[Inter-arm blood pressure difference does not always mean dissection]. / Une anisotension ne signifie pas toujours dissection.

A man presents an atypical neurological disorder. The diagnosis of aortic dissection is evoked with anisotension, but it consists in a paradoxical embolism in the presence of a permeable foramen oval since he presents with a proximal pulmonary embolus and a thrombus in the humeral artery.

Un homme se présente avec un trouble neurologique d'allure atypique. Le diagnostic de dissection aortique est évoqué devant une anisotension, mais il s'agit ici d'un tableau d'embolie paradoxale sur foramen ovale perméable puisqu'il présente une embolie pulmonaire proximale et un thrombus dans l'artère humérale.

[Livedoid vasculopathy secondary to coeliac disease]. / Vasculopathie livédoïde secondaire à une maladie cœliaque.

BACKGROUND: Livedoid vasculopathy (LV) is a painful ulcerative condition involving white atrophy and livedo; a histopathologic feature seen is occlusive dermal vasculopathy. This may be associated with coagulation disorders such as hyperhomocysteinaemia (HHC). PATIENTS AND METHODS: We report the case of a 52-year-old woman presenting LV in which an abnormal scan image led us to diagnose coeliac disease. This enteropathy had caused vitamin B12 and folic acid deficiency, as well as HHC. Vitamin supplementation and a gluten-free diet resulted in complete healing of the lesions. DISCUSSION: This case underlines the importance of screening for and correction of coagulation disorders in patients with LV. It also suggests that in the event of HHC, coeliac disease should be sought, even in the absence of gastrointestinal symptoms.

How to perform low-dose computed tomography for renal colic in clinical practice.

Computed tomography (CT) has become the reference technique in medical imaging for renal colic, to diagnose, plan treatment and explore differential diagnosis. Its main limitation is the radiation dose, especially as urinary stone disease tends to relapse and mainly affects young people. It is therefore essential to reduce the CT radiation dose when renal colic is suspected. The goal of this review was twofold. First, we wanted to show how to use low-dose CT in patients with suspected renal colic in current clinical practice. Second, we wished to discuss the different ways of reducing CT radiation dose by considering both behavioral and technological factors. Among the behavioral factors, limiting the scan coverage area is a straightforward and effective way to reduce the dose. Improvement of technological factors relies mainly on using automatic tube current modulation, lowering the tube voltage and current as well using iterative reconstruction.

Addressing requests for emergency ultrasonographic examinations when implementing teleradiology services.

PURPOSE: To prospectively assess how to address requests for ultrasonographic examinations when setting up an on-call teleradiology service. MATERIALS AND METHODS: An analytical prospective study was performed from January 2012 to December 2012 inclusively. All requests received for after-hours ultrasonographic examinations during this period were analyzed. Ultrasound requests were classified as being postponable until working hours, replaceable by an alternate cross-sectional imaging modality, or urgent and needing to be performed after hours. RESULTS: A total of 176 requests for ultrasonographic examinations were analyzed. They predominantly included requests for abdominal and pelvic ultrasonographic examinations (63%). Thirty-nine requests (22.2%) were considered as postponable, 49 (27.8%) as replaceable and 64 (36.4%) as both postponable and replaceable. Twenty-four requests (13.6%) were considered as urgent; they consisted of 10 requests for venous duplex Doppler ultrasonographic examinations of the lower limbs, eight requests for testicular ultrasonographic examinations, five for pelvic ultrasonographic examinations and one for soft-tissue ultrasonographic examination. In these urgent cases, realistic options were either to transfer the patient to another institution or to train emergency department physicians in ultrasonography for local handling. CONCLUSION: Although the need for addressing requests for ultrasonographic examinations should be taken into account when setting up an on-call teleradiology service, it should not impede such plans.

Standard dose versus low-dose abdominal and pelvic CT: comparison between filtered back projection versus adaptive iterative dose reduction 3D.

PURPOSE: To compare the dose and image quality of a standard dose abdominal and pelvic CT with Filtered Back Projection (FBP) to low-dose CT with Adaptive Iterative Dose Reduction 3D (AIDR 3D). MATERIALS AND METHODS: We retrospectively examined the images of 21 patients in the portal phase of an abdominal and pelvic CT scan before and after implementation of AIDR 3D iterative reconstruction. The acquisition length, dose and evaluations of the image quality were compared between standard dose FBP images and low-dose images reconstructed with AIDR 3D and FBP using the Wilcoxon test. RESULTS: The mean acquisition length was similar for both CT scans. There was a significant dose reduction of 49.5% with low-dose CT compared to standard dose CT (mean DLP of 451mGy.cm versus 892mGy.cm, P<0.001). There were no differences in image quality scores between standard dose FBP and low-dose AIDR 3D images (4.6±0.6 versus 4.4±0.6 respectively, P=0.147). CONCLUSION: AIDR 3D iterative reconstruction enables a significant reduction in dose of 49.5% to be achieved with abdominal CT scan compared to FBP, whilst maintaining equivalent image quality.

Evaluation of the value of abdominopelvic acquisition without contrast injection when performing a whole body CT scan in a patient who may have multiple trauma.

PURPOSE: To evaluate the diagnostic value of non-contrast-enhanced abdominopelvic acquisition when performing a whole body CT scan in a patient who may have multiple trauma. PATIENTS AND METHODS: In a single centre, retrospective study over 1year, we included 84 patients suspected of having multiple trauma who indeed presented an abdominal or pelvic lesion during the initial CT scan. Two readers independently reread the acquisitions without injection, then those with injection, then all the acquisitions, and scored the presence or absence of abdominopelvic lesions. Statistical analysis focused on intra- and inter-observer agreement, and on the sensitivity and specificity of the different acquisitions in relation to consensus rereading. RESULTS: This study did not reveal any significant difference, particularly concerning improvement in sensitivity, between interpretation of the acquisitions with contrast injection and interpretation of all the acquisitions with or without injection. Inter-observer agreement was substantial to almost perfect. Non-contrast-enhanced thoraco-abdominopelvic acquisition represented 20% to 25% of the effective dose for the entire examination. CONCLUSION: Abdominopelvic acquisition without contrast injection in addition to acquisition with contrast injection in a patient suspected of having multiple trauma does not improve detection of traumatic lesions of the liver, spleen, kidneys or adrenal glands, nor of intra- or retroperitoneal effusion, but increases the dose and should be abandoned.

CT dose optimisation and reduction in osteoarticular disease.

With an improvement in the temporal and spatial resolution, computed tomography (CT) is indicated in the evaluation of a great many osteoarticular diseases. New exploration techniques such as the dynamic CT and CT bone perfusion also provide new indications. However, CT is still an irradiating imaging technique and dose optimisation and reduction remains primordial. In this paper, the authors first present the typical doses delivered during CT in osteoarticular disease. They then discuss the different ways to optimise and reduce these doses by distinguishing the behavioural factors from the technical factors. Among the latter, the optimisation of the milliamps and kilovoltage is indispensable and should be adapted to the type of exploration and the morphotype of each individual. These technical factors also benefit from recent technological evolutions with the distribution of iterative reconstructions. In this way, the dose may be divided by two and provide an image of equal quality. With these dose optimisation and reduction techniques, it is now possible, while maintaining an excellent quality of the image, to obtain low-dose or even very low-dose acquisitions with a dose sometimes similar that of a standard X-ray assessment. Nevertheless, although these technical factors provide a major reduction in the dose delivered, behavioural factors, such as compliance with the indications, remain fundamental. Finally, the authors describe how to optimise and reduce the dose with specific applications in musculoskeletal imaging such as the dynamic CT, CT bone perfusion and dual energy CT.

[Evaluation of the knowledge of physicians prescribing CT examinations on the radiation protection of patients]. / Évaluation des connaissances des prescripteurs de scanner en matière de radioprotection des patients.

PURPOSE: To evaluate the knowledge of physicians prescribing CT examinations on the radiation protection of patients. MATERIALS AND METHODS: A questionnaire was distributed to all clinicians on medical staff who prescribe CT examinations. Several questions related to their prescription pattern and their knowledge of radiation protection. RESULTS: Forty-four questionnaires were analyzed. While 70% of physicians claimed that they considered the risks from exposure to ionizing radiation when prescribing a CT examination, only 25% informed their patients about those risks. Knowledge of the radiation dose delivered during CT evaluation of the abdomen and pelvis was poorly understood and the risks related to small doses of radiation were grossly underestimated. Finally, only a third of clinicians had received training with regards to radiation protection. CONCLUSION: While most clinicians claim that they consider the risks from exposure to ionizing radiation when prescribing a CT examination, the risks are either not well known or not known at all. Increased formation of clinicians with regards to the radiation protection of patients, maybe through a dedicated clinical rotation while in medical school, could be a solution to improve the knowledge of hospital clinicians with regards to radiation protection.

A 24-year-old patient with paraplegia and acquired urethral diverticulum: a case report.

Urethral diverticulum is a rare pathology in male patients. It is most often encountered in patients with paraplegia due to iterative catheterizations. The diagnosis of a large diverticulum is easy to make when faced with clinical symptoms, such as: repeated urinary tract infections, perineal pain and especially when there is penile swelling. We report the case of a 24-year-old patient with paraplegia and urethral diverticulum. In this case, the issue lies in the therapeutic possibilities.

[Imaging of cranial gunshot traumas]. / Imagerie des traumatismes crâniens par arme à feu.

Cranial traumas from gunshot wounds are characterised by the impact of a high velocity projectile. There are therefore serious, life threatening traumas. CT Scan is essential in the emergency setting for initial evaluation of traumatic bone and parenchymatous injuries to determine the indication for neurosurgery and appropriate medical management. In case of survival, CT Scan and MRI can be used to monitor progress and any possible complications, in particular vascular or infectious complications which are specific to this type of injury.

[Which is the method of choice for evaluating uterine cavity in infertility workup?]. / Exploration de la cavité utérine dans le bilan d'infertilité : quel examen choisir ?

Uterine factors represent only 2 to 3 % of infertility, but intra-uterine lesions are much more common in infertile women (40-50 %). These lesions can interfere with spontaneous fertility and can compromise pregnancy rates in assisted reproduction. Exploration of the uterine cavity is actually one of the basic explorations in infertility workup. Classically, hysterosalpingography and transvaginal sonography are most communally used for this purpose. Hysteroscopy, with the development and miniaturization of equipment, is currently simple, outpatient cost-effective exploration and it is considered the gold standard for diagnosis of intrauterine lesions. However, the benefit of the systematic use of hysteroscopy in the initial assessment of infertility remains unclear and the exploration of the uterine cavity in the initial assessment of infertility should be based on hysterosalpingography or hysterosonography. Systematic hysteroscopy before IVF is widely accepted practice that is supposed to improve pregnancy rates but still lacks scientific evidence. After repeated implantation failure in IVF cycles, uterine cavity should be reevaluated by hysteroscopy and this practice has been demonstrated to improve pregnancy rates.

[Dose reduction at CT of the lumbar spine using a 320-detector row scanner: initial results]. / Réduction de dose dans l'exploration du rachis lombaire grâce au scanner 320-détecteurs: étude initiale.

PURPOSE: To compare radiation dose and image quality for CT of the lumbar spine between helical CT and wide volume mode scanning with a 320-detector row CT. PATIENTS AND METHODS: Monocenter prospective study on 20 consecutive patients divided into two groups. All 20 patients underwent lumbar spine CT on the 320-detector row scanner (Aquilion One, Toshiba). The CT examinations for group 1 were performed using the wide volume mode with 320 detector rows while the CT examinations for group 2 were performed using a 64-detector row helical CT mode. The acquisition length and delivered dose corresponding to the DLPe (extended dose length product) as well as qualitative and quantitative image quality were compared between both groups. RESULTS: The mean acquisition length was comparable between both groups. There was a significant dose reduction of about 35% for group 1 compared to group 2 (mean DLPe of 970 mGy.cm for group 1 compared to 1503 mGy.cm for group 2, p<0.028) when using the wide volume mode acquisition at 320-detector row CT compared to the 64-detector row helical CT mode. No significant difference was noted for image quality between both groups. CONCLUSION: The acquisition of lumbar CT using the wide volume mode at 320-detector row CT allows significant dose reduction to patients compared to the 64-detector row helical CT mode while preserving image quality.

Clinical practice guidelines on menorrhagia: management of abnormal uterine bleeding before menopause.

BACKGROUND: Normal menstrual periods last 3-6 days and involve blood loss of up to 80ml. Menorrhagia is defined as menstrual periods lasting more than 7 days and/or involving blood loss greater than 80ml. The prevalence of abnormal uterine bleeding (AUB) is estimated at 11-13% in the general population and increases with age, reaching 24% in those aged 36-40 years. INVESTIGATION: A blood count for red cells+platelets to test for anemia is recommended on a first-line basis for women consulting for AUB whose history and/or bleeding score justify it. A pregnancy test by an hCG assay should be ordered. A speculum examination and Pap smear, according to the French High Health Authority guidelines should be performed early on to rule out any cervical disease. Pelvic ultrasound, both abdominal (suprapubic) and transvaginal, is recommended as a first-line procedure for the etiological diagnosis of AUB. Hysteroscopy or hysterosonography can be suggested as a second-line procedure. MRI is not recommended as a first-line procedure. TREATMENT: In idiopathic AUB, the first-line treatment is medical, with efficacy ranked as follows: levonorgestrel IUD, tranexamic acid, oral contraceptives, either estrogens and progestins or synthetic progestins only, 21 days a month, or NSAIDs. When hormone treatment is contraindicated or immediate pregnancy is desired, tranexamic acid is indicated. Iron must be included for patients with iron-deficiency anemia. For women who do not wish to become pregnant in the future and who have idiopathic AUB, the long-term efficacy of conservative surgical treatment is greater than that of oral medical treatment. Placement of a levonorgestrel IUD (or administration of tranexamic acid by default) is recommended for women with idiopathic AUB. If this fails, a conservative surgical technique must be proposed; the choices include second-generation endometrial ablation techniques (thermal balloon, microwave, radiofrequency), or, if necessary, first-generation techniques (endometrectomy, roller-ball). A first-line hysterectomy is not recommended in this context. Should a hysterectomy be selected for functional bleeding, it should be performed by the vaginal or laparoscopic routes.