Qualitative versus automatic evaluation of CT perfusion parameters in acute posterior circulation ischaemic stroke.

PURPOSE: To compare the diagnostic accuracy (ACC) in the detection of acute posterior circulation strokes between qualitative evaluation of software-generated colour maps and automatic assessment of CT perfusion (CTP) parameters. METHODS: Were retrospectively collected 50 patients suspected of acute posterior circulation stroke who underwent to CTP (GE "Lightspeed", 64 slices) within 24 h after symptom onset between January 2016 and December 2018. The Posterior circulation-Acute Stroke Prognosis Early CT Score (pc-ASPECTS) was used for quantifying the extent of ischaemic areas on non-contrast (NC)CT and colour-coded maps generated by CTP4 (GE) and RAPID (iSchemia View) software. Final pc-ASPECTS was calculated on follow-up NCCT and/or MRI (Philips Intera 3.0 T or Philips Achieva Ingenia 1.5 T). RAPID software also elaborated automatic quantitative mismatch maps. RESULTS: By qualitative evaluation of colour-coded maps, MTT-CTP4D and Tmax-RAPID showed the highest sensitivity (SE) (88.6% and 90.9%, respectively) and ACC (84% and 88%, respectively) compared with the other perfusion parameters (CBV, CBF). Baseline NCCT and CBF provided by RAPID quantitative perfusion mismatch maps had the lowest SE (29.6% and 6.8%, respectively) and ACC (38% and 18%, respectively). CBF and Tmax assessment provided by quantitative RAPID perfusion mismatch maps showed significant lower SE and ACC than qualitative evaluation. No significant differences were found between the pc-ASPECTSs assessed on colour-coded MTT and Tmax maps neither between the scores assessed on colour-coded CBV-CTP4D and CBF-RAPID maps. CONCLUSION: Qualitative analysis of colour-coded maps resulted more sensitive and accurate in the detection of ischaemic changes than automatic quantitative analysis.

Can Craniometry Play a Role in Cluster Headache Diagnosis? A Pilot Exploratory TC-3D Based Study.

BACKGROUND: Since the pioneering reports of the so-called leonine face in cluster headache (CH) patients, cranial and facial features of these patients have been poorly investigated with conflicting results. We aimed to investigate whether abnormalities in craniometric measurements could characterize male CH patients and represent reliable and reproducible diagnostic biomarkers able to identify CH patients. METHODS: Brain CT images were recorded between 2018 and 2020 in 24 male patients with CH and in 24 matched healthy controls (HC). Then, craniometric measurements were obtained, and logistic regression and receiver operating characteristic curves analyses were used to identify the craniometric abnormalities able to distinguish CH patients from HC. RESULTS: Logistic regression analyses showed that frontal bone height and facial width were able to discriminate, one independently from the other, CH patients from HC with an overall accuracy of 77%. The optimal cutoff score in detecting the probable presence of CH was 11.50 cm for frontal bone height and 13.30 cm for facial width. DISCUSSION: In the present study we found, for the first time by means of brain 3D computed tomography approach, abnormal craniometric measurements in CH patients when compared with HC. The absence of differences in smoke and alcohol intake suggests that the observed craniometric abnormalities may represent a specific feature of CH patients. CONCLUSION: The craniometric evaluation by means of brain 3D computed tomography could represent a widespread, noninvasive, and accurate tool to support CH diagnosis to avoid frequent misdiagnosis or delay in the diagnostic process.

ODLURO syndrome: personal experience and review of the literature.

INTRODUCTION: The O'Donnell-Luria-Rodan (ODLURO) syndrome, caused by heterozygous mutation in the lysine N-methyltransferase2E (KMT2E) gene in chromosome 7q22, has been recently described. Mutation of KMT2E produces a protein-truncating variant gene that may be responsible for both developmental delay and intellectual disability disorders commonly defined by an Intelligence Quotient < 70 and usually unspecific pathologic brain features demonstrated by brain Magnetic Resonance imaging. The symptoms of ODLURO syndrome include variably developmental and speech delay, autism, seizures, hypotonia, and dysmorphic features. The aim of the study is to search for correlation between this specific gene mutation and clinical/radiological features, trying to provide new insights in this recently described pathological condition. METHODS: We reviewed the 38 cases collected by O'Donnel-Luria et al., adding three cases of a familial heterozygosis novel mutation in KMT2E gene; different degrees of neurological disorder, subtle dysmorphic features, intellectual disability, epilepsy, and various brain Magnetic Resonance features are described. RESULTS: Magnetic Resonance data were integrated by genetic analysis and clinical features. Brain Magnetic Resonance study of our patients confirmed peculiar pathologic features previously reported in ODLURO syndrome; cerebellar dysplasia was identified in one of them. All 3 patients had epilepsy, intellectual disability, and mild dysmorphisms. CONCLUSIONS: Our study adds 3 new patients genetically, clinically, and radiologically evaluated to the ODLURO syndrome case series. While CC hypoplasia and widening of subarachnoid spaces are already reported in literature, we document for the first time the presence of cerebellar dysplasia in ODLURO syndrome. We also highlight the extremely low IQ value and the presence of epilepsy in all 3 patients.

Upper Eyelid Isolated Arterio-Venous Malformation Treated With Embolization in a Patient With Keloid-Prone Skin.

Ocular adnexal aterio-venous malformations (AVMs) are rare congenital disabling anomalies, which may enlarge causing disfiguring deformity and rarely severe hemorrhage. These lesions are generally treated by preliminary endovascular embolization to shrink the arterio-venous malformation, followed by surgical gross total resection. The authors report a case of eyelid arterio-venous malformation in a 12-year-old girl, which progressively increased in size in few months. The patient complained mild itching, blurring of the vision, and mild tenderness. Magnetic resonance imaging showed an expansive mass with multiple arterial vessels at the left superior eyelid and left forehead. The diagnosis of arterio-venous malformation was then confirmed by digital subtraction angiography. Primary surgical excision was excluded because of the high risk of intrasurgical bleeding. Embolization through superselective cannulation of the left external carotid feeder vessels was performed resulting in flow exclusion up to the 80% of the nidus. Subsequent surgical resection was not recommended due to clinical evidence of keloid-prone skin.

Earliest videofluoromanometric pharyngeal signs of dysphagia in ALS patients.

The aim of this study was to find whether there are manometric pharyngeal changes that may have diagnostic and prognostic relevance in the amyotrophic lateral sclerosis (ALS) patient who does not show changes in contrast-medium oropharyngeal transit in a videofluoroscopic swallowing study. Ten ALS patients, with an ALS Severity Scale Score of at least 7, no need to change dietary habit, no aspiration and/or penetration, and no other changes in contrast-medium oropharyngeal transit, were collected from our institution's database of videofluoromanometric swallowing studies. They were included in the study together with a group of 11 healthy volunteers. For each subject, 12 manometric items-7 for the pharyngeal phase and 5 for UES functionality-were evaluated. Statistically significant differences between the ALS patients and the healthy volunteers were found for pharyngeal contraction time of the upper region (median = 1,120, range = 880-1,420 vs. median = 970, range = 800-1,140), pharyngeal contraction time of the intermediate region (median = 1140, range = 960-1,360 vs. median = 770, range = 280-1,180), pharyngeal contraction time of the lower region (median = 1,320, range = 920-1,760 vs. median = 800, range = 620-1,780), and residual pressure after the relaxation of the UES (median = 2.2, range = -20.2 to 27.8 vs. median = -5.7, range = -2.9 to 8.4). A videofluoromanometric swallowing study may show an increase in the pharyngeal contraction time and in residual pressure after relaxation of the UES in ALS patients without videofluoroscopic changes in contrast-medium oropharyngeal transit.

Usefulness and safety of biliary percutaneous transluminal forceps biopsy (PTFB): our experience.

AIM: To evaluate the usefulness and safety of percutaneous transluminal forceps biopsy in patients suspected of having a malignant biliary obstruction. MATERIAL AND METHODS: Forty consecutive patients (21 men and 19 women; mean age, 71.9 years) underwent forceps biopsy through percutaneous transhepatic biliary access performed to drain bile. Lesions involved the common bile duct (n 8), common hepatic duct (n 18), hilum (n 6), ampullary segment of the common bile duct (n 8) and were biopsied with 7-F biopsy forceps. Final diagnosis was confirmed with pathologic findings at surgery, or clinical and radiologic follow-up. RESULTS: Twenty-one of 40 biopsies resulted in correct diagnosis of malignancy. Thirteen biopsy diagnosis were proved to be true-negative. There were six false-negative and no false-positive diagnoses. Sensitivity, specificity and accuracy in aspecific biliary obstructions were 85%, 100% and 88,7% respectively. Sensitivity of biopsy in malignancies was higher than in benign obstructions (100% vs 68,4%, CI = 95%). Sensitivity was lower in the hilum tract and in the common bile duct than in other sites (CI = 95%). No major complications related to biopsy procedures occurred. CONCLUSIONS: Percutaneous transluminal forceps biopsy is a safe procedure, easy to perform through a transhepatic biliary drainage tract, providing high accuracy in the diagnosis of malignant biliary obstructions.

Neuroimaging of the Most Common Meningitis and Encephalitis of Adults: A Narrative Review.

Meningitis is the infection of the meninges, which are connective tissue membranes covering the brain, and it most commonly affects the leptomeninges. Clinically, meningitis may present with fever, neck stiffness, altered mental status, headache, vomiting, and neurological deficits. Encephalitis is an infection of the brain, which usually presents with fever, altered mental status, neurological deficits, and seizure. Meningitis and encephalitis are serious conditions which could also coexist, with high morbidity and mortality, thus requiring prompt diagnosis and treatment. Imaging plays an important role in the clinical management of these conditions, especially Magnetic Resonance Imaging. It is indicated to exclude mimics and evaluate the presence of complications. The aim of this review is to depict imaging findings of the most common meningitis and encephalitis.

[The value of the MRI in defining the morfology of cerebral aging]. / Il ruolo della RM nella definizione morfologica dell'invecchiamento cerebrale.

White matter changes are one of the several aging brain alterations. Actually, magnetic resonance imaging is the best diagnostic tool in investigation and monitoring these lesions that determine some common clinical manifestations in the elderly population.

[Cerebral pseudovasculitic lesion associated with von Recklinghausen's neurofibromatosis: a case report]. / Lesione pseudovasculitica cerebrale associata a neurofibromatosi di von Recklinghausen.

A child with neurofibromatosis type 1 (NF1) with headache was submitted to magnetic resonanace imaging and a pseudovasculitic lesion was found. Vascular lesions are uncommon in patients with NF1 and our case highlights an even more rare feature of this form of vascular disease.

[Diagnostic tools in neurodegenerative disorders of adult-elderly]. / Strumenti diagnostici dei disordini neurodegenerativi nell'adulto-anziano.

Neurodegenerative disorders are an inhomogeneous group of neurological diseases that affect a large part of the population because of the rise in life expectancy. Although clinical manifestations are important to make the correct diagnosis, the new advanced imaging technique represent a very useful tool for the diagnostic work-up.

[Evaluation with multislice CT of the hilar pulmonary nodules for probable infiltration of vascular-bronchial structures]. / Valutazione con TC multistrato di noduli polmonari ilari per l'eventuale infiltrazione delle strutture vascolo-bronchiali.

Tumor stage is an important prognostic factor for patients suffering from lung cancer, because it affects the type of therapeutic treatment to be implemented. Computed tomography is the imaging method of choice for the staging of lung cancer, and for central neoplasm, it is essential to assess any possible involvement of bronchovascular structures that may affect operability. We report our experience based on the use of reconstruction algorithms for the study of the relationship between tumor, bronchi and adjacent vessels.

[Uro-CT protocol for the diagnosis of small urothelial neoplasms of urinary tract by quantitative analysis of contrast enhancement and correlation to the histological grading]. / Protocollo uro-TC per la diagnosi di piccole formazioni eterotransizionali delle vie urinarie con analisi quantitativa dell'enhancement e correlazione al grading istologico.

In the study of urinary tract, traditional imaging modalities still play a vital role in the diagnosis of urothelial tumors of the upper urinary tract; however, the introduction of multidetector computed tomography has greatly changed the way of evaluation of urological patients. In fact, by means of a multiphasic study protocol is possible to recognize with high sensitivity small urothelial lesions and, moreover, to perform at the same time, an evaluation of local and metastatic extension also. The evaluation of the pattern of contrast enhancement in addition, allows a judgement of biological aggressiveness related to tumor grading.

[Ultrasound-guided biopsy of the testis: indications and results]. / Biopsie testicolari sotto guida ecografica: indicazioni e risultati.

Ultrasound examination of the testis is the imaging modality of choice for the evaluation of intratesticular focal lesions. In spite of its high sensibility, eco-Doppler-elastography is lacking of specificity in discrimination between benign and malign lesions, not always allowing us to make a definitive diagnosis of malignancy. When a diagnostic doubt persists, for such lesions that are indeterminate at clinical and radiological evaluation, it is possible to recur to ultrasound-guided testicular needle biopsy. This paper describes the main application scenarios of testicular fine-needle aspiration under ultrasound guidance and the experience in our institute.

Infarct-like versus Non-Infarct-like Clinical Presentation of Acute Myocarditis: Comparison of Cardiac Magnetic Resonance (CMR) Findings.

BACKGROUND: The clinical presentation of acute myocarditis (AM) is widely variable, ranging from a subclinical disease to an infarct-like syndrome. Cardiac magnetic resonance (CMR) has become the reference non-invasive diagnostic tool for suspected AM, allowing the identification of the various hallmarks of myocardial inflammation (edema, fibrosis, and hyperemia). The aim of the study was to investigate any differences in morphological, functional, and tissue characterization CMR parameters between infarct-like AM in patients with unobstructed coronary arteries and non-infarct-like AM, diagnosed according to the original Lake-Louise Criteria (LLC); Methods: We retrospectively selected 39 patients diagnosed with AM according to LLC, divided into 2 groups according to the clinical presentation: infarct-like in group 1 patients and non-infarct-like in group 2 patients. CMR morphologic, functional, and tissue characterization parameters were analyzed and compared. RESULTS: In group 1, CMR tissue characterization parameters were mainly altereda in septal location with mesocardial myocardial involvement; in group 2, CMR tissue characterization parameters were mainly altered in a lateral location with subepicardial myocardial involvement mainly at the mid-cavity. No significant differences in morphological or functional parameters were observed between the two study groups. CONCLUSIONS: Our results showed differences in the localization and distribution of myocardial tissue damage assessed by CMR among forms of AM accompanied by an infarct-like clinical presentation compared with non-infarct-like presentations of AM. The mechanisms underlying the different preferential sites of damage observed in our study are not known, and we do not exclude the possibility of their prognostic implications.

Conventional and Advanced MRI Techniques in the Evaluation of Primary CNS Lymphoma.

Primary central nervous system lymphoma (PCNSL) is a rare form of extranodal non-Hodgkin's lymphoma that accounts for 1%-5% of all central nervous system tumors. Contrast-enhanced MR is the imaging technique of choice. PCNLs have a predilection for the periventricular and superficial regions, often abutting the ventricular or meningeal surfaces. Although PCNLs may have characteristic imaging features on conventional MRI, none of these will unequivocally differentiate PCNSLs from other brain lesions. Diffusion restriction, relative hypoperfusion, increased choline/creatinine, decrease of N-acetyl aspartate (NAA) peak as well as the presence of lactate and lipid peaks are consistent advanced imaging findings in CNS lymphoma that may help in the differentiation of Primary central nervous system lymphomas (PCNSLs) from other malignancies. Furthermore, advanced imaging techniques will presumably play an important role in the planning of new targeted therapies, for prognostication, and for the monitoring of treatment response in the future.

Giant Tumefactive Perivascular Space: Advanced Fusion MR Imaging and Tractography Study-A Case Report and a Systematic Review.

Perivascular spaces (PVSs) are small extensions of the subpial cerebrospinal space, pial-lined and interstitial fluid-filled. They surround small penetrating arteries, and veins, crossing the subarachnoid space to the brain tissue. Magnetic Resonance Imaging (MRI) shows a PVS as a round-shape or linear structure, isointense to the cerebrospinal fluid, and, if larger than 1.5 cm, they are known as giant/tumefactive PVSs (GTPVS) that may compress neighboring parenchymal/liquoral compartment. We report a rare asymptomatic case of GTPVS type 1 in a diabetic middle-aged patient, occasionally discovered. Our MRI study focuses on diffusion/tractography and fusion imaging: three-dimensional (3D) constructive interference in steady state (CISS) and time of fly (TOF) sequences. The advanced and fusion MR techniques help us to track brain fiber to assess brain tissue compression consequences and some PVS anatomic features as the perforating arteries inside them.

[Gastroenteric diseases in the third millennium: a rational approach to optimal imaging technique and patient selection]. / La patologia intestinale nel terzo millennio: la scelta della metodica e la selezione del paziente nella gestione dell'approccio razionale all'imaging.

In the last twenty years, the study of gastroenteric disorders underwent a radical change as a result of rapid advances in diagnostic imaging, with the introduction of more sophisticated and better performing techniques. Although this evolution has significantly contributed to improve diagnostic accuracy, also allowing assessment of different areas of the gastroenteric tract that could not be well evaluated in the past, clinicians may feel confused about deciding the most appropriate diagnostic approach according to lesion type and site. The aim of this paper is to provide an overview of available imaging techniques to guide the diagnostic approach to gastroenteric diseases.

[Role of nuclear imaging in the management and follow-up of patients with inflammatory bowel disease]. / Ruolo delle tecniche di medicina nucleare nella programmazione terapeutica e nel follow-up della malattia infiammatoria intestinale.

The modern approach to diagnostic imaging includes multimodal evaluation of patients. Physician knowledge of the clinical potential of each available imaging technique combined with efficient integration of functional and morphological data is mandatory in order to achieve a timely diagnosis and treatment, and to avoid unnecessary invasive examinations. Recent years have witnessed important advances in nuclear medicine techniques, including the development of a great variety of metabolic tracers that allow accurate detection, characterization and staging of diverse disease states other than neoplastic conditions. Nuclear medicine techniques play an important role in the diagnostic evaluation of different forms of inflammatory bowel disease (Crohn's disease, ulcerative rettocolitis, indeterminate colitis), and can provide optimal anatomo-functional information when used in association with multidetector CT and MRI, enabling tailored therapeutic interventions.

Alert Germ Infections: Chest X-ray and CT Findings in Hospitalized Patients Affected by Multidrug-Resistant Acinetobacter baumannii Pneumonia.

Acinetobacter baumannii (Ab) is an opportunistic Gram-negative pathogen intrinsically resistant to many antimicrobials. The aim of this retrospective study was to describe the imaging features on chest X-ray (CXR) and computed tomography (CT) scans in hospitalized patients with multidrug-resistant (MDR) Ab pneumonia. CXR and CT findings were graded on a three-point scale: 1 represents normal attenuation, 2 represents ground-glass attenuation, and 3 represents consolidation. For each lung zone, with a total of six lung zones in each patient, the extent of disease was graded using a five-point scale: 0, no involvement; 1, involving 25% of the zone; 2, 25−50%; 3, 50−75%; and 4, involving >75% of the zone. Points from all zones were added for a final total cumulative score ranging from 0 to 72. Among 94 patients who tested positive for MDR Ab and underwent CXR (males 52.9%, females 47.1%; mean age 64.2 years; range 1−90 years), 68 patients underwent both CXR and chest CT examinations. The percentage of patients with a positive CT score was significantly higher than that obtained on CXR (67.65% > 35.94%, p-value = 0.00258). CT score (21.88 ± 15.77) was significantly (p-value = 0.0014) higher than CXR score (15.06 ± 18.29). CXR and CT revealed prevalent bilateral abnormal findings mainly located in the inferior and middle zones of the lungs. They primarily consisted of peripheral ground-glass opacities and consolidations which predominated on CXR and CT, respectively.

Orbital myeloid sarcoma (chloroma): Report of 2 cases and literature review.

PURPOSE: Myeloid sarcoma (MS) of the orbit is an uncommon condition in occurring in children, generally coupled to myeloproliferative neoplasms. OBSERVATIONS: We describe two rare cases of orbital MS in young boys with aggressive local symptoms but without evidence of acute myeloid leukemia (AML), both patients underwent orbitotomy for gross-tumor resection and biopsy. At follow up, there was no evidence of recurrence nor evolution of the myeloproliferative neoplasms clinically and by radiological and laboratory work-up. We also provide a detailed description of the magnetic resonance imaging presentation, with an extensive pathological analysis correlation. CONCLUSIONS AND IMPORTANCE: A comprehensive revision of the literature on isolated orbital MS was carried out with particular emphasis on clues for differential diagnosis and treatment options, stressing the need to consider MS even in the absence of sign and symptoms of an underlying myeloproliferative disorders.