Heterogeneous delayed enhancement of hepatic parenchyma after intravenous infusion of sonographic contrast agent: a new hypothesis.

PURPOSE: The aim of this paper was to report a heterogeneous late-phase hepatic enhancement pattern observed after administration of a sonographic contrast agent and to present an aetiological hypothesis for the phenomenon. MATERIALS AND METHODS: A total of 1,729 (1,012 women and 717 men; age range 28-82; mean age 51) patients underwent contrast-enhanced sonography of the liver. The examination was performed with a low mechanical index (MI <0.09) after injection of sulphur-hexafluoride-filled microbubbles, using different sonographic equipment and different contrast-specific algorithms. RESULTS: Heterogeneous delayed liver enhancement was observed in six patients in the late phase (180 s), with the presence of multiple, partially confluent, hyperechoic areas peripheral to the portal vessels. The pattern appeared spontaneously between 1 and 4 h after the examination and was associated with the presence of an anomalous echogenicity in the superior mesenteric vein. No patient experienced adverse reactions. CONCLUSIONS: The phenomenon of heterogeneous hepatic enhancement may be related to gas from the intestinal microcirculation being transported to via the enteroportal circulation and becoming trapped in the hepatic sinusoids.

Diagnostic efficacy of SonoVue, a second generation contrast agent, in the assessment of extracranial carotid or peripheral arteries using colour and spectral Doppler ultrasound: a multicentre study.

The purpose of this study was to demonstrate the improvement in diagnostic quality and diagnostic accuracy of SonoVue microbubble contrast-enhanced ultrasound (CE-US) versus unenhanced ultrasound imaging during the investigation of extracranial carotid or peripheral arteries. 82 patients with suspected extracranial carotid or peripheral arterial disease received four SonoVue doses (0.3 ml, 0.6 ml, 1.2 ml and 2.4 ml) with Doppler ultrasound performed before and following each dose. Diagnostic quality of the CE-US examinations was evaluated off-site for duration of clinically useful contrast enhancement, artefact effects and percentage of examinations converted from non-diagnostic to diagnostic. Accuracy, sensitivity and specificity were assessed as agreement of CE-US diagnosis evaluated by an independent panel of experts with reference standard modality. The median duration of clinically useful signal enhancement significantly increased with increasing SonoVue doses (p< or =0.002). At the dose of 2.4 ml of SonoVue, diagnostic quality evaluated as number of inconclusive examinations significantly improved, falling from 40.7% at baseline down to 5.1%. Furthermore, SonoVue significantly (p<0.01) increased the accuracy, sensitivity and specificity of assessment of disease compared with baseline ultrasound. SonoVue increases the diagnostic quality of Doppler images and improves the accuracy of both spectral and colour Doppler examinations of extracranial carotid or peripheral arterial disease.

[Feasability of real time contrast enhanced ultrasound in renal disease]. / Etude de faisabilité de l'échographie de contraste en temps réel dans la pathologie rénale.

OBJECTIVES: To evaluate feasibility of real-time contrast enhanced ultrasound in renal disease. MATERIALS AND METHODS: Eighteen patients (sex-ratio=1: mean age 62.3 +/-18.1 years) presenting with several renal diseases were enrolled in the present study. Real time contrast enhanced sonography was performed using an ultrasound dedicated system Esatune (Esaote, Firenze, Italy) with a very low mechanical index (MI<0.1) and a dedicated contrast software CnTI after bolus injection of 2.4 ml Sonovue (Bracco, Milan, Italy). Detection, characterization and extension of renal masses as well as inflammatory and ischemic lesions were evaluated. The results were compared to those obtained by reference method such as contrast-enhanced CT-Scan or MRI. RESULTS: This preliminary study gave some valuable results compared to baseline sonography: marked improvement in tumor delineation or internal microvasculature, detection of venous extension, improvement in cystic mass characterization. Diagnosis confidence was improved and reached 83% when diagnosis concordance with reference modality was improved by 50%. CONCLUSION: These preliminary results show that real-time contrast enhanced sonography could improve detection and characterization of renal masses by a complete assessment or arterial phase. Further studies are required to confirm these first results with possible advantages for the diagnosis of renal affections.

The use of contrast-enhanced ultrasound in large vessels.

The introduction of perfluoro-based contrast agents such as SonoVue together with sensitive realtime scanning modes such as cadence contrast pulse sequences (CPS) have made possible significant advances in the management of patients with pathology affecting large vessels. This has been particularly valuable in aortic graft procedures where the lack of nephrotoxicity allows multiple repeat studies for follow-up of leaks. It has also proved valuable in situations where the flow is very slow and undetectable on conventional Doppler

Virtual colonoscopy.

Computed axial colonography, usually called virtual colonoscopy, is a new diagnostic method potentially useful for investigating polyps and tumors of the colon and rectum. It uses spiral axial tomography data to build up images similar to those given by conventional colonoscopy, offering advantages in that it causes no adverse reactions, and is accepted well by patients, who do not need to be sedated. Reports to date show its sensitivity and specificity vary in identifying polyps in the colon, and there are still many problems with the new method, such as its cost, its learning curve, the identification of flat lesions, and detection of extracolonic abnormalities. There is a pressing need to establish the accuracy and cost-effectiveness of virtual colonoscopy as a screening method for colorectal tumors, and for post-polypectomy surveillance.

[Pulse inversion ultrasonography with ultrasonography contrast media (levovist) in the evaluation of hepatic metastasis]. / Ecografia con tecnica di inversione di impulso e mezzo di contrasto ecografico (Levovist) nella valutazione delle metastasi epatiche.

PURPOSE: To evaluate if Pulse Inversion Harmonic Imaging with contrast agent injection (Levovist) is able to determine an increase of echogenicity in normal hepatic parenchyma, and to compare its capability to detect metastatic focal lesions with that of standard US and spiral CT. To define and standardize the technical and methodological aspects of this new technique. MATERIAL AND METHODS: A selected group of 72 patients (42 males and 30 females) with clinical and instrumental suspect of hepatic metastatic lesions was included in the prospective study. Each patient was examined by conventional ultrasound (US), Pulse Inversion Harmonic Imaging (PI) and spiral-CT (spCT). US examination was performed using an HDI 5000 (ATL, Bothell, USA) equipped with a broadband probe (5.0-2.0 MHz). 2.5 g Levovist (Schering AG-Berlin) was administered intravenously, at concentration of 300 mg/ml and a flow rate of 7 ml/min. Video clips obtained with the acquired images before and after contrast medium administration were transferred to a magnet optic disk unit. Examinations were evaluated by an experienced radiologist blindly on a workstation that allowed a qualitative-quantitative analysis. SpCT images were evaluated separately by another experienced radiologist. US images were evaluated qualitatively (number of lesions, site of lesion, diameter of the smallest lesion detectable) and quantitatively (increase in parenchymal echogenicity 20", 40", 60" and 5' after the injection of contrast agent). RESULTS: In all cases examined, the echogenicity of normal hepatic parenchyma increased after contrast agent administration, reaching a peak of about 250% (1DS) at 60 s and a decreasing gradually in 5 minutes. Conventional US detected 195 focal lesions, CT 231, and US with pulse inversion technique and contrast agent (US-PI) 287. Mean differences among the number of lesions detected by the different techniques per each patient were also calculated. Wilcoxon Signed Rank Test showed a statistically significant difference between US-PI and US (p < .0001), CT and US (p = .0052) and US-PI and CT (p = .0121). US-PI detected the smallest lesions, which went undetected by the CT and conventional US examinations. DISCUSSION AND CONCLUSIONS: In 10 cases (14.3%) contrast enhanced US-PI demonstrated the presence of a number of lesions greater than 5 (diffuse metastatization and inoperability) in comparison to that detected by spCT). The greater echogenicity of normal hepatic parenchyma using pulse inversion technique after Levovist infusion allowed to better demonstrate hepatic metastases. This technique showed a higher identification rate of small lesions in comparison to basal examination and to spiral CT. Contrast enhanced US-PI demonstrated a remarkable increase in echogenicity of hepatic parenchyma in portal phase. The technique significantly improves the detection of focal lesions allowing visualization of smaller lesions compared to CT and US. These results indicate that the technique could be used in the staging of liver metastasis. However, large multicentric trials are required to validate US-PI and better define its role in the work-up of patients with neoplastic disorder.

Computed tomographic colonography and conventional colonoscopy for colon diseases: a prospective, blinded study.

OBJECTIVES: Computed tomographic (CT) colonography or virtual colonoscopy is a new diagnostic method for the colon and rectum, developed on the basis of spiral computed axial tomography and employing virtual reality technology. The aim of this study was to determine the sensitivity, specificity, and diagnostic accuracy of CT colonography compared with colonoscopy in a prospective, blinded study in one single institution in Italy. METHODS: Ninety-nine patients randomly selected among those attending the open-access endoscopy unit for diagnostic colonoscopy underwent colonoscopy and spiral CT. The images obtained were transmitted to generate the virtual colonoscopy pictures. A supervisor compared the results with the findings of conventional colonoscopy. RESULTS: CT colonography diagnosed seven of eight tumors, one being missed because the patient had been inadequately prepared. In 28 patients, CT colonography identified 26 polyps of 45 (57.8% sensitivity, 92.6% specificity, 86.7% positive predictive value), regardless of their size. The sensitivity in detecting colonic polyps was 31.8% (7/22) in the first 25 cases and 91.6% (11/12) in the last 20 patients. CT colonography missed one flat adenoma, some angioectasias and colonic lesions because of portal hypertension in one patient, Crohn's disease ulcers in two patients, and ulcerative colitis lesions in three. CONCLUSIONS: CT colonography shows poor sensitivity for identifying colonic polyps and does not always detect neoplastic lesions. Flat lesions are impossible to see by this method.

[Mammography changes associated with hormone replacement therapy in post-menopausal patients]. / Le modificazioni mammografiche nella terapia ormonale sostitutiva nelle pazienti dopo la menopausa.

Hormone replacement therapy (HRT) in post-menopausal or ovariectomized women reduces mortality due to cardiovascular diseases, lowers morbidity due to osteoporosis and improves vasovagal symptoms. Long-term therapy, however, increase the risk of side-effects. HRT may decrease mammographic sensitivity, markedly increasing glandular density. Enlargement of pre-existing cysts and fibroadenomas has also been reported after HRT. The correlation between HRT and breast cancer is highly controversial. We examined 650 women: 550 of them (84.6%) received HRT (157 estrogens and 393 estrogens-progestins) and 100 (15.4%) refused treatment and were thus considered as a control group. All patients underwent mammography and DEXA before HRT and, during treatment, were followed-up yearly with mammography, often combined with US, and DEXA. Fisher's test was used for data analysis (confidence interval: 95%). The statistical analysis showed a significant difference between the HRT group and the control group only for the lumbar spine. Mammographic changes (Tab. II) were shown in 150 of 550 HRT patients. Increased breast density was the most frequent finding. Benign lesions arising de novo or increasing in size and/or number were observed in 41 of 150 patients (27.3%) in the HRT group, where 3 breast carcinomas were detected, versus 1 breast cancer only in the control group. HRT had a marked positive effect on bone mineral content (BMC) at 2 years' follow-up, but it remains debated if it reduces breast cancer risk. In conclusion, our results indicate that a yearly mammography is mandatory in long-term HRT subjects and US may be also needed in particularly dense breasts.

[The role of color Doppler echography in the diagnosis of breast tumors]. / Il ruolo dell'eco Color-Doppler nella diagnostica dei tumori della mammella.

The authors discuss the results from a series of 45 patients with breast lumps. All patients were studied by means of mammography, sonography, color Doppler US, and biopsy. Abnormal Doppler signal was observed in 94% of the patients with breast cancer. However, this finding is not specific because it can be occasionally found in benign lesions too. The use of color Doppler US is suggested in those cases where neither US nor mammography is conclusive.

[CT x-ray in recurrences of lumbar disk herniation. Usefulness of the examination with contrast enhancement]. / La TC nelle recidive di ernia discale lombare. Utilità dell'esame con contrast enhancement.

The CT is an important and valuable instrument in the study of the postoperative lumbar spine, in the patients which presented persistent clinical manifestation. In this report the technique with contrast enhancement is outlined, the criteria for its interpretations are presented, and its advantages and limitations are reviewed; pitfalls in technique interpretation are stressed. Two hundred and fifty patients are referred to the CT without and with i.v. contrast medium for this diagnostic request: scar or herniation at surgery level.

[Preoperative embolization of intracranial meningiomas]. / L'embolizzazione preoperatoria dei meningiomi intracranici.

Embolization of very vascular intracranial meningiomas prior to operation will reduce the loss of blood during the operation. The indications and the technique of preoperative embolization are discussed and 20 cases are presented.

Transcatheter embolization of hypogastric arteries as an aid or alternative to surgery in the management of life-threatening pelvic haemorrhage.

Transcatheter embolization for uncontrollable haemorrhage from pelvic organs was performed in 27 patients (12 women, 15 men) as an aid or alternative to surgery. The advantages and peculiarities of different embolic materials employed, and methods for managing intractable haemorrhage are discussed.

[Lumbar phlebography: methodological choice and reliability in the radiographic study of lumbar disk hernias]. / La flebografia lombare: scelta metodologica ed affidabilitá nello studio radiografico dell ernie discali lombari.

Lumbar epidural venography was used as the examination of choice in the investigation of suspected disc herniation in 270 patients. Compression or occlusion of an epidural and/or radicular vein at the disc level is the most significant venographic abnormality. In 110 patients operated on, the reliability of lumbar epidural venography was equal to 97.2%.

[Lumbar phlebography: anatomy and technique (author's transl)]. / La flebografia lombare: anatomia e tecnica.

This article describes the normal radiological anatomy of the epidural veins whose understanding is necessary for the correct interpretation of venographic studies. Three ways of achieving adequate visualization of the epidural venous plexus are described. Experience with 80 cases is reported; a comparison has been made among the degree of visualization of the epidural venous plexus, the length of time, the cost and the amount of radiation received by the operator and patients during the performance of each technique. Preference is expressed for simultaneous injection of contrast media via two needles introduced into right and left femoral veins.