Prenatal MRI of neck masses with special focus on the evaluation of foetal airway.

BACKGROUND: Prenatal magnetic resonance imaging is the best tool to visualize foetal airway. OBJECTIVE: To evaluate the performance of MRI in the assessment of foetal airway status in the presence of a neck mass. MATERIALS AND METHODS: Two paediatric radiologists with 12- and 2-year experience in foetal imaging retrospectively analysed 23 foetal MRI examinations, performed between 2001 and 2016, after a second-level ultrasound suspicious for presence of a neck mass. Postnatal imaging, postoperative report, histology, autopsy, and clinical outcomes were the reference standard to calculate sensitivity, specificity, accuracy, positive predictive value (PPV), and negative predictive value (NPV) of prenatal MRI in detecting airway patency. We used the Cohen к statistics to estimate the interobserver agreement. We also assessed MRI performance in the diagnosis of the mass nature. RESULTS: We obtained data about postnatal airway status in 19 of 23 patients; prenatal MRI demonstrated a sensitivity of 9/9 [100%, 95% confidence interval (CI) 66-100%], specificity 8/10 (80%, 44-98%), accuracy 17/19 (89%, 67-99%), PPV 9/11 (82%, 48-98%), and NPV 8/8 (100%, 63-100%); the interobserver agreement was perfect. Prenatal MRI correctly identified 21 of 23 masses (к = 0.858); the interobserver agreement was almost perfect (к = 0.851). CONCLUSION: Prenatal MRI demonstrated high accuracy in assessing foetal airway status and diagnosing mass nature, allowing proper delivery planning.

Common and unusual urogenital Crohn's disease complications: spectrum of cross-sectional imaging findings.

Involvement of the urinary tract and genital organs is not uncommon in patients affected with Crohn's disease (CD). Occurring in both sexes, uro-gynecological complications are often clinically unsuspected because of the dominant intestinal or systemic symptoms. Knowledge of their manifestations and cross-sectional imaging appearances is necessary to recognize and report them, since correct medical or surgical treatment choice with appropriate specialist consultation allows to prevent further complications. Besides uncomplicated urinary tract infections that usually do not require imaging, urolithiasis and pyelonephritis represent the most commonly encountered urinary disorders: although very useful, use of computed tomography (CT) should be avoided whenever possible, to limit lifetime radiation exposure. Hydronephrosis due to ureteral inflammatory entrapment and enterovesical fistulization may result from penetrating CD, and require precise imaging assessment with contrast-enhanced CT to ensure correct surgical planning. Representing the majority of genital complication, ano- and rectovaginal fistulas and abscesses frequently complicate perianal inflammatory CD and are comprehensively investigated with high-resolution perianal MRI acquired with phased-array coils, high-resolution T2-weighted sequences and intravenous contrast. Finally, rare gynecological manifestations including internal genital fistulas, vulvar and male genital involvement are discussed.

Urgent MRI with MR cholangiopancreatography (MRCP) of acute cholecystitis and related complications: diagnostic role and spectrum of imaging findings.

Acute cholecystitis, which is usually associated with gallstones, is one of the commonest surgical causes of emergency hospital admission and may be further complicated by mural necrosis, perforation, and abscess formation. Magnetic resonance imaging (MRI) is increasingly available in the emergency setting. Technically improved equipment and faster acquisition protocols allow excellent tissue contrast and MRI is now an attractive modality for imaging acute abdominal disorders. The use of MRI with MR cholangiopancreatography in the emergency setting provides rapid, noninvasive, and confident diagnosis or exclusion of acute cholecystitis and of coexistent choledocholithiasis. To familiarize the reader with these cross-sectional imaging appearances, this paper reviews MRI findings consistent with uncomplicated cholecystitis. These include gallbladder distension, intraluminal sludge and gallstones, impacted stones obstructing the gallbladder neck or cystic duct, thickening of the gallbladder wall, abnormal signal intensity and edematous stratification, and pericholecystic and perihepatic fluid, plus increased enhancement of the gallbladder wall and adjacent liver parenchyma when intravenous paramagnetic contrast is used. Furthermore, MRI allows prompt detection and comprehensive visualization and characterization of cholecystitis-related complications such as gangrene, perforation, pericholecystic abscess, and intrahepatic fistulization. Some previous literature reports, and our experience, suggest that, when available, MRI should be recommended to provide prompt and efficient triage of patients with suspected cholecystitis and inconclusive clinical, laboratory, and sonographic findings. It facilitates appropriate therapeutic planning, including the timing of surgery (emergency or delayed), approach (laparoscopic or laparotomic), and need for preoperative or intraoperative removal of stone(s) in the common bile duct.

Computed tomography coronary angiography in patients without known coronary artery disease can demonstrate possible non-cardiovascular causes of non-acute retrosternal chest pain.

OBJECTIVES: To assess the computed tomography coronary angiography (CTCA) accuracy for demonstrating possible non-cardiovascular causes of non-acute retrosternal chest pain in patients without known coronary artery disease (CAD) and to correlate CTCA results with the patient management and relief from pain. METHODS: This prospective observational study was approved by the ethical committee. Consecutive patients suffering non-acute chest pain who underwent CTCA and with not known CAD were enrolled and classified as having coronary diseases (CD) or extracardiac diseases (ECD). Association between age, sex, body mass index (BMI), cardiovascular risk factors, and type of chest pain with CD or ECD was estimated. Correlation between BMI classes and each risk factor was also calculated. RESULTS: A total of 106 patients (60 males; age 62 ± 14 years [mean ± standard deviation]; mean BMI 27) were enrolled. Hypertension was found in 71/106 (67%); smoking was significantly more frequent among males (p = 0.003) and hypercholesterolemia among females (p = 0.017); hypertension and hypercholesterolemia significantly correlated with age, and hypertension also with BMI. Pain was atypical in 70/106 (66%) patients. The kind of pain did not correlate with disease or gender. CTCA showed possible causes of chest pain in 69/106 (65%) patients; 32/69 (47%) having only CD, 23/69 (33%) only ECD, and 14/69 (20%) both CD and ECD. Prevalence was: hiatal hernia 35/106 (33%); significant CAD 24/106 (23%); myocardial bridging 22/106 (21%). At follow-up of 94/106 (89%) patients, 71/94 (76%) were pain-free, 14/17 (82%) significant CAD had been treated, and only one patient with non-significant CAD was treated after CTCA. CONCLUSION: CTCA suggested possible causes of non-acute pain in 65% of patients. MAIN MESSAGES: • CTCA can either rule in or rule out possible causes of chest pain alternative to CAD. • Clinically relevant findings were detected in 65% of patients with non-acute chest pain. • Non-cardiovascular diseases potentially explained symptoms in 35% of patients.

Use of the ultrasound-based total malignancy score in the management of thyroid nodules.

PURPOSE: The purpose of this study was to validate the role of the total malignancy score (TMS) in identifying thyroid nodules suspicious for malignancy through the sum of their ultrasound features. METHODS: The local ethical committee approved this prospective observational study. We examined 231 nodules in 231 consecutive patients (164 females and 67 males; age range, 20 to 87 years; median age, 59 years; interquartile range, 48 to 70 years) who underwent ultrasound followed by fine-needle aspiration cytology (FNAC). The nodules were further classified using the TMS, which considers ultrasound features (number, echogenicity, structure, halo, margins, Doppler signal, calcifications, and growth), and the Bethesda System for Reporting Thyroid Cytopathology (TBSRTC), which considers cytological features. Patients with non-negative nodules (TBSRTC categories III to VI) underwent histological analysis, repeated FNAC, or 2 years of regular ultrasound follow-up. The associations between the final diagnosis, each of the ultrasound features, and the TMS were estimated using the chi-square test, the Mann-Whitney U test, and multivariate logistic regression. A receiver operating characteristic (ROC) curve was used to evaluate the diagnostic accuracy of the TMS. RESULTS: On ultrasound, 47% of the nodules (108 of 231) had a TMS >3, 18% (42 of 231) had a TMS of 3, and 35% (81 of 231) had a TMS >3. The FNAC results of 85% of the nodules (196 of 231) were benign, while 15% (35 of 231) had non-negative results. Hypoechogenicity, solid structure, the presence of microcalcifications, and the number of nodules were independent predictors of the final diagnosis, and the diagnostic accuracy of the TMS was good (area under the ROC curve, 0.82). CONCLUSION: The TMS system is simple to use, reliable, easily reproducible, and closely reflects malignancy risk. Based on our results, FNAC could be limited to nodules with a TMS ≥3 without missing any cases of carcinoma.

Vascular Map Combined with CT Colonography for Evaluating Candidates for Laparoscopic Colorectal Surgery.

Contrast-enhanced computed tomography colonography (CE-CTC) is a useful guide for the laparoscopic surgeon to avoid incorrectly removing the colonic segment and the failure to diagnose of synchronous colonic and extra-colonic lesions. Lymph node dissection and vessel ligation under a laparoscopic approach can be time-consuming and can damage vessels and organs. Moreover, mesenteric vessels have extreme variations in terms of their courses and numbers. We describe the benefit of using an abdominal vascular map created by CE-CTC in laparoscopic colorectal surgery candidates. We describe patients with different diseases (colorectal cancer, diverticular disease, and inflammatory bowel disease) who underwent CE-CTC just prior to laparoscopic surgery.

Comprehensive MRI diagnosis of sacral osteomyelitis and multiple muscle abscesses as a rare complication of fistulizing Crohn's disease.

Pelvic osteomyelitis is a very uncommon complication of Crohn's disease, usually clinically unsuspected in the setting of acute Crohn's disease relapses. The case of a 21-year old patient is reported, in whom ileo-cecal inflammatory disease was complicated by fistulization to the presacral space and sacral osteomyelitis, plus multiple abscesses involving the iliopsoas, posterior paravertebral and gluteal muscles. As confirmed by surgical and pathological findings, MRI provided comprehensive imaging diagnosis by demonstrating both the pathogenesis and the full extent of the complex, deep pelvic inflammatory process. Low back pain in patients with Crohn's disease should not be underestimated since its differential diagnosis includes serious and potentially life-threatening causes such as osteomyelitis, so prompt assessment with cross sectional imaging, particularly MRI, is necessary.