Takotsubo cardiomyopathy in a man with no trigger and multiple cardioembolic complications-A rare constellation.

Takotsubo Cardiomyopathy (TC) is an uncommon, transient, reversible cardiomyopathy, with a classic pattern of wall-motion abnormalities, usually seen in women after an emotional stressor. Despite its increased recognition, there remain gaps in the exact mechanisms, predisposing factors, and predictors of recovery; this is particularly true for males where the condition occurs far less frequently than in females. TC typically resolves within weeks, and the prognosis is favorable compared to acute coronary syndromes. Nonetheless, about 1% of cases may be complicated by left ventricular (LV) thrombus and embolism. Herein we describe an atypical case of a man with no obvious trigger, who developed TC with left ventricular thrombus and multiple embolic complications, but subsequently showed complete and full resolution. Multimodality imaging including echocardiography, cardiac CT and cardiac MRI was instrumental in this diagnostic dilemma, as well as useful in guiding treatment options and informing prognosis.

Abnormalities of the Coronary Arteries in Children: Looking beyond the Origins.

Coronary arterial abnormalities are uncommon findings in children that have profound clinical implications. Although anomalies of the coronary origins are well described, there are many other disease processes that affect the coronary arteries. Immune system-mediated diseases (eg, Kawasaki disease, polyarteritis nodosa, and other vasculiditides) can result in coronary arterial aneurysms, strictures, and abnormal tapering of the vessels. Because findings at imaging are an important component of diagnosis in these diseases, the radiologist's understanding of them is essential. Congenital anomalies may present at varying ages, and findings in hemodynamically significant anomalies, such as fistulas, are key for both diagnosis and preoperative planning. Pediatric heart surgery can result in wide-ranging postoperative imaging appearances of the coronary arteries and also predisposes patients to a multitude of complications affecting the heart and coronary arteries. In addition, although rare, accidental trauma can lead to injury of the coronary arteries, and awareness and detection of these conditions are important for diagnosis in the acute setting. Patients with coronary arterial conditions at presentation may range from being asymptomatic to having findings of myocardial infarction. Recognition of the imaging findings is essential to direct appropriate treatment. ©RSNA, 2017.

4D flow MR imaging of the portal venous system: a feasibility study in children.

OBJECTIVES: To determine the feasibility of 4D flow MRI for visualization and quantification of the portal venous haemodynamics in children and young adults. METHODS: 4D flow was performed in 28 paediatric patients (median age, 8.5 years; interquartile range, 5.2-16.5), 15 with non-operated native portal system and 13 with surgically created portal shunt. Image quality assessment for 3D flow visualization and flow pattern analyses was performed. Regional 4D flow peak velocity and net flow were compared with 2D-cine phase contrast MRI (2D-PC MR) in the post-surgical patients. RESULTS: Mean 3D flow visualization quality score was excellent (mean ± SD, 4.2 ± 0.9) with good inter-rater agreement (κ,0.67). Image quality in children aged >10 years was better than children ≤10 years (p < 0.05). Flow pattern was defined for portal, superior mesenteric, splenic veins and splenic artery in all patients. 4D flow and 2D-PC MR peak velocity and net flow were similar with good correlation (peak velocity: 4D flow 22.2 ± 9.1 cm/s and 2D-PC MR 25.2 ± 11.2 cm/s, p = 0.46; r = 0.92, p < 0.0001; net flow: 4D flow 9.5 ± 7.4 ml/s and 2D-PC MR 10.1 ± 7.3 ml/s, p = 0.65; r = 0.81, p = 0.0007). CONCLUSIONS: 4D flow MRI is feasible and holds promise for the comprehensive 3D visualization and quantification of portal venous flow dynamics in children and young adults. KEY POINTS: • 4D flow MRI is feasible in children and young adults. • 4D flow MRI has the ability to non-invasively characterize portal haemodynamics. • Image quality of 4D flow MRI is better is older children. • 4D flow MRI can accurately quantify portal flow compared to 2D-cine PC MRI.

T1 mapping in children and young adults with hypertrophic cardiomyopathy.

To assess the global and segmental left ventricular (LV) native T1 and extracellular volume fraction (ECV) in children and young adults with hypertrophic cardiomyopathy (HCM) compared to a control cohort. The study population included 21 HCM patients (mean 14.1 ± 4.6 years) and 21 controls (mean 15.7 ± 1.5 years). Native modified Look-Locker inversion recovery sequence was performed before and after contrast injection in 3 short axis planes. Global and segmental LV native T1 and ECV were quantified and compared between HCM patients and controls. Mean native T1 in HCM patients and controls was 1020.4 ± 41.2 and 965.6 ± 30.2 ms respectively (p < 0.0001). Hypertrophied myocardium had significantly higher native global T1 and global ECV compared to non-hypertrophied myocardium in HCM (p < 0.0001, = 0.14 and 0.048, = 0.01 respectively). In a subset of patients, ECV was higher in LV segments with LGE compared to no LGE (p < 0.0001). No significant correlation was identified between global native T1 and ECV and parameters of LV structure and function. Native T1 cut-off of 987 ms provided the highest sensitivity (95 %) and specificity (91 %) to separate HCM patients from controls. Global and segmental native T1 are elevated in HCM patients. LV segments with hypertrophy and/or LGE had higher ECV in a subset of HCM patients. LV native T1 and ECV do not correlate with parameters of LV structure and function. T1 in children and young adults may be used as a non-invasive tool to assess for HCM and related fibrosis.

Performance of tumor growth kinetics as an imaging biomarker for response assessment in colorectal liver metastases: correlation with FDG PET.

PURPOSE: To correlate RECIST, volumetric criteria, and tumor growth kinetics at multidetector-computed tomography with tumor metabolic activity at FDG PET in colorectal liver metastases (CRCLM) treated with bevacizumab-based chemotherapy. METHODS: Thirty-two CRCLM in 20 patients treated with bevacizumab-based chemotherapy were evaluated. Pre- and post-treatment CT scans were used to calculate reciprocal of doubling time (RDT), percentage change in the lesion's longest transaxial diameter (RECIST 1.1), and percentage change in the tumor volume. The accuracy of these parameters in predicting response based on standard uptake value analysis at FDG PET was assessed. Data were analyzed using Spearman's correlation, student's t, Mann-Whitney, Wilcoxon signed-rank, and Fisher's exact tests. RESULTS: According to FDG PET, 24/32 (75%) lesions were categorized as responders and 8/32 (25%) lesions as nonresponders. Based on RDT, 26/32 (81.25%) lesions were classified as responders and 6/32 (18.75%) lesions as nonresponders. Response classification according to RDT and FDG PET was concordant in 30/32 (93.75%) lesions, whereas RECIST 1.1 and volumetric criteria were concordant with FDG PET for 20/32 (62.5%) and 21/32 (65.63%) lesions, respectively. A strong association was found between RDT and response based on FDG PET (odds ratio = 127.4; 95% CI 5.54-2997; P < 0.0001). CONCLUSIONS: Tumor growth kinetics may be an effective imaging biomarker for response evaluation in CRCLM.

Constrictive Pericarditis as a Cause of Refractory Ascites.

We report a 43-year-old man who presented for evaluation of ascites, varices, and hepatosplenomegaly. Initial labs were notable for normal platelets, mild liver synthetic dysfunction, and disproportionately elevated alkaline phosphatase. He was presumed to have underlying cirrhosis, and diuresis was attempted without success. A transjugular liver biopsy showed marked sinusoidal dilation without cirrhosis. Diagnostic paracentesis revealed fluid studies suggestive of cardiac ascites. Further cardiac evaluation confirmed constrictive pericarditis. The case highlights the importance of considering a broad differential in the evaluation of ascites.

Extranodal Rosai-Dorfman Disease Involving the Left Atrium: Cardiac MRI, CT, and PET Scan Findings.

Rosai-Dorfman disease (RDD) is a rare entity that usually involves the lymph nodes but extranodal involvements have been seen in numerous cases, although RDD with cardiovascular involvement is extremely rare. We describe a case of a young male who presented with intermittent palpitations and was found to have a left atrium mass. Our case not only emphasizes the rarity of the above lesion but also highlights the importance of modern-day imaging like computed tomography, Cardiac Magnetic Resonance Imaging (CMRI), and PET scan in characterizing such nonspecific lesions and directing appropriate line of treatment. RDD should be considered as one of the differentials even for isolated cardiac lesions.

Raghib Syndrome Presenting as a Cryptogenic Stroke: Role of Cardiac MRI in Accurate Diagnosis.

Raghib Syndrome is a rare developmental complex, which consists of persistence of the left superior vena cava (PLSVC) along with coronary sinus ostial atresia and atrial septal defect. This Raghib complex anomaly has also been associated with other congenital malformations including ventricular septal defects, enlargement of the tricuspid annulus, and pulmonary stenosis. Our case demonstrates an isolated PLSVC draining into the left atrium along with coronary sinus atresia in a young patient presenting with cryptogenic stroke without the atrial septal defect. Majority of the cases reported in the literature were found to have the lesion during the postmortem evaluation or were characterized at angiography and/or echocardiography. We stress the importance of modern day imaging like the computed tomography (CT) angiography and cardiac MRI in diagnosis and surgical management of such rare lesions leading to cryptogenic strokes.

Tumor growth kinetics versus RECIST to assess response to locoregional therapy in breast cancer liver metastases.

RATIONALE AND OBJECTIVES: The aim of our study was to evaluate changes in growth kinetics of breast cancer liver metastasis in response to locoregional therapy and compare them to Response Evaluation Criteria in Solid Tumors (RECIST). MATERIALS AND METHODS: This Health Insurance Portability and Accountability Act-compliant retrospective study was Institutional Review Board approved. Thirty-four chemorefractory breast cancer liver metastases from 21 patients treated with yttrium-90 ((90)Y) were evaluated. Pre- and posttreatment computed tomography (CT) scans were used to calculate tumor growth kinetics. The growth parameter analyzed was reciprocal of doubling time (RDT). RDT range for stable disease (SD) was defined by the measurement error rate. A negative RDT below the SD range defined response and was categorized as either partial response (PR) or complete response, whereas a positive RDT value above the SD range indicated progressive disease (PD). Comparison was made to tumor response classification according to percentage change in the lesion's maximal diameter per RECIST. Lin's concordance correlation coefficient, Bland-Altman plot, Wilcoxon signed rank test, and Student t test were used for analysis. Significance was set at 0.05. RESULTS: RDT range for SD ranged from -0.46 to +2.17. Six lesions with PR based on RECIST showed PR based on their volumetric growth rate (mean RDT of -17.3 ± 2.6). Similarly, one lesion with PD according to RECIST was categorized as PD based on its growth kinetics (RDT of 10.2). However, 14 (51.85%) lesions classified as SD by RECIST had PR according to growth kinetics (mean RDT of -7.8), six (22.22%) lesions were categorized as SD (mean RDT of 0.8), whereas seven (25.93%) lesions showed PD (mean RDT of 4.5). Growth kinetic parameters were significantly different for lesions with PR when compared to lesions with PD (P < .0001). CONCLUSIONS: In patients with breast cancer liver metastases undergoing locoregional therapy, RECIST categorization may not be an accurate reflection of treatment response.

Cross-sectional imaging of perforated gallbladder.

Gallbladder perforation is a potentially life-threatening condition commonly seen as a complication of acute cholecystitis. Urgent surgical intervention is often needed to reduce serious morbidity and mortality. It presents a diagnostic challenge due to nonspecific symptoms, leading to a delay in diagnosis. Imaging plays a vital role in early identification of this potentially fatal condition and evaluation by more than one imaging modality may be required to make the diagnosis. Knowledge of specific and ancillary imaging findings is crucial to avoid misdiagnosis. In this article, we will review the risk factors, pathophysiology, and surgical classification of gallbladder perforation and discuss the role of multimodality imaging in its diagnosis. Differential diagnoses on imaging will also be discussed.

Transitional cell carcinoma in urachal cyst.

A 33-year-old male patient with abdominal mass for a year was referred to our institute. CT scan with intravenous contrast was performed, which showed a cystic lesion at the infraumbilical region, beneath the anterior abdominal wall with the presence of solid enhancing mass apposed to the anterior wall of the cyst. We suggested a diagnosis of urachal cyst with possibility of malignancy. On surgical exploration, the cystic mass was found superior to and separate from the urinary bladder dome. Histopathology revealed transitional cell carcinoma in a urachal cyst.