Unusual attempted suicide or covered attempted homicide? A neck stabbing case report and review of literature.

A medico-legal consult is frequently required in a clinical context in order to assess the eventual compatibility of specific wounds with a self- or hetero-infliction. Accordingly, the case of a 52-year-old man with a single, penetrating stab wound of the neck, reported as self-inflicted, is here presented. The forensic aspects, taken into account in order to determine the self- or hetero-infliction nature of the wound, are further discussed and compared to cases described in the literature.

Acute scrotal pain in pediatric patients: diagnosis with an innovative Doppler technique (MicroV).

Acute scrotal pain is one of the most frequent symptoms in pediatric patients visited in the Emergency Department. Ultrasonography with color and power Doppler represents the first-line method that clinicians use to carry out the differential diagnosis between spermatic cord torsion and inflammation, but sensitivity and specificity are 63-100% and 97-100%, respectively; this variability may be related to operator's experience and testis vascular hemodynamics and also to machine performance and patient age. Recent technological innovations have made possible to create a new Doppler mode called ultrasound microvascular imaging. This technique exploits algorithms capable of separating low frequencies of static tissue artifacts from ones of very weak flows. It is known as MicroV (from Esaote) and Superb microvascular imaging (from Toshiba). It provides both macrocirculation vascular maps, as a typical Doppler feature, and microcirculation vascular maps. Furthermore, the use of background subtraction could improve the visibility of small vascular structures. We report a case of a pediatric patient suffering from acute scrotal pain assessed ultrasonographically with this innovative Doppler technique (MicroV) that may give more confidence in detecting testicular vascular signals if compared with traditional Doppler techniques.

Functional constipation masked as irritable bowel syndrome.

BACKGROUND: Rome IV criteria for functional gastrointestinal disorders state that children suspected of having Irritable Bowel Syndrome (IBS) with Constipation (IBS-C) should be preliminarily treated for constipation. We aimed at verifying if functional constipation may indeed lead to an erroneous diagnosis of IBS with diarrhea (IBS-D) or IBS with mixed pattern of diarrhea and constipation (IBS-M). METHODS: We prospectively enrolled in an unblinded fashion 10 and 16 consecutive children referred to our center who met Rome IV criteria for a diagnosis of IBS-D and IBS-M, respectively. Patients who fulfilled criteria for suspect "occult constipation" were then given a bowel cleaning regimen with Polyethylene glycol 3350, re-evaluated at 2 months and followed up for at least 6 months. Sixteen additional patients with IBS with Constipation (IBS-C) referred in the same period served as control. The endpoints were: 1) a decrease of more than 50% in abdominal pain intensity and frequency scores; and 2) for patients with IBS-D and IBS-M: resolution of diarrhea. RESULTS: The endpoints were met by 8 (80%) and 14 (87%) of the patients with IBS-D and IBS-M, respectively, with decrease of abdominal pain and resolution of "diarrhea". The response was not significantly different from that observed in 15 (93%) of the IBS-C control group. CONCLUSION: Acknowledging the limitations of the small number of patients and of the uncontrolled nature of the study, we suggest that a possibly large number of patients labeled as IBS-D or IBS-M may actually simply present functional constipation and should be managed as such.

Embolization of a Bronchial Artery Aneurysm in a Chronic Obstructive Pulmonary Disease (COPD) Patient with Non-Massive Hemoptysis.

BACKGROUND: Bronchial artery aneurysm (BAA) is a rare condition with a reported prevalence of less than 1% of all selective bronchial arterial angiograms. Despite its low incidence, BAA represents a potential cause of hemoptysis. CASE REPORT: We describe the case of a 63-year-old man suffering from chronic obstructive pulmonary disease (COPD), who presented with non-massive hemoptysis. CT angiography revealed a single bronchial artery aneurysm of 9 mm in diameter, abutting the esophageal wall. Other CT findings included hypertrophy of the bronchial arteries along the mediastinal course, diffuse thickening of the walls of numerous bronchial branches and a "ground glass" opacity in the anterior segment of the right upper pulmonary lobe suggestive of alveolar hemorrhage. The final diagnosis was established based on selective angiography, which was followed by transcatheter arterial embolization (TAE) of the BAA and of the pathological bronchial circulation. Follow-up CT scans revealed a total exclusion of the aneurysm from the systemic circulation, resolution of the parenchymal "ground glass" opacity and absence of further episodes of hemoptysis over a period of two years. CONCLUSIONS: An incidental finding of a bronchial artery aneurysm necessitates prompt treatment. CT angiography and TAE represent the methods of choice for an appropriate diagnosis and treatment, respectively. In case of a BAA associated with chronic inflammatory diseases, such as COPD, in patients with hemoptysis, TAE of the BAA and of the pathological bronchial circulation, in association with the treatment of the underlying disease, represents a valid approach that can improve the pulmonary status and prevent further episodes of hemoptysis.

Sclerostin levels in uremic patients: a link between bone and vascular disease.

Sclerostin is a marker of low-turnover bone disease in end stage renal disease patients. The aim of this study was to evaluate serum sclerostin in uremic patients, analyzing its behavior during a single hemodialysis session. Twenty-one adult patients on intermittent hemodialysis treatment were enrolled. Acetate Free Bio-filtration (AFB) was the technique employed. Uremic patients were characterized by higher levels of serum sclerostin when compared with values observed in healthy subjects. Sclerostin assessed in pre-dialysis samples was 1.4 ± 1.02 ng/mL, whereas, in post dialysis samples, a reduction of sclerostin values was observed (0.8 ± 0.6 ng/mL; p: 0.008). Sclerostin correlated with parameters of dialysis adequacy, such as creatinine levels and Kt/V values, and it was significantly associated with atherosclerotic disease. Receiver operating characteristics analysis revealed a good diagnostic profile in identifying atherosclerotic disease. Sclerostin, a full dialyzable substance during AFB dialysis, is closely associated with atherosclerotic disease. Its reduction obtained through AFB could represent a defensive mechanism, improving vascular disease and renal osteodystrophy.

Influence of the X-ray beam quality on the dose increment in CT with iodinated contrast medium.

BACKGROUND: In computed tomography (CT), the image contrast is given by the difference in X-ray attenuation in the various tissues of the patient and contrast media are used to enhance image contrast in anatomic regions characterized by similar attenuation coefficients. OBJECTIVE: Aim of the present work is to enlarge the range of applicability of the method previously introduced for organ dosimetry in contrast-enhanced CT, by studying the effects of X-ray beam quality on the parameters of the model. Furthermore, an experimental method for the evaluation of the attenuation properties of iodinated solutions is proposed. METHODS: Monte Carlo simulations of anthropomorphic phantoms were carried out to determine a bi-parametrical (a and b) analytical relationship between iodine concentration and dose increase in organs of interest as a function of the tube kilo-voltage peak potential (kVp) and filtration. Experimental measurements of increments in Hounsfield Units (HU) were conducted in several CT scanners, at all the kVp available, in order to determine the parameter γ which relates the HU increment with the iodine mass fraction. A cylindrical phantom that can be filled with iodine solutions provided with an axial housing for a pencil ionization chamber was designed and assembled in order to measure the attenuation properties of iodine solutions under irradiation of a CT scanner and to obtain a further validation of Monte Carlo simulations. RESULTS: The simulation-derived parameters of the model, a and b, are only slightly dependent upon the tube kilo-voltage peak potential and filtration, while such scanner-dependent features influence mainly the experimentally-derived γ parameter. Relative dose variations registered by the ionization chamber inside the iodine-filled cylindrical phantom decrease when the X-ray mean energy increases, and reaches about 50% for 10 mg/ml of iodine. CONCLUSIONS: The dosimetric method for contrast-enhanced CT can be applied to all CT scanners by adopting average simulative parameters and by carrying out a simple measurement with a series of iodine contrast solutions. The novel experimental methodology introduced can provide a direct measurement of iodine attenuation properties.

Can contrast media increase organ doses in CT examinations? A clinical study.

OBJECTIVE: The purpose of this article is to quantify the CT radiation dose increment in five organs resulting from the administration of iodinated contrast medium. MATERIALS AND METHODS: Forty consecutive patients who underwent both un-enhanced and contrast-enhanced thoracoabdominal CT were included in our retrospective study. The dose increase between CT before and after contrast agent administration was evaluated in the portal phase for the thyroid, liver, spleen, pancreas, and kidneys by applying a previously validated method. RESULTS: An increase in radiation dose was noted in all organs studied. Average dose increments were 19% for liver, 71% for kidneys, 33% for spleen and pancreas, and 41% for thyroid. Kidneys exhibited the maximum dose increment, whereas the pancreas showed the widest variance because of the differences in fibro-fatty involution. Finally, thyroids with high attenuation values on unenhanced CT showed a lower Hounsfield unit increase and, thus, a smaller increment in the dose. CONCLUSION: Our study showed an increase in radiation dose in several parenchymatous tissues on contrast-enhanced CT. Our method allowed us to evaluate the dose increase from the change in attenuation measured in Hounsfield units. Because diagnostic protocols require multiple acquisitions after the contrast agent administration, such a dose increase should be considered when optimizing these protocols.

Advanced virtual magnetic resonance imaging (MRI) techniques in neurovascular conflict: bidimensional image fusion and virtual cisternography.

PURPOSE: The aim of this study was to evaluate the advantages and limits of virtual magnetic resonance techniques in planning surgery for microvascular decompression in patients with neurovascular conflict. MATERIALS AND METHODS: Between December 2010 and December 2011, we prospectively observed 32 patients (30 with trigeminal neuralgia and two with hemifacial spasm), with a suspected clinical diagnosis of neurovascular conflict. To assess the contact between nerve and vessel, magnetic resonance imaging (MRI) by three-dimensional (3D) constructive interference in steady state (CISS) and high-resolution MR angiography (MRA) were performed in all cases. Moreover, we performed presurgical simulation of microvascular decompression using MR two-dimensional image fusion and virtual cisternography. The neuroradiological findings were compared with the surgical findings. RESULTS: In all cases, we demonstrated the anatomical relations between cranial nerves and offending vessels with an optimal correlation between radiological and surgical patterns. CONCLUSIONS: Advanced virtual MRI techniques, such as image fusion and virtual cisternography, are able to depict the complex anatomical relationships between neural and vascular structures within the cisternal spaces of the skull base. These techniques can be considered an optimal presurgical tool to support traditional MRI evaluation of this region.

Intratesticular Vascular Architecture Seen by Ultrasound Microvascular Imaging (MicroV). Illustration of the Testis Vascular Anatomy.

The testis is a richly vascularized organ supplied by low-flow thin caliber vessels that are only partially detected by traditional Doppler systems, such as color and power Doppler. However, in the vascular representation, these techniques determine, albeit to different extents, a cut of the weak vessels due to the necessary application of wall filters that cut the disturbing frequencies responsible for artifacts generated by pulsations of the vascular walls and surrounding tissues. These filters cut a specific range of disturbing frequencies, regardless of whether they may be generated by low-flow vessels. Recently, a new technology, called Ultrasound Microvascular Imaging (MicroV) has been developed, which is particularly sensitive to slow flows. This new mode is based on new algorithms capable of better selecting the low frequencies according to the source of origin and cutting only the disturbing ones, saving the frequencies originating from really weak flows. When Ultrasound microvascular imaging is used, the vascular map is more detailed and composed of macro and microvasculature, with more subdivision branches, facilitating the interpretation of the normal and, consequently, the pathological. This review aims to describe the vascular architecture of the testis with Ultrasound Microvascular Imaging (MicroV) in healthy testis, compared to traditional color/power Doppler, related to normal anatomy.

Microvascular imaging ultrasound (MicroV) and power Doppler vascularization analysis in a pediatric population with early scrotal pain onset.

INTRODUCTION: The power Doppler is a useful tool in the evaluation of pediatric acute scrotal pain. Nonetheless, it may have some inherent limitations in scrotal vascularization analysis, potentially causing unnecessary surgery. The microvascular imaging ultrasound (MicroV) is an innovative Doppler technique able to improve the detection of very low flow. This retrospective study aims to compare both power Doppler and MicroV in the evaluation of a pediatric population with early-stage scrotal pain onset, first in testis vascularization analysis, and second in their diagnostic performances. MATERIALS AND METHODS: 69 patients met the following inclusion criteria, age < 18-year-old, a clinical diagnosis of acute scrotal disease, pain onset ≤ 6 h, ultrasound examination (including B-mode, power Doppler, and MicroV), 3-months follow-up. For both power Doppler and MicroV, through a defined vascularization scale, it was evaluated the agreement in vascularization detection, and the sensitivity and specificity in US diagnostic abilities. RESULTS: Retrospective diagnoses were of 8 testicular torsion, 15 orchi-epididymitis, and 46 children with other scrotal conditions. Power Doppler provided inconclusive US evaluation in 37.68% of the cases, while MicroV only in the 1.45% (p < 0.0001). Testicular torsion and orchi-epididymitis were identified, respectively, with MicroV in 100% (sensitivity, specificity, PPV, NPV, and accuracy of 100%) and 80% of patients (80% sensitivity, 100% specificity and PPV, 94.73% NPV, 95.65% accuracy); with power Doppler the identification was, respectively, of 87.5% (87.5% sensitivity, 100% specificity and PPV, 98.38% NPV and accuracy) and of 73.3% (73.33% sensitivity, 98.14% specificity, 91.66% PPV, 92.98% NPV, 92.75% accuracy). CONCLUSIONS: Our findings indicate that MicroV is a reliable technique in vascularization detection of pediatric testes, being able also to detect vascularization in healthy testicles with no-flow at power Doppler examination. Moreover, MicroV could be a valuable ally in the US diagnostic of children with early-stage scrotal pain onset.

State-of-the-art review of lung imaging in cystic fibrosis with recommendations for pulmonologists and radiologists from the "iMAging managEment of cySTic fibROsis" (MAESTRO) consortium.

OBJECTIVE: Imaging represents an important noninvasive means to assess cystic fibrosis (CF) lung disease, which remains the main cause of morbidity and mortality in CF patients. While the development of new imaging techniques has revolutionised clinical practice, advances have posed diagnostic and monitoring challenges. The authors aim to summarise these challenges and make evidence-based recommendations regarding imaging assessment for both clinicians and radiologists. STUDY DESIGN: A committee of 21 experts in CF from the 10 largest specialist centres in Italy was convened, including a radiologist and a pulmonologist from each centre, with the overall aim of developing clear and actionable recommendations for lung imaging in CF. An a priori threshold of at least 80% of the votes was required for acceptance of each statement of recommendation. RESULTS: After a systematic review of the relevant literature, the committee convened to evaluate 167 articles. Following five RAND conferences, consensus statements were developed by an executive subcommittee. The entire consensus committee voted and approved 28 main statements. CONCLUSIONS: There is a need for international guidelines regarding the appropriate timing and selection of imaging modality for patients with CF lung disease; timing and selection depends upon the clinical scenario, the patient's age, lung function and type of treatment. Despite its ubiquity, the use of the chest radiograph remains controversial. Both computed tomography and magnetic resonance imaging should be routinely used to monitor CF lung disease. Future studies should focus on imaging protocol harmonisation both for computed tomography and for magnetic resonance imaging. The introduction of artificial intelligence imaging analysis may further revolutionise clinical practice by providing fast and reliable quantitative outcomes to assess disease status. To date, there is no evidence supporting the use of lung ultrasound to monitor CF lung disease.

Non-invasive treatment of the sigmoid volvulus. A pediatric case report.

Sigmoid volvulus occurs when the sigmoid colic loop gets wrapped around its own mesocolon. While this condition is categorized as an extremely rare emergency in the pediatric population, diagnosis is often difficult due to the fact that its aspecific manifestations or sneaky symptoms are similar to other medical conditions. The available treatment options remain controversial up to this day, and the non-operative approach is more preferred in treating hemodynamic stable patients. This paper examines the case study of a 13-year-old girl suffering from sigmoid volvulus, who was treated with water-soluble contrast enema, in order to determine whether this method is efficient and effective in successfully treating the pathology of this condition.

Acute aortic syndrome and radiology liability in Italy: Case reports and medico-legal considerations.

The trend for medical malpractice claims has increased in recent years, both in the USA and in Europe. Although diagnostic radiology is not considered a high-risk field, malpractice claims in this area follow this general trend. The most common legal action taken against radiologists includes failure to diagnose, poor communication between physicians, failure to supervise technologists properly and improper procedures. Recently, the Italian Civil Supreme Court delivered a judgment (Cass. Civ., N.10158-18) regarding the liability of radiologists, stating that in radiological practice, a correct and timely execution of the diagnostic investigation is required. By contrast, the same judgment states that requesting further clinical consultations and/or the execution of in-depth diagnostic examinations are not within their duties. Considering this judgment, we report two cases of radiologist malpractice and related responsibility for negligent conduct regarding the diagnosis of thoracic aortic dissection and the prevention and management of acute aortic syndrome.

Radiological evaluation of a case of chronic intestinal pseudo-obstruction (CIPO).

Chronic intestinal pseudo-obstruction (CIPO) is a severe form of gastrointestinal dysmotility (often due to derangement of the innervation and/or smooth muscle and/or interstitial cells of Cajal) with recurrent episodes of intestinal sub-occlusion. We describe a clinical setting and radiological features of CIPO in an 11-year-old girl with periodic relapses. Our attention was focused firstly on surgical causes, leading to a delay in the diagnosis; thus, is important detecting equivocal symptoms and considering the possible correlation to the CIPO for an early diagnosis and related prevention of acute episodes improving prognosis and quality of life of pediatric patients.

Diagnostic accuracy of computed tomography coronary angiography in patients with a zero calcium score.

To evaluate the diagnostic accuracy of 64-slice CT coronary angiography (CT-CA) for the detection of significant coronary artery stenosis in patients with zero on the Agatston Calcium Score (CACS). We enrolled 279 consecutive patients (96 male, mean age 48 +/- 12 years) with suspected coronary artery disease. Patients were symptomatic (n = 208) or asymptomatic (n = 71), and underwent conventional coronary angiography (CAG). For CT-CA we administered an IV bolus of 100 ml of iodinated contrast material. CT-CA was compared to CAG using a threshold for significant stenosis of >or=50%. The prevalence of disease demonstrated at CAG was 15% (1.4% in asymptomatic). The population at CAG showed no or non-significant disease in 85% (238/279), single vessel disease in 9% (25/279), and multi-vessel disease in 6% (16/279). Sensitivity, specificity, and positive and negative predictive values of CT-CA vs. CAG on the patient level were 100%, 95%, 76%, and 100% in the overall population and 100%, 100%, 100%, and 100% in asymptomatic patients, respectively. CT-CA proves high diagnostic performance in patients with or without symptoms and with zero CACS. The prevalence of significant disease detected by CT-CA was not negligible in asymptomatic patients. The role of CT-CA in asymptomatic patients remains uncertain.

A method to evaluate the dose increase in CT with iodinated contrast medium.

PURPOSE: The objective of this study is to develop a method to calculate the relative dose increase when a computerized tomography scan (CT) is carried out after administration of iodinated contrast medium, with respect to the same CT scan in absence of contrast medium. METHODS: A Monte Carlo simulation in GEANT4 of anthropomorphic neck and abdomen phantoms exposed to a simplified model of CT scanner was set up in order to calculate the increase of dose to thyroid, liver, spleen, kidneys, and pancreas as a function of the quantity of iodine accumulated; a series of experimental measurements of Hounsfield unit (HU) increment for known concentrations of iodinated contrast medium was carried out on a Siemens Sensation 16 CT scanner in order to obtain a relationship between the increment in HU and the relative dose increase in the organs studied. The authors applied such a method to calculate the average dose increase in three patients who underwent standard CT protocols consisting of one native scan in absence of contrast, followed by a contrast-enhanced scan in venous phase. RESULTS: The authors validated their GEANT4 Monte Carlo simulation by comparing the resulting dose increases for iodine solutions in water with the ones presented in literature and with their experimental data obtained through a Roentgen therapy unit. The relative dose increases as a function of the iodine mass fraction accumulated and as a function of the Hounsfield unit increment between the contrast-enhanced scan and the native scan are presented. The data shown for the three patients exhibit an average relative dose increase between 22% for liver and 74% for kidneys; also, spleen (34%), pancreas (28%), and thyroid (48%) show a remarkable average increase. CONCLUSIONS: The method developed allows a simple evaluation of the dose increase when iodinated contrast medium is used in CT scans, basing on the increment in Hounsfield units observed on the patients' organs. Since many clinical protocols employ multiple scans at different circulatory phases after administration of contrast medium, such a method can be useful to evaluate the total dose to the patient, also in view of potential clinical protocol optimizations.

Protecting venous structures during radiosurgery for parasagittal meningiomas.

Symptomatic edema is a potential complication of meningioma radiosurgery. Parasagittal meningiomas are at a particular risk for symptomatic edema, suggesting a role for a venous occlusive complication. The authors sought to develop a strategy to optimize CyberKnife stereotactic radiosurgical treatment parameters to reduce the irradiation of the peritumoral venous system. Multislice CT venography with 3D reconstructions was performed and coregistered with thin-section, contrast-enhanced, volumetric MR images. The tumor and critical volumes were contoured on the MR images. Venous anatomical details obtained from the CT venographic study were then exported onto the MR imaging and fused MR imaging-CT study. Target and critical structure volumes and dosimetric parameters obtained with this method were analyzed. The authors found that reducing the irradiation of veins that course along the surface of the meningioma, which may be at risk for radiation-induced occlusion, is feasible in parasagittal meningioma radiosurgery without compromising other treatment parameters including conformality, homogeneity, and target coverage. Long-term follow-up is needed to assess the clinical validity of this treatment strategy.

The Usefulness of a Multimodality Approach in a Case of Subtle Iatrogenic Aortic Dissection: Sometimes is Better to Look and Wait.

We report a rare case of iatrogenic right coronary artery (RCA) dissection complicated by a retrograde subtle aortic dissection, which occurred during a primary percutaneous transluminal coronary angioplasty (PTCA). A 65-year-old female, with acute anterior ST-elevation myocardial infarction (STEMI), promptly underwent primary PTCA in the left anterior descending artery. After 5 h, the patient's condition becomes worse with recurrence of chest pain and new electrocardiogram modifications suggestive of inferior STEMI. A second coronary angiography revealed a spiral dissection extending from the ostium to the medium tract of the RCA. At the same time, a contrast media extravasation due to coronary ostium fissure occurred. Coronary stents were implanted from the medium tract of the right coronary to the ostium, to promptly arrest the active bleeding and to treat the dissection. After cardiosurgical advice, the patient was referred to the radiology department, where she underwent computed tomography angiography (CTA), which showed a small hematoma in the anterior wall of the ascending aorta. The stable clinical conditions of the patient suggested a conservative therapeutic approach. During the following 6 weeks CTA and transesophageal echocardiography were performed to rule out any other complication, and the patient was fortunately discharged with almost complete resolution of the hematoma.

Volvulus due to a giant sigmoid diverticulum: a rare cause of intestinal occlusion.

The case of a giant sigmoid diverticulum complicated by a volvulus of the bowel is reported. After an exhaustive literature review, the Authors analyse the aetiopathogenetic, physiopathological and clinical aspects of this rare condition, considering its diagnostic and therapeutic implications. The Authors describe surgical problems and therapeutic management, pointing out that without an accurate study by radiological imaging, it is very difficult to diagnose the condition, particularly when no specific symptoms have been observed.

Thin laryngeal foreign bodies in infants: diagnostic potential of MDCT.

A laryngeal foreign body (FB) is a significant, life-threatening event in the paediatric population. Incomplete airways obstruction by a thin, laminar, radiolucent FB lodged in the glottis or supraglottis is a rare occurrence that may present with non-specific symptoms, absence of chest findings, and normal radiographic investigations, resulting in misdiagnosis, delay in diagnosis, or prolonged recovery. We report two cases of 10-month-old male infants, each with a thin radiolucent FB lodged between the vocal folds that was detected with low-dose multidetector computed tomography (MDCT) and thin-slice reconstruction. Both infants presented with symptoms of respiratory airway inflammation at clinical examination and negative neck and chest radiographs. FBs were removed by direct laryngoscopy, without complications. In our experience, low-dose MDCT with thin-slice reconstruction is particularly useful for diagnosis in cases of suspected FB aspiration with uncertain clinical presentation and negative radiographic exams.