Los retos en la evaluación radiológica de las metástasis cerebrales, más allá de la progresión / Challenges in radiological evaluation of brain metastases, beyond progression

La resonancia magnética es la piedra angular en la evaluación de las metástasis cerebrales. Los retos clínicos residen en discriminar las metástasis de imitadores como infecciones o tumores primarios y en evaluar la respuesta al tratamiento. Este, en ocasiones, condiciona un crecimiento, que debe encuadrarse como una pseudoprogresión o una radionecrosis, ambos fenómenos inflamatorios atribuibles al mismo, o bien considerarse como una recurrencia. Para responder a estas necesidades, las técnicas de imagen son objeto de constantes investigaciones. No obstante, un crecimiento exponencial tras la radioterapia debe interpretarse con cautela, incluso ante resultados sospechosos de progresión por técnicas avanzadas, ya que puede tratarse de una radionecrosis. El objetivo de este trabajo es familiarizar al lector con los fenómenos inflamatorios de las metástasis cerebrales tratadas con radioterapia y describir dos signos radiológicos relacionados: la «nube inflamatoria» y el «realce en anillo incompleto», con el fin de adoptar un manejo conservador en estos casos.(AU)

MRI is the cornerstone in the evaluation of brain metastases. The clinical challenges lie in discriminating metastases from mimickers such as infections or primary tumors and in evaluating the response to treatment. The latter sometimes leads to growth, which must be framed as pseudo-progression or radionecrosis, both inflammatory phenomena attributable to treatment, or be considered as recurrence. To meet these needs, imaging techniques are the subject of constant research. However, an exponential growth after radiotherapy must be interpreted with caution, even in the presence of results suspicious of tumor progression by advanced techniques, because it may be due to inflammatory changes. The aim of this paper is to familiarize the reader with inflammatory phenomena of brain metastases treated with radiotherapy and to describe two related radiological signs: «the inflammatory cloud» and «incomplete ring enhancement», in order to adopt a conservative management with close follow-up.(AU)

Manejo de las metástasis vertebrales en la charnela cervico-occipital / Management of vertebral metastases in the cervico-occipital junction

Las metástasis a nivel occipito-cervical corresponden solo al 0,5% de las metástasis del raquis. El manejo de estas lesiones es complejo y conlleva múltiples estudios radiológicos, tales como la radiología simple, la tomografía computarizada (TAC) o la resonancia magnética (RM). Ante la sospecha de afectación vascular también será recomendable la realización de pruebas que valoren la permeabilidad vascular (angio-TC, angio-RM). Este tipo de lesiones, debido a su compleja localización, puede precisar distintos tipos de vías de abordaje; comúnmente será el abordaje posterior, pero en ocasiones se necesitarán abordajes anteriores o anterolaterales asistidos por cirujanos maxilofaciales u otorrinolaringólogos para una correcta exéresis de la tumoración. El dolor con los giros puede orientarnos al diagnóstico en una columna inestable. La RM es la prueba de elección para diagnosticar y estudiar estas lesiones. La presencia de inestabilidad o de clínica neurológica progresiva es indicación de cirugía.(AU)

Occipito-cervical metastases correspond to 0.5% of spinal metastases. The management of these lesions is complex and involves multiple radiological studies, such as simple radiology, computed tomography (CT), magnetic resonance imaging (MRI). Is vascular involvement is suspected, tests to assess vascular permeability are also recommended (angioCT). This type of lesion, due to its complex location, may require different types of approaches, commonly it will be the posterior approach, but sometimes anterior or anterolateral approaches will be needed assisted by maxillofacial surgeons or otorhinolaryngologists for correct excision of the tumor. Pain with head turning can guide us to the diagnosis in an unstable spine. Magnetic resonance is the test of choice to diagnose and study these lesions. The presence of instability or progressive neurological symptoms are an indication for surgery.(AU)

[Translated article] Management of vertebral metastases in the cervico-occipital junction / Manejo de las metástasis vertebrales en la charnela cervicooccipital

Las metástasis a nivel occipito-cervical corresponden solo al 0,5% de las metástasis del raquis. El manejo de estas lesiones es complejo y conlleva múltiples estudios radiológicos, tales como la radiología simple, la tomografía computarizada (TAC) o la resonancia magnética (RM). Ante la sospecha de afectación vascular también será recomendable la realización de pruebas que valoren la permeabilidad vascular (angio-TC, angio-RM). Este tipo de lesiones, debido a su compleja localización, puede precisar distintos tipos de vías de abordaje; comúnmente será el abordaje posterior, pero en ocasiones se necesitarán abordajes anteriores o anterolaterales asistidos por cirujanos maxilofaciales u otorrinolaringólogos para una correcta exéresis de la tumoración. El dolor con los giros puede orientarnos al diagnóstico en una columna inestable. La RM es la prueba de elección para diagnosticar y estudiar estas lesiones. La presencia de inestabilidad o de clínica neurológica progresiva es indicación de cirugía.(AU)

Occipito-cervical metastases correspond to 0.5% of spinal metastases. The management of these lesions is complex and involves multiple radiological studies, such as simple radiology, computed tomography (CT), magnetic resonance imaging (MRI). Is vascular involvement is suspected, tests to assess vascular permeability are also recommended (angioCT). This type of lesion, due to its complex location, may require different types of approaches, commonly it will be the posterior approach, but sometimes anterior or anterolateral approaches will be needed assisted by maxillofacial surgeons or otorhinolaryngologists for correct excision of the tumor. Pain with head turning can guide us to the diagnosis in an unstable spine. Magnetic resonance is the test of choice to diagnose and study these lesions. The presence of instability or progressive neurological symptoms are an indication for surgery.(AU)

Results after the application of biodegradable spacer balloons as a therapeutic option in non-repairable massive ruptures of the shoulder rotator cuff / Resultados tras la aplicación de balones espaciadores biodegradables como opción terapéutica en roturas masivas no reparables del manguito de los rotadores del hombro

Introduction: One of the most frequently treated pathologies in our department are tendon lesions that affect the rotator cuff of the shoulder. There are different types of treatment for massive or irreparable tears. For a few years, a low-invasive technique was introduced based on the placement of a biodegradable subacromial spacer. The objective of the work is to analyse the results of our experience with the use of this device (InSpaceTM).Material and method: The study collects the results obtained in 25 patients with irreparable ruptures of rotator cuff defined by RM, in which they were implanted a balloon subacromial in our centre in the period from January 2015 – until December 2017. All patients were evaluated preoperatively and one year after surgery including the visual analogue scale (VAS), the Constant test (CS) and the QuickDASH (QD). Results: Of the 25 patients, 5 patients (20%) were operated by arthroscopy and 20 (80%) By open approach (mini-open). A total of 22 patients completed the follow-up year. At 12 months, 64% of the patients obtained an improvement of at least 10 points in the CS. Patients departed from an initial average CS of 32 points that improved to 54.9 points of average in the postoperative evaluation at 12 months (average improvement 22.9 points; Value-p < 0.05). In terms of pain assessment, in our study, 87% of patients obtained an improvement of at least 2 points in the EVA at 12 months of follow-up (P-value < 0.05). Patients departed from an initial average EVA of 8.7 that improved to 3.7 points average at 12 months. 73% of the patients responded to be satisfied with the intervention and would return to the surgery.(AU)

Introducción: Una de las patologías más frecuentemente atendida en nuestro medio son las lesiones tendinosas que afectan al manguito rotador del hombro. Existen diferentes modalidades de tratamiento para las roturas masivas o irreparables. Desde hace unos años, se introdujo en el mercado una técnica poco invasiva basada en la colocación de un espaciador subacromial biodegradable. El objetivo del trabajo es analizar los resultados de nuestra experiencia con el uso de este dispositivo (InSpace®). Material y método: En el estudio se recogen los resultados obtenidos en 25 pacientes con roturas irreparables del manguito rotador definidas mediante resonancia magnética (RM), en los que se les implantó un balón subacromial en nuestro centro en el periodo comprendido entre enero de 2015 hasta diciembre de 2017. Todos los pacientes fueron evaluados preoperatoriamente y un año después de la cirugía incluyendo la escala visual analógica (EVA), el test de Constant (CS) y el QuickDASH (QD). Resultados: De los 25 pacientes, cinco pacientes (20%) fueron intervenidos mediante artroscopia y 20 (80%) mediante abordaje abierto (mini-open). Un total de 22 pacientes completaron el año de seguimiento. A los 12 meses, el 64% (14/22) de los pacientes obtuvo una mejoría de al menos 10 puntos en el CS. Los pacientes partían de un CS promedio inicial de 32 puntos que mejoró hasta los 54,9 puntos de media en la evaluación postoperatoria a los 12 meses (Promedio de mejoría 22,9 puntos; p < 0,05). En cuanto a la evaluación del dolor, en nuestro estudio, el 87% (19/22) de los pacientes obtuvo una mejoría de al menos 2 puntos en la EVA a los 12 meses de seguimiento (p < 0,05). Los pacientes partían de una EVA media inicial de 8,7 que mejoró hasta los 3,7 puntos de media a los 12 meses. Un 73% de los pacientes contestaron estar satisfechos con la intervención y volverían a someterse a la cirugía.(AU)

Resultados tras la aplicación de balones espaciadores biodegradables como opción terapéutica en roturas masivas no reparables del manguito de los rotadores del hombro / Results after the application of biodegradable spacer balloons as a therapeutic option in non-repairable massive ruptures of the shoulder rotator cuff

Introducción: Una de las patologías más frecuentemente atendida en nuestro medio son las lesiones tendinosas que afectan al manguito rotador del hombro. Existen diferentes modalidades de tratamiento para las roturas masivas o irreparables. Desde hace unos años, se introdujo en el mercado una técnica poco invasiva basada en la colocación de un espaciador subacromial biodegradable. El objetivo del trabajo es analizar los resultados de nuestra experiencia con el uso de este dispositivo (InSpace®). Material y método: En el estudio se recogen los resultados obtenidos en 25 pacientes con roturas irreparables del manguito rotador definidas mediante resonancia magnética (RM), en los que se les implantó un balón subacromial en nuestro centro en el periodo comprendido entre enero de 2015 hasta diciembre de 2017. Todos los pacientes fueron evaluados preoperatoriamente y un año después de la cirugía incluyendo la escala visual analógica (EVA), el test de Constant (CS) y el QuickDASH (QD). Resultados: De los 25 pacientes, cinco pacientes (20%) fueron intervenidos mediante artroscopia y 20 (80%) mediante abordaje abierto (mini-open). Un total de 22 pacientes completaron el año de seguimiento. A los 12 meses, el 64% (14/22) de los pacientes obtuvo una mejoría de al menos 10 puntos en el CS. Los pacientes partían de un CS promedio inicial de 32 puntos que mejoró hasta los 54,9 puntos de media en la evaluación postoperatoria a los 12 meses (Promedio de mejoría 22,9 puntos; p < 0,05). En cuanto a la evaluación del dolor, en nuestro estudio, el 87% (19/22) de los pacientes obtuvo una mejoría de al menos 2 puntos en la EVA a los 12 meses de seguimiento (p < 0,05). Los pacientes partían de una EVA media inicial de 8,7 que mejoró hasta los 3,7 puntos de media a los 12 meses. Un 73% de los pacientes contestaron estar satisfechos con la intervención y volverían a someterse a la cirugía.(AU)

Introduction: One of the most frequently treated pathologies in our department are tendon lesions that affect the rotator cuff of the shoulder. There are different types of treatment for massive or irreparable tears. For a few years, a low-invasive technique was introduced based on the placement of a biodegradable subacromial spacer. The objective of the work is to analyse the results of our experience with the use of this device (InSpaceTM).Material and method: The study collects the results obtained in 25 patients with irreparable ruptures of rotator cuff defined by RM, in which they were implanted a balloon subacromial in our centre in the period from January 2015 – until December 2017. All patients were evaluated preoperatively and one year after surgery including the visual analogue scale (VAS), the Constant test (CS) and the QuickDASH (QD). Results: Of the 25 patients, 5 patients (20%) were operated by arthroscopy and 20 (80%) By open approach (mini-open). A total of 22 patients completed the follow-up year. At 12 months, 64% of the patients obtained an improvement of at least 10 points in the CS. Patients departed from an initial average CS of 32 points that improved to 54.9 points of average in the postoperative evaluation at 12 months (average improvement 22.9 points; Value-p < 0.05). In terms of pain assessment, in our study, 87% of patients obtained an improvement of at least 2 points in the EVA at 12 months of follow-up (P-value < 0.05). Patients departed from an initial average EVA of 8.7 that improved to 3.7 points average at 12 months. 73% of the patients responded to be satisfied with the intervention and would return to the surgery.(AU)

Diagnosis of transition zone prostate cancer by multiparametric MRI: added value of MR spectroscopic imaging with sLASER volume selection.

BACKGROUND: Current multiparametric MRI (mp-MRI) in routine clinical practice has poor-to-moderate diagnostic performance for transition zone prostate cancer. The aim of this study was to evaluate the potential diagnostic performance of novel 1H magnetic resonance spectroscopic imaging (MRSI) using a semi-localized adiabatic selective refocusing (sLASER) sequence with gradient offset independent adiabaticity (GOIA) pulses in addition to the routine mp-MRI, including T2-weighted imaging (T2WI), diffusion-weighted imaging (DWI) and quantitative dynamic contrast enhancement (DCE) for transition zone prostate cancer detection, localization and grading. METHODS: Forty-one transition zone prostate cancer patients underwent mp-MRI with an external phased-array coil. Normal and cancer regions were delineated by two radiologists and divided into low-risk, intermediate-risk, and high-risk categories based on TRUS guided biopsy results. Support vector machine models were built using different clinically applicable combinations of T2WI, DWI, DCE, and MRSI. The diagnostic performance of each model in cancer detection was evaluated using the area under curve (AUC) of the receiver operating characteristic diagram. Then accuracy, sensitivity and specificity of each model were calculated. Furthermore, the correlation of mp-MRI parameters with low-risk, intermediate-risk and high-risk cancers were calculated using the Spearman correlation coefficient. RESULTS: The addition of MRSI to T2WI + DWI and T2WI + DWI + DCE improved the accuracy, sensitivity and specificity for cancer detection. The best performance was achieved with T2WI + DWI + MRSI where the addition of MRSI improved the AUC, accuracy, sensitivity and specificity from 0.86 to 0.99, 0.83 to 0.96, 0.80 to 0.95, and 0.85 to 0.97 respectively. The (choline + spermine + creatine)/citrate ratio of MRSI showed the highest correlation with cancer risk groups (r = 0.64, p < 0.01). CONCLUSION: The inclusion of GOIA-sLASER MRSI into conventional mp-MRI significantly improves the diagnostic accuracy of the detection and aggressiveness assessment of transition zone prostate cancer.

Sensibilización central en la artrosis / Central sensitization in osteoarthritis

El dolor de los pacientes con artrosis es un problema sociosanitario de primera magnitud y es el responsable de la importante limitación funcional y pérdida de calidad de vida en esta enfermedad.A pesar de haberse producido avances importantes en el conocimiento de los mecanismos fisiopatológicos del dolor, son muchos los interrogantes del dolor artrósico que todavía quedan por contestar.Uno de los aspectos menos estudiados del dolor crónico en la artrosis es el fenómeno de sensibilización central.La resonancia magnética nuclear funcional se ha mostrado como una técnica útil para el abordaje de este fenómeno.Diferentes estudios realizados a pacientes afectos de artrosis con distintos grados de sensibilización ponen de manifiesto que la incidencia de este fenómeno es elevada, que los pacientes sensibilizados y no sensibilizados muestran patrones diferentes en cuanto a la magnitud de la repuesta cerebral al dolor y que los patrones de conectividad difieren de una enfermedad a otra.Finalmente, en los pacientes candidatos a artroplastia de rodilla es importante evaluar el grado de sensibilización previo a la cirugía, puesto que son los pacientes con mayor grado de sensibilización los que presentarán evoluciones más tórpidas y mayores niveles de dolor posquirúrgico.(AU)

Pain in patients with osteoarthritis is a social and health problem of great magnitude and is responsible for the significant functional limitation and loss of quality of life in this disease.Despite the important advances made in the knowledge of the pathophysiological mechanisms of pain, many questions about arthritic pain remain unanswered.One of the least studied aspects of chronic pain in osteoarthritis is the phenomenon of central sensitization.Functional Magnetic Resonance Imaging has shown to be a useful technique for addressing this phenomenon.Many studies carried out in patients with osteoarthritis with different degrees of sensitization show that the incidence of this phenomenon is high, that sensitized and non-sensitized patients show different patterns in terms of the magnitude of the cerebral response to pain and that the connectivity patterns differ from one disease to another.Finally, in patients who are candidates for knee arthroplasty, it is important to evaluate the degree of sensitization prior to surgery, since it is the patients with the highest degree of sensitization who will present more torpid evolutions and higher levels of post-surgical pain.(AU)

Fístula coronário-cavitária da artéria coronária circunflexa para o átrio esquerdo como provável etiologia de insuficiência cardíaca: relato de caso / Coronary­cavitary fistula of the circumflex coronary artery to the left atrium as a probable etiology of heart failure: a case report

Fístulas de artérias coronárias têm incidência baixa, sendo diagnosticadas mais frequentemente pelo ecocardiograma ou angiotomografia coronariana, embora a cineangiocoronariografia seja o método padrão-ouro. Têm origem mais comumente na artéria coronária direita, sendo a drenagem para câmaras de baixa pressão o mais habitual. O tratamento pode ser expectante, cirúrgico ou percutâneo. Este relato descreve o caso de uma rara apresentação de insuficiência cardíaca, dada por fístula da coronária circunflexa com drenagem para o átrio esquerdo. (AU)

Coronary artery fistulas have a low incidence and are often diagnosed by echocardiography or coronary computed tomography angiography, although coronary angiography is the gold standard. They commonly originate in the right coronary artery, with drainage to low-pressure chambers being the most frequent finding. Treatment can be expectant, surgical, or percutaneous. This report describes a case of a rare presentation of heart failure due to a fistula of the circumflex coronary artery with drainage into the left atrium. (AU)

Documento de consenso de un grupo de expertos de la Sociedad Española de Arteriosclerosis (SEA) sobre el uso clínico de la resonancia magnética nuclear en el estudio del metabolismo lipoproteico (Liposcale) / Consensus document of an expert group from the Spanish Society of Arteriosclerosis (SEA) on the clinical use of nuclear magnetic resonance to assess lipoprotein metabolism (Liposcale)

La evaluación y prevención del riesgo cardiovascular (RCV) que persiste en los pacientes con dislipidemia a pesar del tratamiento y de haber alcanzado los objetivos específicos de la concentración plasmática de colesterol unido a lipoproteínas de baja densidad (c-LDL) es un reto clínico en la actualidad, y sugiere que los biomarcadores lipídicos convencionales resultan insuficientes para una evaluación precisa del RCV. Más allá de su contenido lipídico, existen otras características propias de las partículas lipoproteicas que determinan su potencial aterogénico y su influencia en el RCV. Sin embargo, dichas características adicionales no pueden ser analizadas por las técnicas utilizadas habitualmente en los laboratorios clínicos. La espectroscopia por resonancia magnética nuclear (RMN) es una técnica que permite un análisis detallado de la cantidad, composición y tamaño de las lipoproteínas y proporciona información más detallada del estado del metabolismo lipídico y del RCV en los pacientes dislipémicos. En este artículo un grupo de lipidólogos de la Sociedad Española de Arteriosclerosis revisa la evidencia existente sobre los mecanismos aterogénicos de las partículas lipoproteicas y describen el fundamento técnico y la interpretación de los perfiles lipoproteicos obtenidos mediante RMN, haciendo especial referencia al test disponible en España (Liposcale®). Asimismo, se definen los principales perfiles de pacientes en los que dicho análisis aportaría una información de mayor interés clínico, los cuales son: a) sospecha de discordancia entre las concentraciones de lípidos y el número de partículas, situación frecuente en la diabetes, la obesidad, el síndrome metabólico y la hipertrigliceridemia; b) enfermedad cardiovascular aterotrombótica (ECVA) precoz o recurrente sin factores de RCV que la justifiquen; c) trastornos lipídicos infrecuentes o complejos como las concentraciones extremas de c-HDL, y d) situaciones clínicas en las que las técnicas analíticas clásicas no pueden aplicarse, como los valores de c-LDL muy bajos

The assessment and prevention of cardiovascular risk (CVR) that persists in patients with dyslipidaemia despite treatment and achievement of goals specific to the plasma concentration of cholesterol linked to low density (c-LDL) is a clinical challenge today, and suggests that conventional lipid biomarkers are insufficient for an accurate assessment of CVR. Apart from their lipid content, there are other lipid particle characteristics. The results of this study show that there are a number of lipoprotein compounds that determine atherogenic potential and its influence on the CVR. However, such additional characteristics cannot be analysed by the techniques commonly used in clinical laboratories. Nuclear Magnetic Resonance (NMR) is a technique that allows a detailed analysis to be made of the amount, composition, and size of lipoproteins, as well as providing more information about the detailed status of lipid metabolism and CVR in dyslipidaemia patients. In this article a group of lipidologists from the Spanish Society of Arteriosclerosis review the existing evidence on the atherogenic mechanisms of particles and describe the technical basis and interpretation of the profiles lipoproteins obtained by MRI, with special reference to the test available in Spain (Liposcale®). Likewise, the main patient profiles are defined as such that an analysis would provide information of greater clinical interest. These include: a) Suspected mismatch between lipid concentrations and particles, a common situation in diabetes, obesity, metabolic syndrome; b) Early atherothrombotic cardiovascular disease (ECVA) or recurrent without CVR factors to justify it; c) Lipid disorders, rare or complex, such as extreme concentrations of c-HDL, and d) Clinical situations where classical analytical techniques cannot be applied, such as very low c-LDL values

New device permitting non-invasive reversal of fetal endoscopic tracheal occlusion: ex-vivo and in-vivo study.

OBJECTIVE: One of the drawbacks of fetal endoscopic tracheal occlusion (FETO) for congenital diaphragmatic hernia is the need for a second invasive intervention to re-establish airway patency. The 'Smart-TO' device is a new balloon for FETO that deflates spontaneously when placed in a strong magnetic field, therefore overcoming the need for a second procedure. The safety and efficacy of this device have not yet been demonstrated. The aim of this study was to investigate the reversibility, local side effects and occlusiveness of the Smart-TO balloon, both in a simulated in-utero environment and in the fetal lamb model. METHODS: First, the reversibility of tracheal occlusion by the Smart-TO balloon was tested in a high-fidelity simulator. Following videoscopic tracheoscopic balloon insertion, the fetal mannequin was placed within a 1-L water-filled balloon to mimic the amniotic cavity. This was held by an operator in front of their abdomen, and different fetal and maternal positions were simulated to mimic the most common clinical scenarios. Following exposure to the magnetic field generated by a 1.5-T magnetic resonance (MR) machine, deflation of the Smart-TO balloon was assessed by tracheoscopy. In cases of failed deflation, the mannequin was reinserted into a water-filled balloon for additional MR exposure, up to a maximum of three times. Secondly, reversibility, occlusiveness and local effects of the Smart-TO balloon were tested in vivo in fetal lambs. Tracheal occlusion was performed in fetal lambs on gestational day 95 (term, 145 days), either using the balloon currently used in clinical practice (Goldbal2) (n = 5) or the Smart-TO balloon (n = 5). On gestational day 116, the presence of the balloon was assessed by tracheoscopy. Deflation was performed by puncture (Goldbal2) or MR exposure (Smart-TO). Six unoccluded fetal lambs served as controls. Following euthanasia, the lung-to-body-weight ratio (LBWR), lung morphometry and tracheal circumference were assessed. Local tracheal changes were measured using a hierarchical histologic scoring system. RESULTS: Ex vivo, Smart-TO balloon deflation occurred after a single MR exposure in 100% of cases in a maternal standing position with the mannequin at a height of 95 cm (n = 32), 55 cm (n = 8) or 125 cm (n = 8), as well as when the maternal position was 'lying on a stretcher' (n = 8). Three out of eight (37.5%) balloons failed to deflate at first exposure when the maternal position was 'sitting in a wheelchair'. Of these, two balloons deflated after a second MR exposure, but one balloon remained inflated after a third exposure. In vivo, all Smart-TO balloons deflated successfully. The LBWR in fetal lambs with tracheal occlusion by a Smart-TO balloon was significantly higher than that in unoccluded controls, and was comparable with that in the Goldbal2 group. There were no differences in lung morphometry and tracheal circumference between the two balloon types. Tracheal histology showed minimal changes for both balloons. CONCLUSIONS: In a simulated in-utero environment, the Smart-TO balloon was effectively deflated by exposure of the fetus in different positions to the magnetic field of a 1.5-T MR system. There was only one failure, which occurred when the mother was sitting in a wheelchair. In healthy fetal lambs, the Smart-TO balloon is as occlusive as the clinical standard Goldbal2 system and has only limited local side effects. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

Resonancia magnética cardíaca en la miocardiopatía chagásica crónica. Una herramienta para optimizar el diagnóstico, la estratificación de riesgo y el pronóstico / Cardiac magnetic resonance imaging in chronic chagasic cardiomyopathy. A tool to optimize diagnosis, risk stratification and prognosis

Resumen La enfermedad de Chagas es un problema de salud pública en Latinoamérica, donde afecta a aproximadamente a 6 millones de personas. En Costa Rica se ha descrito la enfermedad desde 1941, con varios reportes de casos confirmados agudos y crónicos. La miocardiopatía chagásica afecta al 30% de los individuos con infección crónica y es la manifestación más grave de la enfermedad, con una morbimortalidad mayor que otras miocardiopatías. La resonancia magnética cardíaca, debido a su capacidad de caracterización tisular permite identificar con alta correlación histopatológica la presencia de fibrosis, edema e inflamación en la miocardiopatía chagásica. Esto ha permitido una mejor comprensión de la compleja fisiopatología de la enfermedad y además permite el diagnóstico diferencial con otras patologías simuladoras como lo es la cardiopatía isquémica. En la MCh la presencia de fibrosis miocárdica predice de manera independiente eventos adversos mayores tales como taquicardia ventricular sostenida y muerte cardiovascular. Debido a lo anterior la resonancia magnética cardíaca es una robusta herramienta capaz de mejorar el diagnóstico, la estratificación de riesgo y el pronóstico de estos pacientes, con miras a mejores y oportunas intervenciones terapéuticas.

Abstract Chagas disease is a public health problem in Latin America, where it affects approximately 6 million people. In Costa Rica the disease has been described since 1941, with several reports of acute and chronic confirmed cases. Chagas cardiomyopathy affects 30% of individuals with chronic infection and is the most serious manifestation of the disease, with a higher morbidity and mortality than other cardiomyopathies. Cardiac magnetic resonance, due to its capacity for tissue characterization, identifies the presence of fibrosis, aedema and inflammation in Chagas cardiomyopathy with high histopathological correlation. This has allowed a better understanding of the complex pathophysiology of the disease and also allows differential diagnosis with other pathologies that can simulate, such as ischemic heart disease. In Chagas cardiomyopathy, the presence of myocardial fibrosis independently predicts major adverse events such as sustained ventricular tachycardia and cardiovascular death. Due to the above, cardiac magnetic resonance is a robust tool capable of improving the diagnosis, risk stratification and prognosis of these patients, with a view to better and timely therapeutic interventions.

Resonancia magnética en el atrapamiento del nervio supraescapular por quiste supraglenoideo / Magnetic resonance in nerve entrapment suprascapular supraglenoid cyst

El síndrome de atrapamiento del nervio supraescapular es una causa infrecuente de dolor en el hombro y de difícil diagnóstico clínico. Puede ser consecuencia de traumatismo, infección, compresión extrínseca o estiramiento secundario a movimientos repetitivos. Los quistes supraglenoideos deben considerarse en el diagnóstico diferencial pues son una causa frecuente de compresión del nervio supraescapular que ocurre casi exclusivamente en hombres. Se evaluaron con resonancia magnética (RM) y en forma retrospectiva siete pacientes con diagnóstico de atrapamiento del nervio supraescapular por quiste supraglenoideo. La RM mostró la causa y localización de la compresión nerviosa así como la distribución del edema muscular en todos los casos. Puede evaluar el grado de severidad de la enfermedad y realizar el diagnóstico diferencial con otras causas que provocarían atrapamiento del nervio supraescapular. (AU)

Suprascapular nerve entrapment has been regarded as a relatively uncommon condition that is easily overlooked in the differential diagnosis of shoulder discomfort. The common feature is nerve damage, caused either by trauma, extrinsic compression or by stretching secondary to repeated movements. Ganglion cysts account for the majority of the masses causing entrapment and seem to occur exclusively in men. Seven cases of suprascapular nerve entrapment caused by supraglenoid cyst compression were reviewed with MRI. MRI showed the cause and location of nerve compression as well as the distribution of muscular edema in all cases. MR imaging also allows an evaluation of the severity of the disease. It is also very efficient in excluding several differential diagnoses. (AU)

Treatment of diabetic foot ulcers with Therapeutic Magnetic Resonance (TMR®) improves the quality of granulation tissue.

Diabetic foot ulcers (DFUs) often result in severely adverse outcomes, such as serious infections, hospitalization, and lower extremity amputations. In last few years, to improve the outcome of DFUs, clinicians and researchers put their attention on the application of low intensity pulsating electro-magnetic fields through Therapeutic Magnetic Resonance (TMR®). In our study, patients with DFUs have been divided into two groups: The Sham Group treated with non-functioning TMR® device, and the Active Group treated with a functioning device. Biopsies were recovered from ulcers before and after a 15-day treatment with both kind of TMR® device. To recognize signs of inflammation or healing process, the harvested biopsies were subjected to histological and molecular analyses. The histological analysis showed a change in cell population after treatment with TMR®: an increase of fibroblasts and endothelial cells with a reduction of inflammatory cells. After TMR® application, the gene expression profile analysis revealed an improvement in extracellular matrix components such as matrix metalloproteinases, collagens and integrins, a reduction in pro-inflammatory interleukins, and an increase in growth factors expression. In conclusion, our research has identified histological and molecular features of reduced inflammation and increased cell proliferation during the wound healing process in response to TMR® application.

Mielopatía aguda compresiva por absceso pulmonar. Presentación de un caso / Compressive acute myelopathy by pulmonary abscess. A case report

Las mielopatías constituyen un conjunto heterogéneo de procesos patológicos que directa o indirectamente afectan a la médula espinal. Son poco frecuentes y pueden ser producidos por variadas causas y vías de afectación, que conllevan a grandes secuelas y elevada discapacidad. Se describe un caso de mielopatía aguda compresiva desencadenada por un absceso pulmonar como causa y mecanismo de producción inusual. Hombre de 48 años, con antecedentes de salud y cuadro clínico de inicio brusco de paraparesia fláccida e hiporreflexia osteotendinosa de miembros inferiores asimétrica, con predominio derecho, nivel sensitivo dorsal a nivel de D4 y dolor a la percusión en procesos espinosos dorsales en D3-D6. Los estudios sanguíneos, inmunológicos y de líquido cefalorraquídeo resultaron irrelevantes, excepto muestra de signos indirectos de infección. La radiografía de tórax mostró la presencia del absceso pulmonar primario derecho y la afectación medular se corroboró a través de la realización de la resonancia magnética medular dorsal. Presentó pobre respuesta ante los esteroides parenteral, hasta que se inició la terapia antibiótica, de forma paulatina y con apoyo rehabilitador. Transcurridos tres meses se investigaron y fueron descartadas otras etiologías no compresivas. Las mielopatías agudas representan un grupo heterogéneo de trastornos con distintas etiologías y mecanismos de producción, a través de su estudio se evidenció como causa un absceso pulmonar con afectación medular, por lo que debe ser considerado en la extensa lista de diagnósticos diferenciales (AU).

Myelopathies are a heterogeneous group of pathological processes that directly or indirectly affect the spinal cord. They are rare and can be produced by different causes and affectation pathways leading to major consequences and high disability. A case of acute compressive myelopathy triggered by a lung abscess as unusual cause and production mechanism is described. It is the case of a man, aged 48 years, with a clinical history and symptoms of acute onset of flaccid paraparesis and asymmetric osteotendinous hyporeflexia of lower limbs, with right predominance, dorsal sensitive level at D4, and pain at percussion in D3-D6 dorsal spinal processes. Blood, immune and cerebrospinal fluid (CSF) studies were irrelevant, but showing indirect signs of infection. Chest radiography showed the presence of the right primary lung abscess and spinal cord involvement was confirmed by performing dorsal medullar magnetic resonance (MRI). The patient had poor response to parenteral steroids until antibiotic therapy began, gradually and with rehabilitation support. After three months, other non-comprehensive etiologies were studied and ruled out. Acute myelopathies represent a heterogeneous group of disorders with different etiologies and production mechanisms. The study evidenced a lung abscess with spinal cord involvement as a cause, so it should be considered in the extensive list of differential diagnoses (AU).

Mielopatía aguda compresiva por absceso pulmonar. Presentación de un caso / Compressive acute myelopathy by pulmonary abscess. A case report

Las mielopatías constituyen un conjunto heterogéneo de procesos patológicos que directa o indirectamente afectan a la médula espinal. Son poco frecuentes y pueden ser producidos por variadas causas y vías de afectación, que conllevan a grandes secuelas y elevada discapacidad. Se describe un caso de mielopatía aguda compresiva desencadenada por un absceso pulmonar como causa y mecanismo de producción inusual. Hombre de 48 años, con antecedentes de salud y cuadro clínico de inicio brusco de paraparesia fláccida e hiporreflexia osteotendinosa de miembros inferiores asimétrica, con predominio derecho, nivel sensitivo dorsal a nivel de D4 y dolor a la percusión en procesos espinosos dorsales en D3-D6. Los estudios sanguíneos, inmunológicos y de líquido cefalorraquídeo resultaron irrelevantes, excepto muestra de signos indirectos de infección. La radiografía de tórax mostró la presencia del absceso pulmonar primario derecho y la afectación medular se corroboró a través de la realización de la resonancia magnética medular dorsal. Presentó pobre respuesta ante los esteroides parenteral, hasta que se inició la terapia antibiótica, de forma paulatina y con apoyo rehabilitador. Transcurridos tres meses se investigaron y fueron descartadas otras etiologías no compresivas. Las mielopatías agudas representan un grupo heterogéneo de trastornos con distintas etiologías y mecanismos de producción, a través de su estudio se evidenció como causa un absceso pulmonar con afectación medular, por lo que debe ser considerado en la extensa lista de diagnósticos diferenciales (AU).

Myelopathies are a heterogeneous group of pathological processes that directly or indirectly affect the spinal cord. They are rare and can be produced by different causes and affectation pathways leading to major consequences and high disability. A case of acute compressive myelopathy triggered by a lung abscess as unusual cause and production mechanism is described. It is the case of a man, aged 48 years, with a clinical history and symptoms of acute onset of flaccid paraparesis and asymmetric osteotendinous hyporeflexia of lower limbs, with right predominance, dorsal sensitive level at D4, and pain at percussion in D3-D6 dorsal spinal processes. Blood, immune and cerebrospinal fluid (CSF) studies were irrelevant, but showing indirect signs of infection. Chest radiography showed the presence of the right primary lung abscess and spinal cord involvement was confirmed by performing dorsal medullar magnetic resonance (MRI). The patient had poor response to parenteral steroids until antibiotic therapy began, gradually and with rehabilitation support. After three months, other non-comprehensive etiologies were studied and ruled out. Acute myelopathies represent a heterogeneous group of disorders with different etiologies and production mechanisms. The study evidenced a lung abscess with spinal cord involvement as a cause, so it should be considered in the extensive list of differential diagnoses (AU).

Whole-body diffusion-weighted magnetic resonance imaging (WB-DW-MRI) vs choline-positron emission tomography-computed tomography (choline-PET/CT) for selecting treatments in recurrent prostate cancer

Objective. To determine the effectiveness of whole-body diffusion-weighted magnetic resonance imaging (WB-DW-MRI) in detecting metastases by comparing the results with those from choline-positron emission tomography-computed tomography (choline-PET/CT) in patients with biochemical relapse after primary treatment, and no metastases in bone scintigraphy, CT and/or pelvic MRI, or metastatic/oligometastatic prostate cancer (PCa). Patients with this disease profile who could benefit from treatment with stereotactic body radiation therapy (SBRT) were selected and their responses to these techniques were rated. Materials and methods. This was a prospective, controlled, unicentric study, involving 46 consecutive patients from our centre who presented biochemical relapse after adjuvant, salvage or radical treatment with external beam radiotherapy, or brachytherapy. After initial tests (bone scintigraphy, CT, pelvic MRI), 35 patients with oligometastases or without them were selected. 11 patients with multiple metastases were excluded from the study. WB-DW-MRI and choline-PET/CT was then performed on each patient within 1 week. The results were interpreted by specialists in nuclear medicine and MRI. If they were candidates for treatment with ablative SBRT (SABR), they were then evaluated every three months with both tests. Results. Choline-PET/CT detected lesions in 16 patients that were not observable using WB-DW-MRI. The results were consistent in seven patients and in three cases, a lesion was observed using WB-DW-MRI that was not detected with choline-PET/CT. The Kappa value obtained was 0.133 (p = 0.089); the sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of WB-DW-MRI were estimated at 44.93, 64.29, 86.11, and 19.15%, respectively. For choline-PET/CT patients, the sensitivity, specificity, PPV, and NPV were 97.10, 58.33, 93.06, and 77.78%, respectively. Conclusions. Choline-PET/CT has a high global sensitivity while WB-DW-MRI has a high specificity, and so they are complementary techniques. Future studies with more enrolled patients and a longer follow-up period will be required to confirm these data. The initial data show that the best technique for evaluating response after SBRT is choline-PET/CT (AU)

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Safety and effectiveness of therapeutic magnetic resonance in diabetic foot ulcers: a prospective randomised controlled trial.

OBJECTIVE: To test the efficacy and safety of therapeutic magnetic resonance (TMR) in the management of diabetic foot ulcers (DFU), the authors designed a prospective randomised controlled trial in three highly specialised diabetic foot clinics. METHOD: All the patients consecutively visited in a period of 18 months were screened according to the inclusion (presence of an ulcer >1 cm2 in the foot lasting at least 6 weeks; ABPI>0.6; consent to participate in the study) and exclusion (Charcot's foot; local or systemic infections; chronic renal failure; any wearable electrically-driven life-supporting device) criteria. Patients, who were treated according to international guideline protocols, were randomised into two groups: group A received for four weeks the sham application of TMR, while group B received the active TMR for the same period. People were followed-up to 10 weeks and healing rate (HR), healing time (HT), rate of granulation tissue on wound bed (% GT), reduction of the area of the lesion (∆AL) and a score (0-3) evaluating erythema, oedema, pain and tenderness, respectively, were measured. Adverse events (AE) were registered and monitored throughout the study. RESULTS: No differences were observed in HR, HT and ∆AL between the two groups during follow-up, while % GT and the scores for erythema, oedema and pain at 10 weeks showed significant (p<0.05) improvements in group B compared with group A and versus baseline. When restricted to non-ischaemic patients (ABPI>0.8), ∆AL was significantly (p<0.05) more pronounced in group B than in group A. No difference in AE occurrence was observed between the two groups. CONCLUSION: Our study, despite not being able to demonstrate the effectiveness of TMR on healing rate at 10 weeks, with 4 weeks of active treatment in neuro-ischaemic DFUs, shows positive effects on clinical aspects of the DFU and is associated with a significant increase of GT in the wound bed. DECLARATION OF INTEREST: The study has been fully sponsored by Thereson S.p.A., manufacturer of TMR devices.

Dispositivos de protección embólica durante el TAVI: evidencias e incertidumbres actuales / Embolic protection devices during tavi: current evidence and uncertainties

El implante percutáneo de válvula aórtica (TAVI) es actualmente la principal opción terapéutica para los pacientes con estenosis aórtica grave considerados inoperables o de alto riesgo quirúrgico. La extensión de las indicaciones del TAVI a una población con un perfil de riesgo inferior puede verse limitada por las tasas relativamente altas de eventos cerebrovasculares asociados a la intervención. Estudios realizados con resonancia magnética cerebral con ponderación de difusión demuestran una alta incidencia de infartos cerebrales subclínicos de probable origen embólico tras el TAVI. Algunos estudios han relacionado estas lesiones con un deterioro cognitivo posterior. Los dispositivos de protección embólica nacen como una protección mecánica para impedir la embolización de partículas de material diverso hacia el cerebro durante la intervención. Se presenta una revisión de la evidencia y las incertidumbres existentes respecto a los tres dispositivos actuales (Embrella, TriGuard y Claret) diseñados específicamente para TAVI. Los estudios realizados tienen carácter exploratorio y evalúan el daño neurológico en tres aspectos: clínico, subclínico y cognitivo. El implante de los tres dispositivos parece viable y seguro. Por lo que respecta a la eficacia, ninguno ha mostrado una reducción significativa de las tasas de eventos clínicos. Sin embargo, los dispositivos Embrella y Claret han mostrado reducciones significativas del volumen total de lesión cerebral en las imágenes de resonancia magnética con ponderación de difusión. Los estudios que han evaluado los efectos en la capacidad cognitiva han mostrado resultados poco concluyentes. En conclusión, a pesar de que los dispositivos de protección embólica muestran reducciones del volumen total de lesión cerebral en la resonancia magnética con ponderación de difusión, la eficacia clínica en prevención del ictus/deterioro cognitivo deberá confirmarse en estudios más amplios (AU)

Transcatheter aortic valve implantation (TAVI) is now the principal therapeutic option in patients with severe aortic stenosis deemed inoperable or at high surgical risk. Implementing TAVI in a lower risk profile population could be limited by relatively high cerebrovascular event rates related to the procedure. Diffusion-weighted magnetic resonance imaging studies have demonstrated the ubiquitous presence of silent embolic cerebral infarcts after TAVI, with some data relating these lesions to subsequent cognitive decline. Embolic protection devices provide a mechanical barrier against debris embolizing to the brain during TAVI. We review the current evidence and ongoing uncertainties faced with the 3 currently available devices (Embrella, TriGuard and Claret) in TAVI. Studies evaluated neurological damage at 3 levels: clinical, subclinical, and cognitive. Feasibility and safety were analyzed for the 3 devices. In terms of efficacy, all studies were exploratory, but none demonstrated significant reductions in clinical event rates. The Embrella and Claret devices demonstrated significant reductions of the total cerebral lesion volume on diffusion-weighted magnetic resonance imaging. Studies evaluating the effects on cognition were also somewhat inconclusive. In conclusion, despite embolic protection devices demonstrating reductions in the total cerebral lesion volume on diffusion-weighted magnetic resonance imaging, the clinical efficacy in terms of preventing stroke/cognitive decline requires confirmation in larger studies (AU)

Anamnesis y su relevancia, a propósito de un caso: isquemia arterial por aneurisma poplíteo / Anamnesis and their relevance, a case report: popliteal fossa mass

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