Characterization of the Physiological Displacement of the Aortic Arch Using Non-Rigid Registration and MR Imaging.

OBJECTIVES: The aim of this work was to study physiological aortic arch three-dimensional displacement using non-rigid registration methods and magnetic resonance imaging (MRI). MATERIALS AND METHODS: Ten healthy volunteers underwent thoracic MRI. Prospective cardiac gating was performed with a 3D turbo field echo sequence to obtain end-systolic and end-diastolic MR images. The rigid and elastic behavior between these two cardiac phases was detected and compared using either an affine or an elastic registration method. To assess reproducibility, a second MRI acquisition was performed 14 days later. RESULTS: Affine registration between the end-systolic and end-diastolic MR images showed significant global translations of the aortic arch and the supra-aortic vessels in the x, y, and z directions (2.02 ± 1.6, -0.71 ± 1.1, and -1.21 ± 1.4 mm, respectively). Corresponding elastic registration indicated significant local displacement with a vector magnitude of 5.1 ± 0.89 mm for the brachiocephalic artery (BCA), of 4.26 ± 0.83 mm for the left common carotid artery (LCCA), and of 4.8 ± 0.86 mm for the left subclavian artery (LSCA). There was a difference in displacement between the supra-aortic trunks of the order of 2 mm. Vector displacement was not statistically different between the repeated acquisitions. CONCLUSIONS: The present results showed important deformations in the ostia of supra-aortic vessels during the cardiac cycle. It seems that aortic arch motions should be taken into account when designing and manufacturing fenestrated endografts. The elastic registration method provides more precise results, but is more complex and time-consuming than other methods.

Clinical-radiological correlation after functional endoscopic sinus surgery in patients with chronic rhinosinusitis: interest of a sinonasal aerial volumetry.

BACKGROUND: Although a CT scan is often performed after functional endoscopic sinonasal surgery (FESS) in patients with chronic rhinosinusitis, its role hasn`t been firmly established. The goal of this study is to investigate the correlation between symptoms and CT findings before and after FESS for chronic rhinosinusitis. In addition, the interobserver agreement for both sinonasal aerial volumetry and CT score is assessed. METHODS: Thirty-three patients surgically treated for chronic rhinosinusitis were included in this prospective study. Conventional and modified Lund-Mackay scores and sinonasal volumetry were determined by two radiologists before (M0), at 3 months (M3) and 1 year (M12) after surgery. The symptoms were evaluated by the 22-item SinoNasal Outcome Test (SNOT-22). RESULTS: Change of SNOT-22 and air volume were significantly correlated between M0 and M12, but not between M0 and M3, for both readers. Compared to other scores, volume had the best intraclass correlation coefficient and reproducibility, according to the Bland-Altman analysis. No correlation was found between SNOT-22 and CT scores before and after surgery, except between M12 and M0 for one reader. CONCLUSION: The correlation between CT scan and symptoms is low or absent. The measurement of sinonasal air volume is best correlated with the symptoms after surgery, with the best inter-observer agreement.

[Assessment of the transobturator male sling by a pelvic MRI]. / Évaluation du positionnement de la bandelette rétro-urétrale transobturatrice par IRM pelvienne statique et dynamique.

PURPOSE: To evaluate the usefulness of MRI to assess the anatomical and functional relationships between the transobturator male sling Advance(®) and the uretral sphincter, in patients treated for postprostatectomy urinary incontinence. PATIENTS: For 12 patients treated for postprostatectomy urinary incontinence using the transobturator male sling Advance(®), a pelvic real-time MRI was performed between 1 and 3 months postoperatively. A comparison between pre- and postoperative MRI was performed in eight patients. The static sequences studied the anatomical relationships between the sling and the uretral sphincter, as well as the impact on the location of the vesico-uretral anastomosis. The dynamic sequences by coughing looked for the existence of an uretral sphincter mobility. Finally, the voiding sequences studied the impact of the sling on the uretral lumen during the micturition. RESULTS: The position of the sling was always visible, located at a median distance of 5mm from the posterior wall of the uretra. On transverse sections, the angles between the transobturator arms and the horizontal line between the ischial tuberosities varied from 28 to 59 degrees. The vesico-uretral anastomosis location was not modificated between pre and postoperative MRI. On the preop sequences by coughing, four patients had uretral mobility, which didn't exist on postop sequences. To finish, the seven patients who were able to void during MRI, had micturition without uretral stenosis. CONCLUSION: Pelvic MRI was a useful tool to assess the positioning of the sling and the relationships with the uretral sphincter. When correctly positioned, the sling was retro-uretrally and no urethral stenosis was visible during the micturition.

Chimio-embolisation trans-artérielle des carcinomes hépatocellulaires par billes chargées à la doxorubicine. Transarterial chemoembolization of hepatocellular carcinoma with doxorubicin eluting beads.

OBJECTIVES: The goal of our study was to describe the chemoembolization technique of transarterial catheterization using microspheres loaded with doxorubicin and to evaluate its tolerance and short-term efficacy on a small number of patients. MATERIALS AND METHODS: Our retrospective study was conducted over 8 months (December 2007-July 2008). It was done at the Brest University Medical Centre (France), in the radiology and hepato-gastroenterology departments of the Hôpital de la Cavale Blanche. We performed a transarterial chemoembolization using microspheres loaded with doxorubicin to 9 patients who had hepatocellular carcinoma in relation to alcoholic cirrhosis. RESULTS: Eight of 9 patients have benefited from a complete procedure (88.9% technical success) and in 100% of these cases, there were no clinical complications or biologic modifications immediately after embolization. After 4 weeks, there were seven cases of regression of more than 30% of the size of the tumor nodules, six cases of total tumor necrosis, and two cases of contrast uptake inside the nodules (partial tumor necrosis). In three cases (37.5%), there was an emergence of new tumor nodules. CONCLUSION: Chemoembolization accomplished by transarterial catheterization using microspheres loaded with doxoribicin is a probable technique for the future of palliative treatment of hepatocellular carcinomas. The technique is simple to perform and seems to be well tolerated by patients in terms of clinical and biological aspects.

Overestimation of moderate carotid stenosis assessed by both Doppler US and contrast enhanced 3D-MR angiography in the CARMEDAS study.

PURPOSE: To evaluate the agreement and diagnostic accuracy of Contrast enhanced magnetic resonance angiography (CE-MRA), Doppler ultrasound (DUS) and Digital subtraction angiography (DSA) in the assessment of carotid stenosis. METHODS: DUS, CE-MRA and DSA were performed in 56 patients included in the Carotide-angiographie par résonance magnétique-échographie-doppler-angioscanner (CARMEDAS) multicenter study with a carotid stenosis ≥ 50%. Three readers evaluated stenoses on CE-MRA and DSA (NASCET criteria). Velocities criteria were used for stenosis estimation on DUS. RESULTS: CE-MRA had a sensitivity and specificity of 96-98% and 66-83% respectively for carotid stenoses ≥ 50% and a sensitivity and specificity of 94% and 76-84% respectively for carotid stenoses ≥ 70%. The interobserver agreement of CE-MRA was excellent, except for moderate stenoses (50-69%). DUS had a sensitivity and specificity of 88 and 75% respectively for carotid stenoses ≥ 50% and a sensitivity and specificity of 83 and 86% respectively for carotid stenoses ≥ 70%. Combined concordant CE-MRA and DUS had a sensitivity and specificity of 100 and 85-90% respectively for carotid stenoses ≥ 50% and a sensitivity and specificity of 96-100% and 80-87% respectively for carotid stenoses ≥ 70%. The positive predictive value of the association CE-MRA and DUS for carotid stenoses ≥ 70% is calculated between 77 and 82% while the negative predictive value is calculated between 97 and 100%. CE-MRA and DUS have concordant findings in 63-72%, and the overestimations cases were recorded only for carotid stenosis ≤ 69%. CONCLUSION: Combined DUS-CE-MRA is excellent for evaluation of severe stenosis but remains debatable in moderate stenosis (50-69%) due to the risk of overestimations.

[Anatomic study and CT angiography with 3D reconstructions of the pulmonary arterial tree]. / Etude anatomique et angioscanographique avec reconstructions 3D de l'arbre artériel pulmonaire.

AIM OF THE STUDY: To prove in vivo and on cadaveric lungs, the constancy of the collateral type of distribution for the right and left pulmonary arteries as described in classical books and modern studies; to estimate the frequency of the main branches observed and define an arterial tree of reference set up with the most common branches for reading the CT pulmonary angiographies. PATIENTS AND METHODS: Sixty three-dimensional reconstructions of pulmonary arterial trees (right: 30; left: 30) using the Volume Rendering Technique (VRT) performed from CT angiographic studies of 30 patients without bronchial, arterial or pulmonary pathology. Dissection of 16 pulmonary arteries from eight fresh cadavers injected with latex. Finally, 76 pulmonary arteries (right: 38; left: 38) were examined. RESULTS: The most common division of the pulmonary artery is a collateral distribution but in seven cases from 38 (18.4%) at right and one case from 38 (2.6%) at left the artery ended in two or three terminal lobar trunks which provided the segmental arteries. The mediastinal artery for the upper right lobe was always found, with a complementary scissural artery in 89.5% of cases; a middle lobar trunk was observed in 22 of the 38 right lungs (57.9%). On the left tree, four different but usually not coexisting mediastinal arteries were identified for the upper lobe, three for the culmen and one for the lingula; six various scissural arteries were noted, three for the culmen and three for the lingula; the segment 6 received one or two segmental arteries, exceptionally three. An arterial tree of reference could be defined for both sides. CONCLUSION: The division in terminal lobar trunks of the pulmonary arteries is a variation demonstrated for the first time. The data obtained from 3D reconstruction imaging in vivo are in conformity with the results of studies performed on injected cadaveric lungs for this point and to define the arterial tree of reference.

[MR angiography of peripheral arterial disease of the distal legs: is time resolved MRA (TRICKS) necessary?]. / Angiographie par Résonance Magnétique dans l'artériopathie distale des membres inférieurs: peut-on se passer d'une séquence multiphase (TRICKS)?

PURPOSE: To demonstrate the added diagnostic value of time-resolved imaging of contrast kinetics (TRICKS) in the evaluation of lower limb arteries compared to standard 3 level MRA with stepping table method. PATIENTS AND METHODS: Forty patients (30% diabetics) with lower extremity peripheral arterial disease (87.5% with chronic ischemia) underwent standard contrast MRA including TRICKS of the distal arteries. Five arterial segments were defined per leg, and 395 arterial segments were compared (one patient with amputation). Two reviewers evaluated the quality of arterial imaging, presence of venous return and degree of stenosis per segment. The degree of interobserver agreement for arterial stenosis measurement was calculated. RESULTS: More arterial segments could be analyzed on the TRICKS sequence (good or excellent analysis in 63.03%-66.32% of arterial segments compared to 41.51%-47.08% on routine MRA). There was less venous contamination on TRICKS images (25.57% to 27.60% gain). The degree of interobserver agreement was superior with TRICKS compared to standard MRA (kappa 0.85 vs 0.69). CONCLUSION: The TRICKS sequence can be added to standard MRA for pre-therapeutic evaluation of distal arteries in patients with peripheral arterial disease, especially with chronic ischemic with rest pain and/or trophic changes.

Iodixanol in multidetector-row computed tomography angiography (MDCTA): diagnostic accuracy for abdominal aorta and abdominal aortic major-branch diseases using four-, eight- and 16-detector-row CT scanners.

PURPOSE: To compare iodixanol-enhanced multidetector-row computed tomography angiography (MDCTA) with digital subtraction angiography (DSA), perioperative angiography, or surgical findings in the evaluation of the abdominal aorta and its main branches. MATERIAL AND METHODS: 173 patients with known or suspected aortic aneurysms or stenosis/occlusion of the abdominal aorta or its major branches were enrolled. The iso-osmolar contrast medium iodixanol (320 mg Iota/ml) was used, and data were acquired using four-, eight-, or 16-active-detector-row scanners. Reference diagnoses were provided by surgical findings, interventional findings, or DSA. Diagnostic accuracy was estimated with reference to surgery or interventional arteriography or DSA. Image quality was assessed as excellent, good, sufficient, or insufficient, and correlations were made with attenuation values in the aortic lumen. Tolerability of iodixanol was monitored during the injection for discomfort and other adverse events, and for 72 hours after contrast injection. RESULTS: In 132 of 136 evaluable cases, MDCTA diagnosis matched the reference diagnosis, yielding an agreement rate of 97.1% (95% CI 92.6-99.2%). The quality of most MDCTA scans (147/173) was rated as excellent. Overall mean attenuation was 305.7 HU. MDCTA appeared more accurate than DSA for identification of lesion calcification, thrombus, irregularity, and ulceration. Tolerability of iodixanol was good, and no serious adverse events were reported. CONCLUSION: MDCTA using iodixanol is a promising, noninvasive alternative for evaluating patients with abdominal aortic disease.

Plaque density on CT, a potential marker of ischemic stroke.

The authors sought to determine in a retrospective analysis whether carotid plaque soft TD on CT is associated with recent ischemic neurologic events. Among 141 patients (99 asymptomatic), 106 plaques with more than 50% stenosis were selected for density measurements. They found an odds ratio for neurologic events associated with a 10-point decrease in density of 1.54 (p = 0.002), showing an association between plaque density and neurologic events.

Assessment of coronary artery stents by 16 slice computed tomography.

OBJECTIVE: To analyse coronary stents with multislice spiral computed tomography (MSCT) in comparison with coronary angiography. PATIENTS AND METHODS: 310 patients referred for conventional coronary angiography underwent MSCT on the next day (16 x 0.75 mm cross section, 420 ms rotation, 110 ml contrast agent intravenously at 4 ml/s). Two independent blinded reviewers analysed the MSCT. RESULTS: 143 patients had previous stenting (232 stents) and 190 (82%) of the 232 stents were detected. Intrastent lumen was interpretable in 126 (64%) of the detected stents. Lumen interpretability depended on stent diameter: for stent diameter > 3 mm, 81% of lumens were interpretable, as against 51% with < or = 3 mm stent diameter (p < 0.001). Restenosis detection likewise depended on stent diameter: with small stents (< or = 3 mm), sensitivity and specificity of MSCT were 54% and 100%, respectively; positive and negative predictive values were 100% and 94%. For stents with > 3 mm diameter, corresponding values were 86%, 100%, 100%, and 99%. CONCLUSION: 16 slice MSCT allows analysis of in-stent lumen in about half of all stented angioplasties. It performs better when stent diameter is more than 3 mm and may offer a non-invasive alternative to conventional coronary angiography for monitoring stented coronary arteries. Technical progress may improve interpretability and hence increase the yield of MSCT in this application.

Multi-detector row computed tomography angiography: an alternative imaging method for surgical strategy in lower extremity arterial occlusive disease.

In order to show the value of CT angiography in the pretherapeutic assessment of lower leg ischemia, we studied 93 CT angiographies in 85 patients. Two groups were defined according to the level of revascularization: 52 angioscanner were made prior to suprainguinal revascularization and 41 prior to infrainguinal reconstruction. Two decision attitudes were chosen by two different physicians, a radiologist and vascular surgeon, members of the same team. The attitudes where then compared in order to evaluate the value of CT angiography. The first attitude was a pragmatic strategy based on the images as interpreted by the first physician and on the intraoperative information including surgical treatment and, if necessary, angiography. This indicates that the results of this attitude cover the performed revascularizations. The second attitude determined a virtual strategy and was chosen by the second physician a posteriori, based solely on the medical file with the same CT angiography images. These two strategies were compared in order to assess the agreement on the level of the lesion and the choice of revascularization. In 84 CT angiographies (90.3%), the analysis of the lesions and the choice of lesions to be treated were identical. In 9.6% of scans the strategies were not comparable because the lesions were interpreted differently or the scans were difficult to read. The sensitivity of CT angiography in detecting lesions and guiding the therapeutic strategy was 96% and its positive predictive value was 93%. Follow-up was reported according to the life-table method to assess the overall outcome and the results in both groups. The overall survival rate at 12 months for 85 patients was 90%. Secondary patency rates at 12 months in the group of patients who underwent a suprainguinal and infrainguinal revascularization were 98% and 71% respectively. Overall limb salvage at 12 months was 94%. In this setting, CT angiography allowed us to select adequate treatment in the majority of cases. These results obtained after a strategy based on CT angiography images are comparable with the results as published in the literature after the strategy based on conventional angiography.

Coexistence of annular pancreas with carcinoma in the dorsal part of pancreas divisum: diagnostic value of magnetic resonance cholangiopancreatography.

We report on the incidental observation of a pancreas divisum coexistent with an annular pancreas in a 88-year-old woman presenting with jaundice due to a pancreatic carcinoma. This case report discusses the embryologic hypotheses underlying this peculiar association, highlights the capacities of imaging techniques to depict them, and enhances the performance of magnetic resonance imaging.

[Right-sided duplication of the inferior vena cava]. / Duplication droite de la veine cave inférieure.

An infrarenal duplication of the inferior vena cava with both channels lying on the right side of the aorta was fortuitously found during an abdominal Computed Tomography performed on a 52 year-old woman. Only two same cases seem to be reported in the literature. This very uncommon abnormality probably results from persistence of the infra-renal part of the right subcardinal vein. Radiologists have to be aware of this right-sided ipsilateral duplication for it may be a trap in abdominal imaging as well as "classical" inferior vena cava duplication located on both sides of the abdominal aorta.

[Persistence of the stapedial artery: three cases]. / Persistance de l'artère stapédienne: à propos de trois observations.

The authors report three cases of persistence of the stapedial artery, discovered by computed tomography examination. For two cases, a clinical symptomatology was present but probably related to the association with an aberrant carotid artery in the middle ear; the only case of isolated persistence of the stapedial artery was asymptomatic. Direct visualisation of the abnormal artery was possible on the C. T. scans in two cases and a collateral sign as a larger tympanic part of the facial canal was found in the third case inducing a MRI. The incidence of this anomaly is 0.48 per cent from 1,045 dissections of temporal bones but it is generally clinically unrecognized. The hyoïdo-stapedial artery appears and develops at the 7-18 mm embryonic stages. Partial or complete persistence have been described associated with no regression or no division of the ventral pharyngeal artery.

Two rare anomalies of the left renal vein.

Two uncommon anatomical variations of the left renal vein were found on dissected specimens: a circumaortic venous ring and a retro-aortic bifid left renal vein. The first anomaly results from a persistence of the embryonic renal venous collar. The second one would be related to a particular pattern of left inferior vena cava. Both abnormalities have to be known for they may be undetected or be misleading in imaging. Other clinical implications are also considered.

Dorsal pancreas agenesis: computed tomography appearance with three-dimensional volume rendering reconstruction.

We report a case of a very rare congenital variant consisting in a dorsal (or left) pancreas agenesis due to the lack of development of the dorsal embryonic bud of the gland. This variant is characterized using helical computed tomography (CT). Three-dimensional (3D) computed tomography reconstruction, especially using the volume rendering technique, is very helpful for assessing this entity, which it is important to recognize due to its potential clinical implication (diabetes mellitus). Associated variants of abdominal vessels were also clearly seen in our patient with this technique, including a hepatomesenteric trunk and left retro-aortic renal vein.

Diagnostic accuracy of compression ultrasonography for the detection of asymptomatic deep venous thrombosis in medical patients--the TADEUS project.

We assessed the accuracy of venous compression ultrasonography (CUS) for the detection of asymptomatic deep vein thrombosis in 122 consecutive patients, with a mean age of 69 years, who were hospitalised in an internal medicine unit. All included patients had CUS within 48 h of admission. Twelve out of 17 patients with a positive CUS underwent phlebography, as the others withdrew their consent, whereas the remaining 105 patients with a negative serial CUS testing were clinically followed-up at 3 months. We found that CUS had a sensitivity and a specificity of respectively 1 (95% CI, 0.73 to 1) and 1 (95% CI, 0.96 to 1) for the detection of asymptomatic deep vein thrombosis. Kappa-coefficients for intra-observer and inter-observer agreements were respectively 0.88 and 0.56. We concluded that venous compression ultrasonography, performed as described, fulfils requirements of a screening test that could be available for prophylactic clinical trials or epidemiological researches.

Celiac-bimesenteric trunk: anatomic and radiologic description--case report.

The authors report the case of a 39-year-old man with a common origin of three arteries-the celiac, superior mesenteric, and inferior mesenteric arteries-that has not been described previously in the literature, to their knowledge. This variant, which they call the celiac-bimesenteric trunk, is documented with a selective angiogram, and an embryologic explanation is offered.

Concurrent spinal dural and intradural arteriovenous fistulas. Case report.

Among spinal arteriovenous malformations (AVMs), dural arteriovenous fistulas (DAVFs) should be distinguished from intradural AVMs. The authors report the unusual and well-documented case of a 49-year-old man who suffered from a rapidly progressive myelopathy. Two concurrent spinal AVMs (one DAVF and one intradural direct AVF [Anson-Spetzler Type IV-B AVM]) were found located in the midthoracic region and in the conus medullaris, respectively. Both AVMs were successfully treated by surgery. To the authors' knowledge, the association of these two pathological entities has not been previously described. Clinically, if the patient fails to improve or deteriorates after the treatment of a spinal AVM, the presence of another AVM should be investigated by repeated angiography, especially if a complete spinal angiography study was not initially performed.

The 6-F nitinol TrapEase inferior vena cava filter: results of a prospective multicenter trial.

PURPOSE: The authors report the first results of a new 6-F symmetrically designed permanent nitinol inferior vena cava (IVC) filter, the Cordis TrapEase, evaluated in a multicenter prospective study with 6-months of follow-up. MATERIALS AND METHODS: A total of 65 patients (29 men, 36 women) who ranged in age from 37 to 96 years (mean age, 68 years) and who were at high risk of pulmonary embolism (PE) were enrolled in 12 centers in Europe and Canada. The study was approved by the institutional review boards at all centers. Study objectives were to evaluate filter effectiveness, filter stability, and caval occlusion. Indications for filter placement were deep vein thrombosis with recurrent thromboembolism and/or free-floating thrombus with contraindication to anticoagulation in 37 patients, and complications in achieving adequate anticoagulation in 28 patients. Follow-up included clinical examination, plain film, Doppler ultrasound, CT scan, and nuclear medicine. RESULTS: The analysis of the data revealed a technical success of 95.4% (three filter-system related implantations not at the intended site, no events of filter tilting) and a clinical success of 100% at 6 months (no cases of symptomatic PE), the study primary endpoint. There were no cases (0%) of filter migration, insertion site thrombosis, filter fracture, or vessel wall perforation. During the study period, there were two cases of filter thrombosis: one case of early symptomatic thrombosis that was successfully treated in the hospital, and one case of nonsymptomatic filter thrombosis detected at 1-month follow-up, with spontaneous recanalization at 3 months. In the latter patient, some residual thrombus was still detected at 6 months. Of the study population of 65 patients, there were 23 deaths. These deaths were not related to the device or the implantation procedure but to the underlying disease process. CONCLUSION: This study demonstrates the new nitinol permanent IVC filter to be a safe and an effective device, with a low overall complication rate, for use in patients with thromboembolic disease at high risk of PE.