Whole-body MRI in patients with lymphoma: collateral findings.

PURPOSE: To assess the incidence of collateral findings detected on whole-body magnetic resonance (WB-MRI) scans performed on patients with lymphoma. MATERIALS AND METHODS: 114 patients (65 male; median age 45.2 years, range 15-86) with histologically confirmed lymphoma (47 Hodgkin, 67 Non-Hodgkin) underwent WB-MRI. The collateral findings were classified into three classes, according to their clinical significance, as follows: not or low significant (class 1), moderately or potentially significant (class 2), and significant (class 3). A Chi-square (χ (2)) test was performed to assess the statistical significance of differences in the incidence of collateral findings based on age (≤50 and >50 years old), gender and histology (Hodgkin and Non-Hodgkin Lymphoma). RESULTS: Ninety-one of 114 patients (79.8 %) had one or more incidental findings on WB-MRI. Collateral findings were more frequent in class 1 (43 %); abnormalities found in 35 patients (30.7 %) were considered potentially significant, whereas seven patients (6.1 %) demonstrated significant collateral findings requiring immediate treatment or further diagnostic evaluation. Collateral findings were more frequent in subjects over 50 years old compared to those of 50 years old or younger; differences were statistical significant (χ (2) = 8.42, p < 0.05). There were not statistically significant differences related to gender (χ (2) = 0.17, p > 0.05) and histology (χ (2) = 0.24, p > 0.05). CONCLUSION: WB-MRI is an attractive procedure that allows to detect incidental abnormalities of organs not involved by disease offering the opportunity to obtain an early diagnosis of asymptomatic life-threatening diseases.

Large Bowel Ischemia/Infarction: How to Recognize It and Make Differential Diagnosis? A Review.

Ischemic colitis represents the most frequent form of intestinal ischemia occurring when there is an acute impairment or chronic reduction in the colonic blood supply, resulting in mucosal ulceration, inflammation, hemorrhage and ischemic necrosis of variable severity. The clinical presentation is variable and nonspecific, so it is often misdiagnosed. The most common etiology is hypoperfusion, almost always associated with generalized atherosclerotic disease. The severity ranges from localized and transient ischemia to transmural necrosis of the bowel wall, becoming a surgical emergency, with significant associated morbidity and mortality. The diagnosis is based on clinical, laboratory suspicion and radiological, endoscopic and histopathological findings. Among the radiological tests, enhanced-CT is the diagnostic investigation of choice. It allows us to make the diagnosis in an appropriate clinical setting, and to define the entity of the ischemia. MR may be adopted in the follow-up in patients with iodine allergy or renal dysfunctions, or younger patients who should avoid radiological exposure. In the majority of cases, supportive therapy is the only required treatment. In this article we review the pathophysiology and the imaging findings of ischemic colitis.

Chest Imaging of a rare case of cat-scratch disease in a 2-years-old baby.

Cat-scratch disease (CSD) is usually a self-limiting infection that in the majority of cases occurs as lymphadenitis in children who have been scratched or bitten by a cat. Rarely, Bartonella henselae is cause of fever of unknown origin (FUO), with dissemination to various organs, mimicking an inflammatory rather than a lymphoproliferative disease. This manuscript will present a case of thoracic manifestations of CSD in an immunocompetent 2-years baby without history of cat contact, with fever of unknown origin, investigated by chest CT and MRI.

Whole-body magnetic resonance for staging and response assessment of lymphoma in a pregnant woman treated with antenatal chemotherapy.

A 32-year-old pregnant female presented with bilateral supraclavicular swelling, diffuse itching and right shoulder pain. After lymph nodal biopsy, a diagnosis of nodular sclerosis Hodgkin's lymphoma was obtained. A multidisciplinary team decided to start chemotherapy before the delivery, and whole-body MRI was used to stage the disease and evaluate the response after antenatal chemotherapy. This case shows that whole-body MRI is an attractive procedure that avoids radiation exposure and contrast administration, and enables staging and follow-up of a pregnant patient without risk to the fetus.

[A rare case of intussusception in a seventeen year old boy: diagnosis, management and review of the literature.] / Un raro caso di invaginazione intestinale in un adolescente: diagnosi, management e revisione della letteratura.

Intussusception is the most common cause of intestinal obstruction and acute abdomen in the first year of life. Approximately in the 80% of cases intussusception occurs when the last ileal loop is pulled into the cecum, passing through the ileocecal valve, and finally resulting in the displacement of cecum in the upper abdominal. It could be related with mesenteric adenitis because enlarged lymph nodes, together with peristalsis, can serve as "lead point". Other forms of intussusception are ileo-ileal and colo-colic. The aetiology in infants and adults can be very variable and most often linked with secondary causes, such as benign or malignant lesions (polyps, tumors, lymphomas, intestinal duplication cyst, Meckel's diverticulum). In this paper we describe a rare case of idiopathic ileo-ileal intussusception in a 17 year old boy. We also discuss, with a careful analysis of the literature, the diagnostic and therapeutic protocol in case of intussusception ileo-colic approved at the Meyer Children's Hospital.

Stent-assisted detachable coil embolization of wide-necked renal artery aneurysms.

Renal artery aneurysms (RAAs) are rare with an estimated incidence of 0.1% in the general population, and they represent approximately 25% of all visceral aneurysms. The gold standard of treatment is open surgery, but it is associated with a high risk of nephrectomy, mortality, and morbidity. Less invasive endovascular therapies are becoming increasingly common for the treatment of RAAs. Here, we aimed to report three cases of wide-necked complex renal artery aneurysms treated endovascularly using stent-assisted coil embolization with self-expandable stent nitinol Solitaire AB and Concerto Axium coils. In addition, we describe the use of the waffle-cone technique in a case of wide-necked saccular RAA involving the renal artery bifurcation. Technical success was achieved in all three cases with no early or late complications and no recurrences.

The Endovascular Management of an Iatrogenic Superior Gluteal Artery Rupture Following Bone Marrow Biopsy.

We herein report an uncommon case of a life-threatening retroperitoneal hematoma after a bone marrow biopsy. Two hours after iliac crest bone harvesting, the patient experienced syncope and severe hypotension. Urgent contrast-enhanced computed tomography demonstrated extravasation from the superior gluteal artery. Transcatheter coil embolization was performed successfully, without complications. Life-threatening complications caused by retroperitoneal bleeding after bone marrow biopsy are very rare. There are few reports on the use of endovascular treatment in the management of life-threatening hemorrhagic complications after bone marrow biopsy.

Gluteal Compartment Syndrome Following Abdominal Aortic Aneurysm Treatment: Case Report and Review of the Literature.

Compartment syndrome (CS) is a pathological increase of the interstitial pressure within the closed osseous fascial compartments. Trauma is the most common cause, followed by embolization, burns, and iatrogenic injuries; it usually involves the limbs. The major issue when dealing with CS is the possibility to do an early diagnosis in order to intervene precociously, through a fasciotomy, reducing the risk of tissue, vascular and nervous damage. Although it is an infrequent condition, it is potentially life threatening. In our case report, we present a 59-year-old patient, smoker, affected by hypertension, dyslipidemia, chronic renal failure, and morbid obesity who came at our attention for a 6-cm abdominal aorta aneurysm, treated with an aorto-aortic graft. Within 24 hours from surgery, the patient presented acute ischemia of the right lower limb due to thrombosis of the common iliac artery and underwent the positioning of a kissing stent at the aortic bifurcation. In the immediate postoperative period, a relevant increase in serum creatinine, creatine phosphokinase, and myoglobin value was recorded, associated with clinical presentation of swelling in the right buttock with intense pain. The diagnosis of gluteal CS was confirmed by the measurement of the gluteal compartment pressure, which resulted of 110 mm Hg. The treatment of the CS consisted in gluteal dermofasciotomy, surgical debridement of the buttock, and positioning of negative pressure medication, associated with infusive therapy, avoiding hemodialysis. Because of the epidural anesthesia only later on it was possible to observe a persistent plegia of the right lower limb, which was solved within 1 month of neurological and physical therapy. With our experience, we can state that the CS is an extremely severe complication that can occur in vascular surgeries and it should therefore be kept in mind in the short-term postoperative period in order to guarantee a precocious diagnosis and immediate treatment.

Pre and postoperative evaluation of transcranial Doppler pulsatility index of the middle cerebral artery in patients with severe carotid artery stenosis.

UNLABELLED: In the management of severe carotid artery stenosis particular importance must be given to the evaluation of the risk of perioperative cerebral ischemic events. Our study analysed the possible relationship between the pre-operative middle cerebral artery Gosling Index, calculated after transcranial Doppler (TCD), and intra-operative stump pressure (SP), in order to identify patients with higher risk of ischemic accidents. Moreover, we studied pre- and post- operative Gosling Index values in association with possible events during follow-up. In a one-year time lapse 47 patients underwent either carotid endoarterectomy (CEA) or carotid artery stenting (CAS) with proximal embolic protection system. All patients were subject to pre- and post-operative TCD with calculation of the Gosling Index and intra-operative SP. We observed that higher pre-operative Gosling Index values are associated with lower intra-operative SP values, elements that represent a higher risk for cerebro-vascular ischemic accidents; this result is particularly evident when observing the diabetic sub-population. An increase in ischemic events did not present statistically significant differences when observing the populations treated with CEA or CAS. TCD and SP are valid and simple exams that can help identify precociously patients with a higher risk of cerebro-vascular accidents related to surgical or endovascular treatment. KEY WORDS: Carotid artery stenosis, Carotid endarterectomy, Endovascular treatment.

Use of the directional atherectomy for the treatment of femoro-popliteal lesions in patients with critical lower limb ischemia.

Femoro-popliteal PTA for the treatment of critical limb ischemia is frequently associated with unsatisfactory procedural success rates while directional atherectomy (DCA) has improved success rate since claudicant patients undergoing percutaneous treatment of femoro-popliteal obstructive disease. The aim of this prospective study is to evaluate the safety, efficacy and procedural success of DCA, at one year, in the percutaneous treatment of femoro-popliteal obstructive disease in patients with critical limb ischemia. METHODS: From March 2012 to March 2013 18 consecutive patients with critical limb ischemia were treated with DCA (Turbohawk/Covidien-ev3 Endovascular Inc., North Plymouth, Minnesota, USA) for the treatment of femoro-popliteal obstructive disease. Patients were evaluated at 12 months. RESULTS: Technical and procedural success was achieved in every patient. No in-hospital major adverse cardiovascular events occurred. Primary endpoint: freedom from any amputation was obtained in all patients. Secondary endpoints: clinical (Rutherford class improvement) and hemodynamic success (Ankle-brachial index improvement) was achieved in all patients. CONCLUSION: The use of DCA for the treatment of femoro-popliteal obstructive disease is a safe and effective therapeutic strategy for patients with critical limb ischemia. The data included in our study should be considered hypothesis-generating in order to design of a randomized trial comparison with conventional PTA.

Endovascular treatment of spontaneous isolated abdominal aortic dissection.

Isolated abdominal aortic dissection is a rare clinical disease representing only 1.3% of all dissections. There are a few case series reported in the literature. The causes of this pathology can be spontaneous, iatrogenic, or traumatic. Most patients are asymptomatic and symptoms are usually abdominal or back pain, while claudication and lower limb ischemia are rare. Surgical and endovascular treatment are two valid options with acceptable results. We herein describe nine cases of symptomatic spontaneous isolated abdominal aortic dissection, out of which four successfully were treated with an endovascular approach between July 2003 and July 2013. All patients were men, smokers, symptomatic (either abdominal or back pain or lower limb ischemia), with a history of high blood pressure, with a medical history negative for concomitant aneurysmatic dilatation or previous endovascular intervention. Diagnosis of isolated abdominal aortic dissection were established by contrast-enhanced computed tomography angiography (CTA) of the thoracic and abdominal aorta. All nine patients initially underwent medical treatment. In four symptomatic cases, non-responsive to medical therapy, bare-metal stents or stent grafts were successfully positioned. All patients completed a CTA follow-up of at least 12 months, during which they remained symptom-free. Endovascular management of this condition is associated with a high rate of technical success and a low mortality; therefore, it can be considered the treatment of choice when it is feasible.

What the young physician should know about May-Thurner syndrome.

May-Thurner syndrome (MTS) is an anatomically variable condition resulting in compression of the left common iliac vein between the right common iliac artery and the underlying spine with subsequent development of a left deep vein thrombosis (DVT). Although this syndrome is rare, its true prevalence is likely underestimated. Mainly, clinical symptoms and signs include, but are not limited to, pain, swelling, venous stasis ulcers, skin pigmentation changes and post-thrombotic syndrome. Correct treatment is not well established and is based on clinical presentation. Staged thrombolysis with/without prophylactic retrievable inferior vena cava filter placement followed by angioplasty/stenting of the left iliac vein appears to be the best option in MTS patients with extensive DVT. The aim of this review is to present in a simple and didactic form all variable clinical presentations of MTS and to outline possible management within the current guidelines.

Management of finger gangrene caused by steal syndrome in vascular access for hemodialysis Personal experience and a brief review of the literature.

INTRODUCTION: Severe dialysis-associated steal syndrome (DASS) is an uncommon and severe complication after arteriovenous fistula (AVF) creation that can lead to finger gangrene and amputation. As the number of patients on hemodialysis increases in western countries the number of patients at risk for DASS will continue to rise. METHODS: We retrospectively reviewed all patients who underwent a surgical intervention for the management of DASS with finger gangrene from January 2004 to July 2013. Demographic data, pre-operative work-up, procedure details and outcomes were collected. A literature search using MEDLINE's Medical Subject Heading terms was used to identify recent articles. Cross-references from these articles were also used. RESULTS: A total of nine patients were identified. Mean age was 53 years, 67% were women. All patients presented with finger tissue loss or gangrene. Surgical procedures included AVF closure/ligation (5), distal artery ligation (DRAL) (2), distal revascularization with interval ligation (DRIL) (1), banding (1). All patients had improvement of symptoms during follow-up. No major amputation occurred. CONCLUSIONS: Surgical interventions to correct DASS in patients with finger gangrene are mandatory while conservative management is not recommended. The decision for which type of procedure is made individually, according to clinical symptoms, technical findings, and patients' general state of health.

Carotid artery stenting in patients with brain meningioma.

The association between carotid artery stenosis and brain meningioma is rather rare. Indeed, data in literature about this association are scarce and potential risks of carotid artery stenting using different protection devices are not known. We describe the endovascular treatment of severe carotid stenosis in two patients with intracranial meningioma.

Accidental Coverage of Both Renal Arteries during Infrarenal Aortic Stent-Graft Implantation: Cause and Treatment.

The purpose of this paper is to report a salvage maneuver for accidental coverage of both renal arteries during endovascular aneurysm repair (EVAR) of an infrarenal abdominal aortic aneurysm (AAA). A 72-year-old female with a 6 cm infrarenal abdominal aortic aneurysm was treated by endovascular means with a standard bifurcated graft. Upon completing an angiogram, both renal arteries were found to be accidentally occluded. Through a left percutaneous brachial approach, the right renal artery was catheterized and a chimney stent was deployed; however this was not possible for the left renal artery. A retroperitoneal surgical approach was therefore carried out with a retrograde chimney stent implanted to restore blood flow. After three months, both renal arteries were patent and renal function was not different from the baseline. Both endovascular with percutaneous access via the brachial artery and open retroperitoneal approaches with retrograde catheterization are feasible rescue techniques to recanalize the accidentally occluded renal arteries during EVAR.

A wire-loop technique for implantation of an iliac branched device in a patient with previous surgery for a ruptured abdominal aortic aneurysm.

We described a modified technique for implanting a bridging stent-graft into an iliac branched device. A 79-year-old male who had received aortobiiliac synthetic graft surgery for a ruptured abdominal aortic aneurysm six months earlier was admitted to our unit for treatment of a left common iliac aneurysm involving the origin of the hypogastric artery. A standard technique was unsuccessful at implanting the bridging stent-graft, and therefore a wire-loop guidewire over the graft bifurcation was used to stabilize the contralateral sheaths and to complete the implantation.

Carotid and vagal body paragangliomas.

Between 1972 and 2012, 25 patients presenting 32 paragangliomas of the neck were observed. Tumor locations included the carotid body (CBTs) in 21 patients and the vagus nerve in 4. Four patients had bilateral CBT and one a bilateral vagal tumor; a metachronous bilateral jugulare paraganglioma was diagnosed in one patient with bilateral CBT Shamblin type III. Five patients presented CBTs type II and three type III. Preoperative embolization was performed in 5 CBTs, with no significant difference in blood loss. Twenty-nine paragangliomas were resected (with three internal carotid artery resection): there were no cerebrovascular accident or perioperative death. Nine patients (36%) had cranial nerve palsy prior to surgery and a postoperative nerve dysfunction occurred in four other tumors (16%). Persistent nerve deficits occurred in 3 patients (12%). No evidence of malignancy was shown, intraoperatively or during a postoperative follow-up period (9 months to 18 years; mean: 8 years).

Earlier appearance of the ossification center of the femoral head in breast-fed versus formula-fed infants.

OBJECTIVE: The aim of this study was to evaluate possible differences in the rate of appearance of the femoral head ossification center (FHOC) in infants according to the type of feeding (exclusive breast-feeding, formula, mixed feeding). METHODS: A retrospective study was conducted in a population of 285 healthy infants who consecutively underwent echographic evaluation of the hip as a screening for hip dysplasia from April 1 through October 31, 2008. For each infant, type of feeding, sex, gestational age, weight at birth, and age at the time of echographic examination were recorded. Data analysis was performed in the entire sample population and in a subpopulation of 143 infants after exclusion of preterm or low-birth-weight infants and those who underwent echographic examination outside the scheduled age range. Data were analyzed by chi-square test, Kruskal-Wallis test, and multiple logistic regression analysis. RESULTS: An FHOC was present in 48.3% of breast-fed infants, 25.7% of formula-fed infants, and 28% of the mixed feeding group (P = 0.001). In multiple logistic regression analysis, the best regression model included the following variables: age at test (P = 2.23 × 10(-7)), gestational age (P = 0.0017), and exclusive breast-feeding (P = 0.0003). Similar results were obtained in the selected subpopulation of 143 infants (FHOC in 54.2% of breast-fed group, 28.2% of formula-fed group, and 33.3% of mixed-feeding group, P = 0.01). CONCLUSION: Exclusive breast-feeding may be associated to an earlier appearance of FHOC in a population of normal infants compared with formula feeding.