Emergency arterial embolization of upper gastrointestinal and jejunal tumors: An analysis of 12 patients with severe bleeding.

PURPOSE: The goal of this study was to retrospectively assess the efficacy of emergency percutaneous transcatheter arterial embolization in patients with severe bleeding due to upper gastrointestinal or jejunal tumor. MATERIALS AND METHODS: Twelve patients (7 men, 5 women; mean age, 74 years±14 (SD); range: 54-86 years) with severe bleeding from the upper gastrointestinal tract, with failed endoscopic treatment not eligible for emergency surgery were treated by emergency percutaneous transcatheter arterial embolization. The bleeding cause was gastric tumor in 7 patients, duodenal tumor in 4 patients and jejunal tumor in one patient. Procedure details and follow-up were reviewed. RESULTS: Twelve embolization procedures were performed using various embolic agents. Embolization was achieved and bleeding was stopped in all patients. Five patients underwent surgery within the 30 days following embolization. In the remaining 7 patients, no bleeding occurred at 1 month follow-up in 6 patients and bleeding recurred in one patient at 1 month. In this later patient, endoscopic treatment was successful. CONCLUSION: The results of our study suggest that transcatheter arterial embolization is safe and effective in patients with severe arterial bleeding due to upper gastrointestinal or jejunal tumor. In some patients, transcatheter arterial embolization can be used as a bridge to surgery.

Percutaneous treatment of non-functioning arteriovenous fistulas.

AIM: To show our results in the percutaneous treatment of non-functioning arteriovenous fistulas of patients undergoing haemodialysis and to discuss the results of the literature. METHODS: Thirty-four patients with 37 non-functioning arteriovenous fistulas (29 native, 8 grafts) underwent percutaneous angioplasty. Restoration of vessel lumen and function at the following dialysis were considered as successful outcome. Primary and secondary patency rates at 12 months were calculated by means of Kaplan-Meier analysis. RESULTS: Fifty-six interventions were performed, 42 on native fistulas and 14 on grafts. Immediate technical and clinical success were obtained in 98% of procedures. For native fistulas, primary and secondary patency rates at 12 months were 41% and 62%, respectively. For grafts, 14% and 34%, respectively. Only one complication was observed. CONCLUSION: Minimally invasive percutaneous treatment allows to restore function of most arterio-venous fistulas with good long term patency.

Assessment of patients with acute mesenteric ischemia: multislice computed tomography signs and clinical performance in a group of patients with surgical correlation.

AIM: The aim of this paper was to describe signs and performance of multislice computed tomography (MSCT) in patients with acute mesenteric infarction (AMI). METHODS: MSCT examinations of 26 patients with AMI and of 34 patients with acute abdomen and surgical diagnosis excluding AMI were retrospectively analyzed. All studies were performed with arterial and portal venous phase scans, 2.5 mm thickness, 1.25 mm image interval. All abnormal findings at MSCT in patients with AMI were recor- ded. Patients with MSCT evidence of mesenteric artery occlusion or pneumatosis or venous gas or, alternatively, bowel thicken-ing associated with lack of wall enhancement or venous thrombosis or parenchimal infarction were considered to be affected by AMI. RESULTS: AMI was due to mesenteric artery thrombosis in 17 patients, mesenteric vein thrombosis in 7, and nonocclusive ischemia in 2. In 16/17 patients arterial thrombosis was visualized, in 7/7 venous thrombosis was found. Portal or mesenteric vein gas was seen in 5% and pneumatosis in 38%; bowel wall thickening associated with other signs was found in 31%. Sensitivity and specificity were 92% and 100%, respectively. CONCLUSIONS: MSCT allows an accurate assessment of the mesenteric circulation and the bowel wall. This makes possible optimal visualization of signs of AMI resulting in a good clinical performance.

Tubular carcinoma of the breast: pathological, clinical, and ultrasonographic findings. A review of the literature.

PURPOSE: Tubular carcinoma of the breast is a well-differentiated adenocarcinoma. The aim of this paper is to analyse its clinical and imaging findings and to review the radiological literature. MATERIALS AND METHODS: A retrospective review of 560 consecutive histologically proven carcinomas of the breast was made. RESULTS: Sixteen pure (tubular component >90%) tubular carcinomas were found in 14 women (mean age 55 years). Three lesions were palpable. At mammography, five were not detected, three presented as spiculated masses, two as masses with irregular margins, two as spiculated masses with microcalcifications, two as distortions, one as a cluster of microcalcifications and one as asymmetric density. At ultrasonography, two lesions were not detected; the remaining presenting as hypoechoic nodules with irregular (13) or well-defined (one) contours. Fine-needle aspiration cytology diagnosed 11 carcinomas and two "atypical cells". In three, core biopsy was made: in the first, a complex sclerosing lesion with atypical cells was suggested, in the second differential diagnosis between tubular carcinoma and sclerosing adenosis was proposed and in the third a tubular carcinoma. The mean diameter of the lesions at histopathology was 9.7+/-4.9 mm. Metastatic nodes were found in one patient only. CONCLUSIONS: Tubular carcinoma presents as a small, nonpalpable lesion, with nonspecific imaging patterns. Nodal metastases are rare.

Characterization of adrenal adenomas and metastases: correlation between unenhanced computed tomography and chemical shift magnetic resonance imaging.

PURPOSE: To evaluate the correlation of absolute attenuation values of unenhanced computed tomography (CT) with signal intensity (SI) quantitative analysis on chemical shift (CS) magnetic resonance (MR) imaging in differentiating adrenal adenomas from metastases. MATERIAL AND METHODS: Forty-one adrenal masses (27 adenomas, 14 metastases) were studied with CS MR imaging and unenhanced CT. MR included T1-weighted breathhold gradient-echo in-phase (IP) and opposed-phase (OP) sequences. The SI index (SI-i) [(SIIP-SIOP/SIIP)] x 100% and chemical-shift ratio (CS-r) relative to the spleen [(SIlesion/ SIspleen)OP/(SIlesion/SIspleen)IP] were calculated for each lesion. CT absolute attenuation values were also determined. RESULTS: The mean attenuation value of metastases was significantly greater than that of adenomas (< 0.0001). On MR, the mean SI-i of adenomas was significantly greater than that of metastases (P < 0.0001) and no overlaps were evident. The CS-r of malignant and benign lesions overlapped considerably, and five adenomas (all with indeterminate Hounsfield Unit values at CT) were misclassified as potentially malignant. CT attenuation values were significantly correlated with both MR quantitative analyses. CONCLUSION: Since CS MR imaging and CT both depict the presence of lipids within adrenal lesions, absolute attenuation values are highly correlated with MR quantitative analysis. SI-i is the most reliable tool for differentiating adrenal adenomas from metastases, showing better accuracy than lesion-to-spleen CS-r, in particular for adenomas with indeterminate absolute attenuation values.

MR versus multislice CT cholangiography in evaluating patients with obstruction of the biliary tract.

BACKGROUND: We compared magnetic resonance cholangiography (MRC) with multislice computed tomographic (MSCT) cholangiography in the assessment of patients with bile duct obstruction. METHODS: Thirty-six patients with clinical or biochemical signs of biliary obstruction were prospectively studied. MRC was performed with fast spin-echo and single-shot fast spin-echo sequences. Source images, maximum intensity projection, and multiplanar reconstruction were evaluated. MSCT cholangiography was performed without biliary contrast agent, with intravenous injection of 150 mL of iodinated contrast material at 4 mL/s, 2.5-mm slice thickness, 7.5-mm/s table speed, and 1.25-mm reconstruction interval. Axial, multiplanar, and minimum intensity projection reformatted images were evaluated. MRC and MSCT findings were compared with endoscopic retrograde cholangiopancreatography (ERCP; 20 patients), percutaneous cholangiography (eight patients), intraoperative cholangiography (two patients), surgery (11 patients), and cytology (11 patients) with respect to cause and site of obstruction. RESULTS: With regard to presence and site of obstruction, agreement was observed across MRC, MSCT cholangiography, and reference investigations in all cases. Concerning cause, the correct diagnosis was made by MSCT cholangiography in 34 of 36 patients. Two cases of common bile duct lithiasis, diagnosed on MRC and ERCP, were missed by MSCT cholangiography. CONCLUSION: MSCT cholangiography can be considered a possible noninvasive alternative to MRC.

Partial unilateral intracavernosal hematoma in a long-distance mountain biker: a case report.

We present a case of spontaneous partial unilateral hematoma of the bulb of the corpus cavernosum in a long-mileage mountain biker. Ultrasonography, magnetic resonance imaging, and histopathological findings are described.

Sclerosing stromal tumor of the ovary in pregnancy: clinical, ultrasonography, and magnetic resonance imaging findings.

We report a case of sclerosing stromal tumor of the ovary in a 30-year-old pregnant patient presenting with pelvic pain, dysuria, and metrorrhagia. Very few reports of sclerosing stromal tumor of the ovary during pregnancy have been presented. The purpose of our work is to present the findings at physical examination, ultrasonography, magnetic resonance imaging, and histopathology, to review the literature regarding this uncommon neoplasm, and to show the usefulness of magnetic resonance imaging in the assessment of pelvic masses during pregnancy.

Value of an early arteriographic acquisition for evaluating the splanchnic vessels as an adjunct to biphasic CT using a multislice scanner.

Our objective was to assess the clinical value of an early arterial scan for assessing the hepatic and mesenteric vasculature in patients with suspected primary or metastatic hypervascular liver disease undergoing multislice computed tomography. In 42 patients a very early arteriographic scan was performed before standard arterial and portal venous scans. Technical parameters of the very early acquisition were: 2.5-mm image thickness; table speed 15 mm/s; pitch 6; 120 kVp; 300 mA; 8.9-s scan time; cranio-caudal acquisition direction; 1.25-mm image interval reconstruction;16-s delay after injection of 110 ml of iodinated contrast agent at 5 ml/s; scan volume focused to image hepatic, splenic, and superior mesenteric arteries (SMA). Standard arterial and portal venous phases were performed with 5-mm image thickness, 15-mm/s table speed, pitch 6, 8- to 10-s scan time, 30- and 70-s delay. The three phases were performed during three different breath-holds. Axial, multiplanar reformatted, maximum intensity projection, and volume-rendering images were evaluated. Image quality was scored, and vascular abnormalities were recorded. Digital subtraction angiography (DSA) was performed in 17 patients. In 36 of 42 patients good-quality CT angiograms were obtained. In 9 patients 12 vascular abnormalities were found, all confirmed at DSA: 3 right hepatic arteries originating from the SMA, 2 left hepatic arteries from the gastric artery, 2 stenoses of the SMA, 1 independent origin of the hepatic and splenic arteries, 2 arteriovenous fistulas, and 2 aneurysms of the common hepatic artery and the SMA. This technique could add important information about vascular splanchnic anatomy which would be particularly useful for surgeons and interventional radiologists.

Pictorial essay: magnetic resonance imaging of adrenal masses.

In many cases, adrenal lesions are incidentally discovered during ultrasonography or computed tomography in the staging or follow-up of patients with primary malignancies. The most important issue in the radiological management of adrenal masses is the differential diagnosis between benign and malignant lesions. Magnetic resonance (MR) plays an important role in the characterization of such lesions. Our aim was to present the MR techniques and to review the MR features of most common adrenal masses.

Multislice CT cholangiography without biliary contrast agent: technique and initial clinical results in the assessment of patients with biliary obstruction.

Our objective was to describe our technique for multislice CT cholangiography without cholangiographic contrast agent, and to present our preliminary clinical results. Thirty-seven patients with suspected biliary obstruction were studied. A multislice CT unit was used with the following technical parameters: 2.5-mm collimation; 7.5-mm/s table speed; pitch 6; 0.8-s rotation time; 300 mA; 120 kVp; 18- to 24-s scan time; scan volume ranging from the hepatic dome to below the pancreatic head; 70-s delay after injection of 150 ml of iodinated contrast agent at 4 ml/s. No biliary contrast material was given; oral iodinated contrast agent was administered to opacify bowel loops. Axial, multiplanar reformatted, and minimum intensity projection images were evaluated. The CT findings were compared with the gold standard techniques: endoscopic retrograde cholangiography (ERCP) in 30 patients, percutaneous transhepatic cholangiography in 5, and intraoperative cholangiography in 2. In 5 patients with ampullary lesions biopsy was made during ERCP, 9 underwent surgery, and 11 US-guided fine-needle aspiration. Bile ducts appeared hypodense within the surrounding enhanced structures. Regarding the site of obstruction, agreement between multislice CT and conventional cholangiography was observed in all cases. One patient presented negative findings on both CT and ERCP. In 31 of 36 (86%) patients, multislice CT cholangiography without cholangiographic contrast agent correctly assessed the cause of bile duct obstruction. Multislice CT cholangiography without cholangiographic contrast agent seems to be a promising diagnostic tool in the assessment of patients with bile duct obstruction.

MR evaluation of coronary stents with navigator echo and breath-hold cine gradient-echo techniques.

The aim of this study was to evaluate coronary artery stents with MR. Thirty-eight patients underwent MR imaging 48.1 +/- 6.6 days (range 38-60 days) after placement of 47 coronary stents of 11 different types, using navigator echo (NE) and cine gradient-echo (GE) techniques. For both sequences the low signal artifact was used to localize the stent, whereas the flow-related high signal before and distal to the stent was considered as a patency sign. Exercise electrocardiographic test (EET) had been performed 1-7 days before MR. No adverse event with possible relation to the MR examination was observed. All the stents were recognized as signal void with GE, and all but one with NE. Of the 2 patients with positive EET, the first one, with a stent on the left anterior descending coronary artery, presented low signal distal to the stent at both MR sequences, suggesting dysfunction [60% stenosis at conventional coronary angiography (CCA)]; the second one, with two sequential stents on the right coronary artery, presented lack of signal distal to the stents at both MR sequences, suggesting occlusion (97% stenosis at CCA). For the 44 remaining stents in 36 patients with negative EET, MR high signal before and distal to the stent suggested patency at both sequences. MR seems to be a safe and promising technique for non-invasive evaluation of coronary stents.

Calcified pilomatrixoma of the breast: mammographic and sonographic findings.

The authors report the ultrasonographic and mammographic features of a case of pilomatrixoma of the breast, a rare benign neoplasm originating from the hair matrix.

Volume measurement with magnetic resonance imaging of hippocampus-amygdala formation in patients with anorexia nervosa.

The purpose of our work was to evaluate the volume of hippocampus-amygdala formation (HAF) in patients with anorexia nervosa (AN), being this structure a crucial target for the glucocorticoid action in the adaptative stress-response. AN patients have biochemical hypercortisolism associated to normal ACTH levels, but do not develop the characteristic clinical features of glucocorticoid hypersecretion. Furthermore, in these patients cortisol levels usually do not suppress after dexametasone challenge. Twenty AN females (aged 30.0+/-5.1) with 10.5+/-4.2 yr of disease underwent a brain magnetic resonance (MR) examination during the recovery phase; an age-matched control group (CG) of 20 healthy female volunteers was also studied. Two interleaved T1-weighted spin-echo sequences for 46 contiguous 2-mm coronal slices (pixel 0.98(2) mm) were used. The volumes of both right and left HAFs were calculated with manual contouring from the third ventricle to the Sylvian aqueduct. IGF-I, T3, gonadotropins, 24-h urine free cortisol, and BMI were obtained for both patients (on admission and on present evaluation) and CG. Mann-Whitney, Wilcoxon and Spearman tests were used. AN patients showed a significant (p=0.0001) reduction of total (right plus left) HAF volume (6.6+/-1.3 cm3) when compared with CG (8.9+/-1.1). No significant difference was found between right and left HAF in both patients and CG. In AN patients, no significant correlation was found between the HAF and all the hormonal parameters or BMIs, while a trend towards significance was observed with duration of the disease (r=-0.398; p=0.082). MR imaging demonstrated a significant volume reduction o

Abscesses of the breast. US-guided serial percutaneous aspiration and local antibiotic therapy after unsuccessful systemic antibiotic therapy.

PURPOSE: The usual therapeutic approach to acute breast abscesses (ABAs) not responsive to systemic antibiotics is surgical incision and drainage. Our purpose was to assess the efficacy of treating ABAs with serial US-guided percutaneous aspiration and local injection of antibiotics. MATERIAL AND METHODS: Twenty-six patients with 28 ABAs, in whom systemic antibiotic therapy had failed, underwent serial US-guided aspiration with local injection a of large-spectrum antibiotic. The treatment was repeated weekly until complete resolution was observed at clinical and US examination. The volume of the ABAs was calculated before each US-guided aspiration. Follow-up US examinations were performed at 1, 4, and 12 weeks after clinical and US resolution. A comparison betweeen costs of surgical and US-guided treatment of ABAs in our institution was done. RESULTS: In 27 ABAs the treatment was successful: a progressive volume reduction and a complete resolution at clinical and US examination was observed within 1 to 7 weeks. In 1 case only, with a large ABA markedly increased in volume at the second examination, surgical drainage was performed. CONCLUSION: US-guided aspiration with local antibiotic injection is a safe and effective approach to ABAs, cheaper than surgical drainage of these lesions.

[An evaluation of orthotopic ileal neobladders by dynamic digital urography]. / Valutazione delle neovesciche ileali ortotopiche mediante urografia digitale dinamica.

PURPOSE: To report on the diagnostic capabilities of dynamic digital urography in the evaluation of orthotopic ileal neobladders. MATERIAL AND METHODS: Ten male patients (aged 61.3 +/- 14.7 years) with orthotopic ileal neobladder (4 Studer, 4 Camey type II with spiralized ileal segment and 2 classic Camey type II) underwent dynamic digital urography using an angiographic unit (Philips DVI/ARC-A). Eight patients were asymptomatic and two presented mild nycturia. All patients should have undergone follow-up conventional urography, which was replaced, for the purposes of our study, by dynamic digital urography. The intestinal cleansing regimen usual for the double contrast barium enema was used in all the patients. Ninety mL of a nonionic iodinated contrast agent were administered i.v. with an automatic injector. After precontrast mask images, two postcontrast sequences were acquired 15 s and 30 min after the injection (each made of 20 images acquired every 10 seconds). Postprocessing consisted of digital image subtraction and videorecording. RESULTS: Renal pelvis and calyceal systems were well visualized in 18/20 excretory systems. Eighteen of 20 ureters were visualized completely up to the ureteral jet, and two were only partially visualized. Calyceal, pyelic and ureteral enlargement with ureteral kinking were observed in a patient with classic Camey type II. High motility was seen in 11 ureters, moderate in 5 and mild in 4. The orthotopic ileal neobladder was well opacified in 8/10 patients. Effective peristalsis of the afferent ileal segment was seen in all the Studer type neobladders. Ureteral reflux was not observed in any patient. DISCUSSION: After orthotopic ileal neobladder reconstruction, the most frequent complications include urinary leakage, intestinal obstruction, venous thrombosis, stenosis of the neobladder anastomoses, incontinence, cancer recurrence, stone formation. In the follow-up, many diagnostic tools are used: intravenous urography, retrograde cystography, urodynamic studies, transabdominal and transrectal ultrasonography. With dynamic digital urography the nephrographic evaluation was possible in all patients, as well as the evaluation of calyceal, pyelic and ureteral opacification and even ureteral peristalsis. Moreover, this diagnostic tool allows the morphofunctional dynamic study of the ureteral-neobladder anastomoses and of the orthotopic ileal neobladder, even evaluating the residual peristalsis of the detubularized ileal segment. A major drawback of the new method is the relatively high radiation dose given to the patient. A limitation of the study is the selection of a population of completely or nearly asymptomatic patients. CONCLUSIONS: Dynamic digital urography provides useful morphologic and functional information in the follow-up of patients with orthotopic ileal neobladder and could replace conventional urography in symptomatic patients.

Breast biphasic compression versus standard monophasic compression in X-ray mammography.

Breast biphasic compression (22.5 degrees angled paddle, followed by progressive angle reduction) was compared with standard monophasic compression in x-ray mammography. The presence of the pectoral muscle was recorded for the craniocaudal (CC) view and the presence of the inframammary fold for the mediolateral oblique (MLO) view. The amount of breast in each study and image quality were assessed for both views. For all parameters, biphasic compression performed better than monophasic compression in both CC (P: <.006) and MLO (P: <.04) views.

Adipose replacement and wall motion abnormalities in right ventricle arrhythmias: evaluation by MR imaging. Retrospective evaluation on 124 patients.

We reevaluated the magnetic resonance (MR) examinations of 38 healthy volunteers (control group, CG) and of 124 patients with RV arrhythmia with left bundle branch block (LBBB) morphology: 45 with episodes of RV sustained tachycardia and of polymorphic RV premature beats (RVST-PPB group); 36 with only RV outflow tract sustained or not sustained tachycardia (RVOTT group); 43 with RV monomorphic premature beats (RVMPB group). All the examinations were reevaluated in a blinded fashion for detecting myocardial adipose replacement (AR) and wall bulges or aneurysms. In RVST-PPB patients, no AR was observed in 9%; 1 RV region involvement, 0%; 2 regions, 4%; > or = 3 regions, 87%; left ventricle (LV), 15%. RVOTT patients: 28%, 53%, 14%, 5%, and 0% [corrected], respectively. RVMPB patients: 33%, 46%, 19%, 2%, and 0% [corrected], respectively. In CG, AR was observed in 11% (in RV outflow tract), RV bulges were detected in 75% [corrected] of RVST-PPB, 39% of RVOTT, and 14% of RVMPB patients, none of the CG; RV aneurysms in 33% of RVST-PPB patients, none of RVOTT patients, RVMBP patients, and CG. A significant difference among groups for RV and LV AR as well as RV bulges and aneurysms was found (p < 0.0001). In the direct comparisons, significant differences were found for: disease duration (RVST-PPB vs. RVMPB, p = 0.0396); RV AR (all the patients groups vs. CG, RVST-PPB vs. RVOTT or RVMPB, p < 0.0001); RV aneurysms (RVST-PPB vs. CG, RVST-PPB vs. RVOTT or RVMPB, p < 0.0002); bulges (all comparisons, p < 0.0174). AR is confirmed as a structural substrate in RV arrhythmias. Number and extension of MR abnormalities are correlated to different degrees of RV arrhythmias.

Coronary aneurysms and stenosis detected with magnetic resonance coronary angiography in a patient with Kawasaki disease.

Coronary artery abnormalities in Kawasaki syndrome develop in about 15-25% of young patients, mostly as aneurysms. In the long-term evolution of coronary artery disease thrombotic occlusion of aneurysms, premature atherosclerosis, and stenosis, are observed. Magnetic resonance is an emerging modality in the angiographic assessment of coronary arteries. The authors report a case of coronary artery aneurysms and stenosis in a 26-year-old patient with Kawasaki disease detected by magnetic resonance coronary angiography and confirmed by conventional coronary angiography.

Three-dimensional, navigator-echo MR coronary angiography in detecting stenoses of the major epicardial vessels, with conventional coronary angiography as the standard of reference.

PURPOSE: To test three-dimensional (3D), navigator-echo magnetic resonance (MR) coronary angiography in detecting stenoses of the coronary arteries. MATERIALS AND METHODS: Forty-two patients (age range, 50-79 years) underwent MR coronary angiography (1.5 T). A navigator-echo sequence was used. Two or three 15% overlapped transverse slabs were acquired. Data were analyzed by readers blinded to conventional coronary angiographic results. On conventional coronary angiograms, coronary arterial stenoses of 50% or greater narrowing were considered significant. On MR coronary angiograms, the major coronary vessels were subdivided into proximal (within 5 cm) and distal (beyond 5 cm) segments, except for the left main vessel. Stenoses of 50% or greater were identified on reformatted multiplanar MR coronary angiograms. RESULTS: Three MR coronary angiographic examinations were aborted because of patient claustrophobia; 39 of 39 left main, 117 of 117 proximal, and 78 of 117 distal segments were visualized. MR coronary angiography showed a sensitivity of 82% (95% CI: 73%, 91%) and a specificity of 89% (95% CI: 85%, 94%) in overall stenoses identification, of 90% (95% CI: 81%, 99%) and 90% (95% CI: 83%, 96%) for proximal segments, and of 68% (95% CI: 50%, 86%) and 81% (95% CI: 71%, 92%) for distal segments, respectively. CONCLUSION: Navigator-echo, 3D MR coronary angiography is a promising sequence for assessing coronary arterial stenoses, but further improvements are required for distal segments.