Simultaneous pneumothorax and pneumoperitoneum as a late consequence of traumatic injury of the diaphragm: Multimodality imaging approach with surgical correlation and treatment.

Simultaneous occurrence of pneumothorax and pneumoperitoneum is a rare event, usually related to traumas or surgical procedures involving the diaphragm. However, clinicians should be aware of the possible onset of these two clinical conditions even in patients without a recent clinical history that can clearly explain them. Cross-sectional imaging techniques are of great importance, providing crucial information about the patient's clinical status and guiding the following patient management. This work describes a unique case of a sudden occurrence of simultaneous pneumothorax and pneumoperitoneum in a previous asymptomatic man with a solely clinical history of minor trauma during childhood, evaluated through a multimodality imaging approach and treated with video-assisted thoracoscopy surgery.

Contrast-enhanced voiding urosonography in the assessment of vesical-ureteral reflux: the time has come.

Vesicoureteral reflux (VUR) is a pathological condition contradistinguished by monolateral or bilateral retrograde flow of urine from the bladder to the ureter and to the kidney. If not properly recognized and treated, VUR can potentially be associated to several complications such as recurrent infections and possible secondary scars with Chronic Kidney Disease (CKD). Furthermore, it represents an important risk factor for nephrovascular hypertension. During the last 20 years, the diagnostic approach to this entity has passed through several, drastic changes: indeed, since its introduction in 1994 contrast-enhanced voiding urosonography (ceVUS) has gradually accompanied the voiding cystourethrography (VCUG) as alternative imaging technique for the diagnosis and staging of VUR. Despite a large number of papers has strongly encouraged its use in clinical practice, due to the lack of ionizing radiations and its high sensitivity rate, to date almost all the guidelines only include the VCUG for VUR diagnosis. The introduction of technologically advanced US software and the approval of the intravesical administration of ultrasound contrast agents by the Food and Drug Administration (FDA) and by the European Medicine Agency (EMA) have to induce the Scientific Community to a deep revaluation of the role of ceVUS in the diagnosis and follow-up of VUR: urosonography might extensively replace VCUG as the reference method, reserving to cystourethrography a role in the most complex anatomic settings for pre-surgical evaluation.

Multimodality imaging for thromboembolic risk assessment in atrial fibrillation.

: Atrial fibrillation is the most widely represented sustained arrhythmia in the world. Thromboembolic risk assessment represents the main clinical challenge associated with this condition, requiring enormous medical, social and economical efforts. Several pieces of evidence in literature highlight how clinical risk factors are not enough for a correct thromboembolic risk stratification of patients with atrial fibrillation, since thromboembolic events have been proven to occur even in patients with low clinical risk scores. A comprehensive multimodality imaging approach, with special regard to echocardiography and new technologies seems to be the best method for this purpose. The aim of this review is to propose a hybrid thromboembolic risk stratification system that combinines clinical evaluation with instrumental clues on left atrial remodeling, fibrosis and deformation which, could be useful especially for patients classified at low thromboembolic risk according to clinical scores.

Gastric blunt traumatic injuries: A computed tomography grading classification.

AIM: To produce a radiological grading of gastric traumatic injuries. METHODS: In our study, we retrospectively analyzed 32 cases of blunt gastric traumatic injuries and compared computed tomography (CT) data with patients' surgical or medical development. In all cases, a basal phase was acquired, and an intravenous contrast material was administered via an antecubital venous catheter with acquisition in the venous phase (70-90 s). In addition, a further set of delayed scans was performed 4-5 min after the first scanning session, without supplementary intravenous contrast material, to identify or better define areas of active bleeding. All CT examinations were retrospectively reviewed by two radiologists, with more than 5 years of experience in emergency radiology, to detect signs of gastric injuries and/or associated abdominal lesions according to literature data. Specific CT findings for gastric rupture include luminal content extravasation and discontinuity of the gastric wall, while CT findings suggestive of injury consisted of free peritoneal fluid, extraluminal air, pneumatosis, and thickening and hematoma of gastric wall. RESULTS: We found 32 gastric traumatic injuries. In 22 patients (68.8%), the diagnosis was based on the surgical findings; in the other 10 patients (31.2%), the diagnosis was based on the clinical and CT radiological data. We observed discontinuity of the gastric wall and luminal content extravasation in 1 patient (3.1%); in 10 patients (31.2%), there was extra-luminal air in the peritoneum. In 28 patients (87.5%), there was peritoneal fluid, which was blood in 14 patients (hematoma in 11 patients and contrast material extravasation from active bleeding in 3 patients). In 15 patients (46.9%), there was gastric wall thickening. In 3 patients, it was possible to identify a prevalent involvement of the external layer of the gastric wall, whereas, in 2 patients, the inner side of the gastric wall presented with major involvement. In 3 patients (9.4%), pneumatosis of the gastric wall was detected. In 19 (59.4%) patients, the stomach was full. The fundus was the most frequently damaged part of the stomach because it was involved in 17 patients (53.1%). Based on the observed data, we identified four grades of gastric lesions. CONCLUSION: A radiologic score is helpful for guiding the diagnosis and management (surgical or conservative) of gastric blunt traumatic injuries and stratify patients according to short-term outcomes.

Multicentre external validation of the BIMC model for solid solitary pulmonary nodule malignancy prediction.

OBJECTIVES: To provide multicentre external validation of the Bayesian Inference Malignancy Calculator (BIMC) model by assessing diagnostic accuracy in a cohort of solitary pulmonary nodules (SPNs) collected in a clinic-based setting. To assess model impact on SPN decision analysis and to compare findings with those obtained via the Mayo Clinic model. METHODS: Clinical and imaging data were retrospectively collected from 200 patients from three centres. Accuracy was assessed by means of receiver-operating characteristic (ROC) areas under the curve (AUCs). Decision analysis was performed by adopting both the American College of Chest Physicians (ACCP) and the British Thoracic Society (BTS) risk thresholds. RESULTS: ROC analysis showed an AUC of 0.880 (95 % CI, 0.832-0.928) for the BIMC model and of 0.604 (95 % CI, 0.524-0.683) for the Mayo Clinic model. Difference was 0.276 (95 % CI, 0.190-0.363, P < 0.0001). Decision analysis showed a slightly reduced number of false-negative and false-positive results when using ACCP risk thresholds. CONCLUSIONS: The BIMC model proved to be an accurate tool when characterising SPNs. In a clinical setting it can distinguish malignancies from benign nodules with minimal errors by adopting current ACCP or BTS risk thresholds and guiding lesion-tailored diagnostic and interventional procedures during the work-up. KEY POINTS: • The BIMC model can accurately discriminate malignancies in the clinical setting • The BIMC model showed ROC AUC of 0.880 in this multicentre study • The BIMC model compares favourably with the Mayo Clinic model.

Beyond Thrombus Detection: The Role of Multimodality Imaging Approach.

We present a very rare case of paraneoplastic syndrome characterized by the unusual coexistence of a left ventricular apical thrombus and pulmonary embolism as the first manifestation of an unrecognized lung adenocarcinoma.

Earliest videofluoromanometric pharyngeal signs of dysphagia in ALS patients.

The aim of this study was to find whether there are manometric pharyngeal changes that may have diagnostic and prognostic relevance in the amyotrophic lateral sclerosis (ALS) patient who does not show changes in contrast-medium oropharyngeal transit in a videofluoroscopic swallowing study. Ten ALS patients, with an ALS Severity Scale Score of at least 7, no need to change dietary habit, no aspiration and/or penetration, and no other changes in contrast-medium oropharyngeal transit, were collected from our institution's database of videofluoromanometric swallowing studies. They were included in the study together with a group of 11 healthy volunteers. For each subject, 12 manometric items-7 for the pharyngeal phase and 5 for UES functionality-were evaluated. Statistically significant differences between the ALS patients and the healthy volunteers were found for pharyngeal contraction time of the upper region (median = 1,120, range = 880-1,420 vs. median = 970, range = 800-1,140), pharyngeal contraction time of the intermediate region (median = 1140, range = 960-1,360 vs. median = 770, range = 280-1,180), pharyngeal contraction time of the lower region (median = 1,320, range = 920-1,760 vs. median = 800, range = 620-1,780), and residual pressure after the relaxation of the UES (median = 2.2, range = -20.2 to 27.8 vs. median = -5.7, range = -2.9 to 8.4). A videofluoromanometric swallowing study may show an increase in the pharyngeal contraction time and in residual pressure after relaxation of the UES in ALS patients without videofluoroscopic changes in contrast-medium oropharyngeal transit.

Dual-source dual-energy CT: dose reduction after endovascular abdominal aortic aneurysm repair.

PURPOSE: This study was done to evaluate the possibility of reducing the dose of ionising radiation by using dual-source dual-energy computed tomography (CT) in patients undergoing CT angiography of the aorta to search for endoleaks after endovascular aneurysm repair (EVAR). MATERIALS AND METHODS: One hundred and forty-eight patients (117 M, 31 F; mean age 75 ± 6.5) underwent 171 CT angiography scans for follow-up after EVAR. For each patient we performed a triple-phase acquisition protocol consisting of a nonenhanced phase, an arterial phase and a delayed phase; the latter acquired in dual energy. Two radiologists jointly evaluated the nonenhanced, arterial and delayed phase, and a third radiologist evaluated only the delayed phase and its virtual noncontrast (VNC) reconstruction. Moreover, we compared the cumulative effective doses of the triple-phase acquisition with the dual-energy acquisition. RESULTS: We detected 34 endoleaks (19.8 %), with 100 % agreement between the triple-phase and dual-energy acquisitions. The effective dose of dual-energy acquisition performed during the delayed phase was 61.7 % lower than that of the triple-phase acquisition. CONCLUSIONS: A dual-energy CT scan acquired during the delayed phase and its VNC reconstruction allow detection of endoleaks with a substantial reduction of effective dose and a complete diagnostic agreement with a triple-phase acquisition protocol.

Errors in the radiological evaluation of the alimentary tract: part II.

Plain abdominal radiography and computed tomographic (CT) enteroclysis are 2 essential radiological investigations in the study of gastrointestinal tract. Errors in patient preparation, execution, and interpretation may lead to severe consequences in the diagnosis and thus in patient outcome. Abdominal radiography is one of the most frequently requested radiographic examinations, and has an established role in the assessment of the acute abdomen. CT enteroclysis has revolutionized the assessment of small-bowel pathology, especially in patients with inflammatory bowel. The purpose of this article is to describe the pitfalls in the execution and interpretation of plain abdominal film and CT enteroclysis.

Investigation of compensatory postures with videofluoromanometry in dysphagia patients.

AIM: To investigate the effectiveness of head compensatory postures to ensure safe oropharyngeal transit. METHODS: A total of 321 dysphagia patients were enrolled and assessed with videofluoromanometry (VFM). The dysphagia patients were classified as follows: safe transit; penetration without aspiration; aspiration before, during or after swallowing; multiple aspirations and no transit. The patients with aspiration or no transit were tested with VFM to determine whether compensatory postures could correct their swallowing disorder. RESULTS: VFM revealed penetration without aspiration in 71 patients (22.1%); aspiration before swallowing in 17 patients (5.3%); aspiration during swallowing in 32 patients (10%); aspiration after swallowing in 21 patients (6.5%); multiple aspirations in six patients (1.9%); no transit in five patients (1.6%); and safe transit in 169 patients (52.6%). Compensatory postures guaranteed a safe transit in 66/75 (88%) patients with aspiration or no transit. A chin-down posture achieved a safe swallow in 42/75 (56%) patients, a head-turned posture in 19/75 (25.3%) and a hyperextended head posture in 5/75 (6.7%). The compensatory postures were not effective in 9/75 (12%) cases. CONCLUSION: VFM allows the speech-language the-rapist to choose the most effective compensatory posture without a trial-and-error process and check the effectiveness of the posture.