There are more anatomical variants in heaven and earth, Horatio, than are dreamt of in our philosophy: the precaval left renal artery.

AIM: To describe the CT findings in eight patients with left-sided inferior vena cava (IVC) in whom the left renal artery presented a precaval course (pLRA). MATERIALS AND METHODS: We searched the teaching files of six radiology departments for patients with pLRAs. Eight patients were found, and the available imaging studies and clinical histories were reviewed. Associated vascular and renal anomalies were noted. RESULTS: No patient had been examined for problems related to the vascular anomaly found. Four had a double IVC and two a solitary left IVC; in all, the left-sided IVCs had hemiazygos continuation. One patient had situs viscerum inversus. In one case, there was a left kidney in left iliac fossa. CONCLUSION: Although rare and probably overlooked, a pLRAs can be encountered in patients with situs viscerum inversus or presenting a left-sided IVC with hemiazygos continuation. These vessels can cause technical problems during surgery at the left renal hilum and should be specifically searched for in patients with vascular anomalies.

Epiploic appendage torsed within a spigelian hernia: US and CT findings.

We report the sonographic and CT findings in a patient with an epiploic appendage strangulated within a Spigelian hernia sac. The patient presented with a small, tender, palpable mass, which, at sonography, was located within the abdominal wall, lateral to the rectus abdominis muscle, and had the appearance of an inflamed epiploic appendage. The same findings were confirmed by unenhanced CT. Surgery showed an epiploic appendage of the sigmoid colon within a small Spigelian hernia; the appendage was torsed around its pedicle at the entrance into the hernia sac.

Myeloma Spine and Bone Damage Score (MSBDS) on Whole-Body Computed Tomography (WBCT): Multiple Reader Agreement in a Multicenter Reliability Study.

Objective: To assess the reliability of the myeloma spine and bone damage score (MSBDS) across multiple readers with different levels of expertise and from different institutions. Methods: A reliability exercise, including 104 data sets of static images and complete CT examinations of patients affected by multiple myeloma (MM), was performed. A complementary imaging atlas provided detailed examples of the MSBDS scores, including low-risk and high-risk lesions. A total of 15 readers testing the MSBDS were evaluated. ICC estimates and their 95% confidence intervals were calculated based on mean rating (k = 15), absolute agreement, a two-way random-effects model and Cronbach's alpha. Results: Overall, the ICC correlation coefficient was 0.87 (95% confidence interval: 0.79-0.92), and the Cronbach's alpha was 0.93 (95% confidence interval: 0.94-0.97). Global inter- and intra-observer agreement among the 15 readers with scores below or equal to 6 points and scores above 6 points were 0.81 (95% C.I.: 0.72-0.86) and 0.94 (95% C.I.:0.91-0.98), respectively. Conclusion: We present a consensus-based semiquantitative scoring systems for CT in MM with a complementary CT imaging atlas including detailed examples of relevant scoring techniques. We found substantial agreement among readers with different levels of experience, thereby supporting the role of the MSBDS for possible large-scale applications. Significance and Innovations • Based on previous work and definitions of the MSBDS, we present real-life reliability data for quantitative bone damage assessment in multiple myeloma (MM) patients on CT. • In this study, reliability for the MSBDS, which was tested on 15 readers with different levels of expertise and from different institutions, was shown to be moderate to excellent. • The complementary CT imaging atlas is expected to enhance unified interpretations of the MSBDS between different professionals dealing with MM patients in their routine clinical practice.

Ultrasound demonstration of distal biceps tendon bifurcation: normal and abnormal findings.

We demonstrate the US appearance of the distal biceps tendon bifurcation in normal cadavers and volunteers and in those affected by various disease processes. Three cadaveric specimens, 30 normal volunteers, and 75 patients were evaluated by means of US. Correlative MR imaging was obtained in normal volunteers and patients. In all cases US demonstrated the distal biceps tendon shaped by two separate tendons belonging to the short and long head of the biceps brachii muscle. Four patients had a complete rupture of the distal insertion of the biceps with retraction of the muscle belly. Four patients had partial tear of the distal biceps tendon with different US appearance. In two patients the partial tear involved the short head of the biceps brachii tendon, while in the other two patients, the long head was involved. Correlative MR imaging is also presented both in normal volunteers and patients. US changed the therapeutic management in the patients with partial tears involving the LH of the biceps. This is the first report in which ultrasound considers the distal biceps tendon bifurcation in detail. Isolated tears of one of these components can be identified by US. Knowledge of the distal biceps tendon bifurcation ultrasonographic anatomy and pathology has important diagnostic and therapeutic implications.

Relationship between fatty degeneration of thigh muscles and vitamin D status in the elderly: a preliminary MRI study.

OBJECTIVE: The purpose of this study was to study the relationship between fatty degeneration of thigh muscles and vitamin D status in elderly adults. SUBJECTS AND METHODS: For six months, 121 patients 65 years old or older were evaluated. Myopathy, muscular impairment, and conditions influencing vitamin D status other than diet and sunlight were exclusion criteria. Twenty patients (10 men and 10 women; mean age, 77.6 years) underwent MRI. Thigh muscles were scanned from the hip to the knee with T1- and T2-weighted spin-echo sequences. Skeletal muscles were evaluated for fatty degeneration and atrophy from grade 0 to 3 (grade 0 = normal appearance, grade 3 = severe changes). The relationship between muscular fatty degeneration, 25-hydroxyvitamin D (25-OHD) levels, and scores on Tinetti scales for balance and gait were examined. RESULTS: In the evaluation of the extensor muscles for fatty degeneration and atrophy, grade 0 was present in three patients (15%), grade 1 in 11 (55%), and grade 2 in six (30%). In the flexor muscles, grade 0 was found in one patient (5%), grade 1 in five (25%), and grade 2 in 14 (70%); grade 3 changes were not seen. Muscular fatty degeneration negatively correlated with 25-OHD levels (r = -0.50, p < 0.01) and the Tinetti scores (balance: r = -0.40, p < 0.05; gait: r = -0.50, p < 0.05). In 11 vitamin D-deficient patients (55%), there was selective complete atrophy of at least one thigh muscle. The gracilis and sartorius muscles were spared. CONCLUSION: In elderly adults, fatty degeneration of thigh muscles was associated with vitamin D deficiency and impaired balance and gait. Selective complete fatty degeneration of single muscles was observed.

Muscle variants of the upper and lower limb (with anatomical correlation).

Several accessory muscles in the upper and lower limb have been described in the medical literature. Most are asymptomatic and represent incidental findings at imaging. In some instances, however, these muscles may become clinically relevant producing palpable swelling, entrapment of neurovascular structures, or exercise-related pain. The diagnosis of accessory muscles is based on recognition of their typical location and on cross-sectional imaging features. Familiarity with their most common location and knowledge of the possible clinical syndromes caused by these supernumerary structures may aid in diagnosis and treatment.

Pre- and post-operative work-up in patients affected by early cervical cancer and eligible for fertility-sparing treatment: role of MRI with saline hydrocolpos.

Nowadays young women affected by early invasive uterine cervical cancer (stage IA2-IB1) may be offered a fertility-sparing treatment: the radical trachelectomy with pelvic lymph node dissection. This procedure consists in surgical removal of cervix uteri, proximal parametrial tissue, and vaginal cuff. The morphology and the functions of corpus uteri are preserved. Women candidates for trachelectomy must be closely selected. Gynecologist oncologist needs an imaging modality that can accurately value the tumoral diameter and which can demonstrate proximal extension of tumor to ensure surgical clear resection margins (especially the cranial one). Magnetic resonance imaging (MRI) is a very useful examination in pre-operative study of women affected by early cervical cancer. The aim of this study is to evaluate the role of MRI with hydrocolpos about pre- and post-operative work-up in women eligible for fertility-sparing treatment.

Synchronous parenchymal renal tumors of different histology in the same kidney.

BACKGROUND: Synchronous primary cortical tumors of different histology in the same kidney are rare. Preoperative awareness of this coexistence is important, since it can help in planning the surgical approach. PURPOSE: To describe the imaging findings observed in five patients with two parenchymal malignant tumors of different histology in the same kidney. MATERIAL AND METHODS: We reviewed the pathology reports of 381 patients operated for renal tumors from January 2000 to March 2007. The medical records of all patients with multiple, synchronous, primary lesions of different histology in the same kidney were reviewed with special attention to imaging findings and indications on the nature of the disease process. Computed tomography (CT) examinations were retrospectively evaluated for tumor detection, size, location, and enhancement pattern. RESULTS: We found seven patients with synchronous tumors of different histology in the same kidney (1.8%). Among these, five (1.3%) had two malignancies of different subtypes and represent our study group. Four had preoperative ultrasound; all had CT. Imaging allowed identification of multifocality in 4/5 cases and, in 3/4 patients with visible double tumors, recognition of differences in lesion appearance. In only one patient did the two tumors have similar enhancement patterns. CONCLUSION: It is possible to suspect preoperatively the presence of tumors of different histologic subtypes within the same kidney. Imaging findings may provide information regarding the presence of lesions with different aggressiveness within the kidney, which may be helpful in therapeutic planning.

How often do patients ask for the results of their radiological studies?

OBJECTIVES: To measure how often patients ask directly about their test results at the end of imaging studies. METHODS: A total of 1,171 outpatients underwent ultrasonography (384), CT (382) or MR of the extremities (405). Demographic features including age, sex, educational background, anxiety and type of examination (initial examination vs follow-up) were considered. Statistical analysis was carried out by means of the chi-square test. RESULTS: Of the 1,171 patients, 525 (45%) asked for information about the results of their studies. Only 88/382 (23%) patients asked after CT; 224/405 (55.3%) asked after MR, and 213/384 (55.5%) asked after US (CT vs US and vs MR p < 0.001). There was a highly significant trend regarding education (36.4% with elementary schooling; 41.5% with intermediate education; 55.1% with higher schooling or university degrees; p < 0.001). No other differences were noted. CONCLUSION: We believe these results show the importance of the direct doctor-patient relationship during radiological studies. Communication, time to talk and provision of information are probably the most important things patients want from their doctors. Our study suggests that this is also relevant in radiology and, when given the opportunity to meet the radiologist, patients appreciate the interaction.

Acute obstruction of the afferent loop caused by an enterolith.

Afferent loop obstruction is a relatively rare but significant complication of Billroth II gastrojejunostomy. We report the imaging findings in a patient in whom obstruction presented acutely and was due to the presence of an enterolith. CT showed dilatation of both the main pancreatic duct and the biliary ducts, and a markedly dilated afferent loop within which a 5-cm mass was present. The lesion had a heterogeneous, laminated appearance and did not show any contrast enhancement. Edema of fatty tissues surrounding the pancreatic tail, which extended to the left pararenal spaces, a small amount of free peritoneal fluid surrounding the spleen, and an aneurysm of the splenic artery of about 3 cm were also present. The diagnosis of afferent loop obstruction has to be considered in patients with previous Billroth II gastrojejunostomy who present with acute abdominal pain and laboratory findings indicating pancreatitis. Although rarely, an enterolith can be the cause of obstruction. CT allows to establish the diagnosis.

Crohn disease obstruction of the biliopancreatic limb in a patient operated for biliopancreatic diversion for morbid obesity.

Although rare, patients with biliopancreatic diversion for morbid obesity will be subject to obstruction of the biliopancreatic limb. This condition is commonly due to postoperative adhesions and intussusception and usually presents with misleading clinical and radiographic features that can delay the diagnosis and the treatment. We recently encountered a patient with obstruction of the biliopancreatic limb due to involvement from Crohn disease. We report this case to highlight the clinical and imaging findings of this rare condition.