MR delayed enhancement imaging findings in suspected acute myocarditis.

The purpose of the study was to prospectively assess the clinical impact of routinely performed delayed enhancement imaging in suspected acute myocarditis. A two-centre prospective study was performed in patients with suspected acute myocarditis. The protocol included horizontal long axis, vertical long axis and short axis ciné MR and delayed enhancement imaging after Gd-DTPA infusion (0.2 mmol/kg). Sixty consecutive patients were enrolled (aged 49.4 +/- 17.8 years). MRI demonstrated delayed enhancement sparing the subendocardicardial layer in 51.6% of patients, concordant with the diagnosis of acute myocarditis; 16.7% of patients exhibited delayed enhancement involving the subendocardial layer with irregular margins, concordant with the diagnosis of acute myocardial infarction; 31.7% of patients had delayed enhancement imaging that was considered normal. Routine imaging to identify delayed enhancement provided crucial information in suspected acute myocarditis by reinforcing the diagnosis in 51.6% of patients and correcting a misdiagnosed acute myocardial infarction in 16.7% of patients.

Evolution of coronary artery calcifications following kidney transplantation: relationship with osteoprotegerin levels.

We prospectively assessed the evolution of coronary artery calcification (CAC) and osteoprotegerin (OPG) levels after renal transplantation (RT). Eighty-three recipients were followed-up prospectively during 1 year. Blood was collected before (baseline) and after RT for determination of mineral metabolism parameters including OPG. CAC was measured by multidetector computed tomography at transplantation (baseline) and 1 year later. Progression of CAC was defined as a difference between the follow-up square-root transformed volume (SRV) and the baseline SRV >or= 2.5. By multivariate analysis, baseline OPG level, age and low LDL levels were significantly associated with baseline CAC. RT was accompanied by mineral metabolism improvement with a decrease of OPG from 955 [395-5652] to 527 [217-1818] pg/mL and parathyroid hormone from 94 [1-550] to 62 [16-410] pg/mL. Thirty-one percent of patients did not exhibit CAC at baseline. CAC diminished in 14.5%, stabilized in 59.2% and progressed in 26.3% of patients. Baseline CAC was associated with progression (OR 2.92 [1.02-8.36]). No significant association was found between OPG and CAC progression despite a higher baseline OPG level in progressors (1046 [456-3285]) vs. non-progressors (899 [396-5952] pg/mL). CAC at baseline, but not 1 year after RT, is independently associated with baseline OPG; posttransplant CAC progression is predicted by baseline CAC score.

[Virtual interventional radiology: evaluation of performances as a function of experience]. / Réalité virtuelle en radiologie vasculaire interventionnelle: évaluation des performances de l'opérateur selon son niveau d'expérience.

PURPOSE: To determine the value of an angioplasty simulation to differentiate the users based on their level of experience. To determine the perceived usefulness of an angioplasty simulation program. MATERIALS AND METHODS: Forty-six radiologists performed a renal angioplasty on a VIST simulator (Mentice Corporation, Gothenburg, Sweden); the procedure was completed by 41 radiologists. The radiologists were divided into two groups based on the level of experience. Quantitative variables analyzed included procedure duration time and fluoroscopy time. The radiologists then completed a questionnaire evaluating the simulation program. RESULTS: Radiologists with more than 2 years of clinical experience (n=14) performed the procedures faster (20.4 min vs 27.4 min, p<0.01) using less fluoroscopy time (7.8 min vs 11.2 min, p<0.05) than others. Radiologists performing more than 2 procedures per month (n=14) performed the procedures faster (19.4 min vs 27.9 min, p<0.01) using less fluoroscopy time (7.4 min vs 11.3 min, p<0.05) than other (n=27). The participating radiologists indicated that the simulation was realistic. CONCLUSION: Procedure duration time and duration of fluoroscopy were criteria able to differentiate the users based on their level of experience. The educational value of the simulation program was perceived as helpful by the users.

[A (too) successful renal denervation]. / Une dénervation rénale (trop) réussie.

We report the case of a type-2 myocardial infarction immediately after renal denervation. The patient was followed for coronary artery disease. Low blood pressures were responsible for inferior acute myocardial infarction that revealed a sub occlusive stenosis of the right coronary artery.

Vascular emergencies in liver trauma.

The use of CT in the diagnosis and management of liver trauma is responsible for the shift from routine surgical versus non-surgical treatment in the management of traumatic liver injuries, even when they are of high grade. The main cause of complication and of death in liver trauma is related to vascular injury. The goal of this review focussed on the vascular complications of liver trauma is to describe the elementary lesions shown by CT in liver trauma including laceration, parenchymal hematoma and contusions, partial devascularisation, subcapsular hematomas, hemoperitoneum, active bleeding, pseudoaneurysm of the hepatic artery, bile leak, and periportal oedema, to illustrate the possible pitfalls in CT diagnosis of liver trauma and to underline the key-points which may absolutely be present in a CT report of liver trauma. Then we will remind the grading system based on the CT features and we will analyze the interest and limitations of such grading systems. Last we will discuss the diagnostic strategy at the early phase in patients with suspected liver trauma according to their clinical conditions and underline the conditions of arterial embolization, and then we will discuss the diagnosis strategy at the delayed phase according to the suspected complications.

[Segmental occlusion of the internal carotid artery with collateral reinjection downstream from the carotid sinus]. / Occlusion segmentaire de l'artère carotide interne avec une réinjection collatérale postbulbaire.

The preoperative evaluation before coronary bypass led to the discovery of complete atheromatous obstruction of the internal carotid artery sinus in a 79-year-old man free of any neurological symptom. Downstream from the carotid sinus, the patency of the internal carotid artery was ensured by a collateral branch fed by the ipsilateral external carotid artery. This exceptional anatomic variation can be explained by a persistent embryonic artery. The recognition of this atypical feature is clinically relevant because surgery may be possible in some cases, while it is not technically feasible in patients with total obstruction.

A numerical assessment of wall shear stress changes after endovascular stenting.

This theoretical/numerical study aims at assessing the haemodynamic changes induced by endovascular stenting. By using the classical one-dimensional linear pressure waves theory in elastic vessels, we first show that the modulus of the reflection coefficient induced by an endovascular prosthesis is most likely small since it is proportional to the stent-to-wavelength ratio. As a direct consequence, the wall motion of the elastic (stented) artery can be prescribed a priori and the coupled fluid-structure problem does not have to be solved for assessing the haemodynamic changes due to stenting. Several 2D axisymetric calculations are performed to solve the unsteady incompressible Navier-Stokes equations on moving meshes for different types of (stented) arteries. The numerical results suggest that endovascular stenting increases the systo-diastolic variations of the wall shear stress (by 35% at the middle of the stent, by almost 50% in the proximal transition region). Additional calculations show that over-dilated stents produce less haemodynamic perturbations. Indeed, the increase of the amplitude of the wall shear stress variations over the cardiac cycle is only 10% when the stent radius is equal to the radius of the elastic artery at systole (instead of being equal to the mean artery radius).

Interventional chest radiology.

The authors review the various interventional radiology techniques currently used in 1996 by a Medico-Radio-Surgical team. CT guided needle biopsy has an important place in the diagnostic approach to parenchymal as well as mediastinal tumours. But CT guidance allows also routine drainage of thoracic collections and sometimes thoracic sympatholysis. Superior vena cava and tracheobronchial stenting are palliative treatments as the percutaneous aspergilloma treatment. Embolization of bronchial and thoracic systemic arteries are also palliative but effective therapeutic procedures as well as vasoocclusion for arterio-venous fistulae.

Spontaneous calcific cerebral emboli from calcified aortic valve stenosis.

Calcific cerebral emboli (CE) are a rare complication of calcified aortic valve stenosis (CAS). These emboli usually result from diagnostic manoeuvres (e.g. left heart catheterization) or from therapeutic procedures (e.g. heart valve surgery). Spontaneous calcific emboli are exceptional. We present the cases of two subjects known to have CAS who presented with acute neurological disorders suggesting strokes. In both subjects CT scans of the skull and brain provided a diagnosis of spontaneous CE by showing calcium-dense dots located on vessels or within the cerebral parenchyma. Additional examinations enabled us to determine the origin (heart or carotid artery) of these emboli. The finding of spontaneous cerebral CE is a very strong argument in favour of surgical valve replacement in these patients.

[Imaging of the pulmonary arteries: when, how and when?]. / Quand, comment et pourquoi réaliser une imagerie des artères pulmonaires?

For several years, catheter angiography was the standard imaging technique used for evaluating the pulmonary arteries. Technical advances with computed tomography have had a significant impact on chest imaging, especially the increasing availability of multidetector row CT units. CT pulmonary angiography (CTPA) is now the first line imaging technique to evaluate pulmonary arterial diseases, including pulmonary embolus. Pulmonary angiography is now essentially limited to the endovascular management of pulmonary arteriovenous malformations, pulmonary arteriovenous fistulas or pulmonary arterial aneurysms. Gadolinium enhanced MR angiography of the pulmonary arteries may be helpful in patients with contraindications to the use of iodinated contrast material.

[Embolization treatment of a traumatic adrenal hemorrhage]. / Traitement par embolisation d'un traumatisme hémorragique de la surrénale.

We report a case of adrenal hemorrhage in a blunt abdominal trauma after a motor vehicle crash. The patient was treated by a percutaneous embolization without any complication.

[Value of thoracic CT in the management of severe hemoptysis]. / Hémoptysies sévères: apport de la tomodensitométrie thoracique.

PURPOSE: To assess the value of thoracic CT in the management of patients with severe hemoptysis. PATIENTS AND METHODS: Between January 1997 and January 2001, 62 patients were investigated for severe hemoptysis (>300 ml/24H). The protocol, performed before angiography and embolization, included bronchial fiberoptic examination (BFE) followed by thoracic spiral CT-angiography. Data recorded at CT and BFE were the presence and location of bleeding, the etiology of hemoptysis and the therapeutic modality. RESULTS: Nine patients with life-threatening hemoptysis directly underwent bronchial embolization. CT was available in the 53 remaining patients. No abnormality was found in 4 patients. CT assessed the presence (n=49) and the location (n=38) of the bleeding. The etiology was determined in 49 patients. BFE was feasible in 38/53 patients. BFE assessed the presence (n=38) and location (n=15) of the bleeding. The etiology was determined in 12 cases of bronchial tumour. The available findings of CT and BFE for the presence and the location of the bleeding were concordant. Comparing fiberoptic examination and thoracic CT, the percentages of localized bleedings (39% and 72%) and demonstrated etiologies (32% and 92%), were significantly different (p<0,005 and p<0.0001 respectively). CONCLUSION: Although retrospective and limited by the small number of cases, our study provides arguments to perform thoracic CT before bronchial fiberoptic examination for the management of severe hemoptysis.

[Pulmonary embolism: contribution of spiral x-ray computed tomography]. / Embolie pulmonaire: apport de la tomodensitométrie hélicoïdale.

PURPOSE: Spiral computed tomography was compared retrospectively with digital subtraction pulmonary angiography (PA) in 45 patients suspected of having acute or chronic pulmonary embolism. MATERIALS AND METHODS: 45 patients in whom the presence of acute or chronic pulmonary embolism was suspected underwent examination by spiral CT and PA. Diagnosis of pulmonary embolism was based on the direct visualization of intraluminal clots. The study of the agreement between the two methods was based on the Kappa test. In 35 cases, pulmonary emboli were proved. Acute pulmonary emboli were present in 28 cases and chronic in 7 cases. RESULTS: Spiral computed tomography represents an excellent way to detect acute pulmonary embolism. In the chronic form, spiral CT is better than PA to detect intraluminal clots. However, Spiral CT can fail to detect small embole in the peripheral arterial bed. In the 10 patients without pulmonary embolism, the spiral CT proved diagnosis pulmonary oedema (n = 3), lymphangitic carcinoma (n = 4), pleural effusion (n = 3). CONCLUSION: This study suggest that the spiral CT examination is accurate for diagnosis of pulmonary embolism specifically in case of suspected important embolism. The advantages of spiral CT are multiple (non invasive, wide diagnosis spectrum). However, may be a limitation to is use is insufficient distal thrombi detection. This eventuality (5 to 10% in the Pioped study) justify the practice of pulmonary angiography. Spiral CT improvements should reduce this insufficiency in the next future.

[Pseudotumor form of pulmonary nocardia infection (Nocardia nova) in a renal transplant patient]. / Nocardiose pulmonaire (Nocardia nova) à forme pseudo-tumorale chez un greffé rénal.

The authors report a case of pulmonary nocardiosis due to Nocardia nova occurring in a smoker who had a renal transplant. A pseudo-tumour was found on a standard X-ray and computerised tomography did not suggest the diagnosis. Needle aspiration under computerised tomographic control enabled a diagnosis to be made.

[Unusual spinal and pulmonary metastases]. / De curieuses métastases rachidiennes et pulmonaires.

We present the clinical and imaging findings of a 72 year old man with lytic dorsal bone lesions and a pulmonary spread of nodules (miliary) that were mistakenly attributed to a cancerous disease.

[The use of high resolution x-ray computed tomography in the diagnosis of hypersensitivity pneumopathy to gold salts. Apropos of a case]. / Apport de la tomodensitométrie HR dans le diagnostic de la pneumopathie d'hypersensibilité aux sels d'or. A propos d'un cas.

A hypersensitivity pneumonia is rare during gold therapy. The underlying mechanism is immunological in origin, of Gell and Coombs Type IV. As there are numerous possible pulmonary disorders during the course of inflammatory rheumatism treated with gold, the early detection is vital, in order to prevent progress to fibrosis. In parallel with broncho-alveolar lavage to look for a T8 lymphocytic alveolitis, which is very suggestive, high resolution computed tomography has a place in the early diagnosis, to characterise the lesions, to aid in an aetiological diagnosis, and also to assess progress on treatment. The authors present a case of pneumonitis induced by gold with visible interstitial lesions on computed tomography, accompanied by significant bronchial distortion and bronchiectasis suggestive of fixed lesions. These lesions partially regressed following steroid therapy; the diagnostic and prognostic role for high resolution computer tomography was discussed.

[Contribution of high-resolution volume computed tomography (HRVCT) for the exploration of diffuse pulmonary infiltrative disorders]. / Apport de la TDM avec haute résolution volumique (TDM HRV) dans l'exploration des pneumopathies infiltratives diffuses.

AIM: To assess high-resolution volume computed tomography (HRVCT) for the investigation of diffuse pulmonary infiltrative disorders. PATIENTS AND METHODS: Thirty patients with diffuse interstitial disease (idiopathic fibrosis n = 7, silicosis n = 4, asbestosis n = 5, sarcoidosis n = 7, histiocytosis n = 2, lymphangitis carcinomatosa n = 2, tuberculosis n = 1, bronchiolitis obliterans n = 1) were explored using high-resolution computed tomography (HRCT) and HRVCT. All diagnoses were proven by fiberscopy, bronchoalveolar lavage and respiratory function tests and/or lung biopsy. The HRVCT protocol consisted of spiral tomography using 10 mm slices. Data were processed with a Windows Advantage workstation (GE Milwaukee). Two readers compared multiprojection volume reconstruction (MPVR) using maximal intensity projection (MIP) and minimal intensity projection (MINIP) displays with millimetric HRCT slices acquired at the same volume. RESULTS: Micronodules were detected better with HRVCT than with HRCT. MIP mode enabled better distinction between nodules and vessels. MINIP mode enabled better detection of cysts in the pulmonary parenchyma than HRCT. The honeycomb aspect of pulmonary fibrosis was differentiated better than super-infected central-lobar emphysema. MINIP mode enabled detection of ground glass opacities which were not visible on HRCT. Certain anomalies were however detected only on HRCT. HRVCT was very sensitive to movement effects which altered image quality, particularly in the MINIP mode. CONCLUSION: HRVCT is a new and promising approach for investigating diffuse pulmonary infiltrative disorders.

[Interventional radiology of the thorax]. / Radiologie interventionnelle du thorax.

Interventional radiology of the thorax includes a wide variety of diagnostic and/or therapeutic procedures. Transthoracic needle biopsy is a widely used technique. Generall, computed tomography is used to guide the puncture, less commonly fluoroscopy or in exceptional cases ultrasound. Targets include parenchymatous, pleural and mediastinal lesions. The biopsy specimen is used for cytology, histology, bacteriology, mycology and parasitology studies. Needle biopsy is also the first step in more complex procedures: drainage of thoracic collections, inserting harpoons, thoracic sympatholysis, palliative treatment of aspergillomas. Bronchial arteriography with embolization is an effective emergency symptomatic treatment for severe hemoptysis. Endovascular vaso-occlusion procedures can be used for rare arteriovenous pulmonary fistulas. Superior vena cava obstruction can be treated, usually in a palliative procedure, by installing an endovascular endoprosthesis.

Tumors of the rib.

The authors propose a pictorial review illustrating the imaging features of chest wall tumors and their specific features that discusses the main differential diagnoses. This review is based on published information and on our own experience.