Going for a stroll on lurasidone: Considerations on an atypical case of acute compartment syndrome of both legs.

Non-traumatic acute bilateral compartment syndrome is a rare condition that may lead to limb ischemia. We describe a case of this syndrome occurring after a five-kilometer walk in a young woman receiving chronic treatment with lurasidone, leading to a bilateral foot-drop and rhabdomyolysis of the anterolateral compartment of both legs. Due to her late presentation in the emergency department, we opted for a conservative approach, closely monitoring her renal function. We noticed a subsequent clinical and biochemical improvement over the following days, with the patient returning to her daily routine in a matter of weeks, despite a persisting bilateral foot drop. Since atypical antipsychotics are known to be associated with rhabdomyolysis, while possibly exerting a toxic effect on mitochondria, we hypothesize that a mild aerobic physical exertion might have triggered the event, in the context of an iatrogenic muscle susceptibility to oxidative distress.

Corrigendum to "Going for a stroll on lurasidone: Considerations on an atypical case of acute compartment syndrome of both legs" [Heliyon 9(4) (April 2023) e15047].

[This corrects the article DOI: 10.1016/j.heliyon.2023.e15047.].

[The surgical treatment of inflammatory aneurysms of the abdominal aorta. The usefulness of nuclear magnetic resonance (MR) in the preoperative diagnosis]. / Trattamento chirurgico degli aneurismi infiammatori dell'aorta addominale. Utilità della risonanza magnetica nucleare (RM) nella diagnostica preoperatoria.

Inflammatory abdominal aortic aneurysms (IAAA) represent a peculiar variant compared with the common atherosclerotic origin of aortic aneurysms. Between January 1988 and March 1992, 111 aneurysmectomies were performed at our institution: 98 elective and 13 emergency procedures. In 10 cases (all males, mean age 68.5) an IAAA was found. 8/10 of those patients operated upon electively were studied preoperatively with MRI. All the IAAA but one were correctly identified preoperatively. Identification of IAAA with MRI in these cases improved the surgical approach. In conclusion, patients with IAAA can be operated upon safely especially if a preoperative diagnosis is present. MRI greatly improves our ability to characterize non invasively IAAA.

Impaired left ventricular energy metabolism in patients with hypertrophic cardiomyopathy is related to the extension of fibrosis at delayed gadolinium-enhanced magnetic resonance imaging.

OBJECTIVE: Areas of intramyocardial late enhancement (LE) at delayed enhanced magnetic resonance imaging (DE-MRI) and reduction of myocardial phosphocreatine (PCr)/ATP-ratio at phosphorus magnetic resonance spectroscopy ((31)P-MRS) are both reported in hypertrophic cardiomyopathy (HCM) and indicate areas of increased interstitial myocardial space with fibrosis and impairment of myocardial energy metabolism, respectively. We sought to ascertain whether in HCM patients the abnormal features of left ventricular (LV) interstitial space revealed by DE-MRI correlated with impaired LV energy metabolism shown at (31)P-MRS. METHODS: 19 patients with HCM proved by histological analysis of multiple endomyocardial biopsies and with normal coronary arteries, underwent cardiac MRI including DE-MRI and (31)P-MRS. DE-MRI for detection and quantification of late enhancement (LE) and (31)P-MRS to assess the myocardial PCr/ATP-ratio were performed by means of a 1.5-T magnet. 19 healthy subjects, matched for gender and age were studied by (31)P-MRS as control group. RESULTS: LE areas in the LV wall were found in 17 out of 19 patients with an extension ranging from 0.8% to 19.5% of the LV-mass (mean value 7.6% (SD 5.6%). The PCr/ATP-ratio was lower in HCM patients than in control subjects (2.18 (0.41) vs 2.41 (0.30); p<0.05). LE% and PCr/ATP-ratio were inversely related (R = -0.57; p<0.05) and LE% was the stronger predictor of PCr/ATP-ratio by multivariate analysis. CONCLUSIONS: This study demonstrated that the known alteration of the PCr/ATP-ratio observed in HCM patients is correlated with the presence of fibrotic areas in the myocardium of the left ventricle.

[Magnetic resonance angiography of coronary arteries: assessment in patients with coronary stenosis and control after stent positioning]. / Angiografia con RM delle arterie coronarie: valutazione nei pazienti con stenosi coronarica e controllo dopo posizionamento di stent.

INTRODUCTION: Cardiovascular disease remains the leading cause of death in the world. Invasive coronary angiography is currently the only clinical method available to visualize the coronary arteries, with up to 20% of the procedures demonstrating no evidence of severe coronary artery stenoses. We investigated the role of two-dimensional (2D) coronary magnetic resonance angiography (MRA) in patients with suspected coronary arteries disease and to check the placement and the patency of previously placed coronary artery stents. MATERIAL AND METHODS: Eleven patients with suspected coronary artery disease who underwent elective cardiac catheterization with coronary angiography were examined with 2D coronary MRA to detect coronary artery stenoses. Other 11 patients with 13 stented coronary arteries (6 RCA, 5 LAD, 2 Lcx) were prospectively examined with MRA one day to 8 months after stent placement. Eighteen amagnetic stents were imaged. Imaging was performed with a 1.5 T MR unit (GE Signa Horizon Echo Speed) with a phased array multicoil. Segmented k-space fast GE sequences were acquired with and without fat suppression at several cardiac cycle phases within a single breath-hold. Correlation with coronary angiography was performed in all patients. RESULTS: Thirteen significant stenoses were found at coronary angiography in 11 coronary arteries. The sensitivity and specificity of MR coronary angiography, as compared with conventional angiography, in correctly identifying the single vessels with > 50% angiographic stenoses were 73% and 94%, respectively. The corresponding positive and negative predictive values and accuracy were 88%; 84% and 86%, respectively. As far as the study of coronary artery stents is concerned, no MR-related adverse events were observed. The stents were visualized as signal loss areas. The length of the signal loss corresponded to the length of the stents in all 18 cases (r = 97). The patent blood flow distal to the stents appeared as a high-signal band distal to the signal void, corresponding to stent patency at coronary angiography. CONCLUSIONS: Although in an early stage of technical development, 2D coronary MRA can depict 73% of hemodynamically severe coronary artery stenoses. Moreover breath-hold coronary cine MRA is a safe technique to visualize coronary artery stents. Stent site and patency can be noninvasively studied with this technique.

Magnetic resonance contrast enhancement with gadolinium-DTPA in patients with angina and angiographically normal coronary arteries: effect of chronic beta-blockade.

BACKGROUND: The syndrome of angina and normal coronary arteries (syndrome X) comprises a heterogeneous group of patients with typical chest pain, a positive exercise test, angiographically smooth coronary arteries and no evidence of spasm. Magnetic resonance imaging (MRI) has been used to detect areas of myocardial ischemia and/or recent necrosis both in animal and human studies. Most of these studies have been conducted after intravenous administration of the paramagnetic contrast medium gadolinium-DTPA (Gd-DTPA), that is considered a sensitive marker of extracellular, probably ischemic in origin, edema. On the basis of these data, we used MRI to evaluate the possibility of myocardial Gd-DTPA deposition at rest in patients with syndrome X, and to assess the effects of oral treatment with atenolol. METHODS: We have studied 24 patients with syndrome X, 10 patients with coronary artery disease and 10 age-matched control subjects. The protocol was similar in all study subjects. Exercise testing and MRI were undertaken off therapy after coronary arteriography. Following MRI, patients underwent a 10 day treatment period with atenolol and repeated exercise stress test and MRI while on therapy. RESULTS: In all patients with syndrome X and coronary artery disease were observed effort diagnostic ST-segment changes that were associated with angina in 9 (37%) and 7 (70%) patients, respectively. Of 24 patients with syndrome X, 16 (66.6%) showed areas of myocardial enhancement after Gd-DTPA in comparison to the precontrast imaging. In 4 out of 10 patients with coronary artery disease (40%), Gd-DTPA accumulation was documented. Finally, focal Gd-DTPA myocardial enhancement was not observed in any normal control subject. After beta-blockade, 22 (92%) patients with syndrome X and 2 (20%) with coronary artery disease did not show any ischemic ST-segment changes on effort; 14 syndrome X patients (88%) and 2 coronary artery disease patients (50%) showed complete disappearance of the previously Gd-DTPA enhanced areas on MRI. CONCLUSIONS: Patients with syndrome X often exhibit regional accumulation of Gd-DTPA on MRI. The agent is believed to trace interstitial water accumulation as occurs during ischemia and its accumulation is reduced or abolished by treatment with atenolol, probably by different mechanisms. It is likely that an overactivation of the sympathetic outflow to the cardiovascular system can induce most of the abnormalities observed in syndrome X patients. In this context, beta-blockers probably represent the mainstay of the medical treatment of this condition.

[Magnetic resonance: preoperative assessment of abdominal aortic aneurysms. Comparison with surgical findings in 80 cases]. / Risonanza magnetica: valutazione preoperatoria degli aneurismi dell'aorta addominale. Confronto con i reperti operatori in 80 casi.

This work was aimed at assessing Magnetic Resonance (MR) accuracy in the preoperative investigation of abdominal aortic aneurysms, with a view to suggesting MRI as the method of choice for surgical planning, replacing other relatively invasive investigation techniques like angiography and enhanced CT. In the last 3 years 80 patients with abdominal aortic aneurysms identified with US or CT were examined with 0.5-T MRI and underwent surgical repair within 15 days. Spin-echo (SE) T1-weighted axial, sagittal and coronal sequences were always performed. In 18 patients gradient-echo (GE) flow sequences were also acquired; SE T2-weighted sequences were used to study parietal thrombi in 10 patients and finally Gd-DTPA T1-weighted sequences were obtained in inflammatory aneurysms (3 patients). MR images were blindly evaluated by 2 radiologists. The following variables which are useful for surgical planning were considered for each patient: aneurysm extent, characteristics of parietal thrombi, dissections, fixurations, inflammation signs, involvement of renal arteries, vena cava, ureters, duodenum, the presence of retroaortic renal vein or of other anomalies or associated conditions. MR images were always compared with intraoperative findings, since surgery was considered as the gold standard. MR findings were in agreement with surgical findings in the evaluation of cranio-caudal aneurysm extent (78/80), parietal thrombus features (80/80), dissection (1/1) and fixuration signs (8/9), origin of renal arteries (80/80), inferior vena cava involvement (3/3), other anatomical anomalies or conditions (6/6). Inflammation signs were overestimated (14/8) as well as adhesion between aneurysm and duodenum (17/13). The presence of distal renal polar arteries was underestimated (2/4). In conclusion, MRI proves to be a highly sensitive method to demonstrate abdominal aortic aneurysms and is therefore suggested as the examination of choice before surgery.

[MR (1.5 T) in the evaluation of pancreas transplant rejection]. / La RM (1.5 T) nella valutazione del rigetto del trapianto di pancreas.

Graft rejection is the major cause of graft loss following pancreatic transplantation. Early detection of the rejection process is of great importance towards planning effective treatment when transplant recipients present with aspecific clinical findings suggesting rejection. Up to date, the demonstration of pancreatic transplant rejection has been attempted with nuclear medicine and sonography (US). The authors studied high-field (1.5 T) MR potentials in pancreatic transplantation and rejection and correlated MR findings with clinical and laboratory data. Eleven MR scans were obtained from 4 patients with suspected pancreatic graft rejection, and 9 MR images from 4 patients with normal pancreatic allografts. Qualitative image evaluation showed the pancreatic tissue of the patients diagnosed with rejection to be hypointense on T1-weighted scans and highly hyperintense on T2-weighted scans, as compared to normal grafts. Quantitative data were obtained by comparing the signal intensity of pancreatic grafts to that of the nearby muscle. On both T1- and T2-weighted images, pancreatic tissue/muscle signal-intensity ratios were significantly different, in rejecting transplants, from those of normal allografts (p less than 0.001). Our qualitative and quantitative findings suggest the use of MR imaging as a reliable means of detecting pancreatic graft rejection.

Renal artery stenosis: evaluation with breath-hold, three-dimensional, dynamic, gadolinium-enhanced versus three-dimensional, phase-contrast MR angiography.

PURPOSE: To compare breath-hold, three-dimensional, gadolinium-enhanced magnetic resonance (MR) angiography with three-dimensional, phase-contrast MR angiography in the evaluation of renal artery stenosis. MATERIALS AND METHODS: Fifty-five consecutive adult patients with clinical suspicion of renovascular disease were prospectively examined with three-dimensional, phase-contrast MR angiography and breath-hold, three-dimensional MR angiography with injection of a standard dose of gadopentetate dimeglumine to evaluate the number of renal arteries and the presence and degree of stenosis. The standard of reference was intraarterial digital subtraction angiography. RESULTS: Gadolinium-enhanced MR angiography depicted all 105 main renal arteries, whereas phase-contrast MR angiography depicted 104. The number of accessory renal arteries depicted was significantly higher with gadolinium-enhanced (17 of 18) than with phase-contrast (11 of 18) studies (P = .04). Both techniques depicted 27 of the 29 stenoses (sensitivity, 93%; P > .05). Sensitivities, specificities, and accuracies in the diagnosis of hemodynamically significant stenosis (> 50% narrowing) were, respectively, 94%, 96%, and 96% for phase-contrast and 100%, 97%, and 98% for gadolinium-enhanced MR angiography (P > .05). CONCLUSION: Gadolinium-enhanced MR angiography is superior to phase-contrast MR angiography in accessory renal artery depiction. No statistically significant difference in the assessment of stenosis has been found between the two techniques.

[Postoperative histologic evaluation of hepatocarcinoma treated using chemo-embolization]. / Valutazione istologica postoperatoria dell'epatocarcinoma trattato mediante chemioembolizzazione.

Transcatheter arterial chemoembolization (TAE) is generally considered to be an effective palliative treatment in patients with inoperable hepatocellular carcinoma (HCC). Recently, TAE has also been performed on operable cases, in order to reduce the chances of recurrence. This study was aimed at evaluating the histopathologic changes following chemoembolization in surgically resected HCCs. Chemoembolization was performed by selective intra-arterial injection of Lipiodol-chemotherapeutic agent (Adriamycin), followed by terminal embolization with Spongostan, in 5 patients with operable HCC. All patients underwent Computed Tomography (CT) follow-up and subsequent partial hepatectomy. CT after chemoembolization accurately demonstrated no increase in tumor size in all patients. In all HCCs a thick fibrous capsule was found. Histopathology of the surgically resected HCCs demonstrated complete necrosis of the primary tumor in 4/5 cases; 1 HCC remained viable and tumor cells were found in a few daughter nodules surrounding the tumor. In 1 case there were viable tumor emboli in the small portal vessels around the tumor. In patients with resectable HCC, TAE was useful in preventing tumor growth and in thickening the capsule, thus making surgery safer and reducing the chances of recurrence.

Pancreatic cancer versus chronic pancreatitis: diagnosis with CA 19-9 assessment, US, CT, and CT-guided fine-needle biopsy.

The authors prospectively performed serum CA 19-9 assessment, ultrasound (US), computed tomography (CT), and CT-guided fine-needle aspiration biopsy (FNAB) of the pancreas in 81 consecutive patients with suspected chronic pancreatitis or pancreatic neoplasm. The final diagnosis was pancreatic cancer in 54 patients and chronic pancreatitis in 27 patients. CA 19-9 assessment, US, CT, and FNAB were considered nondiagnostic, respectively, in 0%, 25%, 19%, and 6% of cases. When a definite diagnosis was rendered, the positive predictive value was 90% for CA 19-9 assessment, 95% for US, 98% for CT, and 100% for FNAB; the negative predictive value was, respectively, 69%, 95%, 86%, and 100%. The accuracy of all diagnostic and nondiagnostic studies was 81% for CA 19-9 assessment, 72% for US, 77% for CT, and 94% for FNAB. It is concluded that CT-guided pancreatic FNAB is the most reliable examination for enabling differential diagnosis of pancreatic cancer and chronic pancreatitis. When the pancreas is well visualized at US, the negative predictive value for pancreatic cancer is more accurate than that of CA 19-9 assessment and CT.

[Assessment of the myometrial infiltration of endometrial carcinoma (FIGO stage I-II). The accuracy of magnetic resonance (1.5 T)]. / Valutazione dell'infiltrazione miometriale nel carcinoma dell'endometrio (I-II stadio FIGO). Accuratezza della Risonanza Magnetica (1,5 T).

Thirty-three patients with histological diagnosis of endometrial carcinoma were studied with MR imaging at 1.5 T. All patients were clinically diagnosed as having stage I or II disease (FIGO) and underwent abdominal hysterectomy. MR tissue characteristics and morphological features were compared with morphological features were compared with microscopic pathological findings, in all patients. The following initials were adopted for statistical comparison: M0 = tumor confined to endometrium; M1 = infiltration of the inner third of myometrium; M2 = invasion of the central third of myometrium; M3 = infiltration of the outer third of myometrium. T1-weighted (SE 600/30) and T2-weighted (SE 2000/35.90) (SE 1500/28.60) images were obtained in sagittal plane (section thickness = mm 4). Overall MR accuracy in determining the extent of myometrial invasion was 78%. Correct evaluation of myometrial invasion is essential in patients with stage I or II endometrial carcinoma who are to undergo transvaginal hysterectomy without lymphadenectomy (M0, M1).

Mural thrombi in abdominal aortic aneurysms: MR imaging characterization--useful before endovascular treatment?

PURPOSE: To evaluate magnetic resonance (MR) imaging accuracy in the characterization of mural thrombi in abdominal aortic aneurysms (AAAs). MATERIALS AND METHODS: Forty-five patients (37 men, eight women; mean age, 68 years) with an AAA with mural thrombus thicker than 1 cm at sonography underwent T1- and T2-weighted spin-echo MR imaging. The thrombi were prospectively classified as one of three signal intensity (SI) categories: category 1 corresponds to low SI on both T1- and T2-weighted images; category 2, high SI on T1-and T2-weighted images; and category 3, inhomogeneous SI with hyperintense areas on both T1- and T2-weighted images. During surgery, thrombi were classified as organized, unorganized, and partially organized. MR imaging and surgical findings were compared. RESULTS: SI category 1 corresponded to organized thrombi in 24 of 24 patients. Category 2 corresponded to unorganized thrombi in 11 of 11 patients. In category 3, focal hyperintense areas corresponded (both for presence and location) to unorganized portions of partially organized thrombi in 10 of 10 patients. CONCLUSION: MR imaging is accurate in AAA thrombus characterization.

Renal artery stenosis: value of screening with three-dimensional phase-contrast MR angiography with a phased-array multicoil.

PURPOSE: To evaluate screening with three-dimensional (3D) phase-contrast magnetic resonance (MR) angiography with a phased-array multicoil to detect renal artery stenosis. MATERIALS AND METHODS: Fifty consecutive patients suspected of having renovascular disease were prospectively examined with 3D phase-contrast MR imaging with a phased-array multicoil. Findings were correlated with those at intra-arterial digital subtraction angiography (DSA) as the standard of reference for grade of stenosis. RESULTS: MR angiography depicted 101 of 103 renal arteries depicted at intraarterial DSA; the two missed arteries were an accessory artery outside the imaging volume and an artery with a stent. At intraarterial DSA, a stenosis was found in 31 of 101 arteries. On the basis of findings at 3D phase-contrast MR angiography, the presence of any degree of stenosis was correctly depicted in 29 of 31 cases and the absence of stenosis was correctly depicted in 66 of 70 cases (accuracy, 94%; sensitivity, 94%; negative predictive value, 97%). Overall accuracy was 97% for correct depiction of severe renal artery stenosis (> 50%). CONCLUSION: 3D phase-contrast MR angiography with a phased-array multicoil was an accurate noninvasive screening technique in patients with suspected renal artery stenosis.