were calculated. Results Out of 42,505 histopathology reports from mammary biopsies, we found 19,354 malignancies. We identified 33 cases of secondary breast cancers (0.08% of suspicious breast lesions, 0.17% of breast malignancies). Most common metastases were from lymphoma (23 cases, 0.05% of suspicious breast lesions, 0.12% of breast malignancies) and melanoma (six cases, 0.01% of suspicious breast lesions, 0.03% of breast malignancies). All secondary lesions were hypoechoic on US and showed high density on mammogram. On CT, 83% of the lesions appeared solid/dense, and 17% were mixed, alternating areas of iso/hyperdensity with areas of hypodensity. Conclusion Secondary breast cancer had a prevalence of 0.17% among all breast malignancies. No specific imaging features, characteristic of secondary breast cancer, were found.

Influence of Tumor Subtype, Radiological Sign and Prognostic Factors on Tumor Size Discrepancies Between Digital Breast Tomosynthesis and Final Histology.

Background Influence of tumor subtype, radiological sign and prognostic factors on tumor size discrepancies between DBT and final histology has not been completely investigated so far. Purpose To study the influence of tumor subtype, radiological sign and prognostic factors on tumor size discrepancies between digital breast tomosynthesis and final histology. Material and methods This is a retrospective study conducted between January 2015 and December 2016. After IRB approval, 130 consecutive patients with breast cancer diagnosed with digital breast tomosynthesis (DBT) were evaluated. A discrepancy between DBT and final histology was considered present if the difference was above the cut-off of 5 mm. Tumor subtype, radiological sign and prognostic factors were evaluated in patients with discrepancies. Descriptive statistic and non-parametric tests were used. Results A total of 105 cases of cancer, in 96 patients, all female, were included. Mean age was 61 years (range: 35-82 yrs). In 19 (18.1%) cases, discrepancies were found: 13 (68.4%) were underestimated by DBT. For tumor subtype, 10 (52.6%) were infiltrating lobular carcinomas (ILC) (p < 0.01). Fourteen (73.7%) discordant cases were architectural distortions (p < 0.01). Prognostic factors did not affect tumor size discrepancies. Conclusion ILC or an architectural distortion represents the majority of cases of tumor size discrepancies between DBT and final histology.

Nerve Tumors: What the MSK Radiologist Should Know.

Nerve tumors are rare and heterogeneous soft tissue tumors arising from a peripheral nerve or showing nerve sheath differentiation. In a radiologic setting it is necessary to recognize soft tissue lesions that are of neural origin, their association with a peripheral nerve, and whether they are a true tumor or a so-called pseudotumor such as a neuroma, fibrolipoma, or peripheral nerve sheath ganglion. Ultrasound (US) and magnetic resonance imaging are the best modalities to characterize these lesions. US can be used to guide biopsy in difficult and uncertain cases when the lesion is either indeterminate or possibly malignant. At present, no single imaging feature or reproducible criteria, or a combination, can differentiate reliably between a neurofibroma and a schwannoma or discriminate with certainty between benign and malignant neurogenic tumors. Adequate imaging and consultation with a nerve tumors/sarcoma unit is advised.

Follow-up of recurrences of limb soft tissue sarcomas in patients with localized disease: performance of ultrasound.

OBJECTIVES: To evaluate diagnostic performance of ultrasound in the detection of local recurrences in patients with localized soft tissue sarcomas of the limb. METHODS: An analysis of patients treated for soft tissue sarcomas between 2005 and April 2014 was performed. Sixty-eight patients (men/women, 36:32; age range, 18-84 years) were evaluated. Sensitivity, specificity with 95% confidence intervals (CIs), positive predictive value (PPV), pre-test probability (the prevalence), negative predictive value (NPV), likelihood ratio for positive results (LH+), accuracy and post-test probability (post-P) of ultrasound were reported on a per patient basis using surgical findings and clinical follow-up as reference standard. Effects of independent variables (US equipment, age and sex, body mass index, radiologist) were considered. Comparison with MR was also performed. RESULTS: The overall sensitivity and specificity were 0.88 (0.60-0.94) and 0.94 (0.86-0.98). PPV, pre-test probability, NPV, LH+, accuracy and post-P: 0.83/0.25/0.96/14.9/0.92/0.83. There were two false negative cases both graded as G3 and deeply located and three false positive US cases. Diagnostic accuracy was not dependent by US machine (p = 0.08), age and sex (p = 0.16), body mass index (p = 0.07) and radiologists (p = 0.07). CONCLUSIONS: Diagnostic accuracy of ultrasound was relatively high. Negative US results excluded the presence of a local recurrence with acceptable accuracy. KEY POINTS: • US accuracy is relatively high in sarcoma follow-up. • Negative US results exclude the presence of local recurrence with acceptable accuracy. • US may miss a small proportion of lesions. • False positive US cases are rare.