Influence of clinical suspicion on CT accuracy of acute mesenteric ischemia: Retrospective study of 362 patients

PURPOSE

Acute mesenteric ischemia (AMI) may be underdiagnosed when not clinically suspected before CT is performed. We assessed the influence of a clinical suspicion of AMI on the CT accuracy.

METHOD

This retrospective single-centre study included patients who underwent CT in 2014-2019 and had clinically suspected AMI and/or confirmed AMI. CT protocols were adapted based on each patient's presentation and on findings from unenhanced images. The CT protocol was considered optimal for AMI when it included arterial and portal venous phases. CT protocols, accuracy of reports, and outcomes were compared between the groups with and without suspected AMI before CT.

RESULTS

Of the 375 events, 337 (90 %) were suspected AMI and 66 (18 %) were AMI, including 28 (42 %) with and 38 without suspected AMI. These two groups did not differ significantly regarding the medical history, clinical presentation, or laboratory tests. The CT protocol was more often optimal for AMI in the group with suspected AMI (26/28 [93 %] vs. 28/38 [74 %], p = 0.046). Diagnostic accuracy was not different between groups with and without suspected AMI (26/28 [93 %] vs. 34/38 [90 %], p = 1.00). However, it was lower in the group without suspicion of AMI when the CT protocol was not optimal for AMI (27/28 [96 %] vs 7/10 [70 %], p = 0.048).

CONCLUSIONS

The negative influence of not clinically suspecting AMI can be mitigated by using a tailored CT protocol.

Prognostic value of adrenal gland volume after cardiac arrest: Association of CT-scan evaluation with shock and mortality

BACKGROUND

Adrenal gland volume is associated with survival in septic shock. As sepsis and post-cardiac arrest syndrome share many pathophysiological features, we assessed the association between adrenal gland volume measured by computerized tomography (CT)-scan and post-cardiac arrest shock and intensive care unit (ICU) mortality, in a large cohort of out-of-hospital cardiac arrest (OHCA) patients. We also investigated the association between adrenal hormonal function and both adrenal gland volume and outcomes.

PATIENTS AND METHODS

Prospective analysis of CT-scan performed at hospital admission in patients admitted after OHCA (2007-2012). A pair of blinded radiologist calculated manually adrenal gland volume. In a subgroup of patients, plasma cortisol was measured at admission and 60 min after a cosyntropin test. Factors associated with post-cardiac arrest shock and ICU mortality were identified using multivariate logistic regression.

RESULTS

Among 775 patients admitted during this period after OHCA, 138 patients were included: 72 patients (52.2%) developed a post-cardiac arrest shock, and 98 patients (71.1%) died. In univariate analysis, adrenal gland volume was not different between patients with and without post-cardiac arrest shock: 10.6 and 11.3 cm³, respectively (p = 0.9) and between patients discharged alive or dead: 10.2 and 11.8 cm³, respectively (p = 0.4). Multivariate analysis confirmed that total adrenal gland volume was associated neither with post-cardiac arrest shock nor mortality. Neither baseline cortisol level nor delta between baseline and after cosyntropin test cortisol levels were associated with adrenal volume, post-cardiac arrest shock onset or mortality.

CONCLUSION

After OHCA, adrenal gland volume is not associated with post-cardiac arrest shock onset or ICU mortality. Adrenal gland volume does not predict adrenal gland hormonal response.

From benign adrenal incidentaloma to adrenocortical carcinoma: an exceptional random event

New European guidelines for the management of adrenal incidentalomas were recently released. One of the most novel recommendations is to stop following patients when they present a typical, small and non-secreting adenoma. We report here the case of a 71-year-old man with such an adenoma, who developed an adrenocortical carcinoma (ACC) fourteen years later, with subsequent metastases and death. Clinically, he had a normal blood pressure and no sign of hormonal hypersecretion. The hormonal work-up showed no hormone excess: urinary free cortisol level was normal, the diurnal cortisol rhythm was respected and urinary catecholamine metabolites levels were normal. Computed tomography (CT) scan showed a homogeneous lesion, with a low density. The lesion remained unchanged during the five years of follow-up. Eight years after the last CT, a large right heterogeneous adrenal mass was incidentally discovered during an ultrasound examination. On CT scan, it was a 6 cm heterogeneous tumor. On hormonal work-up, there was no secretion. The patient was operated of an adrenalectomy, and the histology described an ACC with a Weiss score at 8, with no benign contingent. To our knowledge, this is the first case of an ACC occurring in a patient with prior adrenal imaging showing a typical benign adenoma.

Value of 18-F-FDG PET/CT and CT in the Diagnosis of Indeterminate Adrenal Masses

The purpose of this paper was to study the value of 18-FDG PET/CT and reassess the value of CT for the characterization of indeterminate adrenal masses. 66 patients with 67 indeterminate adrenal masses were included in our study. CT/MRI images and 18F-FDG PET/CT data were evaluated blindly for tumor morphology, enhancement features, apparent diffusion coefficient values, maximum standardized uptake values, and adrenal-to-liver maxSUV ratio. The study population comprised pathologically confirmed 16 adenomas, 19 metastases, and 32 adrenocortical carcinomas. Macroscopic fat was observed in 62.5% of the atypical adenomas at CT but not in malignant masses. On 18F-FDG PET/CT, SUVmax and adrenal-to-liver maxSUV ratio were significantly lower in adenomas than in malignant tumors. An SUVmax value of less than 3.7 or an adrenal-to-liver maxSUV ratio of less than 1.29 is highly predictive of benignity.

[Embolization of a ruptured pseudo-aneurysm of the uterine artery at 26weeks of gestation: Materno-fetal consequences; a case-report]

Rupture of a uterine artery pseudo-aneurysm during pregnancy is a rare condition with potential life-threatening complications, and management should take into account the fetal impact of the therapeutic choice. We report the case of a 2cm left uterine artery pseudo-aneurysm revealed by pelvic pain, in a 30-year-old pregnant woman at 26(+0)weeks of gestation (WG). Diagnosis was suspected at ultrasound scan, and confirmed with Magnetic Resonance angiography that showed signs of pre-rupture. An emergency selective embolization attempted in utero allowed the complete exclusion of the aneurysmal sac. The patient gave birth one month later to a girl at 31(+1)WG, initially managed by neonatologists, who is currently in good health.

Ionizing radiation doses during lower limb torsion and anteversion measurements by EOS stereoradiography and computed tomography

OBJECTIVES

To calculate and compare the doses of ionizing radiation delivered to the organs by computed tomography (CT) and stereoradiography (SR) during measurements of lower limb torsion and anteversion.

MATERIALS AND METHODS

A Rando anthropomorphic phantom (Alderson RANDO phantom, Alderson Research Laboratories Inc., Stanford, Conn) was used for the dose measurements. The doses were delivered by a Somatom 16-slice CT-scanner (Siemens, Erlangen) and an EOS stereoradiography unit (EOS-Imaging, Paris) according to the manufacturers' acquisition protocols. Doses to the surface and deeper layers were calculated with thermoluminiscent GR207P dosimeters. Dose uncertainties were evaluated and assessed at 6% at k=2 (that is, two standard deviations).

RESULTS

The absorbed doses for the principal organs assessed were as follows: for the ovaries, 0.1 mGy to the right ovary and 0.5 mGy to the left ovary with SR versus 1.3 mGy and 1.1 mGy with CT, respectively; testes, 0.3 mGy on the right and 0.4 mGy on the left with SR versus 8.5 mGy and 8.4 mGy with CT; knees, 0.4 mGy to the right knee and 0.8 mGy to the left knee with SR versus 11 mGy and 10.4 mGy with CT; ankles, 0.5 mGy to the right ankle and 0.8 mGy to the left with SR versus 15 mGy with CT.

CONCLUSION

The SR system delivered substantially lower doses of ionizing radiation doses than CT to all the organs studied: CT doses were 4.1 times higher to the ovaries, 24 times higher for the testicles, and 13-30 times higher for the knees and ankles. The use of the SR system to study the torsion of lower limbs makes it possible to reduce the amount of medical irradiation that patients accumulate.

Efficiency and tolerance of mitotane in Cushing's disease in 76 patients from a single center

CONTEXT

Alternatives to transsphenoidal pituitary surgery may be required in Cushing's disease (CD) as a first- or second-line treatment. Mitotane is a potent anti-cortisolic drug but has been rarely investigated in the treatment of CD.

OBJECTIVE

Evaluation of the efficacy and tolerance of mitotane in CD patients.

DESIGN AND SETTING

Retrospective analysis of 76 patients treated with mitotane from 219 patients diagnosed with CD between 1993 and 2009 in a single center.

MAIN OUTCOME MEASURE

Remission was defined as normalization of 24-h urinary free cortisol (24-h-UFC).

RESULTS

Remission was achieved in 48 (72%) of the 67 long-term treated patients, after a median time of 6.7 (5.2-8.2) months. Mean plasma mitotane concentration at the time of remission was 10.5 ± 8.9 mg/l, with a mean daily dose of 2.6 ± 1.1 g. A negative linear relationship was observed between plasma mitotane concentration and 24-h-UFC (P<0.0001). Seventeen of 24 (71%) patients with durable remission subsequently experienced recurrence, after a median time of 13.2 (5.0-67.9) months. At the time of treatment discontinuation, ACTH concentration was statistically associated with a lower recurrence probability (hazard ratios 0.57 (0.32-1.00), P=0.05). Intolerance leading to treatment discontinuation occurred in 19 patients (29%). A pituitary adenoma became identifiable during mitotane treatment in 12 (25%) of the 48 patients with initial negative pituitary imaging allowing subsequent transsphenoidal surgery.

CONCLUSION

Mitotane is useful at different stages of CD. Mitotane dose adjustment based on plasma concentration monitoring and side effects could control hypercortisolism in the majority of CD patients.

Temporal interferon-gamma release response to Mycobacterium kansasii infection in an anorexia nervosa patient

Due to the differences in the management of Mycobacterium kansasii disease and tuberculosis, an accurate diagnosis is required. This report, which describes what we believe to be the first documented case of M. kansasii infection in a patient suffering from anorexia nervosa, sheds light on the possible occurrence of a non-tuberculous mycobacterial infection that can mimic tuberculosis, on the risk of a misleading interpretation of interferon-gamma release assays, and on the temporal response to these tests.

Pregnancy does not accelerate corticotroph tumor progression in Nelson's syndrome

CONTEXT

Pituitary surgery is the first line of treatment for Cushing's disease; when surgery fails, bilateral adrenalectomy may be proposed, particularly for women with a desire for pregnancy. Little is known about the impact of pregnancy on corticotroph tumor progression after bilateral adrenalectomy.

OBJECTIVE

The aim was to evaluate the impact of pregnancy on corticotroph tumor progression after bilateral adrenalectomy in Cushing's disease and to assess maternal and pregnancy outcomes.

DESIGN

We conducted a retrospective cohort study.

SETTING

Patients who became pregnant after bilateral adrenalectomy were followed in a single center.

PATIENTS

Twenty pregnancies from 11 patients with Cushing's disease were treated by bilateral adrenalectomy and no pituitary irradiation.

MEASUREMENTS

Corticotroph tumor progression was assessed by serial pituitary magnetic resonance imaging and plasma ACTH measurements before, during, and after pregnancy. Comparisons were performed using paired Wilcoxon rank tests. Data on maternal and neonatal outcomes were recorded by correspondence from patients and obstetricians.

RESULTS

Corticotroph tumor progression occurred in eight of 17 pregnancies, and ACTH increased in eight of 10 pregnancies. However, rates of increase during or after pregnancy were not faster than those observed before pregnancy. Maternal complications occurred in four pregnancies from two patients, including gestational hypertension in three and gestational diabetes mellitus in three. Among these four pregnancies, three had a favorable outcome, and one led to an in utero death after eclampsia, due to loss to follow-up. No other maternal or fetal complications were reported.

CONCLUSION

Pregnancy does not accelerate corticotroph tumor progression after bilateral adrenalectomy. Pregnancy is manageable, provided the patients can be followed closely.

Recurrent liver abscess secondary to ingested fish bone migration: report of a case

Pyogenic liver abscess is an unusual cause of fever and abdominal pain, but it is potentially fatal. It is rarely caused by a local event, but rather by hematogenous dissemination or biliary tract disease. We report an uncommon case of liver abscess caused by the migration of a fish bone through the gastrointestinal wall.

Inter- and intra-observer variability in detection and progression assessment with MRI of microadenoma in Cushing's disease patients followed up after bilateral adrenalectomy

OBJECTIVE

To assess the inter- and intra-observer variability in detection and progression assessment with MRI of pituitary microadenomas in cases of Cushing's disease treated by adrenalectomy.

DESIGN AND METHODS

Two radiologists independently reviewed initial and follow-up MRI studies of 32 patients with a history of Cushing's disease on two occasions each. Five classical qualitative signs and three quantitative measurements of microadenoma were considered. Intra and inter-observer reproducibility was evaluated with kappa statistics (qualitative signs) and intraclass correlation coefficients and Bland-Altman plots (quantitative measurements).

RESULTS

No sign or measurement could be identified as better than others and none displayed consistently high levels of inter- or even intra-observer reproducibility (kappa or intraclass correlation coefficient > 0.80). Both qualitative and quantitative criteria showed lower reproducibility when used for diagnosing progression than when used for diagnosing the presence of an adenoma. Reproducibility of qualitative signs appeared to be influenced by reader's experience.

CONCLUSIONS

Pituitary MRI study of patients with Cushing disease treated by adrenalectomy remains difficult. In practice, interpretation of MRI studies by a well-experienced reader should be preferred, unless a final decision can be reached by consensus between two and several readers.

Succinate dehydrogenase B gene mutations predict survival in patients with malignant pheochromocytomas or paragangliomas

CONTEXT

Pheochromocytomas and paragangliomas may be malignant either at presentation or during recurrence, but the clinical course of malignant tumors is unpredictable.

OBJECTIVE

The objective was to analyze survival according to clinical characteristics at diagnosis of malignancy and the presence or absence of SDHB mutations.

DESIGN

This was a retrospective cohort study.

SETTING AND PARTICIPANTS

A total of 54 patients with malignant tumors were included. Malignancy was scored according to the presence of metastases or histologically documented lymph node invasion.

MAIN OUTCOME MEASURES

The main outcome was the specific survival after the diagnosis of the first metastasis.

RESULTS

Germline mutations were identified in SDHB (n = 23, including 21 patients with apparent sporadic tumors) and VHL (n = 1) genes, and two patients had neurofibromatosis 1. Patients were followed up from the diagnosis of primary tumor and from the diagnosis of the first metastasis to the present or to death with medians of 79 [interquartile range (IQR) 24; 190] and 39 [IQR 14; 94] months, respectively. The 5-yr probability of survival after the diagnosis of the first metastasis was 0.55 (95% confidence interval 0.39-0.69). Patients with SDHB mutations were younger, more frequently had extra-adrenal tumors, and had a shorter metanephrine excretion doubling time. The presence of SDHB mutations was significantly and independently associated with mortality (relative risk 2.7; 95% confidence interval 1.2, 6.4; P = 0.021).

CONCLUSION

SDHB mutations, frequent in patients with malignant pheochromocytomas or paragangliomas, are associated with shorter survival. Therefore, SDHB genetic testing may be of prognostic value for such patients, even those with an apparent sporadic and/or benign presentation at diagnosis.

[A pancreatic pseudocyst associated with three simultaneous hemorragic complications]

The onset of secondary hemorrhagic complications with the development of pancreatic pseudocysts is rare but has a high mortality rate. Management of the hemorrhagic complications of pancreatic pseudocysts is surgical despite the contribution of arterial embolization. We report the observation of a 59-year-old patient who had presented an episode of acute pancreatitis 1 month before consulting for abdominal pain associated with an episode of melena. The CT showed a pancreatic pseudocyst complicated by an intracystic tear, a splenic artery aneurysm in the Wirsung canal, and rupture of the spleen. These three lesions were treated simultaneously with left splenopancreatectomy starting with the splenic vessels. The simultaneous onset of three hemorrhagic complications of a pseudocyst is exceptional and has never been described to our knowledge.

[Sinonasal and cerebral imaging findings in Wegener's granulomatosis]

Sinonasal CT must be studied with both soft tissue and bone algorithms. Sinonasal findings in Wegener's granulomatosis are mucosal thickening, subtotal opacification, air-fluid level, bony destruction (mainly of the nasal septum), and sclerosing osteitis. Orbital MRI helps to define the extent of the disease. Contiguous granulomatous infiltration of the orbit appears dark (hypointense signals) on both T2-weighted-and T1-weighted images, but is enhanced after gadolinium administration. Cerebral MRI findings include diffuse linear dural thickening, enhanced by injection, and local dural thickening contiguous with orbital, nasal and paranasal disease. The remote granulomatous lesions in brain parenchyma are the least common form of central nervous system lesion. The pituitary gland and infundibulum can also be involved in Wegener's granulomatosis. These imaging findings of Wegener's granulomatosis are nonspecific. They should be combined with clinical examination and c-ANCA tests to confirm the diagnosis.

[Radiologically-guided hysterosalpingography and tubal catheterization]

Radiological exploration of hypofertility by means of hysterosalpingography is a method still valid but no longer sufficient. Tubal catheterization has thus become a necessary complementary exam in order to eliminate the pseudo-obturations of hysterosalpingography and, in case of proximal tubal obstructions, to obtain pregnancies. The conditions for the realization of hysteroalpingography and tubal catheterization are hereby described, with emphasis on the rigorous technique that is required together with careful listening to the patients.

[Coronary artery implantation and course abnormalities: the contribution of multislice CT]

Abnormalities in coronary artery origin and course are rare and often asymptomatic. However, visualizing them is of great interest because they can be responsible for iatrogenic trauma during cardiac surgery, and, for some of them, for myocardial infarction, which can lead to sudden death. We show the contribution of multislice CT in the positive diagnosis of these anatomic variations and in the differential diagnosis between benign and malignant forms, potentially responsible for myocardial ischemia.

Corticotroph tumor progression after adrenalectomy in Cushing's Disease: A reappraisal of Nelson's Syndrome

CONTEXT

Adrenalectomy is a radical treatment for hypercortisolism in Cushing's disease. However, it may lead to Nelson's syndrome, originally defined by the association of a pituitary macroadenoma and high plasma ACTH concentrations, a much feared complication.

OBJECTIVE

The objective of the study was to reconsider Nelson's syndrome by investigating corticotroph tumor progression based on pituitary magnetic resonance imaging scan and search for predictive factors.

DESIGN

This was a retrospective cohort study.

SETTING

The complete medical records of Cushing's disease patients at Cochin Hospital were studied.

PATIENTS

Patients included 53 Cushing's disease patients treated by adrenalectomy between 1991 and 2002, without previous pituitary irradiation.

MEASUREMENTS

Clinical data, pituitary magnetic resonance imaging data, and plasma ACTH concentrations for all patients and pituitary gland pathology data for 25 patients were recorded. Corticotroph tumor progression-free survival was studied by Kaplan-Meier, and the influence of recorded parameters was studied by Cox regression.

INTERVENTION

There was no intervention.

RESULTS

Corticotroph tumor progression ultimately occurred in half the patients, generally within 3 yr after adrenalectomy. A shorter duration of Cushing's disease (adjusted hazard ratio: 0.884/yr), and a high plasma ACTH concentration in the year after adrenalectomy [adjusted hazard ratio per 100 pg/ml (22 pmol/liter): 1.069] were predictive of corticotroph tumor progression. In one case, corticotroph tumor progression was complicated by transitory oculomotor nerve palsy. During follow-up, corticotroph tumor progression was associated with the increase of corresponding ACTH concentrations (odds ratio per 100 pg/ml of ACTH variation: 1.055).

CONCLUSION

After adrenalectomy in Cushing's disease, one should no longer wait for the occurrence of Nelson's syndrome: modern imaging allows early detection and management of corticotroph tumor progression.

Spontaneous intracerebral hematoma on diffusion-weighted images: influence of T2-shine-through and T2-blackout effects

BACKGROUND AND PURPOSE

On diffusion-weighted (DW) images, primary hematomas are initially mainly hyperintense, and then hypointense during the first few days after stroke onset. As in other brain disorders, variations in the T2 relaxation time of the hematoma influence the DW imaging signal intensity. Our aim was to evaluate the contribution of the T2 signal intensity and apparent diffusion coefficient (ADC) changes to signal intensity displayed by DW imaging through the course of hematoma.

METHODS

The MR images of 33 patients with primary intracranial hemorrhage were retrospectively reviewed. Variations in T2-weighted echo planar images, DW imaging signal intensity, and apparent diffusion coefficient (ADC) ratios (core of hematoma/contralateral hemisphere) were analyzed according to the putative stages of hematoma, as seen on T1- and T2-weighted images.

RESULTS

On both T2-weighted echo planar and DW images, the core of the hematomas was hyperintense at the hyperacute (oxyhemoglobin, n = 11) and late subacute stages (extracellular methemoglobin, n = 4), while being hypointense at the acute (deoxyhemoglobin, n = 11) and early subacute stages (extracellular methemoglobin, n = 7). There was a positive correlation between the signal intensity ratio on T2-weighted echo planar and DW images (r = 0.93, P < .05). ADC ratios were significantly decreased in the whole population and in each of the first three stages of hematoma, without any correlation between DW imaging findings and ADC changes (r = 0.09, P = .6).

CONCLUSION

Our results confirm that the core of hematomas is hyperintense on DW images with decreased ADC values at the earliest time point, and may thus mimic arterial stroke on DW images. T2 shine-through and T2 blackout effects contribute to the DW imaging findings of hyperintense and hypointense hematomas, respectively, while ADC values are moderately but consistently decreased during the first three stages of hematoma.

[Imaging of non-traumatic intracerebral hematoma]

Intracerebral hematoma is mainly due to the spontaneous rupture of small vessels damaged by chronic hypertension or amyloid angiopathy. In some cases, intracerebral hemorrhage may be associated with a vascular malformation, a tumor, venous thrombosis or hemorrhagic transformation of a cerebral infarct. The objective of brain imaging is to identify the hematoma according to its different stages and to find a potential underlying cause because of the risk of recurrence and the possibilities of treatment. In emergency, a diagnosis of hematoma may be obtained by CT scan or MRI but the etiologic work-up requires early MRI. According to the patient's age, the medical history and the location of the hematoma, it may be necessary to perform conventional angiography in order to exclude an intracranial vascular malformation. The aim of this review is to detail the different aspects of intracerebral hemorrhages and to discuss the main causes that can be found at brain imaging.