The scab-like sign: A CT finding indicative of haemoptysis in patients with chronic pulmonary aspergillosis?

OBJECTIVES: The aim of this study was to assess the CT findings that characterise haemoptysis in patients with chronic pulmonary aspergillosis (CPA). METHODS: We retrospectively identified 120 consecutive patients with CPA (84 men and 36 women, 17-89 years of age, mean age 68.4 years) who had undergone a total of 829 CT examinations between January 2007 and February 2017. In the 11 patients who underwent surgical resection, CT images were compared with the pathological results. RESULTS: The scab-like sign was seen on 142 of the 829 CT scans, specifically, in 87 of the 90 CT scans for haemoptysis and in 55 of the 739 CT scans obtained during therapy evaluation. In 48 of those 55 patients, haemoptysis occurred within 55 days (mean 12.0 days) after the CT scan. In the 687 CT scans with no scab-like sign, there were only three instances of subsequent haemoptysis in the respective patients over the following 6 months. Patients with and without scab-like sign differed significantly in the frequency of haemoptysis occurring after a CT scan (p<0.0001). Pathologically, the scab-like sign corresponded to a fibrinopurulent mass or blood crust. CONCLUSIONS: The scab-like sign should be considered as a CT finding indicative of haemoptysis. KEY POINTS: • Haemoptysis is commonly found in patients with CPA. • A CT finding indicative of haemoptysis in CPA patients is described. • Scab-like sign may identify CPA patients at higher risk of haemoptysis.

Asymptomatic Bartholin Cyst: Evaluation With Multidetector Row Computed Tomography.

OBJECTIVE: The aim of this study was to determine the frequency, morphology, and attenuation characteristics of Bartholin cysts on multidetector computed tomography (MDCT) in asymptomatic women. METHODS: A total of 3280 consecutive MDCT examinations were assessed for Bartholin cysts. The diagnosis was based on shape, contrast enhancement, and anatomical location. Age, laterality, size, and attenuation patterns were recorded. Scans from patients with paravaginal-related symptoms were excluded, and any available follow-up MDCT scans or magnetic resonance images were evaluated. RESULTS: Asymptomatic Bartholin cysts were seen in 17 patients (0.52%) (mean age, 56 years). The mean maximum cyst diameter was 21.8 mm. High-attenuation cysts comprised 47% of cases, all in older (≥50 years) patients. Follow-up MDCT scans showed minimal changes over time. CONCLUSIONS: High-attenuation Bartholin cysts are more common than previously thought and are usually seen in older women. The size and attenuation of Bartholin cysts show only minimal changes over time.

Perirenal lymphatic systems: Evaluation using spectral presaturation with inversion recovery T2 -weighted MR images with 3D volume isotropic turbo spin-echo acquisition at 3.0T.

PURPOSE: To evaluate the normal anatomy of the perirenal lymphatics using spectral presaturation with inversion recovery (SPIR) T2 -weighted magnetic resonance imaging (MRI) with 3D volume isotropic turbo spin-echo acquisition (VISTA) at 3.0T. MATERIALS AND METHODS: This retrospective study was approved by the two Institutional Review Boards and informed consent was waived. Thin-collimated axial images obtained using SPIR T2 -weighted MR imaging sequences with 3D VISTA at 3.0T from 50 patients (100 kidneys) with normal renal function were retrospectively reviewed. The perirenal lymphatic vessels were defined as fluid signal intensity structures on this MRI sequence. Two readers independently assessed the degree of visualization of the perirenal lymphatics using a 4-point scale in four anatomical regions, including the renal hilar, capsular, communicating pericapsular, and subfascial lymphatics, and interobserver agreement was evaluated with weighted kappa statics. The detectability of each lymphatic system was calculated for each reader using confidence level ratings of grades 1 and 2 as positive and grades 3 and 4 as negative. RESULTS: Interobserver agreement for the visualization grades was almost perfect (kappa value = 0.9). The renal hilar lymphatics along the renal vein were clearly identified in all patients. The detectability of other perirenal lymphatics was 44% for the capsular lymphatics, 39% for communicating pericapsular lymphatics, and 22% for the subfascial lymphatics. There was no laterality regarding the detectability of the perirenal lymphatics. CONCLUSION: The findings of this study support the feasibility of SPIR T2 -weighted MR images with 3D-VISTA at 3.0T for evaluating the perirenal lymphatic systems. J. MAGN. RESON. IMAGING 2016;44:897-905.

Balloon-Occluded Retrograde Transvenous Obliteration for Isolated Gastric Varices Draining through Pericardiophrenic Vein without Gastrorenal or Gastrocaval Shunts.

Balloon-occluded retrograde transvenous obliteration (BRTO) is an effective and minimally invasive treatment for isolated gastric varices (GVs) that is usually performed through a gastrorenal shunt (GRS) or gastrocaval shunt (GCS). However, there are some cases in which GVs drain mainly into the left pericardiophrenic vein without an accessible GRS or GCS. This brief report presents four cases of GVs without a GRS/GCS treated by BRTO through the pericardiophrenic vein. BRTO was successfully performed with the use of flexible balloon catheters without any complications in all four patients, and the GVs were completely obliterated.

Renal Arteriovenous Shunts: Clinical Features, Imaging Appearance, and Transcatheter Embolization Based on Angioarchitecture.

Renal arteriovenous (AV) shunt, a rare pathologic condition, is divided into two categories, traumatic and nontraumatic, and can cause massive hematuria, retroperitoneal hemorrhage, pain, and high-output heart failure. Although transcatheter embolization is a less-invasive and effective treatment option, it has a potential risk of complications, including renal infarction and pulmonary embolism, and a potential risk of recanalization. The successful embolization of renal AV shunt requires a complete occlusion of the shunted vessel while preventing the migration of embolic materials and preserving normal renal arterial branches, which depends on the selection of adequate techniques and embolic materials for individual cases, based on the etiology and imaging angioarchitecture of the renal AV shunts. A classification of AV malformations in the extremities and body trunk could precisely correspond with the angioarchitecture of the nontraumatic renal AV shunts. The selection of techniques and choice of adequate embolic materials such as coils, vascular plugs, and liquid materials are determined on the basis of cause (eg, traumatic vs nontraumatic), the classification, and some other aspects of the angioarchitecture of renal AV shunts, including the flow and size of the fistulas, multiplicity of the feeders, and endovascular accessibility to the target lesions. Computed tomographic angiography and selective digital subtraction angiography can provide precise information about the angioarchitecture of renal AV shunts before treatment. Color Doppler ultrasonography and time-resolved three-dimensional contrast-enhanced magnetic resonance angiography represent useful tools for screening and follow-up examinations of renal AV shunts after embolization. In this article, the classifications, imaging features, and an endovascular treatment strategy based on the angioarchitecture of renal AV shunts are described.

Beak-Like Extension of the Pancreatic Uncinate Process on MDCT: Is It Hyperplasia or Movement?

OBJECTIVE: We aimed to evaluate the pancreatic uncinate process with a beak-like extension (BLE) beyond the left border of the superior mesenteric artery, to define the cause of BLE, and to differentiate BLE from hyperplasia. METHODS: We retrospectively reviewed 1042 triple-phase contrast-enhanced multidetector-row computed tomography (3P-CE-MDCT) examinations of 500 patients. Finally, 38 patients (28 men, 10 women; mean age, 66 years) with 140 3P-CE-MDCT images showing BLE were studied regarding BLE size, contour, and cause. The superior mesenteric artery position was also evaluated. RESULTS: Beak-like extensions were found in 7.6% of patients. Most were caused by movement of the small bowel mesentery (n = 21, 55%), with deviation of mesenteric vessels or mass effect from expanded adjacent organs (n = 3, 8%). Seven patients (18.5%) had true hyperplasia. CONCLUSIONS: Beak-like extension is caused by movement of the small bowel mesentery with deviation of mesenteric vessels or by adjacent organ expansion. Beak-like extension closely mimics other pathology on nonenhanced MDCT.

[Transaortic Thoracic Endovascular Aortic Repair Via Right Anterior Mini-thoracotomy;Report of a Case].

An 81-year-old man presented with ruptured thoracic aortic aneurysm under stable condition. He had been suffering from chronic obstructive pulmonary disease, chronic renal failure and rheumatoid arthritis. We performed hybrid thoracic endovascular aortic repair via right anterior mini-thoracotomy inserting a device through a conduit on the ascending aorta. The patient was discharged without aorta-related complications.

Chest HRCT findings in acute transformation of adult T-cell lymphoma/leukemia.

OBJECTIVES: To assess chest high-resolution computed tomography (HRCT) findings in patients with acute transformation of adult T cell leukaemia/lymphoma (ATLL). METHODS: We retrospectively identified 72 consecutive patients at our institution with ATLL between October 2000 and March 2014. The cases included acute type (n = 20), lymphoma type (n = 21), smouldering type (n = 24) and chronic type (n = 7). Sixteen (7 men, 9 women; aged 36-85 years, mean 63.3 years) of 31 patients (24 with smouldering and seven with chronic type; 51.6 %) developed acute transformation of ATLL, and had undergone chest HRCT examinations. Parenchymal abnormalities, enlarged lymph nodes, pericardial effusion, pleural effusion and skin lesions were evaluated on HRCT. RESULTS: Chest HRCT of 15 of the 16 patients showed abnormal findings, including ground-glass opacity (GGO) (n = 8), consolidation (n = 5), interlobular septal thickening (n = 5) and nodules (n = 5). Pleural effusion was found in five patients, lymph node enlargement in 10 patients and multiple skin thickening in two patients. CONCLUSIONS: Almost all patients with acute transformation of ATLL had abnormal findings on chest HRCT, which consisted mainly of lymph node enlargement, GGO, interlobular septal thickening, nodules and bilateral pleural effusions. KEY POINTS: • The recognition of CT findings of acute transformation is important • Almost all patients with acute transformation have abnormal findings on HRCT • Characteristic CT features are present in acute transformation of indolent ATLL.

Shunted pouches of cavernous sinus dural AVFs: evaluation by 3D rotational angiography.

INTRODUCTION: The aims of this study were to evaluate the angioarchitecture of cavernous sinus dural arteriovenous fistulas (CSdAVFs), including the number and location of shunted pouches (SPs), and to evaluate whether the location and number of the SPs affect the outcomes of transvenous embolization of CSdAVFs. METHODS: Nineteen consecutive cases of CSdAVFs that underwent rotational angiography and transvenous embolization were reviewed. Multiplanar reconstruction images of rotational angiography and selective angiography were reviewed with particular interest in the SPs. Relationships of the locations and number of SPs with the results of transvenous embolization were statistically analyzed. RESULTS: All cases showed SPs, with numbers ranging from 1 to 4 (mean, 2.2). The location of the SPs was "posteromedial" in 16, "posterolateral" in 13, "lateral" in 6, and "medial" in 3 patients. Six cases showed posteromedial SPs alone, and three cases showed posterolateral SPs alone. The other 10 cases showed multiple locations of SPs. All cases were treated by transvenous embolization with sinus packing (n = 11) or selective embolization of the SP (n = 8). Complete occlusion of dAVF was obtained in 16 cases immediately after embolization. Locations of SPs and drainage types were significantly associated with the immediate angiographic results (p < 0.01). CONCLUSION: The SP of CSdAVFs is often multiple and is located posteriorly to the CS. The number and location of SPs affect immediate angiographic results of transvenous embolization.

Lymphatic pathway around the pancreatic head and extrahepatic bile duct: evaluation using MR imaging at 3.0-T.

PURPOSE: To evaluate the utility of spectral presaturation with inversion recovery (SPIR) T2-weighted images with 3-dimensional (3D) volume isotropic turbo spin echo acquisition (VISTA) at 3.0-T for the detection of the normal lymphatic systems located around the pancreatic head and extrahepatic bile duct. MATERIALS AND METHODS: Fifty-six patients with suspected hepatic or pancreaticobiliary diseases and diagnosed as normal or benign pathologies were evaluated as having normal lymphatic systems. The protocol consisted of SPIR T2-weighted sequences with 3D-VISTA. The lymphatic systems were defined as fluid signal intensity structures and divided into eight portions and interobserver agreement was evaluated using weighted kappa statistics. Three readers graded the visualization of each portion using a five-point scale. The detectability of each portion was calculated by defining grades 1-2 as detectable and grades 3-5 as undetectable. RESULTS: Interobserver agreement regarding the visualization grades was moderate to almost perfect. All readers rated the detectability of the lymphatic systems of the superior and posterior portions of the pancreatic head, pericholedochal, right abdominoaortic, and interaorticovenous portions as 100%, and that of the anterior portion of the pancreatic head as 98.2%. For the inferior portion of the pancreatic head, the detectability was 100% for reader 2 and 96.4% for readers 1 and 3. CONCLUSION: The lymphatic systems located around the pancreatic head and extrahepatic bile duct could be sufficiently visualized on SPIR T2-weighted images with 3D-VISTA at 3.0-T.

Comparison of the biological effects of (18)F at different intracellular levels.

We herein examined the biological effects of cells treated with (18)F labeled drugs for positron emission tomography (PET). The relationship between the intracellular distribution of (18)F and levels of damaged DNA has yet to be clarified in detail. We used culture cells (Chinese Hamster Ovary cells) treated with two types of (18)F labeled drugs, fluorodeoxyglucose (FDG) and fluorine ion (HF). FDG efficiently accumulated in cells, whereas HF did not. To examine the induction of DNA double strand breaks (DSB), we measured the number of foci for 53BP1 that formed at the site of DNA DSB. The results revealed that although radioactivity levels were the same, the induction of 53BP1 foci was stronger in cells treated with (18)F-FDG than in those treated with (18)F-HF. The clonogenic survival of cells was significantly lower with (18)F-FDG than with (18)F-HF. We concluded that the efficient accumulation of (18)F in cells led to stronger biological effects due to more severe cellular lethality via the induction of DNA DSB.

Comparison of high-resolution computed tomography findings between Pseudomonas aeruginosa pneumonia and Cytomegalovirus pneumonia.

OBJECTIVE: To compare pulmonary high-resolution CT (HRCT) findings in patients with Pseudomonas aeruginosa pneumonia to HRCT findings in patients with Cytomegalovirus (CMV) pneumonia. METHODS: We studied 124 patients (77 men, 47 women; age range, 20-89 years; mean age, 65.4 years) with P. aeruginosa pneumonia and 44 patients (22 men, 22 women; age range, 36-86 years; mean age, 63.2 years) with CMV pneumonia. RESULTS: CT findings of consolidation (p < 0.005), bronchial wall thickening (p < 0.001), cavity (p < 0.05), and pleural effusion (p < 0.001) were significantly more frequent in patients with P. aeruginosa pneumonia than in those with CMV pneumonia. Centrilobular nodules, a crazy-paving appearance, and nodules were significantly more frequent in patients with CMV pneumonia than in those with P. aeruginosa pneumonia (all p < 0.001). CONCLUSION: Pulmonary HRCT findings, such as bronchial wall thickening, crazy-paving appearance, and nodules may be useful in distinguishing between P. aeruginosa pneumonia and CMV pneumonia. KEY POINTS: Distinguishing Pseudomonas aeruginosa pneumonia from Cytomegalovirus pneumonia is important. Characteristic features of underlying conditions are present in each pneumonia species. Bronchial wall thickening and cavities are more frequent in Pseudomonas aeruginosa pneumonia. Nodules and a crazy-paving appearance are more frequent in Cytomegalovirus pneumonia.

Double coaxial microcatheter technique for transarterial aneurysm sac embolization of type II endoleaks after endovascular abdominal aortic repair.

PURPOSE: To evaluate the feasibility and efficacy of transarterial sac embolization with a mixture of N-butyl cyanoacrylate and ethiodized oil (Lipiodol; Guerbet Japan, Tokyo, Japan) (NBCA-LPD) for type II endoleaks after endovascular aortic repair (EVAR) using a double coaxial microcatheter technique. MATERIALS AND METHODS: A retrospective review was performed of 20 consecutive cases of type II endoleaks treated by transarterial embolization using the technique from August 2010 to June 2013. The treatment indication was persistent type II endoleak over 6 months after EVAR associated with aneurysm expansion ≥ 5 mm in maximum diameter. A 1.9-F nontapered microcatheter was advanced to the aneurysmal sac through a 2.7-F microcatheter, which was coaxially introduced through a catheter. The endpoint of the procedure was intrasaccular filling with NBCA-LPD and occlusion of the feeder of the type II endoleak. The technical success rate was defined as success in transarterial intrasaccular approach followed by embolization of the intrasaccular channel and inflow arteries. Clinical success was defined as aneurysmal sac shrinkage or stabilization (freedom from sac expansion > 5 mm in maximum diameter). RESULTS: Technical success was achieved in 18 of 20 cases. During a mean follow-up period of 18.5 months, complete sac occlusion was observed in 13 cases (65%). Clinical success was achieved in 16 cases (80%). No serious complications were observed. CONCLUSIONS: The transarterial intrasaccular approach with a double coaxial microcatheter technique can be successfully performed in most cases, and transarterial aneurysm sac embolization using NBCA-LPD has been proven to be feasible.

Anatomical variations in termination of the uncal vein and its clinical implications in cavernous sinus dural arteriovenous fistulas.

INTRODUCTION: The aim of the study was to investigate the variations in the uncal vein (UV) termination and its clinical implication in cavernous sinus dural arteriovenous fistulas (CSDAVFs). METHODS: Biplane cerebral angiography in 80 patients (160 sides) with normal cerebral venous return (normal group) was reviewed with special interest in the termination of the UV. Frequency and types of uncal venous drainage from CSDAVFs in consecutive 26 patients were also analyzed. RESULTS: In the normal group, the UV was identified in 118 sides (74 %). The UV terminated into cavernous sinus (CS) in 41 sides (34 %), the superficial middle cerebral vein (SMCV) in 58 sides (48 %), the laterocavernous sinus (LCS) in 15 sides (13 %), and the paracavernous sinus (PCS) in 4 sides (3 %). Cerebral venous blood via the UV draining into the CS directly (n=41) or through the SMCV and/or the LCS (n=45) was observed in 86 sides (54 %). Uncal venous drainage from CSDAVFs was found in 13 patients (50 %). The CSDAVFs drained directly into the UV in two patients, drained via LCS into the UV in two patients, and drained through the SMCV into the UV in the remaining nine patients. All cases were successfully treated by transvenous embolization with special attention given to uncal venous drainage. CONCLUSION: There are several variations in UV termination according to the embryological development of the primitive tentorial sinus and the deep telencephalic vein. Careful attention should be paid to uncal venous drainage for the treatment of CSDAVFs.

Pancreatic neuroendocrine tumor with extensive intraductal invasion of the main pancreatic duct: a case report.

CONTEXT: Pancreatic neuroendocrine tumors account for only 1-3% of all pancreatic neoplasms and the intraductal invasion of the main pancreatic duct (MPD) is rare. CASE REPORT: We report a case of a 26-year-old woman with an endocrine tumor of the pancreas extensively invading into the MPD. She presented abdominal pain and her laboratory data showed abnormal liver function. Contrast-enhanced computed tomography demonstrated a well-enhanced mass on the arterial dominant phase in the head of the pancreas. The mass grew within the lumen of the MPD in the body of the pancreas, with dilatation of the upstream MPD. The contrast-enhancement pattern between the main tumor of the head and the intraductal lesion of the body was different. On T2-weighted magnetic resonance (MR) imaging, the pancreatic head lesion showed non homogeneously low signal intensity, while the intraductal lesion of the pancreatic body showed high signal intensity. MR cholangiopancreatography showed obstruction of the MPD in the pancreatic head to body, with dilatation of the upstream MPD. An endocrine tumor or acinar cell carcinoma of the pancreas was considered as preoperative diagnosis, and pancreaticoduodenectomy was performed. As a result, pancreatic endocrine tumor (G2) was confirmed pathologically. CONCLUSION: A rare case of pancreatic neuroendocrine tumor with extensive growth within the MPD was presented. The intraductal extension is a unique growth pattern of nonfunctioning pancreatic neuroendocrine tumor, and the desmoplastic reaction in this tumor may reflect the increased invasiveness.

Unenhanced magnetic resonance angiography with time-spatial labeling inversion pulse for evaluating visceral artery aneurysms after endosaccular packing with detachable coils: preliminary results.

The aim of this brief report is to compare unenhanced magnetic resonance (MR) angiography with time-spatial labeling inversion pulse (Time-SLIP) with conventional digital subtraction angiography (DSA) in assessing degree of saccular visceral artery aneurysm (VAA) occlusion after endosaccular packing with detachable coils. Eight patients with VAAs (five renal and three splenic artery aneurysms) were enrolled in this study. VAA occlusion rates based on Time-SLIP MR angiography were complete occlusion in four patients, neck remnants in three patients, and body filling in one patient. These findings corresponded with the DSA findings.

Multidetector CT anatomy of drainage routes of gastric varices: a pictorial review.

Most gastric varices arise at hepatofugal collateral pathways and drain into the systemic vein through one or both of two different types of portosystemic collateral drainage systems: the gastroesophageal (azygous) venous system and the gastrophrenic venous system. The gastroesophageal venous system consists of gastric varices contiguous with esophageal varices, paraesophageal varices, and the azygos vein, which terminates into the superior vena cava. Gastric varices draining through the gastroesophageal venous system can be treated with endoscopic techniques or creation of a transjugular intrahepatic portosystemic shunt. The gastrophrenic venous system consists of the gastric varices and the left inferior phrenic vein (IPV), which terminates into the left renal vein or the inferior vena cava. The left IPV has abundant anastomoses with peridiaphragmatic and retroperitoneal veins, and these anastomoses can function as drainage pathways from gastric varices. Balloon-occluded retrograde transvenous obliteration is a preferred treatment option for this type of gastric varix. Occasionally, gastric varices can form at the hepatopetal collateral pathway that develops secondary to localized portal hypertension caused by splenic vein occlusion. Splenectomy is often required for the treatment of this type of gastric varix. Multidetector computed tomography permits comprehensive evaluation of these venous drainage systems. Familiarity with and assessment of these draining routes of gastric varices are important for selecting treatment options and interventional techniques.

Maxillary artery: functional and imaging anatomy for safe and effective transcatheter treatment.

The maxillary artery is a terminal branch of the external carotid artery. Although the main maxillary artery trunk and most of its branches course within the extracranial space and supply the organs and muscles of the head and neck, other surrounding soft tissues, and the oral and rhinosinusal cavities, other branches supply the dura mater and cranial nerve and can anastomose to the internal carotid artery (ICA). Various pathologic conditions of the intracranial, head, and neck regions can involve the branches of the maxillary artery. Many of these diseases can be treated with endovascular approaches; however, there is a potential risk of complications in the brain parenchyma and cranial nerves related to the meningoneuronal arterial supply and anastomoses to the ICA. Therefore, familiarity with the functional and imaging anatomy of the maxillary artery is essential. In the past, conventional angiography has been the standard imaging technique for depicting the maxillary artery anatomy and related pathologic findings. However, recent advances in computed tomographic, magnetic resonance, and rotational angiography have further elucidated the maxillary artery anatomy by means of three-dimensional representations. Understanding the functional and imaging anatomy of the maxillary artery allows safe and successful transcatheter treatment of pathologic conditions in the maxillary artery territories.

Spinal ventral epidural arteriovenous fistulas of the lumbar spine: angioarchitecture and endovascular treatment.

INTRODUCTION: Spinal ventral epidural arteriovenous fistulas (EDAVFs) are relatively rare spinal vascular lesions. We investigated the angioarchitecture of spinal ventral EDAVFs and show the results of endovascular treatment. METHODS: We reviewed six consecutive patients (four males and two females; mean age, 67.3 years) with spinal ventral EDAVFs treated at our institutions from May 2011 to October 2012. All patients presented with progressive myelopathy. The findings of angiography, including 3D/2D reformatted images, treatments, and outcomes, were investigated. A literature review focused on the angioarchitecture and treatment of spinal ventral EDAVFs is also presented. RESULTS: The EDAVFs were located in the ventral epidural space at the L1-L5 levels. All EDAVFs were supplied by the dorsal somatic branches from multiple segmental arteries. The ventral somatic branches and the radiculomeningeal arteries also supplied the AVFs in two patients. The AVFs drained via an epidural venous pouch into the perimedullary vein in four patients and into both the perimedullary vein and paravertebral veins in two patients. Four cases without paravertebral drainage were treated by transarterial embolization with diluted glue, and two cases with perimedullary and paravertebral drainages were treated by transvenous embolization alone or in combination with transarterial embolization. An angiographic cure was obtained in all patients. Clinical symptoms resolved in two patients, markedly improved in three patients, and minimally improved in one patient. CONCLUSION: In our limited experience, spinal ventral EDAVFs were primarily fed by somatic branches. EDAVFs can be successfully treated by endovascular techniques selected based on the drainage type of the AVF.