Gastric outlet obstruction in uncomplicated mesentero-axial gastric volvulus associated to hiatal hernia

Gastric volvulus is a rare condition determined by the rotation of one part of stomach around another. Stomach can rotate around its longitudinal or short axis or both. The presentation can be acute, subacute and chronic due to twisting and untwisting andimaging should be performed in the acute phase. MDCT shows high accuracy in thediagnosis and definition of gastric volvulus being the preferred diagnostic test in emergency settings. Gastric volvulus may be associated or determined by pre-existing hiatal hernia and accurate analysis of CT signs may be evaluated on order to differentiate between a stomach in an abnormal position and a volvulus.At CT, a displaced antrum at the same level or cranial to the fundus and a transition point at the pylorus is diagnostic for mesenteroaxial volvulus. We present a case of a 70 years old woman with mesenteroaxial volvulus in hiatal hernia.

Gross hematuria: Renal cell carcinoma mimicking a renal arteriovenous malformation

The differential diagnosis between renal arteriovenous malformations (AVM) and cancer may be a challenge, due to the similar clinical and imaging findings. Herein, we report the case of an 80-year-old male patient presenting gross hematuria, initially diagnosed and treated with embolization for a renal AVM. Due to the recurrence of hematuria and rapid progression and changes of the vascular lesion with detection also of an intralesional solid nodule, a radical nephrectomy was performed revealing the presence of a renal cell carcinoma (RCC). Renal cell carcinoma and renal AVM can be difficult to differentiate from one another, for this reason a short-term follow-up should be carried out in patients diagnosed and treated for renal AVM to confirm the resolution of AVM or to assess any changes, such as atypical neovascularization or intralesional renal masses, which may increase the suspect of a hidden renal tumor.

Utility of Dual-Energy Computed Tomography in Clinical Conundra

Advancing medical technology revolutionizes our ability to diagnose various disease processes. Conventional Single-Energy Computed Tomography (SECT) has multiple inherent limitations for providing definite diagnoses in certain clinical contexts. Dual-Energy Computed Tomography (DECT) has been in use since 2006 and has constantly evolved providing various applications to assist radiologists in reaching certain diagnoses SECT is rather unable to identify. DECT may also complement the role of SECT by supporting radiologists to confidently make diagnoses in certain clinically challenging scenarios. In this review article, we briefly describe the principles of X-ray attenuation. We detail principles for DECT and describe multiple systems associated with this technology. We describe various DECT techniques and algorithms including virtual monoenergetic imaging (VMI), virtual non-contrast (VNC) imaging, Iodine quantification techniques including Iodine overlay map (IOM), and two- and three-material decomposition algorithms that can be utilized to demonstrate a multitude of pathologies. Lastly, we provide our readers commentary on examples pertaining to the practical implementation of DECT's diverse techniques in the Gastrointestinal, Genitourinary, Biliary, Musculoskeletal, and Neuroradiology systems.

CT prognostic signs of postoperative complications in emergency surgery for acute obstructive colonic cancer

PURPOSE

To identify CT prognostic signs of poor outcomes in acute obstructive colonic cancer (AOCC).

METHODS

Demographic, clinical, laboratory, radiological and surgical data of 65 consecutive patients with AOCC who underwent emergency surgery were analyzed. CT exams were reviewed to assess diameters of cecum, ascending, transverse, descending, and sigmoid proximal to the tumor; colon segments' CD/L1-VD ratios, continence of the ileocecal valve, small bowel overdistension, presence of small bowel feces sign and cecal pneumatosis. Post Operative complications (PO), according to the Clavien-Dindo classification, were analyzed.

RESULTS

Gender, age and location of the tumor were not predictive factors of complications. Among laboratory exams, CRP was the most important predictive value of PO (OR 8.23). A cecum distension ≥ 9 cm represented the critical diameter beyond which perforation and cecal necrosis were found at surgery. Cecal pneumatosis at CT was correlated with cecal necrosis at surgery in < 50% of patients. Pre-operative transverse colon CD/L1-VD ratio ≥ 1.43 and descending colon CD/L1-VD ratio ≥ 1.31 were associated with the development of PO (grade ≥ III-V). PO (grade ≥ III-V) occurred in 18/65 patients.

CONCLUSION

Postoperative complications in emergency surgery of AOCC were not related to the age, sex and tumor's location. Preoperative PCR values (≥ 2.17) predict the development of postoperative complications. CT resulted a valid diagnostic tool to identify patients at higher risk of complications: a CD/L1-VD ratios with cut-off values of 1.43 (transverse) and 1.31 (descending) predicted major complications (grade ≥ III-V) and a cecum distension ≥ 9 cm represented the critical diameter beyond which perforation occurred in > 84% of patients.

Teriparatide and clodronate combination as a potential treatment for complex regional pain syndrome type I in delayed consolidation after foot surgery: a case report and review of the literature

BACKGROUND

Complex regional pain syndrome type I is a pathological condition characterized by an exaggerated response of tissues to low or moderate pain stimuli. The exact pathogenesis and optimal medical treatment for complex regional pain syndrome type I are still not fully understood, although bisphosphonates have shown positive effects in reducing pain. Foot surgery can be complicated by the development of complex regional pain syndrome type I, leading to functional decline and difficulties in weight-bearing.

CASE PRESENTATION

The authors present a clinical case involving complex regional pain syndrome type I that developed after surgical foot arthrodesis. The patient, a 42-year-old Caucasian male, did not respond to clodronate treatment but experienced successful outcomes upon the addition of teriparatide, which effectively stimulated the healing of arthrodesis.

CONCLUSION

Teriparatide cannot be considered the primary treatment for complex regional pain syndrome due to insufficient solid clinical data. However, when complex regional pain syndrome is associated with or caused by delayed union, teriparatide can be used to address the underlying cause of complex regional pain syndrome.

Editorial for the Special Issue "Cardiothoracic Imaging: Recent Techniques and Applications in Diagnostics"

Technology is making giant strides and is increasingly improving the diagnostic imaging of both frequent and rare acute and chronic diseases [...].

Abdominal Emergencies in Cancer Patients

Abdominal emergencies in cancer patients encompass a wide spectrum of oncologic conditions caused directly by malignancies, paraneoplastic syndromes, reactions to the chemotherapy or often represent the first clinical manifestation of an unknown malignancy. Not rarely, clinical symptoms are the tip of an iceberg. In this scenario, the radiologist is asked to exclude the cause responsible for the patient's symptoms, to suggest the best way to manage and to rule out the underlying malignancy. In this article, we discuss some of the most common abdominal oncological emergencies that may be encountered in an emergency department.

Artificial Intelligence and Radiomics for Endometrial Cancer MRI: Exploring the Whats, Whys and Hows

Endometrial cancer (EC) is intricately linked to obesity and diabetes, which are widespread risk factors. Medical imaging, especially magnetic resonance imaging (MRI), plays a major role in EC assessment, particularly for disease staging. However, the diagnostic performance of MRI exhibits variability in the detection of clinically relevant prognostic factors (e.g., deep myometrial invasion and metastatic lymph nodes assessment). To address these challenges and enhance the value of MRI, radiomics and artificial intelligence (AI) algorithms emerge as promising tools with a potential to impact EC risk assessment, treatment planning, and prognosis prediction. These advanced post-processing techniques allow us to quantitatively analyse medical images, providing novel insights into cancer characteristics beyond conventional qualitative image evaluation. However, despite the growing interest and research efforts, the integration of radiomics and AI to EC management is still far from clinical practice and represents a possible perspective rather than an actual reality. This review focuses on the state of radiomics and AI in EC MRI, emphasizing risk stratification and prognostic factor prediction, aiming to illuminate potential advancements and address existing challenges in the field.

Non-A Non-B Acute Aortic Dissection: Is There Some Confusion in the Radiologist's Mind?

BACKGROUND

The aim of this study is to define and determine the rate of acute non-A-non-B aortic dissections, and to evaluate CT angiography findings and possible complications, as well as to discuss management strategies and currently available therapy. Non-A non-B type of aortic dissection is still a grey area in the radiologist's mind, such that it is not entirely clear what should be reported and completed in terms of this disease.

METHODS

A retrospective single-center study including 36 pre-treatment CT angiograms of consecutive patients (mean age: 61 years) between January 2012 and December 2022 with aortic dissection involving the aortic arch with/without the thoracic descending/abdominal aorta (type non-A non-B).

RESULTS

According to the dissection anatomy, we identified three modalities of spontaneous acute non-A-non-B anatomical configurations. Configuration 1 (n = 25) with descending-entry tear and retrograde arch extension (DTA entry). Configuration 2 (n = 4) with Arch entry tear and isolated arch involvement (Arch alone). Configuration 3 (n = 7) with Arch entry and anterograde descending (±abdominal) aorta involvement (Arch entry). CT angiogram findings, management, and treatment options are described.

CONCLUSIONS

Acute non-A non-B dissection represents an infrequent occurrence of aortic arch dissection (with or without involvement of the descending aorta) that does not extend to the ascending aorta. The complete understanding of its natural progression, distinct CT angiography subtypes, optimal management, and treatment strategies remains incomplete. Within our series, patients frequently exhibit a complex clinical course, often necessitating a more assertive approach to treatment compared to type B dissections.

Gunshot vaginal trauma

Nonobstetric vaginal or vulva trauma is an extremely rare occurrence, with an incidence of < 0.2% of traumas. CT represents the gold standard in the diagnosis of gunshot lesions due to its ability to detect and stage injuries with very high sensitivity and specificity. A standardized protocol for penetrating trauma is still under debate for the use of intravenous contrast only or also rectal and oral contrast. Herein, we report a case of gunshot vaginal trauma in a 43-year-old patient presenting with vaginal bleeding. In our case, the protocol was "patient's tailored," the intravaginal selective use of air was administered due to symptoms (vaginal bleeding) and CT findings, this 2-step protocol increased diagnostic confidence and allow a correct and challenging diagnosis.

Traumatic segmental renal infarction due to renal apical artery thrombosis by minor blunt abdominal trauma: the role of CEUS

Post-traumatic segmental renal infarction is an extremely rare event, especially in case of minor blunt abdominal trauma. While major trauma guidelines are well established, several problems account for the adequate management of minor trauma. Herein, we report a case of minor blunt abdominal trauma determining traumatic thrombosis of the apical renal artery and segmental renal infarction, firstly diagnosed by CEUS in emergency care setting.

Prognostic Assessment of Gastropancreatic Neuroendocrine Neoplasm: Prospects and Limits of Radiomics

Neuroendocrine neoplasms (NENs) are a group of lesions originating from cells of the diffuse neuroendocrine system. NENs may involve different sites, including the gastrointestinal tract (GEP-NENs). The incidence and prevalence of GEP-NENs has been constantly rising thanks to the increased diagnostic power of imaging and immuno-histochemistry. Despite the plethora of biochemical markers and imaging techniques, the prognosis and therapeutic choice in GEP-NENs still represents a challenge, mainly due to the great heterogeneity in terms of tumor lesions and clinical behavior. The concept that biomedical images contain information about tissue heterogeneity and pathological processes invisible to the human eye is now well established. From this substrate comes the idea of radiomics. Computational analysis has achieved promising results in several oncological settings, and the use of radiomics in different types of GEP-NENs is growing in the field of research, yet with conflicting results. The aim of this narrative review is to provide a comprehensive update on the role of radiomics on GEP-NEN management, focusing on the main clinical aspects analyzed by most existing reports: predicting tumor grade, distinguishing NET from other tumors, and prognosis assessment.

Radiomics Applications in Spleen Imaging: A Systematic Review and Methodological Quality Assessment

The spleen, often referred to as the "forgotten organ", plays numerous important roles in various diseases. Recently, there has been an increased interest in the application of radiomics in different areas of medical imaging. This systematic review aims to assess the current state of the art and evaluate the methodological quality of radiomics applications in spleen imaging. A systematic search was conducted on PubMed, Scopus, and Web of Science. All the studies were analyzed, and several characteristics, such as year of publication, research objectives, and number of patients, were collected. The methodological quality was evaluated using the radiomics quality score (RQS). Fourteen articles were ultimately included in this review. The majority of these articles were published in non-radiological journals (78%), utilized computed tomography (CT) for extracting radiomic features (71%), and involved not only the spleen but also other organs for feature extraction (71%). Overall, the included papers achieved an average RQS total score of 9.71 ± 6.37, corresponding to an RQS percentage of 27.77 ± 16.04. In conclusion, radiomics applications in spleen imaging demonstrate promising results in various clinical scenarios. However, despite all the included papers reporting positive outcomes, there is a lack of consistency in the methodological approaches employed.

Advanced Cardiac Imaging and Women's Chest Pain: A Question of Gender

Awareness of gender differences in cardiovascular disease (CVD) has increased: both the different impact of traditional cardiovascular risk factors on women and the existence of sex-specific risk factors have been demonstrated. Therefore, it is essential to recognize typical aspects of ischemic heart disease (IHD) in women, who usually show a lower prevalence of obstructive coronary artery disease (CAD) as a cause of acute coronary syndrome (ACS). It is also important to know how to recognize pathologies that can cause acute chest pain with a higher incidence in women, such as spontaneous coronary artery dissection (SCAD) and myocardial infarction with non-obstructive coronary arteries (MINOCA). Coronary computed tomography angiography (CCTA) and cardiac magnetic resonance imaging (CMR) gained a pivotal role in the context of cardiac emergencies. Thus, the aim of our review is to investigate the most frequent scenarios in women with acute chest pain and how advanced cardiac imaging can help in the management and diagnosis of ACS.

ECG-Gated CCTA in the Assessment of Post-Procedural Complications

INTRODUCTION

The aim of our study was to assess the role of ECG-gated coronary CT angiography (CCTA) in the diagnosis, imaging follow-up, and treatment guidance in post-procedural/surgical interventions in the heart and thoracic aorta (PTCA, TAVI, PMK/ICD placement, CABGs).

MATERIALS AND METHODS

We retrospectively evaluated 294 ECG-gated CCTA studies performed in our center from January 2020 to January 2023. CCTA studies were acquired to detect/exclude possible complications related to the endovascular or surgical procedure.

RESULTS

There were 27 cases (9.2%) of post-procedural complications. Patients enrolled in the study were 18 males and 9 females (male/female ratio: 2), with age ranging from 47 to 86 years (mean age, 68.3 years). Among percutaneous coronary intervention (PCI) complications, coronary intimal dissection with ascending aorta involvement was found to be the most frequent complication after PTCA (22.2%). Vascular wall pseudoaneurysm formation (11.1%) and coronary stent misalignment or displacement (14.8%) were complications less frequently encountered after PTCA. Right atrial or ventricular perforation with associated hemopericardium were the most common complications (18.5%) after pacemaker implantation. Complications encountered after aortic valve interventions were loosening and dislocation of the prosthesis associated with aortic root pseudoaneurysm (7.4%), para-valvular leak (11.1%), and hemopericardium (7.4%). In one patient who underwent transcatheter repair of patent foramen ovale (3.7%), CTTA detected the dislocation of the Amplatzer septal occluder.

CONCLUSIONS

ECG-gated CCTA is a fundamental diagnostic tool for the detection of post-procedural endovascular/surgical complications to enable optimal patient management. Radiologists must be familiar with the use of cardiac synchronization in the course of CT and must be aware of all possible complications that can occur in the context of acute settings or routine follow-up studies.

Case Series of MRI and CT Assessment of Acquired Hepato-Biliary and Pancreatic Transdiaphragmatic Fistulae

Transdiaphragmatic fistulae are rare conditions characterized by pathological communication between two epithelium-lined surfaces. Hepato-thoracic fistula consists of abnormal communication between the liver and/or the biliary system and the thorax; while the pancreaticopleural fistula consists of abnormal communication between the pancreas and the thorax, the pleuro-biliary fistula represents the more common type. Clinical symptoms and laboratory findings are generally non-specific (e.g., thoracic and abdominal pain, dyspnea, cough, neutrophilia, elevated CPR, and bilirubin values) and initially, first-level investigations, such as chest RX and abdominal ultrasound, are generally inconclusive for the diagnosis. Contrast-enhanced CT represents the first two-level radiological imaging technique, usually performed to identify and evaluate the underlying pathology sustained by transdiaphragmatic fistulae, their complications, and the evaluation of the fistulous tract. When the CT remains inconclusive, other techniques such as MRI and MRCP can be performed. A prompt and accurate diagnosis is crucial because the recognition of fistulae and the precise definition of the fistulous tract have a major impact on the management acquisition process.

Multidetector CT Imaging Biomarkers as Predictors of Prognosis in Shock: Updates and Future Directions

A severe mismatch between the supply and demand of oxygen is the common sequela of all types of shock, which present a mortality of up to 80%. Various organs play a protective role in shock and contribute to whole-body homeostasis. The ever-increasing number of multidetector CT examinations in severely ill and sometimes unstable patients leads to more frequently encountered findings leading to imminent death, together called "hypovolemic shock complex". Features on CT include dense opacification of the right heart and major systemic veins, venous layering of contrast material and blood, densely opacified parenchyma in the right hepatic lobe, decreased enhancement of the abdominal organ, a dense pulmonary artery, contrast pooling in dependent lungs, and contrast stasis in pulmonary veins. These findings are biomarkers and prognostic indicators of paramount importance which stratify risk and improve patient outcomes. In this review, we illustrate the various CT patterns in shock and review the spectrum and prognostic significance of thoraco-abdominal vascular and visceral alarming signs of impending death with the intention of increasing awareness among radiologists and radiographers to prepare for immediate resuscitation when required.

Non-Contrast and Contrast-Enhanced Cardiac Computed Tomography Imaging in the Diagnostic and Prognostic Evaluation of Coronary Artery Disease

In recent decades, cardiac computed tomography (CT) has emerged as a powerful non-invasive tool for risk stratification, as well as the detection and characterization of coronary artery disease (CAD), which remains the main cause of morbidity and mortality in the world. Advances in technology have favored the increasing use of cardiac CT by allowing better performance with lower radiation doses. Coronary artery calcium, as assessed by non-contrast CT, is considered to be the best marker of subclinical atherosclerosis, and its use is recommended for the refinement of risk assessment in low-to-intermediate risk individuals. In addition, coronary CT angiography (CCTA) has become a gate-keeper to invasive coronary angiography (ICA) and revascularization in patients with acute chest pain by allowing the assessment not only of the extent of lumen stenosis, but also of its hemodynamic significance if combined with the measurement of fractional flow reserve or perfusion imaging. Moreover, CCTA provides a unique incremental value over functional testing and ICA by imaging the vessel wall, thus allowing the assessment of plaque burden, composition, and instability features, in addition to perivascular adipose tissue attenuation, which is a marker of vascular inflammation. There exists the potential to identify the non-obstructive lesions at high risk of progression to plaque rupture by combining all of these measures.

Artificial Intelligence Applications in Cardiovascular Magnetic Resonance Imaging: Are We on the Path to Avoiding the Administration of Contrast Media?

In recent years, cardiovascular imaging examinations have experienced exponential growth due to technological innovation, and this trend is consistent with the most recent chest pain guidelines. Contrast media have a crucial role in cardiovascular magnetic resonance (CMR) imaging, allowing for more precise characterization of different cardiovascular diseases. However, contrast media have contraindications and side effects that limit their clinical application in determinant patients. The application of artificial intelligence (AI)-based techniques to CMR imaging has led to the development of non-contrast models. These AI models utilize non-contrast imaging data, either independently or in combination with clinical and demographic data, as input to generate diagnostic or prognostic algorithms. In this review, we provide an overview of the main concepts pertaining to AI, review the existing literature on non-contrast AI models in CMR, and finally, discuss the strengths and limitations of these AI models and their possible future development.

Imaging in Non-Traumatic Emergencies

"Emergency" is a scenario that every medical professional must face since the first day of her/his career [...].

Coronary Computed Tomography Angiography with Deep Learning Image Reconstruction: A Preliminary Study to Evaluate Radiation Exposure Reduction

Coronary computed tomography angiography (CCTA) is a medical imaging technique that produces detailed images of the coronary arteries. Our work focuses on the optimization of the prospectively ECG-triggered scan technique, which delivers the radiation efficiently only during a fraction of the R-R interval, matching the aim of reducing radiation dose in this increasingly used radiological examination. In this work, we analyzed how the median DLP (Dose-Length Product) values for CCTA of our Center decreased significantly in recent times mainly due to a notable change in the technology used. We passed from a median DLP value of 1158 mGy·cm to 221 mGy·cm for the whole exam and from a value of 1140 mGy·cm to 204 mGy·cm if considering CCTA scanning only. The result was obtained through the association of important factors during the dose imaging optimization: technological improvement, acquisition technique, and image reconstruction algorithm intervention. The combination of these three factors allows us to perform a faster and more accurate prospective CCTA with a lower radiation dose. Our future aim is to tune the image quality through a detectability-based study, combining algorithm strength with automatic dose settings.

Role of artificial intelligence in oncologic emergencies: a narrative review

Oncologic emergencies are a wide spectrum of oncologic conditions caused directly by malignancies or their treatment. Oncologic emergencies may be classified according to the underlying physiopathology in metabolic, hematologic, and structural conditions. In the latter, radiologists have a pivotal role, through an accurate diagnosis useful to provide optimal patient care. Structural conditions may involve the central nervous system, thorax, or abdomen, and emergency radiologists have to know the characteristics imaging findings of each one of them. The number of oncologic emergencies is growing due to the increased incidence of malignancies in the general population and also to the improved survival of these patients thanks to the advances in cancer treatment. Artificial intelligence (AI) could be a solution to assist emergency radiologists with this rapidly increasing workload. To our knowledge, AI applications in the setting of the oncologic emergency are mostly underexplored, probably due to the relatively low number of oncologic emergencies and the difficulty in training algorithms. However, cancer emergencies are defined by the cause and not by a specific pattern of radiological symptoms and signs. Therefore, it can be expected that AI algorithms developed for the detection of these emergencies in the non-oncological field can be transferred to the clinical setting of oncologic emergency. In this review, a craniocaudal approach was followed and central nervous system, thoracic, and abdominal oncologic emergencies have been addressed regarding the AI applications reported in literature. Among the central nervous system emergencies, AI applications have been reported for brain herniation and spinal cord compression. In the thoracic district the addressed emergencies were pulmonary embolism, cardiac tamponade and pneumothorax. Pneumothorax was the most frequently described application for AI, to improve sensibility and to reduce the time-to-diagnosis. Finally, regarding abdominal emergencies, AI applications for abdominal hemorrhage, intestinal obstruction, intestinal perforation, and intestinal intussusception have been described.

Non-Operative Management of Polytraumatized Patients: Body Imaging beyond CT

In the transition from the operative to the conservative approach for the polytraumatized patients who undergo blunt trauma, diagnostic imaging has assumed a pivotal role, currently offering various opportunities, particularly in the follow-up of these patients. The choice of the most suitable imaging method in this setting mainly depends on the injury complications we are looking for, the patient conditions (mobilization, cooperation, medications, allergies and age), the biological invasiveness, and the availability of each imaging method. Computed Tomography (CT) represents the “standard” imaging technique in the polytraumatized patient due to the high diagnostic performance when a correct imaging protocol is adopted, despite suffering from invasiveness due to radiation dose and intravenous contrast agent administration. Ultrasound (US) is a readily available technology, cheap, bedside performable and integrable with intravenous contrast agent (Contrast enhanced US—CEUS) to enhance the diagnostic performance, but it may suffer particularly from limited panoramicity and operator dependance. Magnetic Resonance (MR), until now, has been adopted in specific contexts, such as biliopancreatic injuries, but in recent experiences, it showed a great potential in the follow-up of polytraumatized patients; however, its availability may be limited in some context, and there are specific contraindications, such as as claustrophobia and the presence non-MR compatible devices. In this article, the role of each imaging method in the body-imaging follow-up of adult polytraumatized patients will be reviewed, enhancing the value of integrated imaging, as shown in several cases from our experience.

MDCT Diagnosis and Staging of Xanthogranulomatous Pyelonephritis

Background: Benign nephrectomy to treat patients with renal inflammatory disease in cases of severe urinary infection represents a diagnostic and management challenge because of significant inflammatory, fibrotic, and infectious components. Among renal inflammatory diseases, fistulization and invasiveness to adjacent structures are some of the hallmarks of xanthogranulomatous pyelonephritis (XGP). The aims of this study were as follows 1. to retrospectively determine key demographic and clinical features of XGP among benign nephrectomies; 2. to assess the CT preoperative diagnostic accuracy; and 3. to define the imaging characteristics of the CT stage. Material and Methods: A retrospective review of clinical, laboratory, and radiological features and operative methods of patients who underwent benign nephrectomy with histologically proven XGP was performed. Results: XPG was diagnosed in 18 patients over a 4-year (2018–2022) period. XGP represented 43.90% among benign nephrectomies. The mean age of the patients was 63 years, and the sex prevalence was higher in women (72.22%). Symptoms were vague and not specifically referrable to urinary tract disorders and unilateral (100%), with the left kidney affected in 61.11% of cases. Staghorn calculi and stone disease were the most common underlying cause (72.22%). All patients underwent CT. The preoperative CT imaging accuracy for renal inflammatory disease was 94.44% and indeterminate in 5.56%. A suspected diagnosis of XGP was formulated in 66.67% (12/18; 2 stage II/10 stage III), meanwhile, in 33.33% (6 patients with stage I), a non-specific diagnosis of renal inflammatory disease was formulated. CT was reported according to the Malek and Elder classification and staged in the stage I nephric form (33.33%), stage II perinephric form (11.11%), stage III paranephric form (55.56%). Conclusions: The CT diagnostic accuracy for kidney inflammatory disease was extremely high, whereas the suspected diagnosis of XGP was formulated preoperatively in only 66.67% of high-stage disease, where the hallmarks of invasiveness and fistulization of the pathology increased the diagnostic confidence.

Accuracy of computed tomography in staging acute appendicitis and its impact on surgical outcome and strategy: a multi-center retrospective case-control study

INTRODUCTION

The aims of this study were to evaluate the concordance between AAST-CT appendicitis grading criteria, first published in 2014, and surgical findings and to assess the impact of CT staging on the choice of surgical approach.

METHODS

This was a multi-center retrospective case-control study including 232 consecutive patients undergoing surgery for acute appendicitis and who had undergone preoperative CT evaluation between 1 January 2017 and 1 January 2022. Appendicitis severity was classified in 5 grades. For each degree of severity, the surgical outcome between patients undergoing open and surgical approach was compared.

RESULTS

An almost perfect agreement (k = 0.96) was found between CT and surgery in staging acute appendicitis. The vast majority of patients with grade 1 and 2 appendicitis underwent laparoscopic surgical approach and showed low morbidity rate. In patients with grade 3 and 4 appendicitis, laparoscopic approach was adopted in 70% of cases and was associated, if compared to open, with a higher prevalence of postoperative abdominal collections (p = 0.05; fisher's exact test) and a significantly lower prevalence of surgical site infections (p = 0.0007; fisher's exact test). All the patients with grade 5 appendicitis were treated by laparotomy.

CONCLUSIONS

AAST-CT appendicitis grading system seems to show a relevant prognostic value and a potential impact on the choice of surgical strategy, directing toward a laparoscopic approach in patients with grade 1 and 2, an initial laparoscopic approach, replaceable by the open one, for grade 3 and 4 and an open approach in patients with grade 5.

Dose Reduction Strategies for Pregnant Women in Emergency Settings

In modern clinical practice, there is an increasing dependence on imaging techniques in several settings, and especially during emergencies. Consequently, there has been an increase in the frequency of imaging examinations and thus also an increased risk of radiation exposure. In this context, a critical phase is a woman's pregnancy management that requires a proper diagnostic assessment to reduce radiation risk to the fetus and mother. The risk is greatest during the first phases of pregnancy at the time of organogenesis. Therefore, the principles of radiation protection should guide the multidisciplinary team. Although diagnostic tools that do not employ ionizing radiation, such as ultrasound (US) and magnetic resonance imaging (MRI) should be preferred, in several settings as polytrauma, computed tomography (CT) nonetheless remains the examination to perform, beyond the fetus risk. In addition, protocol optimization, using dose-limiting protocols and avoiding multiple acquisitions, is a critical point that makes it possible to reduce risks. The purpose of this review is to provide a critical evaluation of emergency conditions, e.g., abdominal pain and trauma, considering the different diagnostic tools that should be used as study protocols in order to control the dose to the pregnant woman and fetus.

Lower Limb Ischemia as Acute Onset of Primary Aortic Occlusion: CTA Imaging and Management

Primary aortic occlusion (PAO) is defined as acute occlusion in the absence of aortic atherosclerosis or aneurysm. PAO is a rare disease with acute onset and can determine massive parenchymal ischemia and distal arterial embolization. The aim of our study was to focus on the assessment of clinical characteristic, CT signs, medical and surgical treatment, complication rates and the overall survival of PAO.

MATERIALS AND METHODS

We retrospectively analyzed the data of all patients with acute lower limb ischemia and a final surgical or discharge diagnosis of PAO who underwent aortic CT angiography in ER settings in our hospital from January 2019 to November 2022.

RESULTS

A total of 11 patients (8 males/3 females; male/female ratio, 2.66:1, age range 49 to 79 years-old, mean age 65.27 y/o) with acute onset of lower limb impotence or ischemia were diagnosed with PAO. The etiology was thrombosis in all patients. The aortic occlusion was always located in the abdominal aorta and extended bilaterally through the common iliac arteries. The upper limit of the thrombosis was detected in the aortic subrenal tract in 81.8% of the cases, and in the infrarenal tract in 18.2%. A total of 81.8% of the patients were referred to the ER for symptoms related to lower limb: bilateral acute pain, hypothermia and sudden onset of functional impotence. Two patients (18.2%) died before undergoing surgery for multi-organ failure determined by the severe acute ischemia. The other patients (81.8%) underwent surgical treatment that included aortoiliac embolectomy (54.5%), aortoiliac embolectomy + aorto-femoral bypass (18.2%) and aortoiliac embolectomy and right lower limb amputation (9.1%). The overall mortality was 36.4% while the estimated survival at 1 year was 63.6%.

CONCLUSIONS

PAO is a rare entity with high morbidity and mortality rates if not recognized and treated promptly. Acute onset of lower limb impotence is the most common clinical presentation of PAO. Aortic CT angiography is the first-choice imaging technique for the early diagnosis of this disease and for the surgical treatment, planning and assessment of any complications. Combined with surgical treatment, anticoagulation is considered the first-line medical therapy at the time of diagnosis, during surgical treatment and after at discharge.

Radiomics in Lung Metastases: A Systematic Review

Due to the rich vascularization and lymphatic drainage of the pulmonary tissue, lung metastases (LM) are not uncommon in patients with cancer. Radiomics is an active research field aimed at the extraction of quantitative data from diagnostic images, which can serve as useful imaging biomarkers for a more effective, personalized patient care. Our purpose is to illustrate the current applications, strengths and weaknesses of radiomics for lesion characterization, treatment planning and prognostic assessment in patients with LM, based on a systematic review of the literature.

Reliability of a Multidisciplinary Multiparametric Approach in the Surgical Planning of Laryngeal Squamous Cell Carcinomas: A Retrospective Observational Study

(1) Background: Endoscopy and morphological imaging are the mainstay of the diagnostic work up of laryngeal squamous cell carcinomas (LSCCs), which can be integrated in a multidisciplinary discussion to obtain a shared pretreatment staging. (2) Methods: A retrospective evaluation of patients, managed at a tertiary university hospital in Italy and submitted to major laryngeal surgery, has been performed. Four different stagings have been defined and compared: epTN (based on endoscopy and physical ENT examination); radTN (based on CT scan); cTN (based on multidisciplinary integration of the two above); pTN based on pathology on surgical samples. Oncological outcomes have been assessed. (3) Results: Three-year relapse free and disease specific survival were 88% and 92.5%, respectively, without significant differences between partial surgeries (n = 13) and total laryngectomies (n = 32). As for the pretreatment staging, and in particular the T classification, the cTN has been revealed as more reliable than epTN and radTN alone in predicting the final pT (Cohen kappa coefficient: 0.7 for cT, 0.44 for radT, 0.32 for epT). In the partial surgery group, we did not record any positive margin nor local recurrence, with a 100% overall and disease-specific survival. (4) Conclusions: The multidisciplinary approach is fundamental in the definition of the primary lesion in LSCC, in particular in order to safely perform surgical preservation of laryngeal function, which is associated with a higher laryngectomy-free survival than irradiation but to a lower salvageability in case of recurrence.

Extra credit for disruption: trend of disruption in radiology academic journals

AIM

To identify the most disruptive publications, which are those that are cited more frequently than their own references, in academic radiology journals and their characteristics, such as the number of authors and relative time to publication.

MATERIAL AND METHODS

A comprehensive literature search was undertaken to identify the 100 most disruptive publications in the field of radiology. Subsequently, statistical analysis was applied to establish the distribution of disruptive scores of the isolated publications using a non-parametric probability density function. The relation between disruptive scores and citation counts was then determined, with the aid of a correlation coefficient. Finally, data regarding any significant connection between disruption scores and time of publication, number of authors, and study design were examined.

RESULTS

Analysing the top 100 papers in increments of 10-year periods showed no significant difference in the distribution of disruption scores over time. No correlation between an article's citation count and disruption score was established. Additionally, no significant relation between the number of authors/study design and disruption scores was identified.

CONCLUSION

The disruption score highlights significant impact elements not entirely accounted for by citation count. Its potential benefit in assessing scientific impact should be contemplated.

CT Marker in Emergency Imaging of Acute Basilar Artery Occlusion: Thrombosis vs. Embolism

Purpose: Acute basilar artery occlusion, a neurovascular emergency leading to high rates of morbidity and mortality, is usually diagnosed by CT imaging. The outcome is partly dependent on etiology, with a worse outcome in occlusions with underlying basilar artery stenosis. As this occlusion type requires a more complex angiographic therapy, this study aimed to develop new CT markers in emergency admission imaging to rapidly identify underlying stenosis. Methods: A total of 213 consecutive patients (female n = 91, age in years (mean/SD/range): 72/13/28−97), who received endovascular treatment at a single comprehensive stroke center for acute basilar artery occlusion, were included in this study. After applying strict inclusion criteria for imaging analyses, novel CT imaging markers, such as ‘absolute density loss’ (ADL) and relative thrombus attenuation (CTA-index), that measure perviousness, were assessed for n = 109 patients by use of CT-angiography and correlated to different occlusion patterns (thrombotic vs. embolic). Inter-observer agreement was assessed using an intraclass correlation coefficient for independent measures of a radiologist and a neuroradiologist. Associations between the imaging markers and clinical and interventional parameters were tested. Results: CT markers differ between the subgroups of basilar artery occlusions with and without underlying stenosis (for ADL: 169 vs. 227 HU (p = 0.03), for CTA-index: 0.55 vs. 0.70 (p < 0.001)), indicating a higher perviousness in the case of stenosis. A good inter-rater agreement was observed for ADL and CTA-index measures (ICC 0.92/0.88). For the case of embolic occlusions, a more pervious thrombus correlates to shorter time intervals, longer procedure times, and worse reperfusion success (p-values < 0.05, respectively). Conclusions: ADL and CTA-index are easy to assess in the emergency setting of acute basilar artery occlusion with the use of routinely acquired CT-angiography. They show a high potential to differentiate thrombotic from embolic occlusions, with an impact on therapeutic decisions and angiographic procedures. Measurements can be quickly performed with good reliability, facilitating implementation in clinical practice.

Contrast Enhanced Ultrasound Compared with MRI and CT in the Evaluation of Post-Renal Transplant Complications

Renal transplantation (RT) is the treatment of choice for end-stage renal disease, significantly improving patients’ survival and quality of life. However, approximately 3–23% of patients encounter post-operative complications, and radiology plays a major role for their early detection and treatment or follow-up planning. CT and MRI are excellent imaging modalities to evaluate renal transplant post-operative course; nevertheless, they are both associated with a high cost and low accessibility, as well as some contraindications, making them not feasible for all patients. In particular, gadolinium-based contrast can lead to the rare condition of nephrogenic systemic fibrosis, and iodine-based contrast can lead to contrast-induced nephropathy (CIN). CT also exposes the patients who may require multiple examinations to ionizing radiation. Therefore, considering the overall advantages and disadvantages, contrast-enhanced ultrasound (CEUS) is presently considered an effective first-line imaging modality for post-operative early and long-term follow-up in RT, reducing the need for biopsies and providing adequate guidance for drainage procedures. Hence, this paper aims to review the updated knowledge on CEUS compared with CT and MRI for the evaluation of RT renal transplant complications; advantages, limitations, and possible recommendations are provided.

The impact of RF wattage level on local impedance and procedural parameters in AF ablation cases

Funding Acknowledgements

Type of funding sources: None.

Background

Local impedance (LI) measurement can provide information on catheter tip contact, but also changes in LI during ablation can inform the extent and effectiveness of RF energy delivery. To date the relationship between highly LI measurements and contact force (CF) during atrial fibrillation (AF) ablation at different levels of energy delivery is still lacking.

Purpose

We aimed to evaluate the impact of power setting on LI and key procedural parameters in AF ablation cases.

Methods

A novel CF ablation catheter equipped with dedicated algorithm was used to measure LI at the distal electrode of this catheter. Radiofrequency (RF) catheter applications ≥45 watts were categorized as high power (HP) and applications &lt;45w as standard power (SP). Ablations were also grouped according to different levels of CF (&lt;5g, 5-14g, 15-24g and ≥25g). Data are reported as mean±SD.

Results

Sixty-two consecutive pts undergoing RF catheter ablation of AF from the CHARISMA registry were included A total of 4619 ablation spots performed around PVs were analyzed (58% paroxysmal, 84% de novo, RF deliveries per pt=76±27, RF delivery time=9.1±5s, CF=12.3±8g). The majority of these were HP applications (n=4192, 91%). The mean LI was 158±17Ω prior to ablation and 138±14Ω after ablation (p&lt;0.0001, absolute LI drop of 21.9±8Ω) with a LI drop rate equal to 4.4±3Ω/s. HP ablations had significantly shorter RF delivery times, 8.8±4s vs 12±7s (p&lt;0.0001), larger LI drops (22.2±8Ω vs 19.3±9Ω, p&lt;0.0001) and higher LI drop rates (4.5±3Ω/s vs 3.6±2Ω/s, p&lt;0.0001) than SP, respectively. For both HP and SP settings, the magnitude of LI drop increased and RF delivery time decreased with increasing amounts of CF. The largest differences between HP and SP were found when CF was &lt;15g (RF delivery time: 9±5s at HP vs 12.9±7s at SP, percentage of difference 26.3%, p&lt;0.0001; LI drop: 21.2±8Ω at HP vs 18.6±9Ω, percentage of difference -14.3%, p&lt;0.0001). No major complications occurred during the procedures. All PVs were successfully isolated.

Conclusions

This preliminary experience suggests that, HP ablation is effective and safe and resulting in shorter RF delivery times and larger LI drops than SP ablation.

Long term success of cavotricuspid isthmus ablation guided by the ablation index: results of the FLAI registry

Funding Acknowledgements

Type of funding sources: None.

Introduction

Cavotricuspid isthmus ablation (CTIA) is an effective treatment for typical atrial flutter (AFL) with a recurrence rate of about 10%. A prospective multicentric registry (FLAI registry) has recently shown that a protocol including ‘point by point’ CTI ablation targeting an a quality lesion marker (Ablation Index AI) ≥ 500 and a maximum inter-lesion distance (ILD) measurement of ≤6 mm allowed an acute success rate of 98.3%. In this study, we aimed to describe the incidence and predictors of recurrence of both AFL and atrial fibrillation (AF) in a long-term follow-up of the patients enrolled in the FLAI registry.

Methods

The FLAI registry was a multicentric non-randomized study that enrolled 412 consecutive patients (mean age 64.9±9.8; 72.1% males; 27.7% with structural heart disease). Patients with typical AFL underwent an AI-guided cavotricuspid isthmus ablation. The procedures targeted an AI of 500 and an ILD measurement of ≤ 6mm. The primary endpoints were CTI ‘first pass’ block and persistent block after a 20-minute waiting period. The CTI bidirectional "first pass block" was reached in 355 patients (88.3%), whereas CTI block at the end of the waiting period was achieved in 405 patients (98.3%). No complications were reported.

The mean time of follow-up was 21±4.24 months and it was available for 397 patients. The FU included outpatient clinical evaluation, ECG and 24-h Holter ECG at three, six- and 12-months post-ablation, followed by an annual clinical evaluation and ECG. Documented ECG Atrial fibrillation events, in follow up, were also included in the data set.

Results

Atrial flutter recurrence: 22 AFL events were observed (5.5%) at 34 months. According to the Kaplan Meier analysis, the growth of recurrence rate was constant between 6 and 12 months, after 19 months recurrences were unlikely. At the univariate analysis predictors of AFL recurrence were: absence of bidirectional block after the waiting time period (p= 0,001); failure of the CTIA index procedure (p=&lt;0,0005); ablation line lengths &gt; 32 mm (p=0.,018), number of automatic ablation lesion tags (VISITAG) &gt; 20 (p=0,.005) and At the increathe reported numbers of ‘g"gap’" in the ablation line lengths: the more the gaps increase the more the probability of AFL recurrence in FU increases (p=0.,037).

In the Multivariate aAnalysis, the independent predictors of AFL recurrence were: the procedural success and the number of VISITAG (OR =1.062)

Atrial fibrillation recurrence: 45 patients developed atrial fibrillation after CTI ablation (11.3%). In the multivariate analysis, the major independent predictor was a documented pre-procedural Afib and the risk increases with the younger age (&lt; 53 yo).

Conclusions

The FLAI protocol is safe, reproducible and effective in the follow-up, with a long term success of 94,5%. The reported incidence of atrial fibrillation in FU was 11,3%

Ventricular tachycardia channels ablation incorporating automated high-density mapping guidance: data from the CHARISMA registry

Funding Acknowledgements

Type of funding sources: None.

Background

Ventricular tachycardia (VT) ablation targeting conducting channels (CC)s based on timing of late potentials (LPs) during sinus rhythm (dechanneling) may facilitate a scar homogenization strategy without the need for extensive ablation and possibly lead to higher successful rate.

Purpose

We evaluated the feasibility and safety of a CC identification and ablation approach by means of an ultra-high density mapping system with a novel automated algorithm in ischemic VT procedures.

Methods

Consecutive patients indicated for ischemic VT ablation were prospectively included. A complete map of the left ventricle was performed prior and after ablation through the Rhythmia mapping system. Channels were defined as any signal activity bounded by anatomic and functional barriers and characterized through the Lumipoint (LM) tool and continuous activation was used on the whole ventricular substrate. Procedural end point was the elimination of all identified CCs by ablation at the CC entrance and exit followed by abolition of any residual LPs inside the CC. The ablation endpoint was noninducibility. Data are reported as mean±SD.

Results

A total of 36 channels were identified through LM from 28 patients (1.2±0.5 per patient): 21 (75%) patients had 1 CC, 6 (21.4%) had 2 CCs and 1 (3.6%) had 3 CCs. LPs were identified inside CCs in 19 cases (67.9%). In 8 cases (28.6%) LPs were present both inside and outside and in 1 (3.6%) case LPs were present only outside the CC. LPs inside channels covered an area of 7.6±5 mm2 with a ratio between LPs area and CCs’ area of 67.4±31.8%. In 12 (43%) cases LPs area covered more than 90% of the CCs’ area. At voltage map analysis a total of 34 CC were identified: 1 CC was present in 75% of the cases, 2 CCs in 17.9% and 3 CCs in 3.6%. LPs were identified only inside CCs in 46.4% of the cases, both inside and outside in 42.9% and only outside in 10.7%. Healthy tissue (voltage level≥0.5mV) was prevalent (68.2±17%), followed by intermediate voltage areas (0.5-0.05 mV; 31.1±17%) and very low voltage areas (&lt;0.05mV; 0.7±1%). LPs were found mostly at intermediate voltage areas (57.0±34% of the covered area; 39.1±33% at healthy tissue and 3.4±13% at very low voltage areas). LM was more accurate than traditional voltage mapping in identifying CCs: in 6 (21.4%) cases voltage map overestimated LPs areas, in 2 (7.1%) cases failed to fully identify LPs and only in 19 out 28 (67.8%) LM and voltage map had a complete agreement. All CCs’ entrance and exit were successfully ablated and abolition of any residual LPs inside the CC was achieved in all patients. No complication occurred. Noninducibility was achieved in all (100%) the cases.

Conclusions

In this experience, a channel identification approach through the advanced Lumipoint tool was more accurate than traditional voltage mapping and seems to be safe, feasible, and effective at least in the acute setting of ischemic VT ablation.

P172 AN ACCESSORY PATHWAY WITHOUT REENTRANT TACHYCARDIA

A 65–year–old patient, hypertensive, dyslipidemic, strong smoker. He has heart disease with hypokinetic evolution EF 47%, mild MI. Negative Dipyridamole–stress echocardiography dated January 2008. Recently atrial fibrillation (AF) is found and anticoagulant therapy was started. Dyspnea and weight loss occurred in past two months. Detected keratinizing squamous pulmonary Ca with negative markers. This injury was judged to be inoperable, and the patient get indications for chemotherapy and radiotherapy. The patient also starts complaining of dyspnea and chest pain on exertion: Not serological modification, not ischemic ECG. Echocardiogram LVEF 47–50% highlights diffuse hypokinesia, regular valves. Ergometric test was not evaluable for ischemia. Coronary angiography shows stenosis of proximal and middle anterior interventricular coronary and non–critical lesions of circumflex and right coronary. Ecodobutamine test was positive for ischemia and arrhythmias (AF and wide QRS tachycardias in recovery phase), but negative for angor. The patient was treated with CT and IVA I – II. angioplasty Monitoring shows AF with high penetrance, wide QRS tachycardia runs and very short TVNS. ECG 1: During atrial tachycardia, show broad QRS conduction to BBSX alternating with narrow QRS with the same RR interval. ECG 2. show fusion between the wavefront conducted with narrow QRS and that with wide QRS. These are supraventricular arrhythmias that run along the atrioventricular nodal pathway (NAV) in the narrow QRS tracts and take an accessory pathway in the wide QRS run.

The Mahaim fibers have decremental conductivities like the AV node, therefore high ventricular frequencies does not occur AF appeared during ecodobutamine, but some beats were conducted by an anomalous path in a discontinuous way); they are generally directed from the atrium or the NAV, towards another part of the right ventricular conduction system, with atrium wave or NAV – RB, therefore the early activation of the RB generates a widened QRS, with a LBB morphology. ECG 3 Re–entry on Mahaim pathway, ventricular activation widened through Mahaim fiber, which generate LBB morphology with retrograde atrial depolarization. In this case there is no reentry, but we have an atrial tachycardia conducted alternately on an accessory pathway and across the NAV. Given the patient‘s clinical problems and the total absence of symptoms, the patient remains asymptomatic during therapy with amiodarone and beta–blocker.

Economic and clinical benefits of immediate total-body CT in the diagnostic approach to polytraumatized patients: a descriptive analysis through a literature review

Major trauma is an event causing injuries that may determine an immediate or potential risk to the patient survival. A correct management of major trauma is decisive in reducing disability, which has relevance both from the point of view of the quality of life of the single individual and from the point of view of health expenditure. The primary clinical approach to the polytraumatized patients is managed, in most cases, as outlined in the guidelines of Advanced Trauma Life Support, proposing conventional radiological investigations, such as chest and pelvis x-ray, and of FAST (focused abdominal sonography in trauma)/E-FAST (extended FAST) examinations, followed by selective targeted computed tomography (CT). This approach is questionable and is increasingly common in clinical practice the adoption of the immediate total-body CT in the diagnostic approach to the hemodynamically stable polytraumatized patient. However, the potential advantages of such conduct both in terms of clinical benefits and in terms of cost-effectiveness still need to be discussed. The objective of this review article consists of a descriptive analysis of the economic and clinical benefits of the adoption of immediate total-body CT in polytrauma patients through a literature review.

Small bowel obstruction and intestinal ischemia: emphasizing the role of MDCT in the management decision process

The objective of this article is to assess the computed tomography (CT) findings of small bowel obstruction (SBO) complicated by ischemia. SBO is a frequent clinical entity characterized by high morbidity and mortality. The radiologic aim is not just to diagnose the obstruction itself but to rule out the presence of complications related to SBO. This is crucial for differentiating which patients can be safely treated non-operatively from the ones who may need an urgent surgical approach. The main complication of SBO is intestinal ischemia. In the emergency setting, CT imaging is the modality of choice for SBO because of its ability to assess the bowel wall, the supporting mesentery and peritoneal cavity all in one. On the other hand, the radiologist who documents an intestinal ischemia should think about SBO as possible cause. In this case, the main finding which helps the radiologist in the identification of SBO is the presence of multiple and packed valvulae conniventes in the dilated bowel wall and the "transition zone" that indicates the passage between compressed and decompressed small bowel, otherwise the localization of the obstruction cause. Once the site of obstruction has been recognized, the other issue is to assess the cause of obstruction, considering that the most common cause of SBO remains "unidentified" and related to intra-abdominal adhesions. After that, the following most important point is to rule out the presence of an ischemic bowel and mesenteric changes associated to SBO. CT signs of bowel ischemia include reduced or increased bowel wall enhancement, mesenteric edema or engorgement, fluid or free air in the peritoneal cavity. This condition usually leads to an urgent laparotomy and, in some cases, to a surgical resection.

Clinical and radiographical outcome after surgical treatment of periprosthetic type B proximal femur fractures: a retrospective study

PURPOSE

Periprosthetic fractures after hip prosthesis represent a constantly increasing clinical problem and a challenging complication to treat surgically. Among these, type B proximal femur fractures should be diagnosed correctly to be treated surgically. The aim of this study was to re-evaluate the type of surgical treatment of periprosthetic fractures.

METHODS

We examined the cases treated between January 2012 and February 2018, classifying them according to the U.C.S. AO/OTA. We evaluated the radiographic outcome according to the Beals and Tower criteria. Patients still alive were also re-evaluated according to the H.H.S. and the WOMAC score.

RESULTS

We treated 48 patients (12 men, 35 women, average age 81 years), divided into 24 type B1, 14 type B2 and 10 type B3 fractures. The overall consolidation rate was 95.4%, while the major complication (implant dislocation, pseudoarthrosis and deep infection) rate was 12.5%. Clinically, it was possible to reassess 34 patients with a mean follow-up of 38.4 months, an average HHS of 75.89 and a mean WOMAC score of 79.93.

CONCLUSIONS

Periprosthetic type B fractures are difficult to manage and require careful preoperative planning and appropriate intraoperative management. However, the overall clinical and radiographic result was satisfactory, although patients should still be aware of the risk of complications associated with this type of fracture.

The Use of Ceus Software with No Contrast Media Administration in the Diagnosis of Pneumoperitoneum

Background: Pneumoperitoneum is defined by the presence of free air in the abdominal cavity; gastrointestinal perforation is an important cause of this pathological condition. In emergency situations, radiology is considered vital in the early detection and identification of the site and cause of the perforation, which is critical for proper surgical planning. Aim: The aim of our study was to evaluate a new diagnostic US tool, based on the US contrast-specific software generally used during contrast-enhanced US examination (CEUS), without the administration of sonographic contrast media, and to describe the specific imaging features in the detection of free intra-peritoneal air. Subjects and Methods: One hundred and fifty-seven consecutive and hemodynamically stable patients, who arrived in our E.D. with an acute abdomen between April 2018 and October 2019, underwent US and CT examination, performed by three radiologists (with 5, 5, and 25 years of experience). The US was performed first and divided into two steps, using B-mode US and both B-mode and contrast-specific software US, with no contrast media administration. All the patients underwent CT examination. Results: In 32 out of 157 patients, the surgery confirmed GI perforation. CT correctly detected 31 out of 32 patients; the contrast-specific software US identified 30 perforated patients. CT reached a sensitivity value of 97% and specificity value of 100%; contrast-specific software US demonstrated higher values than B-mode US in sensitivity (93% vs. 70%, respectively) and specificity (98% vs. 88%, respectively). Conclusion: the use of contrast-specific software in emergencies improves image quality, and reaches higher levels of sensitivity and specificity with no time delay compared to standard US examination, helping radiologists expedite diagnoses.

Current Standards for and Clinical Impact of Emergency Radiology in Major Trauma

In industrialized countries, high energy trauma represents the leading cause of death and disability among people under 35 years of age. The two leading causes of mortality are neurological injuries and bleeding. Clinical evaluation is often unreliable in determining if, when and where injuries should be treated. Traditionally, surgery was the mainstay for assessment of injuries but advances in imaging techniques, particularly in computed tomography (CT), have contributed in progressively changing the classic clinical paradigm for major traumas, better defining the indications for surgery. Actually, the vast majority of traumas are now treated nonoperatively with a significant reduction in morbidity and mortality compared to the past. In this sense, another crucial point is the advent of interventional radiology (IR) in the treatment of vascular injuries after blunt trauma. IR enables the most effective nonoperative treatment of all vascular injuries. Indications for IR depend on the CT evidence of vascular injuries and, therefore, a robust CT protocol and the radiologist's expertise are crucial. Emergency and IR radiologists form an integral part of the trauma team and are crucial for tailored management of traumatic injuries.

Use of Statins and Hip Fracture Risk: a Case-Control Study

PURPOSE OF THE STUDY To evaluate a possible association between hip fracture and statin use. MATERIAL AND METHODS In this case-control study we compared the use of statins between two groups of 210 patients: the first group (case group) included patients hospitalized for hip fractures while the second group (control group) included patients who did not suffer femur bone injuries. The two groups were matched for age, sex, year of hospitalization and possible confounding factors. Inside the group of cases, we also evaluated the differences in terms of fracture type, presence of previous fragility fracture and mortality between statin users and non-users. RESULTS The use of statins was most common among patients without previous fractures (OR=0.54; 95% CI=0.33-0.89; p=0.0138), especially in older patients (OR=0.40; 95% CI=0.22-0.76). We did not find any significant difference in statin intake between men and women in the control group. In the case group, those who did not use statins were more likely to undergo a medial hip fracture (28.5% vs 16.1%). Patients from case group also presented a greater mortality (27.9% vs 19.35%) and an higher percentage of previous hip fractures (20.11% vs 9.7%). However, they didn't presented a significant higher rate of fragility fractures in other sites. DISCUSSION AND CONCLUSIONS Our study suggests a reduced hip fracture risk, especially in cases aged 80 or more, a different fracture pattern (lower percentage of medial fractures) and a reduced mortality at 9 months in patients treated with HMG-CoA reductase inhibitors, confirming the previous evidences reported in literature. Key words: statin, hip fractures, fracture risk, osteoporosis.

Role of MRI in early follow-up of patients with solid organ injuries: How and why we do it?

Trauma represents one of the most common causes of death or permanent disability in the population below 50 years. At present, non-operative treatment is the commonly adopted strategy in hemodynamically stable patients with solid organ injuries, when there are not concomitant bowel and mesenteric injuries requiring a prompt surgical approach, but it may require multiple imaging follow-up examinations, especially in the case of major injuries. No data are available about magnetic resonance imaging utilization in the early follow-up of trauma patients with solid organ injuries, particularly in liver and spleen trauma. We report our preliminary experience in this field.