Atherosclerotic renovascular disease: medical therapy versus medical therapy plus renal artery stenting in preventing renal failure progression: the rationale and study design of a prospective, multicenter and randomized trial (NITER).

BACKGROUND: Many studies suggest a major prevalence of atherosclerotic renovascular disease (ARVD), caused by mono or bilateral renal artery stenosis (RAS). Unfortunately, there is no definite therapy to cure this disease to date; therefore, ARVD is burdened by important clinical complications with high social and economic costs. The last few years have seen important advancements in both medical therapy and in interventional radiology (for example, percutaneous transluminal renal artery stenting (PTRS)). All of them could affect, in some way, the natural history of ARVD, but to date the optimal strategy has not been established. METHODS: The protocol of a prospective, multicenter, randomized trial "Nephropathy Ischemic Therapy (NITER)" is presented. It enrolls patients with stable renal failure (glomerular filtration rate (GFR) >or=30 ml/min) and hypertension, and hemodynamically significant atherosclerotic ostial RAS (>or=70%) diagnosed by duplex Doppler (DD) ultrasonography and confirmed by magnetic resonance angiography (MRA). This study aims to evaluate whether medical therapy plus interventional PTRS is superior to medical therapy alone according to the following combined primary endpoint: death or dialysis initiation or reduction by >20% in estimated GFR after 0.5, 1, and 2 yrs of follow-up and an extended follow-up until the 4th year. Medical therapy means drugs to control hypertension, improve dyslipidemia and optimize platelet anti-aggregant therapy. The sample size is estimated in 50 patients per group to achieve a statistical significance of 0.05 in case of a reduction by 50% in the combined endpoints.

[Recurrence of bronchial cancer after surgery. Radiologic data]. / Récidives du cancer bronchique après chirurgie. Données radiologiques.

The post-surgical malignant recurrences of bronchogenic cancer may be classified as local, regional, locoregional. The present series is based on 115 patients observed in 1982-1987. In all of them a tumour recurrence was clinically and/or radiologically suspected: the histological findings or the follow-up confirmed such a diagnosis in 52 cases. A correct radiological assessment is based on a full knowledge of three items: 1) early and late complications of the surgical intervention; 2) available diagnostic tools for a differential diagnosis between usual post-operatory sequelae and neoplastic recurrences. 3) pathologic history of the patient and his tumour.

[The role of magnetic resonance in the follow-up of aortofemoral prosthetic reconstructions]. / Ruolo della risonanza magnetica nel follow-up delle ricostruzioni protesiche aorto-femorali.

The authors report their experience with the use of Magnetic Resonance (MR) in the follow-up of patients undergone aortofemoral bypass or substitution procedures for aneurysmal and/or steno-occlusive lesions of the aortoiliofemoral vascular bed. Twenty-eight patients, at least 2 years from aorto-bifemoral revascularization were evaluated by means of coronal and parasagittal MR planes (mean follow up 78.9 months). One exam over 28 was found to be not diagnostic; whereas the technique showed great usefulness in the morphological and haemodynamic evaluation of each of the graft sites explored (proximal anastomosis, graft body and limbs, femoral anastomosis and periprosthetic tissues) in the remaining 27 cases. The use of this method, in spite of some setting up problems peculiar to the type of examination, according to the authors is very promising because of the chance to obtain morphological and functional data at once and because of the interesting current and future developments of this diagnostic device.

The legal implications of error in radiology.

Evaluation of the legal implications of error in radiology and therefore the assessment of criminal and civil liability in the practice of the profession requires an analysis of how the public perception of the right to health has radically changed. This change has initiated a defensive approach to medicine and radiology that tends to be oriented towards precautionary measures, with a proliferation of often unnecessary imaging studies. In radiology, errors of omission or commission are frequent. A critical appraisal of the different types of error in radiology will help practitioners undertake the essential corrective measures. Through analysis of several cases derived from legal or insurance proceedings brought against radiologists, the most common forms of error are described, and their implications for criminal and civil liability are illustrated, although it is emphasised that the existence of an error does not always translate into the presence of malpractice.

Multislice CT in emergency room management of patients with chest pain and medium-low probability of acute coronary syndrome.

PURPOSE: The main cause of acute chest pain, which accounts for 6.5% of urgent medical examinations in emergency rooms in Italy, is acute coronary syndrome (ACS). We performed this prospective study to evaluate the diagnostic accuracy of a 16-channel computed tomography (CT) scanner with dedicated software in a group of patients with chest pain and medium to low risk of ACS. MATERIALS AND METHODS: This study involved a selected group of 31 patients reporting chest pain with a medium to low probability of ACS, defined on the basis of preliminary tests [electrocardiogram (ECG) and serum cardiac markers]. Coronary angiography, performed within 24 h of MSCT, was used as the gold standard. RESULTS: MSCT identified the presence of occlusions and significant (>50%) or nonsignificant stenoses in the main coronary segments, with a sensitivity of 65%, a specificity of 98.8%, a positive predictive value (PPV) of 81.2%, a negative predictive value (NPV) of 97.3% and an accuracy of 96.4%. Significant stenoses and occlusions were detected with a sensitivity of 71.4%, a specificity of 99.6%, a PPV of 93.7%, an NPV of 97.7% and an accuracy of 97.5%. CONCLUSIONS: Due to its high NPV, this technique can rule out significant stenoses or coronary occlusions provided that image quality is excellent. In patients with a medium to low coronary risk, MSCT is a more accurate indicator of the need for coronary angiography than is exercise stress testing, which is less expensive but has lower predictive values.

Spinal intradural extramedullary haemangioma: MRI and neurosurgical findings.

Haemangiomas, have rarely been encountered in the spinal intradural extramedullary space and the MRI findings of this entity have been described only in a few cases. We present the Magnetic Resonance Imaging (MRI) and surgical findings of a rare case of intradural extramedullary cavernous angioma located at the T1-T2 level in a 65-year-old man presented progressive paraparesis and upper thoracic back pain. On MRI, a well-circumscribed intradural solid mass, 1 cm in diameter, was detected and another enhancing nodular mass was found at the nerve roots of the cauda equina. The thoracic spinal lesion was removed and the histological diagnosis confirmed cavernous haemangioma. Although very uncommon, haemangioma should be included in the differential diagnosis when a spinal intradural extramedullary lesion is discovered and some neuroradiological findings could allow a presumptive diagnosis.

[Local-regional recurrence after mastectomy. CT as a tool of diagnosis and treatment planning]. / Recidive loco regionali in pazienti mastectomizzate. Accertamento diagnostico e programmazione terapeutica con TC.

In 19 out of 25 patients with local-regional recurrence of breast cancer, CT provided significant information better than any other procedure; in 15 patients CT contributed to a change in the treatment chosen on the basis of physical examination and routine studies. CT should be considered as part of the diagnostic work-up in patients with locally recurrent breast cancer who are being planned for comprehensive radiotherapy.

[Neurogenic osteo-arthropathies due to chronic alcoholism]. / Le osteo-artropatie neurogene da etilismo cronico.

Recognised forms of neurogenic osteo-arthropathy, their aetiology and pathogenesis are reviewed. Seven unusual cases are presented. Chronic alcoholism was a possible pathogenetic factors in these cases of neurogenic osteo-arthropathy from persistant drunkeness and not osteo-arthropathy occurring in alcoholics. Thus a new clinical entity is proposed.

[Do clinical or physiopathological parameters exist for rationalizing the demand for thoracic radiograms in patients admitted to an intensive care unit]. / Esistono parametri clinici o fisiopatologici per razionalizzare la richiesta di radiogrammi del torace nei pazienti ricoverati in un centro di rianimazione?

To rationalize the demand of chest radiography in Intensive Care Unit patients, 423 radiographs of 35 patients were studied prospectively. The radiologic findings were compared with clinical data, blood gas analysis and laboratory data. No significant correlation was demonstrated between pulmonary radiographic changes and patient clinical conditions classified as unchanged, improving and worsening. In contrast, a good correlation (R = 0.65; p < 0.001) was observed between the chest radiographic score of pulmonary changes and the PaO2/FiO2 ratio. Changes in this parameter may be a good reason to perform bedside chest radiographs, whereas this exam appears rather useless when PaO2/FiO2 ratio is unchanged.

[Magnetic resonance in the study of the temporo-mandibular joint. I. Anatomo-functional findings]. / La risonanza magnetica nello studio dell'articolazione temporo-mandibolare. Parte prima. Riscontri anatomo-funzionali normali.

Thirty-four temporomandibular joints (TMJ) were examined in 17 normal subjects with two superconductive MR units at 1T and 1.5T. TMJ evaluation was performed with both SE sequences in occlusal position and with "fast" sequences (flash) during the gradual opening of the mouth. Therefore, both the anatomic features of the TMJs and their dynamic behavior during mouth opening were analyzed. The information acquired allowed the complete and non-invasive evaluation of TMJ function. The knowledge of the normal anatomic and functional patterns is of paramount importance for the diagnostic approach to TMJ pathologic conditions.

[Magnetic resonance imaging in study of the temporo-mandibular joint. II. Pathologic findings]. / La Risonanza magnetica nello studio dell'articolazione temporo-mandibolare. Parte seconda. Riscontri patologici.

A total of 107 temporomandibular joints (TMJ) were examined with two superconductive MR units at 1T and 1.5T. In 73 TMJs, MR revealed 55 disk displacements, 7 disk perforations, 10 joint space adhesions, 33 osteoarthrities, 3 avascular necroses of the mandibular condyle, and 25 joint effusions. These abnormalities are described and discussed. In spite of some limitations--e.g., motion artifacts and patients' claustrophobia--MR imaging is the procedure of choice in abnormal TMJs, because it yields useful information as to therapeutic choice (conservative versus surgical). Arthrography can be used as a complementary study technique in the patients with marked disagreement between clinical and MR findings. Arthroscopy should be used as a surgical procedure in abnormal TMJs selected by previous MR studies.

[The dynamic magnetic resonance study of focal liver lesions by FLASH sequences with bolus intravenous gadolinium-DTPA]. / Studio dinamico con risonanza magnetica delle lesioni focali epatiche mediante sequenze FLASH con gadolinio-DTPA endovena in bolo.

Thirty-five patients with hepatic hemangioma (n = 12), metastasis (n = 10), hepatocellular carcinoma (HCC) (n = 10) and focal nodular hyperplasia (n = 3) were examined with the fast low-angle shot (FLASH) technique and an intravenous bolus injection of Gd-DTPA. In order to differentiate the lesions, the following criteria were used: a) pre Gd-DTPA intensity of lesions; b) post Gd-DTPA patterns of contrast enhancement. On the basis of these criteria, an unquestionable differential diagnosis could be made. Hemangiomas were characterized by an hypointense mass before Gd-DTPA, by peripheral contrast enhancement and by subsequent continuous hyperintense fill-in; thus, hemangiomas were visualized as hyperintense lesion during the late phase. Before contrast administration hypovascular metastases appeared as hypointense; they were characterized by delayed uptake of contrast agent. HCCs were hyperintense lesions before contrast administrations; then, quick contrast enhancement and rapid decrease in signal intensity were observed with visualization of a hyperintense ring due to the capsule. Finally, focal nodular hyperplasia appeared isointense or hypointense relative to normal liver on precontrast scans; the lesions were enhanced transiently with subsequent quick dismission of contrast agent. This initial experience suggests dynamic contrast-enhanced MR imaging as an effective method to improve the differential diagnosis among hepatic tumors when precontrast T2-weighted images are equivocal.

[Anatomo-radiologic definition of minimal interstitial silicosis and diagnostic contribution of high-resolution computerized tomography]. / Definizione anatomo-radiologica della silicosi minima interstiziale e contributo diagnostico della tomografia computerizzata con alta risoluzione.

Minimal interstitial silicosis (MIS) is a histologic entity characterized by questionable radiologic findings--i.e., the p/p 0/1 and 1/0 classes of the International Labour Office (ILO) 1980 classification. Thus, the condition may be responsible for borderline radiologic findings ("suspect" phase of pneumoconiosis). In order to test an alternative method to conventional radiology (CR), HRCT was performed on 35 workers exposed to silica and with histologic diagnosis of MIS: HRCT scans were compared with posteroanterior chest radiographs by using the ILO classification. Histology was the gold standard. HRCT identified many more MIS lesions. Moreover, the superiority of HRCT over CR was also proved by its better correlation with pathologic findings. HRCT provided pieces of information which could not always be obtained by means of conventional chest films. Thus, HRCT can be considered the method of choice in MIS before transbronchial lung biopsy.

[Malignant mesothelioma of the pleura: correlations between thoracoscopy and radiology]. / Mesoteliomi maligni della pleura: correlazioni tra toracoscopia e radiologia.

The frequency of malignant pleural mesothelioma has increased greatly in the past three decades; it is a tumor of great clinical, epidemiologic and therapeutical interest. Therapy should not be started before the tumor has been correctly diagnosed and staged with thoracoscopy and computed tomography (CT) which have replaced plain chest radiography. To help optimize the combination of these techniques, the authors report on their experience in 37 patients examined with conventional radiology and then with thoracoscopy. In 26 patients with CT findings of malignant pleural mesothelioma, the authors compared thoracoscopy and CT findings in the assessment of neoplastic spread to the parietal (stage IA) and/or visceral (stage IB) pleura. CT appears to be the technique of choice after plain chest radiography: if the suspected malignant pleural mesothelioma is classified as stage II, III or IV, thoracoscopy should be used only for histologic confirmation. Conversely, in stages IA and IB, thoracoscopy--besides histology--should be used to confirm malignant spread to the visceral pleura.

[Magnetic resonance angiography with TOF-TONE tridimensional sequences in the study of steno-occlusive diseases of the renal arteries. Comparison with digital angiography]. / Angiografia con Risonanza Magnetica con sequenze tridimensionali TOF-TONE nello studio delle malattie steno-occlusive delle arterie renali. Confronto con angiografia digitale.

The authors examined 32 patients (68 renal arteries in all) with suspected renovascular hypertension with MRA (3D TOF-TONE sequences) and DSA. MRA visualization of the renal vessels was considered good in 96.8%, 91.6%, 76.6% and 16.6% of cases for the ostium, the proximal third, the distal third and the hilum, respectively. MRA correctly assessed the 4 occlusions in our series and 19/20 atherosclerotic stenoses, all in proximal site. In proximal stenosis detection, MRA had 100% sensitivity and 98% specificity in atherosclerotic sclerosis-occlusion grading considering a 50% caliber reduction as the cut-off value. The two techniques were in agreement in 68% of cases; MRA overestimated stenosis grade in 25% of cases. The 3D TOF-TONE sequence is a reliable diagnostic tool in the study of the proximal tract of the renal arteries, but its major limitation remains in distal tract studies. Nevertheless, this technique has elective indications in a selected group of patients, namely the elderly with hypertension and impaired renal function.

[Delayed consolidation and pseudarthrosis in posttraumatic pathology of the carpal scaphoid. A magnetic resonance study]. / Ritardi di consolidazione e pseudoartrosi nella patologia postraumatica dello scafoide carpale. Studio con risonanza magnetica.

Delayed unions and fibrous or sclerotic non-unions of the carpal scaphoid are frequent sequelae of non-diagnosed or not properly treated fractures. The most important cause of abnormal unions is ischemic necrosis, due to the terminal vascularity of the carpal scaphoid. Conventional X-rays, scintigraphy, and CT do not yield sufficient information for a complete diagnosis; at present, MR imaging represents a valuable alternative, for it is a noninvasive technique able to provide a "biological imaging" of bone. Fourteen patients underwent surgical/nonsurgical treatment, based on the findings supplied by MR imaging. MR reliability was evaluated in relation to the therapeutic results obtained. The study proved MR imaging to provide important information as to therapy planning; in case of surgical treatment, MR imaging helped in choosing the most appropriate location for the insertion of bone graft or screw.

[Magnetic resonance in the study of aseptic necrosis of the femur head]. / La Risonanza Magnetica nello studio dell'osteonecrosi asettica della testa del femore.

Avascular necrosis (AVN) of the femoral head is a common clinical problem due to the frequent use of corticosteroids and to the high incidence of hip fractures from osteoporosis and traumas. In order to demonstrate MR diagnostic capabilities, 31 patients (62 hips) were studied with MR imaging, CT, and conventional radiology. The patients had already been diagnosed as having AVN of the femoral head, or the condition was clinically suspected. MR staging of the disease was compared with CT staging and with plain radiographs. The authors suggest new MR staging method and adapt the radiographic classification developed by Ficat, Arlet, and Lecestre. The results of this comparative study demonstrate MR imaging to be most appropriate in the patients with equivocal/negative radiological/CT findings. On the contrary, MR imaging is unnecessary when AVN has already been diagnosed by means of other imaging modalities, because in these advanced cases MR diagnostic contribution either equals or is inferior to that of CT and conventional radiology.