Early myocardial gadolinium enhancement in patients with myocarditis: Validation of "Lake Louise consensus" criteria using a single bolus of 0.1mmol/Kg of a high relaxivity gadolinium-based contrast agent.

OBJECTIVES: Global early gadolinium enhancement (EGE) is an accepted cardiac magnetic resonance (CMR) criterion for diagnosis of myocarditis. However, recommended enhancement thresholds are based specifically on standard-relaxivity Gd-chelates. We evaluated the performance of a high relaxivity MR contrast agent for detection of myocardial hyperemia in patients referred for endomyocardial biopsy (EMB). METHODS: We retrospectively enrolled 54 patients (mean age: 44.1 years [range=18-77years]; 72% men) with suspected myocarditis who underwent CMR and EMB within four weeks of clinical onset. CMR imaging protocol included T2-weighted short tau inversion-recovery sequence, EGE and late gadolinium enhanced (LGE) imaging. For EGE imaging, free-breathing ECG-gated turbo spin echo T1-weighted (TSE T1w) sequences were acquired before and within the first three minutes after gadobenate dimeglumine (0.1mmol/Kg) administration. The ratio (EGEr) between myocardial and musculoskeletal early enhancement was calculated. Myocardial edema, EGE and late gadolinium enhancement (LGE) were correlated with EMB results. Receiver operating characteristic (ROC) curve analysis of EGE values was applied on the overall population. RESULTS: EMB revealed myocarditis in 34/54 patients. Sensitivity, specificity and accuracy values of 0.61, 0.85 and 0.70, respectively, were obtained for a standard EGE threshold (EGEr>4.0). ROC analysis revealed an area under the curve of 0.701 for EGEr (IC95%:0.556-0.846, p=0.014) and 0.706 for absolute enhancement (IC95%:0.563-0.849, p=0.012). Sensitivity, specificity and accuracy values were 0.67, 0.80 and 0.72, respectively, for myocardial edema and 0.76, 0.75 and 0.76, respectively, for LGE. CONCLUSIONS: High relaxivity contrast agents provide comparable results to standard-relaxivity chelates for EGE assessment in diagnosing myocarditis.

Magnetic resonance-guided focused ultrasound for the treatment of painful bone metastases: role of apparent diffusion coefficient (ADC) and dynamic contrast enhanced (DCE) MRI in the assessment of clinical outcome.

PURPOSE: To assess the correlation between functional MRI, including ADC values obtained from DWI and DCE, and clinical outcome in patients with bone metastases treated with MRgFUS. METHODS AND MATERIALS: Twenty-three patients with symptomatic bone metastases underwent MRgFUS treatment (ExAblate 2100 system InSightec) for pain palliation. All patients underwent clinical and imaging follow-up examinations at 1, 3 and 6 months after treatment. Visual Analog Scale (VAS) score was used to evaluate treatment efficacy in terms of pain palliation while ADC maps obtained by DWI sequences, and DCE data were used for quantitative assessment of treatment response at imaging. Spearman Correlation Coefficient Test was calculated to assess the correlation between VAS, ADC and DCE data. RESULTS: All treatments were performed successfully without adverse events. On the basis of VAS score, 16 (69.6 %) patients were classified as complete clinical responders, 6 (26.1 %) as partial responders and only one (4.3 %) was classified as a non-responder. The mean VAS score decreased from 7.09 ± 1.8 at baseline to 2.65 ± 1.36 at 1 month, 1.04 ± 1.91 at 3 months and 1.09 ± 1.99 at 6 months (p < 0.001). Baseline mean ADC value of treated lesions was 1.05 ± 0.15 mm2/s, increasing along follow-up period (1.57 ± 0.27 mm2/s 1st month; 1.49 ± 0.3 mm2/s 3rd month; 1.45 ± 0.32 mm2/s 6th month, p < 0.001). Non perfused volume (NPV) was 46.4 at 1 month, 45.2 at 3 months and 43.8 at 6 months. Spearman Coefficient demonstrated a statistically significant negative correlation between VAS and ADC values (ρ = -0.684; p = 0.03), but no significant correlation between VAS and NPV (ρ = 0.02216, p = 0.9305). Among other DCE data, Ktrans significantly changed in complete responders (3 months Ktrans = 2.14/min; -ΔKt = 52.65 % p < 0.01) and was not significantly different in partial responders (3 months Ktrans 0.042/min; ΔKt = 11.39 % p > 0.01). CONCLUSION: In patients with painful bone metastases treated with MRgFUS, ADC and Ktrans variation observed in the ablated lesions correlate with VAS values and may play a role as objective imaging marker of treatment response.

Tracheal Bronchus: High Resolution Computed Tomography diagnosis in a symptomatic patient.

A 75-year-old female underwent a High Resolution Computed Tomography (HRCT) scan for recurrent bronchitis and cough. HRCT images showed an anomalous supernumerary bronchus to the right upper lobe directly arising from the right side of distal trachea, corresponding to Tracheal Bronchus (TrB). TrB can cause recurrent right upper lobe pneumonia and special care is requiring during endotracheal intubation.

MR imaging-guided focused ultrasound for treatment of bone metastasis.

Magnetic resonance (MR) imaging-guided focused ultrasound is an alternative noninvasive method for reducing the pain in skeletal metastases. MR imaging-guided focused ultrasound ablation offers several key advantages over other noninvasive treatment modalities. This technology enables the performance of three-dimensional treatment planning with MR imaging and continuous temperature mapping of treated tissue by using MR thermometry, thereby enabling real-time monitoring of thermal damage in the target zone. The concentration of acoustic energy on the intact surface of cortical bone produces a rapid temperature increase that mediates critical thermal damage to the adjacent periosteum, the most innervated component of mature bone tissue. Such thermal ablation has been shown to be an extremely effective approach for pain management. Energy delivered during MR imaging-guided focused ultrasound ablation and accumulated inside the pathologic soft tissue of the metastases can create a variable amount of tissue necrosis. This technique has also a potential role in achieving local tumor control, allowing remineralization of trabecular bone or reduction in lesion size. The current report presents a detailed step-by-step guide for performing MR imaging-guided focused ultrasound ablation of bone metastases, including use of MR thermometry for monitoring treatment, protocol selection for simple palliation of pain or for local tumor control, and a description of imaging features of periosteal neurolysis or metastasis ablation. Two case studies are also presented: in the first, the technique provided palliation of pain in bone metastases, and in the second, the technique achieved tumor control as further proof of primary efficacy. MR imaging-guided focused ultrasound ablation is a promising method for successful palliation of bone metastasis pain and tumor control, because of the bony structure remodeling induced by thermo-related coagulative necrosis.

Giant adrenal cavernous hemangioma: a rare abdominal mass.

An 84-year-old woman with left flank pain presented to our institution. Contrast-enhanced computed tomography demonstrated a large spherical adrenal mass (diameter 13 cm) showing features of a benign lesion. Histologic examination revealed a giant adrenal hemangioma. Surgical resection was curative, with no recurrence at 2 years of follow-up. Surgery is usually recommended for symptomatic patients or in the case of a large lesion (>6 cm) because of the possibility of the coexistence of a malignancy or potential complications (ie, hemorrhage, rupture).

MR-guided high-intensity focused ultrasound: current status of an emerging technology.

The concept of ideal tumor surgery is to remove the neoplastic tissue without damaging adjacent normal structures. High-intensity focused ultrasound (HIFU) was developed in the 1940s as a viable thermal tissue ablation approach. In clinical practice, HIFU has been applied to treat a variety of solid benign and malignant lesions, including pancreas, liver, prostate, and breast carcinomas, soft tissue sarcomas, and uterine fibroids. More recently, magnetic resonance guidance has been applied for treatment monitoring during focused ultrasound procedures (magnetic resonance-guided focused ultrasound, MRgFUS). Intraoperative magnetic resonance imaging provides the best possible tumor extension and dynamic control of energy deposition using real-time magnetic resonance imaging thermometry. We introduce the fundamental principles and clinical indications of the MRgFUS technique; we also report different treatment options and personal outcomes.

Persistence of the sciatic artery: a case report of a combined (complete and incomplete) type causing leg ischemia.

Persistent sciatic artery is a very uncommon embryologic vascular variant, with a prevalence of 0.05% based on angiographic studies. Two different types of this anomaly can occur, complete or incomplete, on the basis of the relationship between sciatic artery and femoral artery. Although many of these patients are asymptomatic, it may represent a threat to the viability of the lower extremity because of atherosclerotic degeneration resulting in aneurysmal dilatation, occlusive thrombosis, or embolic phenomena with distal complication. We present a case of a 64-year-old man with combined, complete and incomplete, type of persistent sciatic artery causing ischemic ulcer of the first toe.