Effects of hyper-early (<12 hours) endovascular treatment of ruptured intracranial aneurysms on clinical outcome.

Despite the encouraging results obtained with the endovascular treatment of ruptured intracranial aneurysms, few data are available on the effects of the timing of this approach on clinical outcome. The aim of our study was to evaluate the effects of the hyper-early timing of treatment and of pre-treatment and treatment-related variables on the clinical outcome of patients with ruptured intracranial aneurysms. Five hundred and ten patients (167 M, 343 F; mean age 56.45 years) with 557 ruptured intracranial aneurysms were treated at our institution from 2000 to 2011 immediately after their admission. The total population was divided into three groups: patients treated within 12 hours (hyper-early, group A), between 12-48 hours (early, group B) and after 48 hours (delayed, group C). A statistical analysis was carried out for global population and subgroups. Two hundred and thirty-four patients (46%) were included in group A, 172 (34%) in group B and 104 (20%) in group C. Pre-treatment variables (Hunt&Hess, Fisher grades, older age) and procedure-related variable (ischaemic/haemorrhagic complications) showed a significant correlation with worse clinical outcomes. The hyper-early treatment showed no correlation with good clinical outcomes. The incidence of intra-procedural complications was not significantly different between the three groups; 1.2% of pre-treatment rebleedings were observed. The hyper-early endovascular treatment of ruptured intracranial aneurysm does not seem to be statistically correlated with good clinical outcomes although it may reduce the incidence of pre-treatment spontaneous rebleedings without being associated with a higher risk of intra-procedural complications. However, since no significant differences in terms of clinical outcome and pre-treatment rebleeding rate were observed, a hyper-early treatment is not be supported by our data.

E-learning in radiology: Italian multicentre experience.

PURPOSE: The aim of our work was to design, implement and evaluate an e-learning programme in favour of trainee radiologists enrolled at the many specialty schools located throughout Italy, in the spirit of "sharing culture". MATERIALS AND METHODS: Once a common educational programme and time slot had been identified and planned, the programme was delivered via Internet-based video conferencing once a week for 2-h lectures. Each lecture was followed by interaction between the teaching staff and trainees at the individual sites. The universities involved were Trieste, Udine, Verona, Milano Bicocca, Novara, Varese, Genova, Sassari, Rome "Campus", Rome "Cattolica", Chieti, Foggia, Catania, Modena and Firenze. The University of Rome "Cattolica" participated in the project with two locations: Rome "Policlinico Gemelli" and Rome "Cattolica Campus of Campobasso". RESULTS: Eighteen lectures were conducted, for a total of 36 h. "Transient" connection interruption occurred 13 times for a total of 33 min over 2,160 min of lessons. Video quality and, in particular, details of radiological images shown in slides or moving pictures, were rated as very good by 71% of trainees, good by 24% and satisfactory by 4.5%; no one gave a rating of unsatisfactory. CONCLUSIONS: Based on our experience, whereas e-learning in radiology has become established and compulsory, there is the need for legislation that on the one hand protects online teaching activity and on the other allows study and continuing medical education (CME) credits to be recognised.

Transient hepatic attenuation differences (THAD) not connected to focal lesions.

PURPOSE: To report our experience with helical CT evaluation of transient hepatic attenuation differences (THAD), and in particular of those not associated with focal lesions, in an attempt to provide an aetiopathogenetic picture that accounts for the morphology, evolution and density of THAD. MATERIALS AND METHODS: Between January 1998 and January 2001 we observed THAD in 130/988 biphasic helical CT liver examinations performed in the arterial and portal dominant phase. THAD were associated to focal hepatic lesions in 87 patients; in 43 patients there was no such association. This second group of patients, composed of 23 males and 20 females ranging in age from 17 to 80 years (average = 58.8), was enrolled in the study. THAD were associated to: Budd-Chiari syndrome (9), portal venous thrombosis (10), liver cirrhosis (7), acute inflammation of an adjacent organ (4), dilatation of the entire biliary tree (3), hepatic stasis caused by heart failure (2) and constrictive pericarditis (1), fine-needle percutaneous biopsy (2), arterioportal shunting (2), parenchymal compression by fractured ribs (2) and by a strengthened phrenic pillar (1). THAD were evaluated according to extension, morphology and density. For each case at least 10 density measurements were performed by sampling regions of interest on the parenchyma with THAD and on the contralateral parenchyma. The results (mean and standard deviation) were compared to those relative to 30 healthy patients. 22/43 patients were followed up for 6#150;24 months by at least one US and helical CT examination. During CT, the direct appreciation of vascular thrombus during the portal dominant phase was also considered. RESULTS: We detected 18 localised and 25 diffuse THAD. The localised sectoral THAD (11), wedge-shaped with clear border sign, were associated to thrombosis of a portal branch (6), fine-needle percutaneous biopsy (2), arterioportal shunting (2) and partial Budd-Chiari syndrome (1). The localised non-sectoral THAD (7), with variable morphology and without the clear border sign, were associated to acute inflammation of an adjacent organ (4) and to parenchymal compression by the ribs or diaphragm (3). Diffuse THAD associated to Budd-Chiari syndrome (8) and to heart failure (3) showed mosaic enhancement of hepatic parenchyma (patchy pattern); those linked to portal trunk thrombosis (4) and cirrhosis (7) revealed predominant enhancement of external hepatic parenchyma (central-peripheral phenomenon); finally, those concurrent with dilatation of the entire biliary tree showed parenchymal enhancement close to the dilated bile ducts (peribiliary pattern). Follow-up (22/43) demonstrated complete THAD regression after removal (5/22) and less conspicuity of THAD after partial overcome of the stoppage (1/22). In 2/22 cases of arterioportal shunting no substantial changes were seen. The remaining 14/22 cases showed a gradual, slow tendency towards THAD regression with hypotrophy of the involved parenchyma and compensatory contralateral hypertrophy even in the case of endurance of the causative agents. CONCLUSIONS: Based on our experience and the literature we suggest a classification for THAD unrelated to focal hepatic lesions. We recognise 4 causes: portal vein stoppage-obstruction, portal in-flow diversion, trauma and inflammation. When THAD is related to the first three causes pathogenesis is portal hypoperfusion. In the fourth group the mediators of the arterial phenomena are those of inflammation even though portal hypoperfusion might be involved as well. THAD identification makes the detection of vascular thrombi easier by comparison with their direct finding during the portal dominant phase. Finally, THAD are to be investigated for their potential utility in the detection and characterisation of several hepatic diseases. As a consequence, hepatic CT studies cannot ignore arterial dominant phase evaluation, even if no focal hepatic lesions are expected.

Ultrasonographic study on the growth and dimensions of healthy children and adults organs.

We measured by ultrasound the spleen, the kidneys, the pancreas in 323 children (age 0-12), the thyroid in 60 children of same age range, and all these organs in 180 adults (in adults we measured additionally the testis, the gallbladder and the choledochus). Children and adults were all healthy, without evidence of pathologies potentially involving these organs. The children have been selected looking at clinical and hematological parameters, while the adults have been selected among a military population, that is the most significant sample of healthy young adults. We measured the length, the transversal diameter and the thickness of the spleen, kidneys, pancreas, testis and thyroid, the diameter of the choledochus and the maximum length of the gallbladder (pre and post stimulus). We found a good correlation between age and dimensions for pancreas, kidneys and spleen in children, representing the progressive growth of these organs. Our data represent an assessment of the normal dimensions of these organs in vivo by means of ultrasound, and therefore they are an useful tool to discriminate pathologically enlarged or reduced organs, both in children and in adults.

[Bilateral Morgagni-Larrey hernia. Report of a clinical case]. / Ernia di Morgagni-Larrey bilaterale. Descrizione di un caso clinico.

A rare case of bilateral diaphragmatic hernia, containing a long segment of transverse colon in the left breach and most of the omentum and a short segment of colon in the right one, is described. Diaphragmatic hernia can occur at any age in both males and females and it is often asymptomatic and diagnosed by chance. The epidemiological, etiopathogenic, clinic, diagnostic and therapeutic aspects of the disease are discussed. The only treatment, which is advisable in asymptomatic patients too, is the closure of the hernial orifice. This closure can be done directly or through the insertion of prosthetic material. The conventional access can be thoracic or abdominal, but laparoscopy is going to replace both of them successfully in the future.

Optic neuropathy in Behçet's disease. Report of two cases.

Orbital magnetic resonance imaging demonstrated increased signal of the optic nerve in short time inversion recovery (STIR) images of two young women with unilateral visual blurring. In both, recurrent oral and genital ulcerations and papulopustular lesions appeared within the next 14-15 months, respectively, allowing a diagnosis of Behçet's disease. Optic neuropathy may be an early manifestation of Behçt's disease and clinical follow-up is crucial for its diagnosis.

Aorto-iliac steal syndrome. A rare case of renal hypoperfusion.

In aorto-iliac occlusive disease a diversion of blood flow from visceral arteries to lower limbs rarely occurs. This condition is known as aorto-iliac steal syndrome. This report is about the case of a male patient affected by chronic atherosclerotic occlusion of the aorta associated with an aorto-iliac steal supported by an anomalous vessel coming from the left renal artery to the homolateral external iliac artery to the detriment of the renal blood flow. Renal sequential scintiscan (RSS) at rest and after stress test was employed to assess renal blood flow and excretory functions before and after an aorto-bifemoral bypass. Surgical revascularization permitted reversal of the steal phenomenon and the improvement of left renal blood flow.

[The correlations between the echographic aspect of the perioral and masticatory muscles and dento-skeletal characteristics]. / Correlazioni tra l'aspetto ecografico dei muscoli periorali e masticatori e le caratteristiche dento-scheletriche.

INTRODUCTION: US of some muscular components of the stomatognathic system (orbicularis oris and masseter muscles) has proved to provide important information about their morphologic features. The purpose of this study is to explore the US features of the perioral and masticatory muscles in patients affected with any type of malocclusion and to analyze the correlations between dento-skeletal characteristics and muscle changes. MATERIAL AND METHODS: We examined 26 untreated patients (10 men and 16 women); we measured their cephalometric parameters on lateral skull teleradiographs and then we measured with US both the masseter and orbicular muscles dimensions. The US images were acquired with 5 MHz and 7.5 MHz probes, measuring the masseter muscle with transversal and longitudinal scans, and the two parts of the orbicularis oris with longitudinal scans. The cephalometric measures were calculated with: angular parameters useful to determine the sagittal relationships, both angular and linear parameters to define the vertical relationships and angular measures that define the incisor position. We applied the Spearman test to assess if there was a relationship between the US dimensions of the orbicularis oris and the masseter, and the dento-skeletal characteristics of these 26 patients. RESULTS: Our results show that there is a strong correlation between mandibular morphology, the palatal plane, respectively, and the masseter length. There is a direct correlation with the masseter dimension for the palatal plane obliquity, and an inverse correlation for the mandibular morphology. The incisor position is influenced by the orbicular oris muscle dimension and by the asymmetric position of the superior and inferior incisors. CONCLUSIONS: This noninvasive diagnostic examination is a useful aid to the clinical examination of the muscles, especially in orthodontic diagnosis, together with MRI and CT, respectively more expensive and unhealthier.

Anatomical-radiological and morphometric analysis of the lateral atlantoaxial joint.

The width of the articular space of the lateral atlantoaxial joint was measured to evaluate normal range values and possible variations according to age and sex. The study was based on X-rays of the lateral atlantoaxial joint of 52 females (age range: 18-82 ys) and 50 males (age range: 20-82 ys). The radiograms were taken using a semiautomatic computerized morphometric system (Videoplan II, Image Analysis system-Kontron, Munich, Germany). The articular space width of the lateral atlantoaxial joint was measured on both sides, at the medial, lateral and median levels. The mean value at these levels, on both sides, was calculated. Regression analysis was performed to evaluate the relationships between the width of the articular space at the three different levels and the patient's age and gender. No significant differences were found in the mean values of the articular space width at the three levels as regards gender. However, a significant inverse correlation was found between the articular space width and the patients' age in both males and females. Comparative analysis of regression lines showed that the slope of these lines was not significantly different when the sexes were compared. On the contrary, the intercept of the regression lines at the medial and median levels was significantly higher in the females than in the males; the contrary was encountered at the lateral level. This feature is probably due to the different types of inclination of the articular facets of the axis or of those of the atlas in the two sexes.

Measurement reliability of dynamic x-rays of the cervical spine: an experimental model.

A blind test of measurement reliability was performed in vitro using lateral x-rays of cervical vertebrae. Dry specimens of C3 and C4 were mounted in a movable frame and flexion/extension was simulated. Lateral x-rays were taken for each degree from 15 degrees flexion to 15 degrees extension. Then the x-rays were measured by four raters. The results show a high level of absolute measurement error. This suggests caution in accepting existing literature data on cervical x-ray measurements unless some indicator of the personal measuring accuracy of the rater is specified. The procedure described in this paper can be used to ascertain such accuracy.

[Insertion and management of long-term central venous devices: role of radiologic imaging techniques]. / Posizionamento e gestione dei sistemi per accesso venoso centrale a lungo termine: contributo della diagnostica per immagini.

INTRODUCTION: Anticancer chemotherapy causes irreversible damage to the endothelial wall of small vessels. This is the reason why long-term (more than 3 months) central venous devices are essential to administer chemotherapy drugs to cancer patients and antibiotics for chronic or severe infections and in patients requiring long-term parenteral nutrition. We report our experience with the percutaneous implantation of central venous devices in a radiology department. MATERIAL AND METHODS: March, 1993, to August, 1997, eighty-seven consecutive patients (26 men and 61 women, mean age: 55 years) were examined. The indications for central venous catheter placement included anticancer chemotherapy in 82 cancer patients, repeated blood transfusion in one patient with bone marrow aplasia and nutritional support in four cancer patients. Eighty-four central venous devices (75 totally subcutaneous systems--Port-a-cath Dome--, and 9 partially tunneled catheters--Groshong) were inserted. The average follow-up was 6.5 months (range: 1-18). All procedures were performed in the radiology department and venous access was achieved with fluoroscopy using the Seldinger technique. Chest radiography with the patient standing was routinely performed after the procedure and repeated the day after to assess the catheter position and the presence of pneumothorax. The venous catheters were placed in the subclavian vein in 68 cases (12 in the right side and 56 in the left side), internal jugular vein in 12 cases (9 in the right side and 3 in the left side) and right femoral vein in 4 cases. We prefer the subclavian vein (80.9%) for better cosmetic results, wider catheter angulation and easier fixation to the deep plane. RESULTS: The first access failed in 6 cases (6.8%). A pneumothorax occurred in 4 patients (4.7%) and late complications were seen in 15 patients (17.8%) after a mean of 15.7 weeks (range: 2-48). Catheter-related infections developed in 6 patients (7.1%) after a mean of 20 weeks (range: 5-48). The microorganisms cultured from these catheters was the Staphylococcus epidermidis. After two weeks' specific antibiotic therapy, all the devices were removed. Deep venous thrombosis occurred only in one patient after 10 months and was successfully treated with direct thrombolytic infusion. The catheter was displaced in the right atrium in two patients after 11 and 12 weeks, respectively: both catheters were removed by transfemoral catheterization. CONCLUSIONS: The percutaneous implantation of--long-term central venous devices is a safe and tolerable procedure. In our experience, the radiology-assisted placement of these devices offers many advantages over surgical implantation. In particular, fluoroscopy allows direct visualization of the catheter position while insertion and positioning are essentially "blind" at surgery, which complicates venous access and increases the risk of catheter malpositioning. Radiologic follow-up is also useful to depict and correct complications.

Extracranial carotid artery aneurysms.

BACKGROUND: Extracranial carotid aneurysms are quite rare diseases. Their importance is linked both to critical localization and natural history which can lead to neurological events such as TIA and stroke. The importance of an accurate diagnosis is related to the necessity to carry out an early repair of these lesions and so to achieve the prevention of serious complications with minimal surgical risk. MATERIALS AND METHODS: At the Department of Vascular Surgery of the University of Florence from January 1982 to December 1995, 2138 surgical procedures on extracranial carotid arteries carried out. Twenty-one (0.98%) were performed for aneurysms. On the basis of clinical history and instrumental findings we divided the patients into three groups: atherosclerotic aneurysms (AA, 10 cases), dysplasic aneurysms (DA, 6 cases) and pseudoaneurysms (PA, 5 cases). RESULTS: Global mortality and major morbility rate was 4.7% (one patient suffered perioperative stroke). Eighteen (85.7%) were followed by echo color Doppler. No one stenosis and/or dilatation of operated vessel was observed during the mean follow-up period of 24 months. In one case (5.5%) of pseudoaneurysms group an asymptomatic internal carotid artery occlusion was discovered 3 months after surgery. CONCLUSIONS: In our experience, surgical treatment of extracranial carotid aneurysms is associated with satisfactory results and low incidence of perioperative complications that justified an extensive and early surgical therapy.

Morphometric analysis of the acromioclavicular joint.

The width of the articular space of the acromioclavicular (AC) joint was investigated to evaluate normal range values and any possible variations in relation to age and sex. Radiographs of the AC joints of 72 males and 28 female (age range: 38-83 yrs) were studied. The articular space width of the AC joint was measured using a semiautomatic computerized system. The measurements were performed bilaterally at the level of smallest distance between the articular surfaces in all the radiograms. The mean value of the articular space width was calculated for all the subjects as a single group, for that of the males and for that of the females. The films were then divided into four groups according to age (< 50; 50-59; 60-69; > 70 yrs) and the mean value per group was calculated. The values obtained were studied using variance analysis. No significant difference were found in the mean values of the articular space width when males and females were compared as regards to age. However, even if the articular space width diminished, in both sexes, with an increase in age, the differences between age classes were not statistically significant.

Morphometric analysis of the sacroiliac joint.

The sacroiliac (SI) joint is the point of articulation between the sacrum and the innominate bone of the pelvis. The anterior portion is synovial, and the posterosuperior portion is a typical syndesmosis. The SI joint may be affected by inflammatory or degenerative changes which include narrowing, minor sclerosis and erosion. Alterations in the anatomy of this joint may be involved in causing lower back pain. Radiodiagnosis of the width of the articular space is one of the tools utilized to evaluate the normal state of any joint. Scanty data is available on the morphometric characteristics of the SI joint. Therefore, the articular width space of the SI joint was measured to define its normal size in relation to age and sex. The study included 198 x-rays of the abdomen, in anteroposterior projection, of 112 males and 86 females (age range: 17 to 91 yrs). Individual films were divided into four classes according to age (< 50; 50-59; 60-69; > 70). The articular space of the SI joint is made up of a lateral and a medial part: the first representing the anterior articular space; the latter the posterior one. The anterior articular space of both the right and left joint, which was more easily visible and measurable was measured at the medium and inferior levels. Measurements were taken from the radiograms using a semiautomatic computerized system (Videoplan II, Image Analysis system-Kontron). The mean value of the articular space width a the medium and inferior levels, according to age group, was measured in both the males and females. The values obtained were studied using variance analysis. No significant differences were found in the mean values of the articular space width at the SI joint, when males and females were compared in relation to age. Moreover, the articular space width diminished with increasing the age. This fact was not always statistically significant.

Morphometric evaluation of the symphysis pubis joint.

The Symphysis Pubis (SP) joint was investigated by X-ray in 96 adults without any history of disease of the joints. We evaluated the width of this joint by measuring the distance between the two articular surface at three points. We calculated the mean for the three interpubic distances and carried out statistical analysis so as to evaluate if there is a significative difference between the four age classes (< 50; 50-59; 60-69; > 70) and between males and females. We did not found statistically-significative differences between males and females, and between the age classes; nevertheless, it is to be noted that a slight widening of the SP joint can be seen in the elderly, which is thus not significant. We also noted that the medium part of the SP joint undergoes a larger widening in older people: this is probably due to degenerative changes in the fibrocartilagineous disc and the ligaments.

Magnetic resonance in the study of cranial nerves.

The course of cranial nerves was studied by means of magnetic resonance (MR), which allowed a multiplane visualization of the investigated structures. The obtained results showed that MR was an excellent method for visualization of the optic, trigeminal, facial and acoustica nerves. The oculomotor and the abducent nerves were detectable only in some regions where the contrast with the surrounding structures was greater. The glossopharingeus, vegus and accessory nerves were identifiable only in the first tract of emergency from the encephalic trunk and they could no be distinguished separately. The trochlear nerve was seldom visible whereas the olfactory nerve failed to be revealed. Further technological progress will allow for additional advances as regards the acquisition of knowledge concerning these important nerves.

A radiological-anatomical comparison between formalin-preserved organs and "plastinated" ones.

By using conventional radiology and computerized tomography, plastinated organs as will as those preserved in formalin were examined and compared as regards morphological, structural and densitometri differences. Two examiners separately compared and evaluate the images obtained using the two preservation. Plastinated organs presented better preservation of the morphology and structure of the organs than did those preserved in formalin.