Assessment of main pancreatic duct cutoff with dilatation, but without visible pancreatic focal lesion on MDCT: a novel diagnostic approach for malignant stricture using a CT-based nomogram.

OBJECTIVES: To identify useful features to predict hidden pancreatic malignancies in patients with main pancreatic duct (MPD) abrupt cutoff and dilatation, but without visible focal pancreatic lesions on CT. METHODS: This retrospective study included 92 patients (mean age, 63.4 ± 10.6 years, 63 men and 29 women) with MPD abrupt cutoff and dilatation, but without visible focal pancreatic lesion on contrast-enhanced CT between 2009 and 2021. Two radiologists independently evaluated the CT imaging features. Multivariable logistic regression analysis was performed to identify clinical and CT imaging features for hidden pancreatic malignancies. A nomogram was developed based on these results and assessed its performance. RESULTS: Thirty-eight (41.3%) and 54 (58.7%) were classified into the malignant and benign groups, respectively. In the multivariable analysis, CA19-9 elevation (odds ratio [OR] 7.5, p = 0.003), duct cutoff site at the head/neck (OR 7.6, p = 0.006), parenchymal contour abnormality at the duct cutoff site (OR 13.7, p < 0.001), and presence of acute pancreatitis (OR 11.5, p = 0.005) were independent predictors of pancreatic malignancy. A combination of any two significant features showed an accuracy of 77.2%, and a combination of any three features exhibited a specificity of 100%. The CT-based nomogram showed an area under the curve (AUC) of 0.84 (95% confidence interval, 0.77-0.90). CONCLUSIONS: The three CT imaging features and CA19-9 elevation translated into a nomogram permit a reliable estimation of hidden pancreatic malignancies in patients with MPD abrupt cutoff without visible focal pancreatic lesion. It may facilitate determining whether to proceed to further diagnostic tests. KEY POINTS: • Isoattenuating pancreatic ductal adenocarcinoma can manifest only as an isolated main pancreatic duct (MPD) dilatation with abrupt cutoff, making it difficult to distinguish from benign strictures. • Along with the serum CA 19-9 elevation, MPD cutoff site at the pancreas head or neck, parenchymal contour abnormality at the duct cutoff site, and associated acute pancreatitis indicated a higher probability of the malignant MPD strictures. • The CT-based nomogram provided excellent diagnostic performance (AUC of 0.84) for hidden pancreatic malignancies in patients with MPD abrupt cutoff and dilatation.

Expert consensus and evidence-based recommendations for the assessment of flow-mediated dilation in humans.

Endothelial dysfunction is involved in the development of atherosclerosis, which precedes asymptomatic structural vascular alterations as well as clinical manifestations of cardiovascular disease (CVD). Endothelial function can be assessed non-invasively using the flow-mediated dilation (FMD) technique. Flow-mediated dilation represents an endothelium-dependent, largely nitric oxide (NO)-mediated dilatation of conduit arteries in response to an imposed increase in blood flow and shear stress. Flow-mediated dilation is affected by cardiovascular (CV) risk factors, relates to coronary artery endothelial function, and independently predicts CVD outcome. Accordingly, FMD is a tool for examining the pathophysiology of CVD and possibly identifying subjects at increased risk for future CV events. Moreover, it has merit in examining the acute and long-term impact of physiological and pharmacological interventions in humans. Despite concerns about its reproducibility, the available evidence shows that highly reliable FMD measurements can be achieved when specialized laboratories follow standardized protocols. For this purpose, updated expert consensus guidelines for the performance of FMD are presented, which are based on critical appraisal of novel technical approaches, development of analysis software, and studies exploring the physiological principles underlying the technique. Uniformity in FMD performance will (i) improve comparability between studies, (ii) contribute to construction of reference values, and (iii) offer an easy accessible and early marker of atherosclerosis that could complement clinical symptoms of structural arterial disease and facilitate early diagnosis and prediction of CVD outcomes.

Usefulness of imaging techniques in the management of giant cell arteritis. / Utilidad de las técnicas de imagen en la valoración de la arteritis de células gigantes.

Imaging has become an essential tool in the management of patients with giant cell arteritis. Cranial involvement detected by Doppler ultrasonography is an unquestionable diagnostic finding. Imaging of the aorta and its branches with positron emission tomography, computed tomography angiography or magnetic resonance imaging may also have a role in diagnosis and in the assessment of disease activity and response to treatment, but standardisation and validation are still needed before their widespread use as an outcome measure. Aortic structural damage is associated with increased mortality in giant cell arteritis; therefore, periodic screening is recommended.

Venous leg symptoms in patients with varicocele: A multicenter assessment study (VEIN-TURKEY study).

OBJECTIVE: The aim of this study is to evaluate chronic venous disease symptoms by using the Venous Insufficiency Epidemiological and Economic Study-Quality of Life/Symptoms (VEINES-QoL/Sym) questionnaire in varicocele patients. MATERIAL AND METHODS: The study was designed as a prospective, case controlled study and conducted in four hospitals from Turkey. A total of 600 patients who admitted to urology outpatient clinic were enrolled to the study. After the exclusion of 44 patients who do not match the inclusion criteria, the remaining 556 patients were examined for the presence and grade of varicocele and subsequently examined clinically for the presence of chronic venous disease findings. Finally, patients were asked to answer the VEINES-Sym questionnaire consisting of 10 items. All patients' demographic parameters, cardiovascular risk factors, other co-morbid diseases and drug usage were noted. RESULTS: Patients were classified into two groups: varicocele (+) group ( n = 269) and varicocele (-) group ( n = 287). VEINES-Sym scores of varicocele patients were lower compared to patients without varicocele (41.41 ± 5.21, 43.19 ± 3.22, respectively, p < 0.001). Grades of varicocele significantly but inversely correlated with VEINES-Sym score ( r = 0, -206, p = 0.001). Logistic regression analysis revealed that presence of varicocele irrespective of grading significantly and independently associated with the presence of aching (odds ratio: 2.054, 95% confidence interval: 1.265-3.338, p = 0.004) and throbbing (odds ratio: 2.586, 95% confidence interval: 1.353-4.943, p = 0.004). CONCLUSION: Varicocele patients have lower VEINES-Sym scores compared to patients without varicocele and this finding is inversely correlated with the degree of the varicocele. This association supports the hypothesis that there may be a systemic vessel wall abnormality in venous disease patients. Patients with symptoms related to vascular dilatation in any territory may deserve to be assessed systematically with the support of further clinical studies.

Primary care assessment of capillaroscopy abnormalities in patients with Raynaud's phenomenon.

Raynaud's phenomenon is a clinical symptom that can commonly present to a primary care provider or generalist. Proper identification of an underlying connective tissue disease in a patient with Raynaud's could allow for the prevention of possible critical digital ischemia. Capillaroscopy is a tool which can identify abnormalities associated with connective tissue disease. Patients presenting with a complaint of Raynaud's phenomenon were assessed with capillaroscopy. In twenty consecutive Raynaud patients, 8 digits were assessed by a ×200 magnification dermatoscope and an image was obtained. Each image was assessed for the following abnormalities: drop-out (<9 capillaries in 1 mm); microhemorrhage; dilated loops; and neoangiogenesis. These 160 images were then shown to 20 primary care physicians, who assessed these same abnormalities. The interrater reliability, a measure of agreement, of individual primary care providers with the expert provider was assessed using kappa statistics. Three raters had slight agreement (in the range 0 to 0.20), one rater had fair agreement (0.21 to 0.40), 11 raters had moderate agreement (0.41 to 0.60), five raters had substantial agreement (0.61 to 0.80), and no rater had almost perfect agreement (0.81 to 1.00) (14). The total agreement from the 20 primary care providers (n = 3,156) was moderate (Κ = 0.50, 95 % CI 0.49, 0.55). For the four providers with the slight to fair interrater reliabilities, the most common disagreement was providing a positive diagnosis when the expert rater diagnosed the digit negative. Ten of the twenty primary care providers provided at least one additional diagnosis following an abnormal diagnosis (n = 35 digits or 35 % of the 1556 abnormal ratings by the primary care providers). The four providers with the poorest interrater reliabilities were not among the ten providers who participated in making these additional specific diagnoses. These providers achieved the moderate agreement with the expert provider for diagnoses of microhemorrhage (Κ = 0.64, 95 % CI 0.57, 0.70), but fair agreement with the expert provider for diagnoses of dilated (Κ = 0.27, 95 % CI 0.20, 0.34) and neoangiogenesis (Κ = 0.22, 95 %CI 0.13, 0.31). Capillaroscopy is a potentially contributive clinical exam skill that could assist primary care providers and generalists in identifying and qualifying changes associated with the common presentation of Raynaud's disease. However, formal training is needed to ensure accuracy and reproducibility. Furthermore, training and scoring systems should address time constraints of busy primary care practitioners.

Cardiothoracic ratio may be misleading in the assessment of right- and left-ventricular size in patients with repaired tetralogy of Fallot.

AIM: To assess the relationship between cardiothoracic ratio (CTR) and ventricular and atrial volumes in patients with repaired tetralogy of Fallot (TOF). MATERIALS AND METHODS: Patients with repaired TOF undergoing cardiac magnetic resonance (CMR) and chest radiography within 1 day were included (n = 82; median age: 24.7 years, interquartile range: 21.5-35.9). The CTR was obtained from upright posteroanterior chest roentgenograms. Analyses of CMR images and radiographs were performed in a blinded fashion. RESULTS: There were 35.1% (13/37) of patients with normal CTR (<0.5) who had severe right ventricular (RV) dilatation. There were six patients (13.3%, 6/45) with high CTR with both normal RV and left-ventricular (LV) volumes. CTR did not correlate with either RV or LV volumes but showed a weak correlation with right- and left-atrial volumes (r = 0.43, p = 0.0001; r = 0.27, p = 0.01, respectively). CTR ≥0.5 showed poor ability in the identification of severe RV dilatation (sensitivity: 61.8%, specificity: 50%). The combination of CTR and signs of RV enlargement on lateral radiographs did not improve the diagnostic accuracy of any of those parameters alone. CONCLUSION: CTR in patients with repaired TOF reflected atrial rather than ventricular dilatation. The use of CTR or lateral radiographs in patients with repaired TOF may lead to false conclusions concerning ventricular size.

Dural ectasia in adolescent idiopathic scoliosis: quantitative assessment on magnetic resonance imaging.

To our knowledge, the assessment of dural sac diameters in patients with adolescent idiopathic scoliosis (AIS) is not reported in the literature. The aim of this study was to find out if, dural ectasia occurs more frequently among patients with AIS, to define cut-off values for dural sac ratio and test the validity of such values. A total of 126 spine MRIs (79 patients with AIS and 47 control subjects) were included in this retrospective analysis (age range 7-25 years, 62% were females). Dural sac diameter (DSD) and vertebral body diameter (VBD) were estimated and dural sac ratio (DSR = DSD/VBD) was calculated at T5 and L3. DSR at T5 and L3 were 0.69 +/- 0.12, and 0.52 +/- 0.10, respectively, in patients with AIS compared with 0.62 +/- 0.11, and 0.44 +/- 0.07, respectively, in controls (P = 0.001 at T5 and <0.001 at L3). Our estimated cut-off values for DSR were 0.84 and 0.58 at T5 and L3, respectively. This resulted in 100% sensitivity compared with 74% when using the cut-off values proposed by Oosterhof et al. No statistically significant association was found between the occurrence of dural sac enlargement in patients with AIS and the severity of scoliotic deformity, the apical vertebral rotation, epidural fat thickness, occurrence of pain, neurological deficit, atypical scoliosis or rapid curve progression. Females were affected more frequently than males. As dural sac enlargement means thinning of the pedicles, we believe that the findings of this study have important clinical implications on the preoperative workup of AIS.

Ultrasonographic alterations associated with the dilatation of mammary ducts: feature analysis and BI-RADS assessment.

OBJECTIVE: The purpose of this study was to analyse the lesion characteristics and the patterns of dilated ducts on ultrasonography (US) to determine the appropriateness of the Breast Imaging Reporting and Data System (BI-RADS) categories. MATERIALS AND METHODS: From July 2001 to June 2006, 172 consecutive pathologically proved lesions with dilated ducts on US were reviewed retrospectively. All the lesions were classified into four types according to their US features, and in combination with the size, location, margins and number of lesions, the corresponding positive predictive values (PPVs) were obtained. RESULTS: Of the 172 lesions, 55 (32%) were classified as type I, 68 (40%) as type II, 14 (8%) as type III and 35 (20%) as type IV. The PPVs for malignancy were 9% for type I, 13% for type II, 43% for type III and 17% for type IV. There was a significantly higher frequency of malignancy among type III lesions than among type I (43% vs 9%, respectively, P = 0.002; chi (2) test) or type II lesions (43% vs 13%, respectively, P = 0.009; chi (2) test). Lesions with a nonsubareolar location and noncircumscribed margins had a high probability of malignancy (P < 0.001 and P = 0.03, respectively). CONCLUSION: The four types of US classifications used in our study establish reliable references for the dilated duct patterns when stratified according to BI-RADS categories, and they clarify the indications for biopsy of these lesions.

Natural history of brain lesions in extremely preterm infants studied with serial magnetic resonance imaging from birth and neurodevelopmental assessment.

OBJECTIVES: The aim was to survey the range of cerebral injury and abnormalities of cerebral development in infants born between 23 and 30 weeks' gestation using serial MRI scans of the brain from birth, and to correlate those findings with neurodevelopmental outcome after 18 months corrected age. METHODS: Between January 1997 and November 2000, consecutive infants born at < 30 weeks' gestational age underwent serial MRI brain scans from birth until term-equivalent age. Infants were monitored after 18 months of age, corrected for prematurity, with the Griffiths Mental Development Scales and neurologic assessment. RESULTS: A total of 327 MRI scans were obtained from 119 surviving infants born at 23 to 30 weeks of gestation. Four infants had major destructive brain lesions, and tissue loss was seen at term for the 2 survivors. Fifty-one infants had early hemorrhage; 50% of infants with term scans after intraventricular hemorrhage had ventricular dilation. Twenty-six infants had punctate white matter lesions on early scans; these persisted for 33% of infants assessed at term. Early scans showed cerebellar hemorrhagic lesions for 8 infants and basal ganglia abnormalities for 17. At term, 53% of infants without previous hemorrhage had ventricular dilation and 80% of infants had diffuse excessive high signal intensity within the white matter on T2-weighted scans. Complete follow-up data were available for 66% of infants. Adverse outcomes were associated with major destructive lesions, diffuse excessive high signal intensity within the white matter, cerebellar hemorrhage, and ventricular dilation after intraventricular hemorrhage but not with punctate white matter lesions, hemorrhage, or ventricular dilation without intraventricular hemorrhage. CONCLUSIONS: Diffuse white matter abnormalities and post-hemorrhagic ventricular dilation are common at term and seem to correlate with reduced developmental quotients. Early lesions, except for cerebellar hemorrhage and major destructive lesions, do not show clear relationships with outcomes.

Coronary artery ectasias: imaging, functional assessment and clinical implications.

Coronary artery ectasia is a relatively common entity characterized by inappropriate dilatation of the coronary vasculature. The exact mechanism of its development is unknown, but evidence suggests a combination of genetic predisposition, common risk factors for coronary artery disease and abnormal vessel wall metabolism. It frequently coexists with aneurysms elsewhere, mostly involving the aorta. In this review, the flow disturbances that are associated with this condition and the imaging modalities, which can be used for diagnosis and prospective follow-up are described. The prognosis of coronary ectasias is controversial and prospective studies focusing on conservative or invasive strategies to prevent cardiac complications are needed.

Assessment of the impact of the removal of cerebrospinal fluid on cerebral tissue volumes by advanced volumetric 3D-MRI in posthaemorrhagic hydrocephalus in a premature infant.

Current clinical practice in the premature infant with posthaemorrhagic ventricular dilatation (PHVD) includes drainage of cerebrospinal fluid (CSF). This case study used advanced volumetric three dimensional magnetic resonance imaging to document the impact of CSF removal on the volume of regional brain tissues in a premature infant with PHVD. The removal of a large volume of CSF was associated with an identical reduction in CSF volume, but more dramatically with a significant increase in the regional volumes of cortical grey matter and myelinated white matter. The alterations in cerebral cortical grey matter and myelinated white matter volumes may provide insight into the established association of PHVD with deficits in cognitive and motor functions.

Coronary artery remodelling and the assessment of stenosis by pathologists.

When atherosclerotic plaques develop, the cross-sectional area of the artery at that point often increases to accommodate the plaque without any reduction in lumen size. In consequence the angiogram does not detect a high proportion of atherosclerotic plaques. The increase in size of the artery (compensatory dilatation-arterial remodelling) varies widely in degree between different plaques even in the same artery. Dilatation of a degree to prevent any loss of lumen size is regarded as adequate compensatory dilatation. In contrast, other plaques are associated with no or minimal increase in the vessel cross-sectional area and a reduction in lumen size in present (inadequate compensation). High-grade stenosis is in particular associated with a total failure of remodelling. Such plaques may have had a rapid growth phase, out-pacing the ability of the medial smooth muscle cells to undergo a rearrangement. The phenomenon of remodelling has important consequences for pathologists who use the traditional method of comparing the lumen size relative to the cross-sectional area of the vessel at the site of a plaque to measure stenosis. The area of the vessel at this point may be anything up to 60% above its size before the plaque developed. An error is introduced which on average overestimates diameter stenosis by 30% when compared to an angiographic equivalent method in which the lumen size at the lesion is compared to the lumen size at an adjacent segment of artery without a plaque.

Sonographic estimates of vein size in the lower extremities: subjective assessment compared with direct measurement.

PURPOSE: We studied whether subjective impression of vein size is a valid means of assessment during sonographic evaluation for deep vein thrombosis. METHODS: Diameter was assessed at 5 predetermined venous segments on 975 legs of 721 patients referred for evaluation for lower extremity deep vein thrombosis. The sonographer recorded a subjective assessment of whether the venous segment was enlarged, normal, or narrowed based on a visual impression of sonographic images obtained without compression. This subjective impression was then compared with the absolute measurements of vein diameter and vein diameter:artery diameter ratio at each segment. RESULTS: A significant correlation was found between the subjective characterization of vein size as enlarged, normal, and narrowed and both the absolute vein diameter and the vein:artery ratio at all 5 segments. CONCLUSIONS: Vein size can be reliably categorized by the subjective impression of experienced sonographers. Therefore, actual measurement of the vein diameter is not necessary in the evaluation for deep vein thrombosis in the majority of patients.

Epidural venous system (meningorachidian venous plexus) in juvenile amyotrophy of distal upper extremity: assessment with GD-DTPA enhanced volumetric MR study.

The epidural venous system (meningorachidian venous plexus) was analyzed utilizing gadolinium-diethylenetriamine pentaacetic acid (DTPA) (Gd-DTPA) enhanced volumetric magnetic resonance (MR) images in 11 patients with focal cervical spinal cord atrophy, clinically consistent with juvenile amyotrophy of distal upper extremity. In our series, all of the patients showed unusual posterior epidural venous enhancement at the C5-6 level, suggesting posterior epidural venous dilatation. Three patients also showed prominent dilatation of cervico-thoracic epidural veins surrounding the thecal sac. These MR findings were also demonstrated by spinal phlebography. Gd-DTPA enhanced MR images, especially high resolutional volumetric MR images, were efficient for evaluating these vessels. The observation of meningorachidian venous plexus along the disease course should be necessary for searching the pathogenesis of this disease.

Interruption of systemic venous return with portal continuation: assessment using magnetic resonance imaging.

A case of interruption of both the superior and infrahepatic inferior vena cava with portal continuation of the systemic venous return is described. This unusual abnormality is probably acquired and represents the result of earlier, silent thrombosis of the venae cavae. Magnetic resonance imaging provided valuable anatomic information supplementing venography.

Sonographic assessment of the bowel wall.

The thickness and regularity of the bowel wall can often be assessed by sonographic imaging. In 26 normal patients, the bowel wall averaged 3 mm in thickness when distended and 5 mm when nondistended. In contrast, in 12 patients with an abnormally thickened bowel wall, bowel wall thickness averaged 23 mm and the affected bowel segment exhibited decreased or absent peristalsis on real-time scanning. The data derived from this study may enable the sonographic distinction of abnormally thickened bowel wall from normal bowel segments in the collapsed and distended state.