The assessment of atlantoaxial joint involvement in patients with rheumatoid arthritis, results from an observational "real-life" study.

Atlantoaxial joint is a possible affected site during rheumatoid arthritis (RA) and, in this work, we evaluated its occurrence and associated characteristics in a "real-life" cohort. By a medical records review study of RA patients longitudinally followed-up, the occurrence of severe atlantoaxial joint involvement was estimated (incidence proportion and incidence rate per 1000 person-years at risk). Regression analyses were also exploited to evaluate possible associated factors. Based on these findings, a prospective recruitment was performed to build a descriptive cross-sectional study in evaluating a subclinical atlantoaxial joint involvement in patients with the same clinical characteristics. Retrospectively, 717 patients (female 56.6%, age 64.7 ± 12.3 years) were studied. The incidence proportion of severe atlantoaxial joint involvement was 2.1% [1.5-2.5], occurring in 15 out of 717 patients, and identified by both MRI and CT scan. Considering over 3091 person-years, an incidence rate of 5.2 × 1000 [2.9-8.3] person-years was estimated. Regression analyses suggested that male gender, a longer disease duration, ACPA positivity and extra-articular manifestations resulted to be significantly associated with a severe atlantoaxial joint involvement. Given these findings, 30 asymptomatic patients were selected according to these clinical characteristics and underwent MRI of cervical spine. To date, almost 50% of these asymptomatic patients showed a subclinical atlantoaxial joint involvement. The occurrence of the severe atlantoaxial joint involvement in RA patients was estimated in a "real-life" setting. Male gender, ACPA positivity, long disease duration, and extra-articular manifestations could be associated with the severe atlantoaxial joint involvement in RA. MRI could provide a useful clinical tool to early evaluate the atlantoaxial joint involvement in RA, also in asymptomatic patients.

White matter hyperintensities in migraine are not mediated by a dysfunction of the glymphatic system-A diffusion tensor imaging magnetic resonance imaging study.

OBJECTIVE: We assessed whether brain magnetic resonance imaging (MRI) markers of glymphatic function are altered in patients with migraine and brain white matter hyperintensities (WMHs). BACKGROUND: The glymphatic system is responsible for the outflow of waste products from the brain. An impaired glymphatic system has been associated with WMH; however, this impairment has not been shown in patients with migraine. METHODS: The present cross-sectional study included consecutive patients with migraine from a single tertiary headache center. Glymphatic function was assessed by measuring the diffusion tensor imaging along the perivascular space (DTI-ALPS) technique, resulting in an index value. WMHs were assessed and quantified by using the Scheltens semi-quantitative score. RESULTS: We included 147 patients (120 women [81.6%]) with a median (interquartile range [IQR]) age of 45 (36-50) years. In all, 74 (50.3%) patients had WMHs. The median (IQR) ALPS index was similar in patients with WMHs compared with those without, at 2.658 (2.332-3.199) versus 2.563 (2.222-3.050) (p = 0.344). The Scheltens score did not correlate with ALPS index (rho = 0.112, p = 0.268). CONCLUSIONS: Our results suggest that the presence of WMHs is not associated with an impairment in the glymphatic system in patients with migraine. Although negative and worthy of further confirmation, our finding has implications for the understanding of the nature of WMH in patients with migraine.

Magnetic Resonance-guided Focused Ultrasound thalamotomy for refractory neuropathic pain: a systematic review and critical appraisal of current knowledge.

Background: Magnetic Resonance-guided Focused Ultrasound (MRgFUS) is an innovative therapeutical approach for medically refractory tremor. It is currently under investigation for other neurological diseases including refractory neuropathic pain (NP). Objective: The objective of this systematic review is to analyze available evidence about the effectiveness and safety profile of MRgFUS in the treatment of refractory NP. Methods: Eligible studies were identified by searching published studies in PubMed and Scopus databases from inception to December 2022 and by identifying ongoing studies registered on the clinicaltrials.gov website. The study was registered in PROSPERO (ID: CRD42021277154). Results: We found three published observational studies and nine ongoing studies. In published studies, the involved population ranged from 8 to 46 patients with overall 66 patients being included with NP or trigeminal neuralgia. The target lesion was in the posterior part of the central lateral nucleus of the thalamus, bilaterally. Outcomes were assessed at different times through the Visual Analog Scale, showing a variable degree of improvement. Adverse events were rare, mild, and transient (vertigo, paresthesias, and dysesthesias) with intracerebral bleeding being reported as major adverse event in one case only. Among ongoing studies, we found three prospective, randomized, sham-controlled, crossover trials (RCTs) and six observational studies. Inclusion criteria are previous failure of more than three pharmacological treatments and NP duration longer than 6 months. The thalamus is the main proposed target and measured outcomes are accuracy of the procedure and pain relief, with a follow-up period ranging from 1 week to 1 year. Conclusion: This systematic review suggests that, although high-quality studies are lacking, available evidence endorses the effectiveness and safety of MRgFUS in the management of NP. Ongoing RCTs will provide more robust data to understand benefits and risks of the procedure. Registration: PROSPERO (ID: CRD42021277154).

Tips and Tricks in Thoracic Radiology for Beginners: A Findings-Based Approach.

This review has the purpose of illustrating schematically and comprehensively the key concepts for the beginner who approaches chest radiology for the first time. The approach to thoracic imaging may be challenging for the beginner due to the wide spectrum of diseases, their overlap, and the complexity of radiological findings. The first step consists of the proper assessment of the basic imaging findings. This review is divided into three main districts (mediastinum, pleura, focal and diffuse diseases of the lung parenchyma): the main findings will be discussed in a clinical scenario. Radiological tips and tricks, and relative clinical background, will be provided to orient the beginner toward the differential diagnoses of the main thoracic diseases.

Update on the Applications of Radiomics in Diagnosis, Staging, and Recurrence of Intrahepatic Cholangiocarcinoma.

BACKGROUND: This paper offers an assessment of radiomics tools in the evaluation of intrahepatic cholangiocarcinoma. METHODS: The PubMed database was searched for papers published in the English language no earlier than October 2022. RESULTS: We found 236 studies, and 37 satisfied our research criteria. Several studies addressed multidisciplinary topics, especially diagnosis, prognosis, response to therapy, and prediction of staging (TNM) or pathomorphological patterns. In this review, we have covered diagnostic tools developed through machine learning, deep learning, and neural network for the recurrence and prediction of biological characteristics. The majority of the studies were retrospective. CONCLUSIONS: It is possible to conclude that many performing models have been developed to make differential diagnosis easier for radiologists to predict recurrence and genomic patterns. However, all the studies were retrospective, lacking further external validation in prospective and multicentric cohorts. Furthermore, the radiomics models and the expression of results should be standardized and automatized to be applicable in clinical practice.

Imaging of Bone Anatomical Variants Around the Foot and Ankle.

Different anatomical variants can be found in the ankle and foot, generally as occasional findings, although they can be the cause of diagnostic pitfalls and difficulties, especially in radiographic interpretation in trauma. These variants include accessory bones, supernumerary sesamoid bones, and accessory muscles. In most cases, they represent developmental anomalies found in incidental radiographic findings. This review discusses the main bony anatomical variants, including accessory and sesamoid ossicles, most commonly found in the foot and ankle that can be a cause of diagnostic challenges.

Recent Advances in Ultrasound Breast Imaging: From Industry to Clinical Practice.

Breast ultrasound (US) has undergone dramatic technological improvement through recent decades, moving from a low spatial resolution, grayscale-limited technique to a highly performing, multiparametric modality. In this review, we first focus on the spectrum of technical tools that have become commercially available, including new microvasculature imaging modalities, high-frequency transducers, extended field-of-view scanning, elastography, contrast-enhanced US, MicroPure, 3D US, automated US, S-Detect, nomograms, images fusion, and virtual navigation. In the subsequent section, we discuss the broadened current application of US in breast clinical scenarios, distinguishing among primary US, complementary US, and second-look US. Finally, we mention the still ongoing limitations and the challenging aspects of breast US.

Radiomics in Lung Metastases: A Systematic Review.

Due to the rich vascularization and lymphatic drainage of the pulmonary tissue, lung metastases (LM) are not uncommon in patients with cancer. Radiomics is an active research field aimed at the extraction of quantitative data from diagnostic images, which can serve as useful imaging biomarkers for a more effective, personalized patient care. Our purpose is to illustrate the current applications, strengths and weaknesses of radiomics for lesion characterization, treatment planning and prognostic assessment in patients with LM, based on a systematic review of the literature.

MR Imaging of the Lower Limb: Pitfalls, Tricks, and Tips.

The purpose of this article is to discuss most common diagnostic pitfalls of the lower limb with specific attention to the knee, ankle, and foot joints. The knowledge of normal anatomic variants, correlation with age, symptoms, and medical history together with these potential MR imaging pitfalls is fundamental for an accurate interpretation of the imaging findings of the lower limb.

Post-Surgical Imaging Assessment in Rectal Cancer: Normal Findings and Complications.

Rectal cancer (RC) is one of the deadliest malignancies worldwide. Surgery is the most common treatment for RC, performed in 63.2% of patients. The type of surgical approach chosen aims to achieve maximum residual function with the lowest risk of recurrence. The selection is made by a multidisciplinary team that assesses the characteristics of the patient and the tumor. Total mesorectal excision (TME), including both low anterior resection (LAR) and abdominoperineal resection (APR), is still the standard of care for RC. Radical surgery is burdened by a 31% rate of major complications (Clavien-Dindo grade 3-4), such as anastomotic leaks and a risk of a permanent stoma. In recent years, less-invasive techniques, such as local excision, have been tested. These additional procedures could mitigate the morbidity of rectal resection, while providing acceptable oncologic results. The "watch and wait" approach is not a globally accepted model of care but encouraging results on selected groups of patients make it a promising strategy. In this plethora of treatments, the radiologist is called upon to distinguish a physiological from a pathological postoperative finding. The aim of this narrative review is to identify the main post-surgical complications and the most effective imaging techniques.

Exploring Radiologists' Burnout in the COVID-19 Era: A Narrative Review.

Since its beginning in March 2020, the COVID-19 pandemic has claimed an exceptionally high number of victims and brought significant disruption to the personal and professional lives of millions of people worldwide. Among medical specialists, radiologists have found themselves at the forefront of the crisis due to the pivotal role of imaging in the diagnostic and interventional management of COVID-19 pneumonia and its complications. Because of the disruptive changes related to the COVID-19 outbreak, a proportion of radiologists have faced burnout to several degrees, resulting in detrimental effects on their working activities and overall wellbeing. This paper aims to provide an overview of the literature exploring the issue of radiologists' burnout in the COVID-19 era.

Risk Assessment and Cholangiocarcinoma: Diagnostic Management and Artificial Intelligence.

Intrahepatic cholangiocarcinoma (iCCA) is the second most common primary liver tumor, with a median survival of only 13 months. Surgical resection remains the only curative therapy; however, at first detection, only one-third of patients are at an early enough stage for this approach to be effective, thus rendering early diagnosis as an efficient approach to improving survival. Therefore, the identification of higher-risk patients, whose risk is correlated with genetic and pre-cancerous conditions, and the employment of non-invasive-screening modalities would be appropriate. For several at-risk patients, such as those suffering from primary sclerosing cholangitis or fibropolycystic liver disease, the use of periodic (6-12 months) imaging of the liver by ultrasound (US), magnetic Resonance Imaging (MRI)/cholangiopancreatography (MRCP), or computed tomography (CT) in association with serum CA19-9 measurement has been proposed. For liver cirrhosis patients, it has been proposed that at-risk iCCA patients are monitored in a similar fashion to at-risk HCC patients. The possibility of using Artificial Intelligence models to evaluate higher-risk patients could favor the diagnosis of these entities, although more data are needed to support the practical utility of these applications in the field of screening. For these reasons, it would be appropriate to develop screening programs in the research protocols setting. In fact, the success of these programs reauires patient compliance and multidisciplinary cooperation.

Diagnostic imaging strategies of acute intracerebral hemorrhage in European academic hospitals-a decision-making analysis.

PURPOSE: To evaluate and compare which factors are relevant to the diagnostic decision-making and imaging workup of intracerebral hemorrhages in large, specialized European centers. METHODS: Expert neuroradiologists from ten large, specialized centers (where endovascular stroke treatment is routinely performed) in nine European countries were selected in cooperation with the European Society of Neuroradiology (ESNR). The experts were asked to describe how and when they would investigate specific causes in a patient who presented with an acute, atraumatic, intracerebral hemorrhage for two given locations: (1) basal ganglia, thalamus, pons or cerebellum; (2) lobar hemorrhage. Answers were collected, and decision trees were compared. RESULTS: Criteria that were considered relevant for decision-making reflect recommendations from current guidelines and were similar in all participating centers. CT Angiography or MR angiography was considered essential by the majority of centers regardless of other factors. Imaging in clinical practice tended to surpass guideline recommendations and was heterogeneous among different centers, e.g., in a scenario suggestive of typical hypertensive hemorrhage, recommendations ranged from no further follow-up imaging to CT angiography and MR angiography. In no case was a consensus above 60% achieved. CONCLUSION: In European clinical practices, existing guidelines for diagnostic imaging strategies in ICH evaluation are followed as a basis but in most cases, additional imaging investigation is undertaken. Significant differences in imaging workup were observed among the centers. Results suggest a high level of awareness and caution regarding potentially underlying pathology other than hypertensive disease.

Imaging of metabolic and overload disorders in tissues and organs.

Metabolic and overload disorders are a heterogeneous group of relatively uncommon but important diseases. While imaging plays a key role in the early detection and accurate diagnosis in specific organs with a pivotal role in several metabolic pathways, most of these diseases affect different tissues as part of a systemic syndromes. Moreover, since the symptoms are often vague and phenotypes similar, imaging alterations can present as incidental findings, which must be recognized and interpreted in the light of further biochemical and histological investigations. Among imaging modalities, MRI allows, thanks to its multiparametric properties, to obtain numerous information on tissue composition, but many metabolic and accumulation alterations require a multimodal evaluation, possibly using advanced imaging techniques and sequences, not only for the detection but also for accurate characterization and quantification. The purpose of this review is to describe the different alterations resulting from metabolic and overload pathologies in organs and tissues throughout the body, with particular reference to imaging findings.

Imaging Features of Main Hepatic Resections: The Radiologist Challenging.

Liver resection is still the most effective treatment of primary liver malignancies, including hepatocellular carcinoma (HCC) and cholangiocarcinoma (CCA), and of metastatic disease, such as colorectal liver metastases. The type of liver resection (anatomic versus non anatomic resection) depends on different features, mainly on the type of malignancy (primary liver neoplasm versus metastatic lesion), size of tumor, its relation with blood and biliary vessels, and the volume of future liver remnant (FLT). Imaging plays a critical role in postoperative assessment, offering the possibility to recognize normal postoperative findings and potential complications. Ultrasonography (US) is the first-line diagnostic tool to use in post-surgical phase. However, computed tomography (CT), due to its comprehensive assessment, allows for a more accurate evaluation and more normal findings than the possible postoperative complications. Magnetic resonance imaging (MRI) with cholangiopancreatography (MRCP) and/or hepatospecific contrast agents remains the best tool for bile duct injuries diagnosis and for ischemic cholangitis evaluation. Consequently, radiologists should be familiar with the surgical approaches for a better comprehension of normal postoperative findings and of postoperative complications.

Cognitive outcomes after focused ultrasound thalamotomy for tremor: Results from the COGNIFUS (COGNitive in Focused UltraSound) study.

INTRODUCTION: Magnetic resonance-guided focused ultrasound (MRgFUS) thalamotomy is an innovative method for the unilateral treatment of essential tremor (ET) and Parkinson's disease (PD) related tremor. Our aim was to assess cognitive changes following MRgFUS thalamotomy to better investigate its safety profile. METHODS: We prospectively investigated the cognitive and neurobehavioral profile of patients consecutively undergoing MRgFUS within a 2-year period. Patients had a comprehensive clinical and neuropsychological assessment before and six months after MRgFUS thalamotomy. RESULTS: The final sample consisted of 40 patients (males 38; mean age±SD 67.7 ± 10.7; mean disease duration±SD 9.3 ± 5.6; ET 22, PD 18 patients). For the whole sample, improvements were detected in tremor (Fahn-Tolosa-Marin Clinical Rating Scale for tremor 35.79 ± 14.39 vs 23.03 ± 10.95; p < 0.001), anxiety feelings (Hamilton Anxiety rating scale 5.36 ± 3.80 vs 2.54 ± 3.28, p < 0.001), in the overall cognitive status (MMSE 25.93 ± 3.76 vs 27.54 ± 2.46, p 0.003; MOCA 22.80 ± 4.08 vs 24.48 ± 3.13, p < 0.001), and in quality of life (Quality of life in Essential Tremor Questionnaire 36.14 ± 12.91 vs 5.14 ± 6.90, p < 0.001 and PD Questionnaire-8 5.61 ± 4.65 vs 1.39 ± 2.33, p 0.001). No changes were detected in frontal and executive functions, verbal fluency and memory, abstract reasoning and problem-solving abilities. CONCLUSION: Our study moves a step forward in establishing the cognitive sequelae of MRgFUS thalamotomy and in endorsing effectiveness and safety.

Diffusion kurtosis imaging and standard diffusion imaging in the magnetic resonance imaging assessment of prostate cancer.

Background and Objective: In recent years, magnetic resonance imaging (MRI) has shown excellent results in the study of the prostate gland. MRI has indeed shown to be advantageous in the prostate cancer (PCa) detection, as in guiding targeting biopsy, improving its diagnostic yield. Although current acquisition protocols provide for multiparametric acquisition, recent evidence has shown that biparametric protocols can be non-inferior in PCa detection. Diffusion-weighted imaging (DWI) sequence, in particular, plays a key role, particularly in the peripheral zone which accounts for the larger part of the prostate. High b-values are generally recommended, although with the possibility of obtaining non-Gaussian diffusion effects, which requires a more sophisticated model for the analysis, namely through the diffusion kurtosis imaging (DKI). Purpose of this narrative review was to analyze the current applications and clinical evidence regarding the use of DKI with a main focus on PCa detection, also in comparison with DWI. Methods: This narrative review synthesized the findings of literature retrieved from main researches, narrative and systematic reviews, and meta-analyses obtained from PubMed. Key Content and Findings: DKI analyses the non-Gaussian water diffusivity and describe the effect of signal intensity decay related to high b-value through two main metrics (Dapp and Kapp). Differently from DWI-apparent diffusion coefficient (DWI-ADC) which reflects only water restriction outside of cells, DKI metrics are supposed to represent also the direct interaction of water molecules with cell membranes and intracellular compounds. This review describes current evidence on ADC and DKI metrics in clinical imaging, and finally collect the results derived from the main articles focused on DWI and DKI models in detecting PCa. Conclusions: DKI advantages, compared to conventional ADC analysis, still remain controversial. Wider application and greater technical knowledge of DKI, however, may help in proving its intrinsic validity in the field of oncology and therefore in the study of clinically significant PCa. Finally, a deep understanding of DKI is important for radiologists to better understand what Kapp and Dapp mean in the context of different cancer and how these metrics may vary specifically in PCa imaging.

Cerebello-Thalamo-Cortical MR Spectroscopy in Patients with Essential Tremor Undergoing MRgFUS Thalamotomy: A Pilot Study.

Previous literature studies explored the association between brain neurometabolic changes detected by MR spectroscopy and symptoms in patients with tremor, as well as the outcome after deep brain stimulation (DBS) treatment. The purpose of our study was to evaluate the possible changes in cerebello-thalamo-cortical neurometabolic findings using MR spectroscopy in patients submitted to MRgFUS thalamotomy. For this pilot study, we enrolled 10 ET patients eligible for MRgFUS thalamotomy. All patients were preoperatively submitted to 3T MR spectroscopy. Single-voxel MRS measurements were performed at the level of the thalamus contralateral to the treated side and the ipsilateral cerebellar dentate nucleus. Multivoxel acquisition was used for MRS at the level of the contralateral motor cortex. At the 6-month follow-up after treatment, we found a statistically significant increase in the Cho/Cr ratio at the level of the thalamus, a significant increase of the NAA/Cr ratio at the level of the dentate nucleus and a significant decrease of the NAA/Cho ratio at the level of the motor cortex. We found a significant positive correlation between cortical NAA/Cr and clinical improvement (i.e., tremor reduction) after treatment. A significant negative correlation was found between clinical improvement and thalamic and cerebellar NAA/Cr. Confirming some previous literature observations, our preliminary results revealed neurometabolic changes and suggest a possible prognostic role of the MRS assessment in patients with ET treated by MRgFUS.

Heart Failure and Cardiomyopathies: CT and MR from Basics to Advanced Imaging.

Since 1997, heart failure (HF) has been designated as a new epidemic. However, it is not easy to find a proper definition since different descriptors are used in clinical practice. Moreover, HF is not a single clinical entity, and there is a close relationship between HF and all cardiomyopathies (CMs). This leads us to also consider accuracy in the characterization of CMs, which is essential to define the therapeutic process of HF patients. This narrative review aims to describe the main mechanisms leading to HF in different CMs, as well as the current diagnostic and prognostic advantages deriving from advanced imaging in the cardiac field.

Advanced MRI imaging of nerve roots in lumbar radiculopathy due to discoradicular conflict: DWI, DTI, and T2 mapping with clinical and neurophysiological correlations.

PURPOSE: To evaluate the lumbar nerve root alterations in patients with lumbar disc herniation sciatica using advanced multimodality MRI sequences and the correlations with clinical and neurophysiological findings. MATERIAL AND METHODS: We prospectively evaluated 45 patients suffering from unilateral lumbar radiculopathy due to disco radicular conflict. All patients underwent MRI examinations using a standard MRI protocol and additional advanced MRI sequences (DWI, DTI, and T2 mapping sequences). Relative metrics of ADC, FA, and T2 relaxation times were recorded by placing ROIs at the pre-, foraminal, and post-foraminal level, either at the affected side or the contralateral side, used as control. All patients were also submitted to electromyography testing, recording the spontaneous activity, voluntary activity, F wave amplitude, latency, and motor evoked potentials (MEP) amplitude and latency, both at the level of the tibialis anterior and the gastrocnemius. Clinical features (diseases duration, pain, sensitivity, strength, osteotendinous reflexes) were also recorded. RESULTS: Among clinical features, we found a positive correlation of pain intensity with ADC values of the lumbar nerve roots. The presence of spontaneous activity was correlated with lower ADC values of the affected lumbar nerve root. F wave and MEP latency were correlated with decreased FA values at the foraminal level and increased values at the post-foraminal level. The same neurophysiological measures correlated positively with pre-foraminal T2 mapping values and negatively with post-foraminal T2 mapping values. Increased T2 mapping values at the foraminal level were correlated with disease duration. CONCLUSIONS: Evaluation of lumbar nerve roots using advanced MRI sequences may provide useful clinical information in patients with lumbar radiculopathy, potentially indicating active inflammation/myelinic damage (DTI, T2 mapping) and axonal damage/chronicity (DWI).