Renal Cell Carcinoma: Accuracy of Multidetector Computed Tomography in the Assessment of Renal Sinus Fat Invasion.

PURPOSE: The purpose of this study was to evaluate the accuracy of multidetector computed tomography (MDCT) in the preoperative assessment of renal sinus fat invasion (RSFI) in patients with renal cell carcinoma (RCC) and to assess imaging features that improve detection of RSFI on CT. METHODS: This is a single-institution retrospective review of 53 consecutive patients with histologically proven RCC who underwent triple-phase preoperative contrast MDCT prior to partial or radical nephrectomy. Two experienced radiologists (R1 and R2), blinded to the final histology result, independently reviewed the preoperative MDCT studies to assess for RSFI. Histopathology was used as the gold standard for the presence of RSFI. RESULTS: Of 55 surgically resected RCCs that were evaluated with contrast-enhanced MDCT, 34.5% (19/55) of RCCs had RSFI on final histopathology. Multidetector CT demonstrated high sensitivity (R1, 100%; R2, 93.7%) for the detection of RSFI, but a low positive predictive value (R1, 40%; R2, 53%) and specificity (R1, 38.4%; R2, 66.6%). Interreader agreement for RSFI was moderate (κ = 0.56). Renal tumors were significantly larger in cases with RSFI (6.3 ± 3.219 cm) than tumors without RSFI (4.1 ± 2.9 cm) (P = 0.0275). Renal sinus fat invasion was more commonly associated to an irregular tumor margin at the tumor renal sinus fat interface (P < 0.001). CONCLUSIONS: Multidetector computed tomography demonstrates a high sensitivity but low positive predictive value in diagnosing RSFI with implications for prognosis and treatment planning. Tumor size, location, irregular tumor margin at the tumor/renal sinus interface, and invasion into pelvicaliceal structures can aid in the diagnosis of RSFI on preoperative MDCT.

Frequency of nonthromboembolic imaging abnormalities in pregnant women referred for computed tomography pulmonary arteriography.

PURPOSE: The study sought to determine the frequency of nonthromboembolic imaging abnormalities in pregnant women referred for computed tomography pulmonary arteriography (CTPA). MATERIALS AND METHODS: CTPA studies on 100 consecutive pregnant women performed over a 5-year period were reviewed independently by 2 radiologists, with conflicts resolved by consensus. Age range was 18-43 years (mean 28 years). The presence or absence of pulmonary embolism and of nonthromboembolic imaging abnormalities was recorded. These were graded as A if the abnormalities were thought to provide potential alternative explanations for acute symptoms, B if findings were incidental that required clinical or radiologic follow-up, and C if the findings did not require further action. RESULTS: Pulmonary embolism was seen in 5 women. In 2 of these additional findings of consolidation and infarction were seen. Ninety-five women did not have pulmonary embolism. Eleven women (12%) had grade A abnormalities; 6 cases of consolidation, 2 cases of lobar collapse, and 3 cases of heart failure with pleural effusions. One woman had a grade B abnormality due to the presence of pulmonary nodules. Ten women had incidental grade C abnormalities. CONCLUSION: Pulmonary embolism occurs in 5% of pregnant women referred for CTPA. In pregnant women without embolism on CTPA, potential alternative causes for patient symptoms are seen on CT in 12% of cases.

Catheter directed thrombolysis and mechanical intervention in deep venous thrombosis: What is the status after the ATTRACT Trial?

Deep venous thrombosis (DVT) is a major cause of acute and chronic morbidity, mortality, and increased healthcare costs. Endovascular methods for thrombus removal and reestablishing venous patency are increasing in both scope and usage. The most commonly used method for endovascular thrombectomy is catheter-directed thrombolysis (CDT). Several studies have shown promise for CDT in alleviating acute symptomatology in acute lower extremity DVT as well as mitigating potential long-term consequences of DVT, such as post-thrombotic syndrome (PTS). The Acute Venous Thrombosis: Thrombus Removal with Adjunctive Catheter-Directed Thrombolysis (ATTRACT) trial is the largest and most comprehensive randomized-controlled trial to date evaluating CDT compared to anticoagulation alone for the treatment of acute symptomatic proximal lower extremity DVT. This review discusses the current status of CDT and adjunctive endovascular interventions for DVT, particularly in the context of the ATTRACT trial.

MR imaging of spinal haematoma: a pictorial review.

Spinal haematoma is a rare occurrence, however has the potential to cause significant spinal injury and morbidity. MRI is the gold-standard of investigation, and urgent imaging is required for early diagnosis and treatment to ensure best patient outcomes. We present a pictorial review demonstrating the imaging features of spinal haematoma based on meningeal space assignment; epidural, subdural, subarachnoid, intramedullary and a combination of these locations. In this review, we summarise the literature and imaging findings of spinal haematoma on MRI. Particular imaging features which help to differentiate between haematoma in the different spinal meningeal compartments are discussed below.

"Mixed" trauma to the carotid artery in a mixed martial arts injury - A case report and review of the literature.

We present the case of a mixed martial arts (MMA) cage fighter who presented to the emergency department with a right sided common carotid artery pseudoaneurysm as a result of a neck trauma at an MMA event. We discuss the management of blunt force neck trauma, differential diagnosis, imaging findings and review the literature on blunt cerebrovascular injury following blunt force injury to the neck.

Water-enhanced antegrade MR pyelography in pregnancy: a novel radiation-free approach.

Our aim was to determine if water-enhanced antegrade magnetic resonance (MR) pyelography can be an alternative to conventional antegrade pyelography in pregnant patients who require percutaneous nephrostomy placement for urosepsis and/or obstructive uropathy. The pregnant patient was placed supine in a 1.5-T MRI scanner seven days after percutaneous nephrostomy placement using ultrasound. Serial axial and coronal T2-weighted echo-planar fast spin-echo sequences were performed before and after injection of the catheter. The right nephrostomy catheter hub was sterilised using chlorhexidine. Sixty millilitres of sterile water were slowly injected. No Gd-based contrast agent was utilised due to safety concerns for the foetus. MR antegrade pyelography demonstrated the level of ureteric obstruction and the absence of renal calculi using sterile water as a contrast medium injected through a percutaneous nephrostomy followed by T2-weighted imaging. Air bubbles in the injected solution were differentiated from calculi due to their mobility on serial scans and their anti-dependent position. Water-enhanced antegrade MR pyelography was a safe and effective method of imaging the pregnant patient. It served as an alternative to conventional antegrade pyelography and minimised potential risks to the foetus.

Novel Use of a Pneumatic Compression Device for Haemostasis of Haemodialysis Fistula Access Catheterisation Sites.

PURPOSE: Transradial pneumatic compression devices can be used to achieve haemostasis following radial artery puncture. This article describes a novel technique for acquiring haemostasis of arterio-venous haemodialysis fistula access sites without the need for suture placement using one such compression device. MATERIALS AND METHODS: A retrospective review of fistulograms with or without angioplasty/thrombectomy in a single institution was performed. 20 procedures performed on 12 patients who underwent percutaneous intervention of failing or thrombosed arterio-venous fistulas (AVF) had 27 puncture sites. Haemostasis was achieved using a pneumatic compression device at all access sites. Procedure details including size of access sheath, heparin administration and complications were recorded. RESULTS: Two diagnostic fistulograms, 14 fistulograms and angioplasties and four thrombectomies were performed via access sheaths with an average size (±SD) of 6 Fr (±1.12). IV unfractionated heparin was administered in 11 of 20 procedures. Haemostasis was achieved in 26 of 27 access sites following 15-20 min of compression using the pneumatic compression device. One case experienced limited bleeding from an inflow access site that was successfully treated with reinflation of the device for a further 5 min. No other complication was recorded. CONCLUSIONS: Haemostasis of arterio-venous haemodialysis fistula access sites can be safely and effectively achieved using a pneumatic compression device. This is a technically simple, safe and sutureless technique for acquiring haemostasis after AVF intervention.

Intraductal papillary mucinous neoplasm of the pancreas: can benign lesions be differentiated from malignant lesions with multidetector CT?

Intraductal papillary mucinous neoplasm (IPMN) of the pancreas is a distinct clinicopathologic entity that is being recognized with increasing frequency. In 25%-44% of IPMNs treated with surgical resection, associated invasive carcinoma has been reported. Surgical resection is the treatment of choice for most IPMNs. Preoperative determination of the presence or absence of associated invasive carcinoma is crucial. The prognosis is worse if there is associated invasive carcinoma; when invasive carcinoma is present, the surgical procedure may be modified to include resection of regional lymph nodes. The spectrum of appearances of IPMN, which includes adenoma, borderline lesion, and lesions with associated carcinoma in situ or invasive carcinoma, was studied with 16-section multidetector computed tomography (CT) and histologic correlation. CT was performed with dual-phase acquisition; the reconstructed images were reviewed on a workstation with axial scrolling and interactive multiplanar reformation and three-dimensional reformation techniques. Features predictive of invasive carcinoma in IPMN at CT and other imaging studies include involvement of the main pancreatic duct, marked dilatation of the main pancreatic duct, diffuse or multifocal involvement, the presence of a large mural nodule or solid mass, large size of the mass, and obstruction of the common bile duct.

Adult ureteropelvic junction obstruction: insights with three-dimensional multi-detector row CT.

Ureteropelvic junction obstruction (UPJO) is a benign, congenital condition that remains an enigma in terms of both diagnosis and therapy. On the basis of a series of cases that were referred to the authors in their clinical practice, they found that the unprecedented quality and novel perspectives of multi-detector row computed tomography (CT) with two- and three-dimensional postprocessing allow a comprehensive, single-study assessment of the ureterovascular relationships in UPJO. This topic is important because the causative role of crossing vessels may be questioned on the basis of such studies, and the therapeutic approach may be altered by using precise anatomic images customized to the pathologic features of the individual patient. Although CT images can provide only circumstantial or supportive evidence of the pathophysiology of UPJO, they greatly facilitate therapeutic intervention when it is clinically indicated and may eliminate the need for it in select cases. Careful attention to the postprocessing of CT images may show that the crossing vasculature has no direct relationship to the transition point of the UPJO in many cases.

Pulmonary capillary hemangiomatosis: multidetector row CT findings and clinico-pathologic correlation.

Pulmonary capillary hemangiomatosis (PCH) is a rare potentially fatal cause of post-capillary pulmonary hypertension. We present a case demonstrating the CT imaging features of the underlying capillary proliferation and invasion of alveoli and vasculature.

MR imaging of the bladder.

MR imaging of the bladder can now be routinely and easily performed with consistent quality. The latest techniques provide high-resolution images of the soft tissue contrast and the ability to perform dynamic contrast imaging and functional pelvic floor studies. MR imaging fits in as a complimentary tool to cystoscopy and to conventional pelvic floor dynamic studies and can provide a unique imaging perspective of the bladder. It is important, however, to remain cognizant of the limitations of its use in tumor detection and discrimination.

Thoracic venous anatomy multidetector row CT evaluation.

Two-dimensional CT angiography provides much information of the systemic and pulmonary thoracic veins. The combination of MDCT and volume-rendering techniques postprocessing provides higher-quality data sets and a method fully to harness the potential for image display and interpretation. Although this may not radically alter sensitivity for detection of systemic or pulmonary venous pathology it does provide a more comprehensive and sophisticated evaluation through volume acquisition and interpretation.

CT findings in sclerosing mesenteritis (panniculitis): spectrum of disease.

Sclerosing mesenteritis is a complex inflammatory disorder of the mesentery. Although sclerosing mesenteritis is often associated with other idiopathic inflammatory disorders such as retroperitoneal fibrosis, sclerosing cholangitis, Riedel thyroiditis, and orbital pseudotumor, its exact cause is unknown. The computed tomographic (CT) appearance of sclerosing mesenteritis will vary depending on the predominant tissue component (fat, inflammation, or fibrosis). CT plays an important role in suggesting the diagnosis in the proper clinical setting and can be useful in distinguishing sclerosing mesenteritis from other mesenteric diseases with similar CT features such as carcinomatosis, carcinoid tumor, lymphoma, desmoid tumor, and mesenteric edema. Nevertheless, surgical biopsy and pathologic analysis are usually necessary to make the diagnosis. Treatment may consist of therapy with steroids, colchicine, immunosuppressive agents, or orally administered progesterone. Surgical resection is sometimes attempted for definitive therapy, although the surgical approach is often limited by vascular involvement. CT with three-dimensional volume rendering is optimal for accurate, noninvasive follow-up of sclerosing mesenteritis and of any potential complications.

Peripancreatic masses that simulate pancreatic disease: spectrum of disease and role of CT.

A number of entities can simulate pancreatic disease at computed tomography (CT), which may lead to misdiagnosis. Common pitfalls include peripancreatic lesions of the foregut, adrenal gland, and kidney as well as disease of the mesentery and neurovascular structures. Optimal design and application of multi-detector row CT protocols with multiplanar reformation and maximum-intensity-projection and volume-rendering postprocessing improves the specificity of image interpretation. In most cases, helical CT is highly accurate for distinguishing primary disease of the pancreas from adjacent disease, although there are cases in which the differential diagnosis is more challenging and the potential for misdiagnosis still exists. Familiarity with some of the entities that can simulate pancreatic disease, careful attention to scanning protocol and contrast material administration, use of the full potential of multi-detector row CT data sets, and judicious application of postprocessing tools may help avoid some of the pitfalls caused by peripancreatic lesions.

Multi-detector row CT evaluation of living renal donors prior to laparoscopic nephrectomy.

Since its introduction in 1995, laparoscopic nephrectomy has become the preferred technique at many medical centers for the harvesting of kidneys from living donors for transplantation. Because the field of view at laparoscopic surgery is limited, preoperative radiologic evaluation of the donor's anatomy---the renal veins and arteries, collecting system, and parenchyma--is critical. Spiral computed tomographic (CT) angiography is a fast, safe, minimally invasive, and generally accepted method for preoperative evaluation of the renal vessels. Multi-detector row CT scanners offer shorter image acquisition time, narrower collimation, better spatial resolution, and less tube heating than do single-detector row CT scanners. Multi-row scanners also provide more complete anatomic coverage, increased contrast enhancement of the arteries, and greater longitudinal spatial resolution--all of which are important both for accurate imaging of the renal vasculature and for three-dimensional postprocessing of image data. Dual-phase multi-detector row CT angiography combined with three-dimensional postprocessing enables minimally invasive and highly accurate depiction of the preoperative donor anatomy. To make the most effective use of this method, radiologists must be familiar with its technical aspects, advantages, and potential pitfalls. They also must be able to identify variations in vasculature and in renal and extrarenal anatomy that are important for laparoscopic donor nephrectomy.

Multidetector row computed tomography of the aorta and peripheral arteries.

MDCT represents a significant advance on SDCT and the advantages it brings are particularly clear in CTA applications. It allows cost effective assessment of longer segments of vascular territories to be imaged with higher spatial, contrast, and temporal resolution. It has replaced SDCT as the new CT standard and its technical abilities are rapidly approaching the temporal resolution of EBCT. With 3-D post processing tools its main benefit is in imaging studies customized to the patient's pathology, with greater measurement accuracy and reliable longitudinal assessment. MDCTA is increasingly applied not to individual vascular territories but to a complete assessment dictated by the pathology, such as the entire aorta and branch vessels in aneurysm evaluation and the aorta and the coronary arteries in dissection cases or the vascular and non-vascular chest in acute chest pain. Greater accuracy of vessel assessment will lead to a refinement of interventional and surgical techniques for an individual patient and facilitates conservative management of conditions that can be reliably monitored non-invasively and the development of intervention criteria. MDCTA will continue to increase its major role in peripheral vascular evaluation in the future though its reliability in assessing small vessels below the knee and in the foot remains to be conclusively proven to obviate the need for diagnostic catheter angiography.

Plasmacytoma with involvement of the urinary bladder. Report of a case diagnosed by urine cytology.

BACKGROUND: Plasmacytoma of the bladder is a rare but important entity. We report a case of plasmacytoma of the bladder that was diagnosed by urinary cytology. CASE: A 71-year-old male with a history of multiple myeloma presented in renal failure. Renal ultrasound revealed right-sided, moderate hydronephrosis with a 4 x 4-cm, posterolateral, obstructing mass. Magnetic resonance imaging demonstrated a bladder mass involving the bladder base, right lateral wall and dome with extension into the perivesical tissues on the right. The mass showed a moderate degree of enhancement following intravenous gadolinium administration. Urine cytology was performed to evaluate for bladder carcinoma or other malignancies besides plasmacytoma. The specimen was signed out as multiple myeloma of the bladder. Cystoscopy and biopsy were subsequently performed on the bladder mass. The diagnosis of plasmocytoma was made, confirming the urine cytology diagnosis. CONCLUSION: Urinary cytology can be a diagnostic tool for plasmocytoma involving the bladder.

Multidetector row computed tomography with volume rendering--an aid to understanding pelvic anatomy and disease.

Recent progress in computed tomography (CT) imaging has included multidetector row CT and volume rendering 3-dimensional post processing platforms. The growth in each of these areas has been synergistic and has offered new avenues for the formation and interpretation of diagnostic CT imaging studies. There is untapped added information in a conventional 2-dimensional axial planar pelvis study that may be harnessed with these tools. This article seeks to review the principles and application of these techniques when images of the normal pelvis are obtained. It is hoped the reader will gain insight into the design of such studies and an enhanced appreciation of the anatomic features routinely obtained on conventional CT studies.

Endovascular management of an acquired aortobronchial fistula following aortic bypass for coarctation.

Aortobronchial fistula (ABF) in the setting of aortic coarctation repair is very rare but uniformly fatal if untreated. Endovascular stenting of the descending aorta is now the first-choice approach for ABF presenting with haemoptysis and offers a less-invasive technique with improved outcomes, compared with open repair. We report a case of late ABF occurring following bypass for aortic coarctation. Management focused on two key manoeuvres: use of a covered endovascular stent to occlude the aortic bypass thus controlling the fistula and dilatation and stenting of native coarctation.