Dual-energy CT in the differentiation between adrenal adenomas and metastases: Usefulness of material density maps and monochromatic images.

OBJECTIVE: To evaluate the behavior of adrenal adenomas and metastases with dual-energy CT, analyzing the attenuation coefficient in monochromatic images at three different levels of energy (45, 70, and 140 keV) and the tissue concentrations of fat, water, and iodine in material density maps, with the aim of establishing optimal cutoffs for differentiating between these lesions and comparing our results against published evidence. MATERIALS AND METHODS: This retrospective case-control study included oncologic patients diagnosed with adrenal metastases in the 6-12 months prior to the study who were followed up in our hospital between January and June 2020. For each case (patient with metastases) included in the study, we selected a control (patient with an adrenal adenoma) with a nodule of similar size. All patients were studied with a rapid-kilovoltage-switching dual-energy CT scanner, using a biphasic acquisition protocol. We analyzed the concentration of iodine in paired water-iodine images, the concentration of fat in the paired water-fat images, and the concentration of water in the paired iodine-water and fat-water images, in both the arterial and portal phases. We also analyzed the attenuation coefficient in monochromatic images (at 55, 70, and 140 keV) in the arterial and portal phases. RESULTS: In the monochromatic images, in both the arterial and portal phases, the attenuation coefficient at all energy levels was significantly higher in the group of patients with metastases than in the group of patients with adenomas. This enabled us to calculate the optimal cutoffs for classifying lesions as adenomas or metastases, except for the arterial phase at 55 KeV, where the area under the receiver operating characteristic curve (AUC) for the estimated threshold (0.68) was not considered accurate enough to classify the lesions. For the arterial phase at 70 keV, the AUC was 0.76 (95% CI: 0.663‒0.899); the optimal cutoff (42.4 HU) yielded 92% sensitivity and 60% specificity. For the arterial phase at 140 keV, the AUC was 0.94 (95% CI: 0.894‒0.999); the optimal cutoff (18.9 HU) yielded 88% sensitivity and 94% specificity). For the portal phase at 55 keV, the AUC was 0.76 (95% CI: 0.663‒0.899); the optimal cutoff (95.4 HU) yielded 68% sensitivity and 84% specificity. For the portal phase at 70 keV, the AUC was 0.82 (95% CI: 0.757‒0.955); the optimal cutoff (58.4 HU) yielded 80% sensitivity and 84% specificity. For the portal phase at 140 keV, the AUC was 0.9 (95% CI: 0.834‒0.987); the optimal cutoff (16.35 HU) yielded 96% sensitivity and 84% specificity. In the material density maps, in the arterial phase, significant differences were found only for the iodine-water pair, where the concentration of water was higher in the group with metastases (1018.8 ±â€¯7.6 mg/cm3 vs. 998.6 ±â€¯8.0 mg/cm3 for the group with adenomas, p < 0.001). The AUC was 0.97 (95% CI: 0.893‒0.999); the optimal cutoff (1012.5 mg/cm3) yielded 88% sensitivity and 96% specificity. The iodine-water pair was also significantly higher in metastases (1019.7 ±â€¯12.1 mg/cm3 vs. 998.5 ±â€¯9.1 mg/cm3 in adenomas, p < 0.001). The AUC was 0.926 (95% CI: 0.807‒0.977); the optimal cutoff (1009.5 mg/cm3) yielded 92% sensitivity and 92% specificity. Although significant results were also observed for the fat-water pair in the portal phase, the AUC was insufficient to enable a sufficiently accurate cutoff for classifying the lesions. No significant differences were found in the fat-water maps or iodine-water maps in the arterial or portal phase or in the water-fat map in the arterial phase. CONCLUSIONS: Monochromatic images show differences between the behavior of adrenal adenomas and metastases in oncologic patients studied with intravenous-contrast-enhanced CT, where the group of metastases had higher attenuation than the group of adenomas in both the arterial and portal phases; this pattern is in line with the evidence published for adenomas. Nevertheless, to our knowledge, no other publications report cutoffs for this kind of differentiation in contrast-enhanced monochromatic images obtained in rapid-kilovoltage-switching dual-energy CT scanners, and this is the first new contribution of our study. Regarding the material density maps, our results suggest that the water-iodine pair is a good tool for differentiating between adrenal adenomas and metastases, in both the arterial and portal phases. We propose cutoffs for differentiating these lesions, although to our knowledge no cutoffs have been proposed for portal-phase contrast-enhanced images obtained with rapid-kilovoltage-switching dual-energy CT scanners.

Relevance of subclinical right ventricular dysfunction measured by feature-tracking cardiac magnetic resonance in non-ischemic dilated cardiomyopathy.

BACKGROUND: Right ventricular (RV) dysfunction in patients with non-ischemic dilated cardiomyopathy (NICM) is associated with cardiovascular events. To analyze the feasibility of assessing RV myocardial deformation by feature tracking (FT)-cardiac magnetic resonance (CMR), and its usefulness as a prognostic marker. METHODS: Retrospective study of NICM patients undergoing CMR. Longitudinal FT-RV free wall (LFT-RVFW) and fractional area change (FAC) were obtained. Correlation with standard RV parameters was studied. An association with combined event (heart failure (HF), ICD implantation or cardiovascular death) was assessed using a logistic regression model. RESULTS: 98 patients (64 ± 13 years) were included. Left ventricular (LV) systolic function (LVEF 29.5 ± 9.6%, 47% with LVEF ≥ 30%) and RV (RVEF 52.2 ± 14.6%, 72% with RVEF ≥ 45%). Follow-up of 38 ± 17 months, 26.5% presented at least one admission for HF. An excellent correlation of LFT-RVFW (r = 0.82) and FAC (r = 0.83) with RVEF was evident. No association of RV-FT parameters with prognosis entire study population was found. However, in patients with LVEF ≥ 30%, admissions for HF were associated with lower LFT-RVFW (-21.6 ± 6.6% vs -31.3 ± 10%; p = 0.006) and FAC (36.6 ± 9.6% vs 50.5 ± 13.4%; p < 0.001) values. Similar differences were observed when only patients with RVEF ≥ 45% were considered. An LFT-RVFW cut-off point of -19.5% and FAC of 36.5% showed good prognostic performance. Decreased LFT-RVFW or FAC represented an independent predictor of combined event in patients with LVEF ≥ 30%. CONCLUSIONS: In NICM patients without severe LV dysfunction, decreased values of LFT-RVFW and/or FAC were associated with HF admissions, independently of RVEF.

Pseudotrombo en ventrículo izquierdo. "Imagen fantasma" en tomografía axial computarizada. Diagnóstico multimodalidad / Left ventricular pseudothrombus: multimodality imaging rules out a "ghost image" of a thrombus seen on cardiac computed tomography

Varón de 57 años con antecedente de infarto de miocardio anterior. En una tomografía axial computarizada (TAC) cardíaca realizada 3 años más tarde, se objetiva una imagen hipodensa en el ápex del ventrículo izquierdo. Ante la sospecha de trombo, se completa el estudio mediante resonancia magnética cardíaca (RMC) con gadolinio, ecocardiografía transtorácica (ETT) 2D con ecopotenciador y ETT tridimensional. A través de la imagen multimodalidad se comprueba la ausencia de trombo

Cardiac computed tomography showed a hypodense area in the apex of the left ventricle in a 57-year-old man with a history of anterior myocardial infarction three years earlier. To confirm or rule out a suspected thrombus, he underwent gadolinium-enhanced cardiac magnetic resonance imaging, contrast-enhanced two-dimensional transthoracic echocardiography, and three-dimensional transthoracic echocardiography. Multimodality imaging ruled out the presence of a thrombus

Left ventricular pseudothrombus: multimodality imaging rules out a "ghost image" of a thrombus seen on cardiac computed tomography. / Pseudotrombo en ventrículo izquierdo. "Imagen fantasma" en tomografía axial computarizada. Diagnóstico multimodalidad.

Cardiac computed tomography showed a hypodense area in the apex of the left ventricle in a 57-year-old man with a history of anterior myocardial infarction three years earlier. To confirm or rule out a suspected thrombus, he underwent gadolinium-enhanced cardiac magnetic resonance imaging, contrast-enhanced two-dimensional transthoracic echocardiography, and three-dimensional transthoracic echocardiography. Multimodality imaging ruled out the presence of a thrombus.

Correlación neurorradiológica de las afasias. Mapa cortico-subcortical del lenguaje / Neuroradiologic correlation with aphasias. Cortico-subcortical map of language

La afasia es una alteración adquirida del lenguaje debida a una lesión cerebral, que se caracteriza por errores en la producción, la denominación o la comprensión del lenguaje. Aunque la mayoría de las afasias suelen ser mixtas, desde un punto de vista práctico se clasifican en diferentes tipos según sus rasgos clínicos principales: afasia de Broca, afasia de Wernicke, afasia de conducción, afasia transcortical y alexia con o sin agrafia. Presentamos los hallazgos clínicos de los principales subtipos representándolos con casos radiológicos, y proporcionamos una revisión actualizada de la red del lenguaje con imágenes de resonancia funcional y de tractografía

Aphasia is an acquired language disorder due to a cerebral lesion; it is characterized by errors in production, denomination, or comprehension of language. Although most aphasias are mixed, from a practical point of view they are classified into different types according to their main clinical features: Broca's aphasia, Wernicke's aphasia, conduction aphasia, transcortical aphasia, and alexia with or without agraphia. We present the clinical findings for the main subtypes of aphasia, illustrating them with imaging cases, and we provide an up-to-date review of the language network with images from functional magnetic resonance imaging and tractography

Neuroradiologic correlation with aphasias. Cortico-subcortical map of language. / Correlación neurorradiológica de las afasias. Mapa cortico-subcortical del lenguaje.

Aphasia is an acquired language disorder due to a cerebral lesion; it is characterized by errors in production, denomination, or comprehension of language. Although most aphasias are mixed, from a practical point of view they are classified into different types according to their main clinical features: Broca's aphasia, Wernicke's aphasia, conduction aphasia, transcortical aphasia, and alexia with or without agraphia. We present the clinical findings for the main subtypes of aphasia, illustrating them with imaging cases, and we provide an up-to-date review of the language network with images from functional magnetic resonance imaging and tractography.

Mapa cortical y subcortical del lenguaje. Correlación de la resonancia magnética funcional y tractografía en 3 T con la estimulación intraoperatoria cortical y subcortical en tumores cerebrales localizados en áreas elocuentes / Cortical and subcortical mapping of language areas: correlation of functional MRI and tractography in a 3 T scanner with intraoperative cortical and subcortical stimulation in patients with brain tumors located in eloquent areas

Objetivo. Describir, con estudios funcionales de activación y tractografía en una RM de 3 Teslas (3 T), las áreas corticales y vías subcorticales implicadas en el lenguaje, y mostrar la buena correlación de estos estudios funcionales con la estimulación directa cortical y subcortical intraoperatoria. Material y métodos. Presentamos una serie de 14 pacientes con lesiones focales cerebrales junto a áreas elocuentes. Todos los pacientes se evaluaron neuropsicológicamente antes y después de la cirugía, se estudiaron con RM con secuencias estructurales, de perfusión, espectroscopia, resonancia magnética funcional y del lenguaje y tractografía 3D, y se sometieron a un mapeo cortical de estimulación cortical y subcortical y resección de la lesión. Se hizo un control posquirúrgico a las 24 h. Resultados. La correlación funcional motora y del haz corticoespinal con el mapeo intraoperatorio cortical y subcortical motor fue completa. Las áreas elocuentes del lenguaje expresivo y del lenguaje receptivo presentaron una alta correlación con el mapeo cortical intraoperatorio en todos los casos menos 2, un glioma infiltrativo de alto grado y un glioma de bajo grado frontal. La tractografía 3D identificó los fascículos arcuato, frontoparietal, subcalloso, frontooccipital inferior y las radiaciones ópticas, lo que permitió marcar los límites de la resección. La correlación con el mapeo subcortical en la disposición anatómica de los fascículos con respecto a las lesiones, fue completa. Conclusión. La máxima resección tumoral sin déficits asociados es el mejor tratamiento posible ante un tumor cerebral, lo que resalta la necesidad de estudios funcionales de alta calidad en la planificación prequirúrgica (AU)

Objective: To describe the detection of cortical areas and subcortical pathways involved in language observed in MRI activation studies and tractography in a 3 T MRI scanner and to corre- late the findings of these functional studies with direct intraoperative cortical and subcortical stimulation. Material and methods: We present a series of 14 patients with focal brain tumors adjacent to eloquent brain areas. All patients underwent neuropsychological evaluation before and after surgery. All patients underwent MRI examination including structural sequences, perfusion imaging, spectroscopy, functional imaging to determine activation of motor and language areas, and 3D tractography. All patients underwent cortical mapping through cortical and subcortical stimulation during the operation to resect the tumor. Postoperative follow-up studies were done 24 hours after surgery. Results: The correlation of motor function and of the corticospinal tract determined by functional MRI and tractography with intraoperative mapping of cortical and subcortical motor areas was complete. The eloquent brain areas of language expression and reception were strongly correlated with intraoperative cortical mapping in all but two cases (a high grade infiltrating glioma and a low grade glioma located in the frontal lobe). 3D tractography identified the arcuate fasciculus, the lateral part of the superior longitudinal fasciculus, the subcallosal fasciculus, the inferior fronto-occipital fasciculus, and the optic radiations, which made it possible to mark the limits of the resection. The correlation with the subcortical mapping of the anatomic arrangement of the fasciculi with respect to the lesions was complete. Conclusion: The best treatment for brain tumors is maximum resection without associated deficits, so high quality functional studies are necessary for preoperative planning (AU)

Cortical and subcortical mapping of language areas: correlation of functional MRI and tractography in a 3T scanner with intraoperative cortical and subcortical stimulation in patients with brain tumors located in eloquent areas.

OBJECTIVE: To describe the detection of cortical areas and subcortical pathways involved in language observed in MRI activation studies and tractography in a 3T MRI scanner and to correlate the findings of these functional studies with direct intraoperative cortical and subcortical stimulation. MATERIAL AND METHODS: We present a series of 14 patients with focal brain tumors adjacent to eloquent brain areas. All patients underwent neuropsychological evaluation before and after surgery. All patients underwent MRI examination including structural sequences, perfusion imaging, spectroscopy, functional imaging to determine activation of motor and language areas, and 3D tractography. All patients underwent cortical mapping through cortical and subcortical stimulation during the operation to resect the tumor. Postoperative follow-up studies were done 24 hours after surgery. RESULTS: The correlation of motor function and of the corticospinal tract determined by functional MRI and tractography with intraoperative mapping of cortical and subcortical motor areas was complete. The eloquent brain areas of language expression and reception were strongly correlated with intraoperative cortical mapping in all but two cases (a high grade infiltrating glioma and a low grade glioma located in the frontal lobe). 3D tractography identified the arcuate fasciculus, the lateral part of the superior longitudinal fasciculus, the subcallosal fasciculus, the inferior fronto-occipital fasciculus, and the optic radiations, which made it possible to mark the limits of the resection. The correlation with the subcortical mapping of the anatomic arrangement of the fasciculi with respect to the lesions was complete. CONCLUSION: The best treatment for brain tumors is maximum resection without associated deficits, so high quality functional studies are necessary for preoperative planning.

Papel de las técnicas de imagen en la nueva clasificación TNM del carcinoma broncogénico no microcítico / Role of imaging techniques in the TNM classification of non-small cell bronchogenic carcinoma

La séptima edición de la clasificación TNM para los carcinomas broncogénicos no microcíticos incluye una serie de cambios en los descriptores T y M, particularmente una reclasificación de los derrames malignos pleurales y pericárdicos y de los nódulos tumorales separados, nuevos valores de corte de tamaño tumoral y subdivisiones de las categorías T1-T2 y M1. Revisamos estas correcciones, que generan cambios en el sistema de estadificación que afectan a los estadios II-III. Además, describimos e ilustramos el papel de las diferentes técnicas de imagen en la estadificación tumoral (TC, PET, PET-TC y RM), resaltando sus respectivas indicaciones, ventajas y desventajas, así como su función complementaria (AU)

The Seventh Edition of the TNM Classification for non-small cell bronchogenic carcinomas include a series of changes in the T and M descriptor, in particular a re-classification of malignant pleural and pericardial effusions and of separated tumour nodes, new tumour size cut-off values and sub-divisions of the T1-T2 and M1 categories. We review these corrections that led to the changes in the staging system that affects stages II-III. Furthermore, we describe and illustrate the role of the different imaging techniques in tumour staging (CT, PET, PET-CT and MRI), highlighting their respective indications, advantages and disadvantages, as well their complementary function (AU)

[Role of imaging techniques in the TNM classification of non-small cell bronchogenic carcinoma]. / Papel de las técnicas de imagen en la nueva clasificación TNM del carcinoma broncogénico no microcítico.

The Seventh Edition of the TNM Classification for non-small cell bronchogenic carcinomas include a series of changes in the T and M descriptor, in particular a re-classification of malignant pleural and pericardial effusions and of separated tumour nodes, new tumour size cut-off values and sub-divisions of the T1-T2 and M1 categories. We review these corrections that led to the changes in the staging system that affects stages II-III. Furthermore, we describe and illustrate the role of the different imaging techniques in tumour staging (CT, PET, PET-CT and MRI), highlighting their respective indications, advantages and disadvantages, as well their complementary function.

Resonancia magnética en flexoextensión en el diagnóstico de la mielopatía cervical en la enfermedad de Hirayama / MRI in flexed and extended positions for the diagnosis of cervical myelopathy in Hirayama's disease

Se expone el caso de un varón joven que debutó con atrofia de la musculatura del antebrazo y mano derechos, en el que el clínico, sospechando esta entidad, y basándose en los hallazgos electromiográficos, recomendó la realización de una resonancia magnética cervical en posición neutra y en flexión, objetivándose los principales signos radiológicos típicos de esta etiología, lo que concretó el diagnóstico. Los hallazgos claves de la enfermedad de Hirayama constituyen la atrofia medular asimétrica con afección de astas anteriores, despegamiento dorsal de la duramadre y dilatación del plexo venoso epidural (AU)

We report the case of a young man who presented with atrophy of the musculature of theright forearm and hand. The clinician suspected cervical myelopathy in Hirayama’s diseaseon the basis of the findings at electromyography and recommended an MRI examinationinboth flexed and neutral position. The typical imaging findings for cervical myelopathy inHirayama’s disease were observed and the diagnosis was confirmed. The key findingsfor Hirayama’s disease consist of a symmetrical medullary atrophy with involvement of theanterior horns, dorsal detachment of the duramater, and dilatation of the epidural venous plexus (AU)

Sinus pericranii / Sinus pericranii

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[Orbital vasculonervous network and orbital surgical compartments by high field magnetic resonance]. / Dotación vasculonerviosa y espacios anatomoquirúrgicos de la órbita por resonancia magnética de alto campo.

PURPOSE: To elucidate the possibilities and indications of high-resolution magnetic resonance imaging (MRI) in the study of the orbit and its contents. METHODS: Orbital anatomy was studied in sliced specimens of fifteen fresh frozen cadavers and the results were compared with those obtained in thirty asymptomatic subjects who underwent a magnetic resonance with 1.5 Tesla equipment. The information obtained was used to interpret the findings in twenty-two patients with various orbital diseases. RESULTS: High-resolution MRI allows visualization of structures difficult to assess previously, like the cerebrospinal fluid (CSF) surrounding the optic nerve, the complete intraorbital route and the exit of the third cranial nerve, the ophthalmic artery and the intraorbital relationships of the sixth cranial nerve, which can be clearly differentiated from the lateral rectus muscle. CONCLUSIONS: High-resolution MRI is a very useful tool for the study of the orbit and its content. It provides accurate diagnoses through non-invasive procedures and facilitates the planning of the surgical approaches by improving the visualization of pathologic orbital structures. lcarlos@correo.uniovi.es