Suprasellar Lipoma.

BACKGROUND: A 48-year-old woman suffering from headaches for a longer period of time underwent a MRI scan. Based on the MRI findings, she was referred to our hospital for further analysis of a suprasellar lesion. In addition, we performed a non-contrast and a contrast-enhanced CT scan.

Uterine artery embolisation for symptomatic adenomyosis with polyzene F-coated hydrogel microspheres: three-year clinical follow-up using UFS-QoL questionnaire.

PURPOSE: This study was designed to assess midterm outcome of uterine artery embolisation (UAE) for women with therapy-resistant adenomyosis using polyzene F-coated hydrogel microspheres. METHODS: Between September 2006 and January 2010, 29 consecutive women with adenomyosis (15 in combination with fibroids) were treated with UAE using polyzene F-coated hydrogel microspheres. Junction zone thickness was assessed with MRI at baseline and 3 months. Women filled out the uterine fibroid symptom and quality of life questionnaire at baseline, 3 months and after a mean clinical follow-up of 37 months (median 35, range 29-64 months). RESULTS: At baseline, symptom severity score of 29 women was mean 67 (median 72, range 23-100). At 3 months, this score decreased to mean 22 (median 15, range 0-66) and mean 15 (median 17, range 0-34) at final follow-up. At final follow-up of mean 37 months (median 35, range 29-64 months), 22 of 29 (76 %) patients were asymptomatic. Of these 22 women, 3 underwent a second UAE at 6, 7, and 14 months. The remaining seven patients clinically improved but still had symptoms; one underwent a hysterectomy. There was no difference in outcome between women with pure adenomyosis and women with additional fibroids. The junction zone of 4 women with additional therapy was significantly thicker compared with the remaining 25 patients. CONCLUSIONS: In women with therapy resistant adenomyosis, UAE using polyzene F-coated hydrogel microspheres resulted in 3 years preservation of the uterus in 28 of 29 (97 %) with good clinical outcome in the vast majority of patients. Initial thickness of the junction zone is related to additional therapy.

Spinal dural fistulas without swelling and edema of the cord as incidental findings.

SUMMARY: SDAVFs cause hypertension and hence outflow obstruction in the perimedullary venous system resulting in swelling and edema of the cord followed by dysfunction. Clinical presentation is usually with gradual progressive paraparesis, numbness, and sphincter problems. MR imaging typically demonstrates the dilated perimedullary veins and the swelling and edema of the cord. During the past few years, we incidentally found an SDAVF on MR imaging with dilated perimedullary veins but without swelling and edema of the cord in 5 patients with unrelated presenting clinical symptoms. Spinal angiography confirmed the presence of an SDAVF in all 5 patients. Although the indication was considered questionable, eventually all 5 fistulas were endovascularly or surgically treated, resulting in normalization of the MR images.

Long-term follow-up of uterine artery embolization for symptomatic adenomyosis.

INTRODUCTION: Long-term results of uterine artery embolization (UAE) for adenomyosis are largely unknown. We assess long-term outcome of UAE in 40 women with adenomyosis. MATERIALS AND METHODS: Between March 1999 and October 2006, 40 consecutive women with adenomyosis (22 in combination with fibroids) were treated with UAE. Changes in junction zone thickness were assessed with magnetic resonance imaging (MRI) at baseline and again at 3 months. After a mean clinical follow-up of 65 months (median 58 [range 38-129]), women filled out the uterine fibroid symptom and quality of life (UFS-QoL) questionnaire, which had additional questions on the long-term evolution of baseline symptoms and adverse events. RESULTS: During follow-up, 7 of 40 women (18%) underwent hysterectomy. Among these 7 women, the junction zones were significantly thicker, both at baseline (mean 23 vs. 16 mm, P = 0.028) and at 3-month follow-up (mean 15 vs. 9 mm, P = 0.034). Of 33 women with preserved uterus, 29 were asymptomatic. Four patients had symptom severity scores of 50 to 85 and overall QoL scores of 60 to 66, indicating substantial clinical symptoms. There was no relation between clinical outcome and the initial presence of fibroids in addition to adenomyosis. CONCLUSION: In women with therapy-resistant adenomyosis, UAE resulted in long-term preservation of the uterus in the majority. Most patients with preserved uterus were asymptomatic. The only predictor for hysterectomy during follow-up was initial thickness of the junction zone. The presence or absence of fibroids in addition to adenomyosis had no relation with the need for hysterectomy or clinical outcome.

Contrast agent induced obliteration of a spinal arteriovenous malformation.

We present a patient undergoing spinal angiography and suspected of having an AVM. During the first injection of nonionic contrast, a nidal AVM supplied by the great anterior radiculomedullary artery at T9 left was found. The second injection at T9 left no longer showed the contrast filling of the AVM. Follow-up angiography showed persistent AVM obliteration with an intact arterial spinal axis. The patient's symptoms resolved. Interaction between nonionic contrast, blood, and vessel wall most likely induced the obliteration.

Contrast-enhanced magnetic resonance angiography findings prior to hemodialysis vascular access creation: a prospective analysis.

PURPOSE: To determine prospectively the clinical value of contrast-enhanced magnetic resonance angiography (CE-MRA) for assessment of the arterial inflow and venous outflow prior to vascular access (VA) creation. METHODS: Seventy-three patients underwent duplex ultrasonography (DUS) and CE-MRA prior to VA creation for detection of stenoses and occlusions. Two observers read the CE-MRA images for determination of inter-observer agreement. A VA was considered functional if it could be used for successful two-needle hemodialysis therapy within 2 months after creation. RESULTS: CE-MRA detected 6 stenosed, 8 occluded arterial vessel segments and 12 stenosed and 41 occluded venous vessel segments in 70 patients. Inter-observer agreement for detection of upper extremity arterial and venous stenoses and occlusions with CE-MRA was substantial to almost perfect (kappa values 0.76-0.96). CE-MRA detected lesions, not detected by DUS, that were associated with VA early failure and non-maturation in 33% of patients (7/21). Accessory veins detected preoperatively were the cause of VA non-maturation in a substantial group of patients (47%: 7/15). CONCLUSION: CE-MRA enables accurate detection of upper extremity arterial and venous stenosis and occlusions prior to VA creation. Preoperative CE-MRA identified arterial and venous stenoses, not detected by DUS that were associated with VA early failure and non-maturation. However, the use of gadolinium containing contrast media is currently contraindicated due the reported incidence of nephrogenic systemic fibrosis.

Advances in spinal cord MR angiography.

Novel developments in MR angiography are reviewed that enable non-invasive clinical imaging of normal and abnormal vessels of the spinal cord. Current fast contrast-enhanced MR techniques are able 1) to visualize vessels supplying or draining the spinal cord and 2) to differentiate spinal cord arteries from veins. The localization of the Adamkiewicz artery, the largest artery supplying the thoracolumbar spinal cord, has become possible in a reproducible and reliable manner. Knowledge of the anatomic location of this artery and its arterial supplier may be of benefit in the work-up for aortic aneurysm surgery to reduce incidences of ischemic injury. Spinal cord MR angiography is ready to become a diagnostic tool that can compete with catheter angiography for detecting and localizing arterial feeders of vascular lesions and is strongly advised for use prior to invasive catheter angiography. Successful clinical application strongly relies on in depth knowledge of the complex spinal cord vasculature and skills in image postprocessing.

Value and limitations of contrast-enhanced MR angiography in spinal arteriovenous malformations and dural arteriovenous fistulas.

BACKGROUND AND PURPOSE: The purpose of this work was to study the validity of MR angiography (MRA) for identification of spinal arteriovenous (AV) abnormalities. MATERIALS AND METHODS: Thirty-four consecutive patients with suspicion of spinal vascular abnormalities underwent digital subtraction angiography (DSA) after MRA. The level and side of the suspected spinal dural arteriovenous fistula (SDAVF) and the feeding arteries in spinal arteriovenous malformations (SAVMs) were determined from the MRA and compared with DSA. RESULTS: DSA revealed SDAVF in 20 abnormalities of which 19 were spinal and 1 was tentorial with spinal drainage, as well as SAVM in 11 patients. In 3 patients, MRA and DSA were both normal. For detection of spinal arteriovenous abnormalities, neither false-positive nor false-negative MRA results were obtained. The MRA-derived level of the feeding artery in SDAVF agreed with DSA in 14 of 19 cases. In 5 cases, a mismatch of 1 vertebral level (not side) was noted for the feeding artery. For the tentorial AVF, only the spinal drainage was depicted; the feeding artery was outside the MRA field of view. In intradural SAVM, the main feeding artery was identified by MRA in 10 of 11 patients. MRA could differentiate between glomerular and fistulous SAVM in 4 of 6 cases and between sacral SDAVF and filum terminale SAVM in 2 of 5 cases. CONCLUSIONS: MRA reliably detects or excludes various types of spinal AV abnormalities and localizes the (predominant) arterial feeder of most spinal AV shunts. Although classification of the subtype of SAVMs remains difficult, with MRA it greatly helps to focus subsequent DSA.

Surgical repair of thoracoabdominal aortic aneurysms.

Morbidity and mortality following thoracoabdominal aortic aneurysm (TAAA) repair are tremendous. Preoperative assessment is essential in detecting cardiac and pulmonary risk factors in order to reduce cardiopulmonary complications. Paraplegia and renal failure are main determinants of postoperative mortality and therefore gained substantial attention during the last decades. Left heart bypass, cerebrospinal fluid (CSF) drainage and epidural cooling have significantly reduced paraplegia rate, however, this dreadful event still occurs in up to 25% of patients undergoing type II repair. Renal failure has been partly prevented by means of retrograde aortic perfusion and cooling but renal failure still remains a significant problem. We have evaluated the effects of protective measures aiming for reduction of paraplegia and renal failure. Monitoring motor evoked potentials (MEPs) is an accurate technique to assess spinal cord integrity during TAAA repair, guiding surgical strategies to prevent paraplegia. Selective volume- and pressure controlled perfusion is a technique to continuously perfuse the kidneys during aortic cross clamping and subsequent circulatory exclusion In patients with atherosclerotic thoracoabdominal aortic aneurysms, blood supply to the spinal cord depends on a highly variable collateral system. In our experience, monitoring MEPs allowed detection of cord ischemia, guiding aggressive surgical strategies to restore spinal cord blood supply and reduce neurologic deficit: overall paraplegia rate was less than 3%. We believe that these protective measures should be included in the surgical protocol of TAAA repair, especially in type II cases. Renal and visceral ischemia can be reduced significantly by continuous perfusion during aortic cross clamping in TAAA repair. Not only sufficient volume flow but also adequate arterial pressure appears to be essential in maintaining renal function.Obviously, endovascular modalities have been successfully applied in TAAA patients, the majority of which as part of hybrid procedures. Technological innovation will eventually cause a shift from open to minimal invasive surgical repair. At present, however, open surgery is considered the gold standard for TAAA repair, especially in (relatively) young patients and patients suffering from Marfan's disease.

MR angiography of the great anterior radiculomedullary artery (Adamkiewicz artery) validated by digital subtraction angiography.

BACKGROUND AND PURPOSE: Imaging of the anterior superficial spinal cord arteries by MR angiography is hindered by their small calibers and the similarity in configuration with the anterior superficial spinal cord veins. To validate the location and spatial configuration of the great anterior radiculomedullary artery, (ie, the Adamkiewicz artery [AKA]), contrast-enhanced MR angiography (CE-MRA) was compared with digital subtraction angiography (DSA). METHODS: Fifteen patients with suspected spinal cord vascular pathology underwent both spinal CE-MRA and selective spinal DSA. Two phase CE-MRA was performed with the use of a centric k-space filling scheme synchronized to the contrast bolus arrival. The level and side of the AKA origin were scored on the DSA and CE-MRA images and compared regarding image quality in terms of vessel conspicuity, contrast, continuity, sharpness, and background homogeneity on a relative 5-point scale. RESULTS: Localization and spatial configuration of the AKA by CE-MRA was in agreement with DSA findings in 14 of 15 cases. One mismatch of 1 vertebral level (not side) appeared as a result of the tangled vascular pathology. Comparison of image quality revealed that DSA is superior to CE-MRA concerning vessel continuity, sharpness, and background homogeneity (P < .001). Overall vessel conspicuity and contrast were judged to be similar. CONCLUSION: CE-MRA can visualize and localize the level of the AKA correctly. Image quality of CE-MRA is sufficient for detection of the AKA but is inferior to DSA.

MR angiography of the Adamkiewicz artery and anterior radiculomedullary vein: postmortem validation.

SUMMARY: Spinal cord arteries and veins are difficult to visualize and distinguish by MR angiographic techniques because of their small sizes, similar spatial course, and close vascular anatomy. Contrast-enhanced MR angiography was demonstrated to dynamically resolve the Adamkiewicz artery from the anterior radiculomedullary vein in the thoracolumbar spinal cord. The location of the Adamkiewicz artery and the anterior radiculomedullary vein could be validated in the postmortem specimen of a thoracoabdominal aortic aneurysm patient.

Need for background suppression in contrast-enhanced peripheral magnetic resonance angiography.

To determine if background suppression is beneficial for peripheral magnetic resonance angiography (pMRA), nonsubtracted, subtracted, and fat-saturated contrast-enhanced (CE) pMRA were compared in 10 patients with peripheral arterial disease. Signal-to-noise ratios (SNRs) and contrast-to-noise ratios (CNRs), as well as venous enhancement and subjective interpretability, were determined in a station-by-station fashion for each technique. In three patients X-ray angiography was available as a standard of reference. SNRs and CNRs were significantly higher for fat-saturated vs. the other two techniques (P = 0.005). Subjective interpretability was best for subtracted data sets in the lower-leg station. In the iliac station, fat-saturated data sets were considered to have significantly lower interpretability than subtracted data sets. Venous enhancement occurred significantly more often in the lower-leg station with the fat-saturated technique. The value of subtraction depends on the hardware one has available and is a useful tool if dedicated surface coils are used. Background suppression by means of magnitude subtraction leads to the best lower-leg image interpretability. Care must be taken to avoid venous enhancement in the lower-leg station when using fat saturation.