Twig-like middle cerebral artery in a case of neurofibromatosis type 1.

Neurofibromatosis type 1 (NF1) is an autosomal dominant genetic disorder with multisystemic involvement, affecting central nervous system, skin, bone system and vessels, with a very heterogeneous clinical presentation. Vascular abnormalities are typically recognized in neurofibromatosis type 1 affecting cardiovascular and cerebrovascular systems. The incidence of circle of Willis anomalies in children with NF1 is twofold higher than in general population. In this paper, we report of 19-years-old female with NF1 and twig-like middle cerebral artery.

Magnetic Resonance Imaging in degenerative disease of the lumbar spine: Fat Saturation technique and contrast medium.

PURPOSE: To examine both anterior and posterior elements of the lumbar spine in patients with low back pain using MRI T2-weighted sequences with Fat Saturation (FS) and contrast enhanced T1-weighted sequences with FS. MATERIALS AND METHODS: Two thousand eight hundred and twenty (2820) patients (1628 male, 1192 female, mean age 54) presenting low back pain underwent MRI standard examination (Sagittal T1w TSE and T2w TSE, axial T1 SE) with the addition of sagittal and axial T2w Fat Sat (FS) sequences. Among all the patients, 987 (35%) have been studied adding Contrast Enhanced (CE) T1w FS sequences after administration of contrast medium. RESULTS: Among 987 patients studied with contrast medium, we found: active-inflammatory intervertebral osteochondrosis in 646 (65%) patients; degenerative-inflammatory changes in facet joints (facet joint effusion, synovitis, synovial cysts) in 462 (47%); spondylolysis in 69 (7%); degenerative-inflammatory changes of the flava, interspinous and supraspinous ligaments in 245 (25%); inflammatory changes of posterior perispinal muscles in 84 (8%) patients. CONCLUSIONS: In patients with suspected no-disc-related low back pain, the implementation of T2w FS and CE T1w FS sequences to the standard MR protocol could allow a better identification of degenerative-inflammatory changes more likely associated to the pain.

Computed Tomography and MR Imaging in Spondyloarthritis.

This article provides an overview of the computed tomography (CT) and MR imaging appearances suggestive of spondyloarthritis, with a specific emphasis on the MR imaging findings of vertebral and sacroiliac involvement, and presents relevant clinical features that assist early diagnosis. CT is a sensitive imaging modality for the assessment of structural bone changes, but its clinical utility is limited. MR imaging is the modality of choice for early diagnosis, because of its ability to depict inflammation long before structural bone damage occurs, for monitoring of disease activity, and for evaluating therapeutic response.

Conventional Radiology in Crystal Arthritis: Gout, Calcium Pyrophosphate Deposition, and Basic Calcium Phosphate Crystals.

This article reviews the main radiographic features of crystal deposition diseases. Gout is linked to monosodium urate crystals. Classic radiographic features include subcutaneous tophi, large and well-circumscribed paraarticular bone erosions, and exuberant bone hyperostosis. Calcium pyrophosphate deposition (CPPD) can involve numerous structures, such as hyaline cartilages, fibrocartilages, or tendons. CPPD arthropathy involves joints usually spared by osteoarthritis. Basic calcium phosphate deposits are periarticular or intraarticular. Periarticular calcifications are amorphous, dense, and round or oval with well-limited borders, and most are asymptomatic. When resorbing, they become cloudy and less dense with an ill-defined shape and can migrate into adjacent structures.

Analysis of size and shape differences between ancient and present-day Italian crania using metrics and geometric morphometrics based on multislice computed tomography.

The Museum of Human Anatomy in Naples houses a collection of ancient Graeco-Roman crania. The aim of this study was to use multislice computed tomography (MSCT) to evaluate and objectively quantify potential differences in cranial dimensions and shapes between ancient Graeco-Roman crania (n = 36) and modern-day southern Italian crania (n = 35) and then to characterize the cranial changes occurring over more than 2000 years, known as secular change. The authors used traditional metric criteria and morphometric geometry to compare shape differences between the sets of crania. Statistically significant differences in size between the ancient and modern crania included shorter facial length, narrower external palate, smaller minimum cranial breadth, shorter right and left mastoid processes, and wider maximum occipital and nasal breadth. The shape changes from the ancient to modern crania included a global coronal enlargement of the face and cranial diameters, with more anterior projection of the face at the anterior nasal spine, but also posterior projection at the glabella and the nasion. It is not possible to determine whether these differences result exclusively from secular changes in the cranium or from other factors, including a mix of secular change and other unknown factors. To the best of our knowledge, this is the first MSCT-based study to compare ancient Graeco-Roman and modern-day southern Italian crania and to characterize shape and size differences.

Renal Failure: A Modern Semiology for an Old Disease.

Chronic kidney disease (CKD) is a complex systemic disease that induces mineral metabolic dysfunction leading to bone fragility and tissue calcifications. Bone abnormalities in CKD can include increased bone turnover and resorption due to secondary hyperparathyroidism, decreased bone turnover and bone formation, defective bone mineralization, or a mixed pattern of these abnormalities. Other features of musculoskeletal involvement include synovial, tendon, and ligament thickening due to ß2-microglobulin amyloidosis, soft tissue masses, or axial and peripheral arthropathies. The accurate assessment of bone involvement in early-stage CKD is crucial for the success of therapeutic interventions. We summarize the key semiologic features of bone abnormalities in CKD and review musculoskeletal complications as depicted by conventional radiography, computed tomography, magnetic resonance, and ultrasound imaging. We also discuss different experimental diagnostic approaches developed for the purpose of identifying changes in bone quality and structure in early-stage CKD.

Spectrum of Signs of Pneumoperitoneum.

Pneumoperitoneum is caused by rupture of a hollow viscus that includes the stomach, small bowel, and large bowel, with the exception of those portions that are retroperitoneal in the duodenum and colon. The causes of pneumoperitoneum are numerous, ranging from iatrogenic and benign causes to more life-threatening conditions. In the absence of a benign cause of pneumoperitoneum, the identification of free intraperitoneal gas usually indicates the need for emergency surgery to repair a perforated bowel. The plain film is the primary diagnostic tool for detecting pneumoperitoneum: multiple signs of free intraperitoneal air can be found especially on supine abdominal radiographs. Computed tomography (CT) examination has been shown to be more sensitive than abdominal radiographs for the detection of free intraperitoneal air. It is important that the radiologist become familiar with the signs of pneumoperitoneum that can be discerned on abdominal radiographs, on CT scout view, and on CT scan.

Cerebral Hypoperfusion in Hereditary Coproporphyria (HCP): A Single Photon Emission Computed Tomography (SPECT) Study.

BACKGROUND: Hereditary Coproporphyria (HCP) is characterized by abdominal pain, neurologic symptoms and psychiatric disorders, even if it might remain asymptomatic. The pathophysiology of both neurologic and psychiatric symptoms is not fully understood. Therefore, aiming to evaluate a possible role of brain blood flow disorders, we have retrospectively investigated cerebral perfusion patterns in Single Photon Emission Computed Tomography (SPECT) studies in HCP patients. MATERIALS & METHODS: We retrospectively evaluated the medical records of patients diagnosed as being affected by HCP. A total of seven HCP patients had been submitted to brain perfusion SPECT study with 99mTc-Exametazime (hexamethylpropyleneamine oxime, HMPAO) or with its functionally equivalent 99mTc-Bicisate (ECD or Neurolite) according with common procedures. In 3 patients the scintigraphic study had been repeated for a second time after the first evaluation at 3, 10 and 20 months, respectively. All the studied subjects had been also submitted to an electromyographic and a Magnetic Resonance Imaging (MRI) study of the brain. RESULTS: Mild to moderate perfusion defects were detected in temporal lobes (all 7 patients), frontal lobes (6 patients) and parietal lobes (4 patients). Occipital lobe, basal ganglia and cerebellar involvement were never observed. In the three subjects in which SPECT study was repeated, some recovery of hypo-perfused areas and appearance of new perfusion defects in other brain regions have been found. In all patients electromyography resulted normal and MRI detected few unspecific gliotic lesions only in one patient. Discussion & Conclusions: Since perfusion abnormalities were usually mild to moderate, this can probably explain the normal pattern observed at MRI studies. Compared to MRI, SPECT with 99mTc showed higher sensitivity in HCP patients. Changes observed in HCP patients who had more than one study suggest that transient perfusion defects might be due to a brain artery spasm possibly leading to psychiatric and neurologic symptomatology, as already observed in patients affected by acute intermittent porphyria. This observation, if confirmed by other well designed studies aiming to demonstrate a direct link between artery spasm, perfusion defects and related symptoms could lead to improvements in HCP treatments.

Quantitative Assessment of Abdominal Aortic Calcifications Using Lateral Lumbar Radiograph, Dual-Energy X-ray Absorptiometry, and Quantitative Computed Tomography of the Spine.

Abdominal aortic calcifications (AACs) represent an independent determinant of cardiovascular events and are strongly associated with cardiovascular disease. To our knowledge, a comparison between lateral lumbar radiography, lateral spine dual-energy x-ray absorptiometry (DXA), and quantitative computed tomography (QCT) in the assessment of AAC has not been performed. Our objective was to compare those methods in the detection and quantification of AAC using a simplified 8-point score system (AAC-8). Three hundred twenty-three postmenopausal women underwent lateral lumbar radiography, lateral spine DXA, and QCT for osteoporosis screening and were scored for AAC using the AAC-8. Lateral lumbar radiographs, lateral spine DXA, and QCT detected AAC in 58%, 55%, and 60% of the subjects, respectively. The nonparametric intraclass correlation coefficient between lateral lumbar radiograph and lateral spine DXA and lateral lumbar radiograph and QCT were 0.699 (95% confidence interval [CI]: 0.638-0.752) and 0.829 (95% CI: 0.783-0.865). Area under operating curve (receiver operating characteristic [ROC]) for lateral spine DXA was 0.826 (95% CI: 0.764-0.888), whereas for QCT was 0.948 (95% CI: 0.922-0.974) considering lateral lumbar radiograph as gold standard. AAC has been shown to be a significant predictive marker of overall cardiovascular disease. DXA may be a screening tool among asymptomatic patients with low radiation exposure to identify an important cardiovascular disease risk factor. QCT represents a reliable technique that may be applied as a future standard to facilitate the detection of abdominal aortic calcification as well as to provide more accurate measurement of bone densitometry.

Quantitative ultrasound at the phalanges in a cohort of monozygotic twins of different ages.

PURPOSE: The aim of our study was to evaluate bone quality by quantitative ultrasound (QUS) at the phalanges in 129 monozygotic twin couples, outlining the differences between growing subjects and adults. MATERIALS AND METHODS: A total of 129 healthy monozygotic twin couples (42 of children under 18 years of age and 87 of adults) were studied by phalangeal QUS, measuring amplitude-dependent speed of sound (AD-SoS) and bone transmission time (BTT). Anthropometric data were also recorded. RESULTS: In children AD-SoS and BTT were positively correlated with age (r = 0.91, r = 0.91), height (r = 0.88, r = 0.90) and weight (r = 0.81, r = 0.87); in adults AD-SoS was negatively related to age (r = -0.36), AD-SoS and BTT were positively related to height (r = 0.37, r = 0.58). Absolute value differences between twins for AD-SoS and BTT were significantly higher in adult twins (25.9 ± 21.9 for AD-SoS and 0.08 ± 0.08 for BTT) than in children (14.5 ± 12.4 for AD-SoS and 0.05 ± 0.04 for BTT). CONCLUSION: Differentiation in bone tissue quality in twins increases with age, probably reflecting lifestyle, personal habits, likely acting through epigenetic mechanisms.

Comprehensive vertebral deformity and vertebral fracture assessment in clinical practice: intra- and inter-reader agreement of a clinical workflow tool.

STUDY DESIGN: Study design randomized intra- and inter-reader reproducibility study. OBJECTIVE: To evaluate reproducibility of quantitative morphometry (QM) and agreement of dichotomous fracture/no-fracture status on lateral spinal radiographs acquired during routine clinical practice using a clinical workflow tool. SUMMARY OF BACKGROUND DATA: Several recent guidelines have underlined the importance of Genant semi-quantitative scoring and selective QM to confirm and grade suspected vertebral fractures in clinical practice. METHODS: Thoracic and lumbar spine radiographs were acquired from 98 consecutive subjects (mean age, 60.1 ± 11.7 yr) attending the clinic for osteoporosis evaluation. For each subject, QM and Genant semi-quantitative scoring were performed on all evaluable vertebrae from L4 to T4 using a software workflow tool. A radiologist and an experienced radiographical technician performed 2 repeat reading sessions of the radiographs 12 months apart, blinded to each other's results; for the second read, the cases were anonymized and the order was randomized. RESULTS: Inter-reader reproducibility results were 3.1% and 3.2% coefficient of variation (%) for heights, 0.030 and 0.031 root mean square standard deviation for height ratios. For intrareader reproducibility, these values were 2.2% and 3.5% coefficient of variation %; 0.023 and 0.034 root mean square standard deviation. Kappa score results for agreement of dichotomous fracture/no-fracture status were 0.67 and 0.72 (inter-rater) and 0.50 and 0.67 (intrarater). CONCLUSION: The software assessed in this study is a reliable clinical tool that facilitates QM and Genant semi-quantitative scoring of the spine in routine clinical practice. LEVEL OF EVIDENCE: 3.

Early diagnosis of vertebral fractures.

Vertebral fractures are a common clinical entity, caused by trauma or related to osteoporosis (benign). Their recognition is especially important in the post-menopausal female population but also important is their differentiation from pathological (malignant) fractures (1). A vertebral fracture is evidenced by vertebral body deformity or reduction in vertebral body height beyond a certain threshold value in the absence of bone discontinuity. For prognosis and treatment it is extremely important to recognize the cause of the fracture. In contrast to fractures that occur in other locations, vertebral fractures often go unrecognized in the acute phase as the pain may be transient and radiographic and evaluation of the spine may be difficult (2). Objective measurement of the vertebral deformity provides invaluable information to the interpreting physician and helps grade fracture severity. The recognition and diagnosis of vertebral fractures can be performed using additional diagnostic tools.

Diagnostic performance of magnetic resonance arthrography of the shoulder in the evaluation of anteroinferior labrum abnormalities: a prospective study.

OBJECTIVE: To evaluate the diagnostic performance of magnetic resonance (MR) arthrography of the shoulder in the diagnosis of anteroinferior labrum lesions, using arthroscopy as the reference standard and to classify these lesions. METHODS: Institutional review board approval was obtained. The study population included 59 consecutive patients with history and clinical diagnosis of acute or chronic anterior shoulder instability. A total of 62 MR arthrograms were performed, since three patients had undergone a bilateral procedure. Arthroscopy, which was performed within a mean of 3 months (range 2-5 months) after MR arthrography, was used as the reference standard. Sensitivity, specificity, accuracy, positive and negative predictive values were then calculated. RESULTS: MR arthrography showed a sensitivity of 96 % and a specificity of 80 % for the overall detection of anteroinferior labrum abnormalities. The diagnostic accuracy was 95 % and the positive and negative predictive values were 98 % and 66 % respectively. Ten lesions were non-classifiable on surgery, of which eight were non classifiable on MR arthrography also. CONCLUSIONS: MR arthrography is highly accurate for the detection and classification of shoulder anteroinferior labrum lesions. Shoulder surgeons can confidently rely on this method to determine which patients will benefit from arthroscopy. MAIN MESSAGES: • MR arthrography is accurate for the detection and classification of shoulder labrum lesions. • MR arthrography is a valuable tool for the preoperative planning in acute or chronic instability. • Shoulder surgeons can rely on this method to determine which patients will benefit from arthroscopy.

Radiological diagnostic progress in skeletal diseases.

High-resolution bone imaging has made tremendous progress in the recent past. Both imaging modalities, computed tomography as well as MR imaging, have improved image quality. New developments such as HR-pQCT now make it possible to acquire in vivo images at peripheral sites with isotropic voxel size in a very short time. Further enhancements in the MR field have made it possible to image more central body sites such as the proximal femur with very high spatial resolution. New analysis methods can obtain direct estimates of biomechanical properties and important information related to bone's topology, as well as parameters of scale and orientation. These accomplishments will be essential in the noninvasive assessment of osteoporosis and fracture risk, will provide insight into the mechanisms behind bone loss, and will increasingly play a role as a tool for assessing treatment efficacy.