A bump in the neck. Myositis ossificans of the omohyoid muscle: Imaging findings

Myositis ossificans is a benign ossifying soft-tissue mass that occurs in muscle. In the majority of cases it is related to trauma but rarely observed in the neck. A 54 year-old-man with history of minor trauma and anticoagulant drug assumption for V Leiden mutation, was referred to our institution for a painless mass in the right supraclavicular fossa. On CT plan study a mass with negative attenuation values located in the posterior triangle of the neck, into the inferior belly of the right omohyoid muscle was evident. On MRI the lesion appears as an ovalar mass, with smooth borders, isointense to muscles on T1 images, isointense to fat on T2 images, intensely enhancing after i.v. Gd administration. After surgical removal the pathologist concluded for the nature of myositis ossificans. This is the first case, as far as we know, reported in the literature of a myositis ossificans arising in the inferior belly of the omohyoid muscle in a patient treated with dicumarol.

Moderate hypofractionated helical tomotherapy for prostate cancer in a cohort of older patients: a mono-institutional report of toxicity and clinical outcomes

PURPOSE OR OBJECTIVE

To evaluate toxicity and outcomes of moderately hypofractionated helical tomotherapy for the curative treatment of a cohort of patients aged ≥ 75 years with localized prostate cancer (PC).

MATERIALS AND METHODS

From January 2013 to February 2017, 95 patients with median age 77 years (range 75-88) were treated for PC. 39% were low risk, 33% intermediate risk (IR), 28% high risk (HR). Median iPSA was 9.42 ng/ml (1.6-107). Androgen deprivation was prescribed according to NCCN recommendations. All patients received 70 Gy in 28 fractions to the prostate; 61.6 Gy were delivered to the seminal vesicles for IR; whole pelvis irradiation with a total dose of 50.4 Gy was added in the HR group. Toxicity evaluation was based on CTCAE V4.0 criteria, biochemical failure was defined following Phoenix criteria. Quality of Life was assessed with the EPIC-26 index. Overall survival and biochemical failure-free survival were analysed with Kaplan-Meier method.

RESULTS

With a median follow-up of 36 months (range 24-73), acute and late toxicity were acceptable. No correlation between toxicity patterns and clinical or dosimetric parameter was registered. EPIC-26 showed a negligible difference in urinary and bowel function post-treatment that did not reach statistical significance. The 2- and 3-years OS were 93% and 87% with cancer specific survival of 97.9% and 96.2%.

CONCLUSION

Moderate hypofractionated RT reported excellent outcomes in our cohort of older patients. Shorter schedules may be proposed regardless of chronological age facilitating the treatment compliance in the older population.

Barotraumatic blowout fracture of the orbit after sneezing: Cone beam CT demonstration

A 40-year-old man with no history of trauma or previous sinus surgery complained sudden right diplopia after vigorous sneezing. The patient was submitted elsewhere to a MRI study for persisting diplopia, with inconclusive findings. One week later the patient was submitted to a maxillofacial cone beam CT (CBCT) in our Institution. A blowout fracture of the right orbital floor and lateral orbital wall with an intact orbital rim and a ipsilateral maxillary sinus effusion with an air liquid level, were detected at the CBCT study. Our conclusion, confirmed by the clinician, was the patient had a barotraumatic, isolated, pure blowout fracture of the right orbit consequence of the episode of vigorous sneezing. The patient was treated by steroid and antibiotic therapy and diplopia resolved after two weeks. Clinicians and radiologists should be aware that a barotraumatic blowout fracture of the orbit after sneezing should be included among the unusual causes of sudden diplopia.

Secondary septal mucocele diagnosed by MRI and CBCT and treated surgically

OBJECTIVE

Here we report a case of a mucocele of the nasal septum diagnosed by MRI and cone beam CT (CBCT) 23 years after Ogston Luc surgery.

METHOD

A 49-year-old man with nasal obstruction was examined by endoscopy, MRI, and CBCT.

RESULTS

Endoscopy showed a smooth and soft septum swelling. MRI revealed an ovalar lesion with high-intensity content on both T1 and T2 images, and a peripheral enhancing rim after i.v. administration of contrast medium. CBCT revealed that the lesion was located in the posterior portion of the septum involving the perpendicular plate of the ethmoid, and destroying the anterior ethmoid cells on the left side but sparing the left lamina papyracea. The patient underwent endoscopic marsupialization of the lesion.

CONCLUSION

A mucocele of the nasal septum is a rare occurrence. MRI and CBCT are effective and affordable diagnostic tools for this condition, enabling differentiation of mucocele from other sinonasal diseases.

Intratumoral haemorrhage causing an unusual clinical presentation of a vestibular schwannoma

We present a case of an elderly woman with no history of audiological disease with sudden onset of visual and hearing deficits associated with systemic clinical signs. On examination she had impairment of right CNs from V to X. CT and MR imaging demonstrated a cystic vestibular schwannoma with a rare intralesional fluid-fluid level correlated to a recent bleed. We include high quality MR images to show the acute impairment of the cranial nerves next to the tumour after acute bleeding. Our case report includes a voxel-based morphometry (VMB) analysis of the tumour that, as far as we know, has never been done before for such a tumour. VBM analysis was performed to calculate the hypothesized volume changes after the acute bleed which likely resulted in a sudden increase in the overall size of the tumour resulting in atypical clinical signs and symptoms due to the establishment of a mechanical conflict with the adjacent cranial nerves.

Comparison of iodinated contrast media for the assessment of atherosclerotic plaque attenuation values by CT coronary angiography: observations in an ex vivo model

OBJECTIVE

To compare the influence of different iodinated contrast media with several dilutions on plaque attenuation in an ex vivo coronary model studied by multislice CT coronary angiography.

METHODS

In six ex vivo left anterior descending coronary arteries immersed in oil, CT (slices/collimation 64×0.625 mm, temporal resolution 210 ms, pitch 0.2) was performed after intracoronary injection of a saline solution, and solutions of a dimeric isosmolar contrast medium (Iodixanol 320 mgI ml(-1)) and a monomeric high-iodinated contrast medium (Iomeprol 400 mgI ml(-1)) with dilutions of 1/80 (low concentration), 1/50 (medium concentration), 1/40 (high concentration) and 1/20 (very high concentration). Two radiologists drew regions of interest in the lumen and in calcified and non-calcified plaques for each solution. 29 cross-sections with non-calcified plaques and 32 cross-sections with calcified plaques were evaluated.

RESULTS

Both contrast media showed different attenuation values within lumen and plaque (p<0.0001). The correlation between lumen and non-calcified plaque values was good (Iodixanol r=0.793, Iomeprol r=0.647). Clustered medium- and high-concentration solutions showed similar plaque attenuation values, signal-to-noise ratios (SNRs) (non-calcified plaque: medium solution SNR 31.3±15 vs 31.4±20, high solution SNR 39.4±17 vs 37.4±22; calcified plaque: medium solution SNR 305.2±133 vs 298.8±132, high solution SNR 323.9±138 vs 293±123) and derived contrast-to-noise ratios (p>0.05).

CONCLUSION

Differently iodinated contrast media have a similar influence on plaque attenuation profiles.

ADVANCES IN KNOWLEDGE

Since iodine load affects coronary plaque attenuation linearly, different contrast media may be equally employed for coronary atherosclerotic plaque imaging.

Pediatric sialolithiasis distinctive characteristic in radiological imaging

AIM

Aim of the present paper was to investigate the imaging and related clinical characteristics of sialolithiasis in Italian pediatric population trying to determine the difference between pediatric and adult.

METHODS

Twenty-nine pediatric patients (age range 1-17 years) with pain and postprandial swelling and/or purulent discharge in the salivary gland areas were referred to radiology department after pediatric ear, nose and throat (ENT) evaluation. They all were submitted to ultrasound examination of the main salivary glands. Multidetector computed tomography (MDCT) only was performed in 2/6 patients, in 2/6 patients both sialography and MDCT were performed due to inconclusive MDCT features, 2/6 only sialography was performed. Sialoliths were classified on their location and size.

RESULTS

In 6 out of 29 patients (4 males, 2 females, age range 1-17 years) salivary stones were detected. Sialoliths were detected in 5/6 patients in the submandibular gland and 1/6 in the parotid gland. All sialoliths, excepted for a case of multiple sialoliths, were located in the distal part of the main salivary ducts.

CONCLUSION

Imaging characteristics of sialolith in pediatric group are similar than in adult population in few aspects. In fact sialoliths are smaller in size and located more frequently in the distal part of the main salivary duct, than in adult, making sialography cannulation more complex and requiring short thickness in MDCT.

Sialographic findings in Wharton duct evagination

Ductal evagination is a rare condition affecting the Wharton duct. The aim of this study was to establish the incidence, imaging features and clinical significance of ductal evagination in patients undergoing submandibular gland sialography. The sialographic findings and reports of 322 patients undergoing submandibular gland sialography during the period 1998-2007 were retrospectively reviewed. Ductal evagination was identified on sialograms as a unique diverticulum, filled with contrast medium, of the Wharton duct, with a narrow neck and a blind end. A ductal evagination was found in 5/322 patients with swelling and pain in the submandibular gland. It was always located in the middle tract of the Wharton duct. Other findings were: in 5/5 patients, an enlargement of the primary and secondary ducts due to sialodochitis; in 3/5 patients, salivary stones; in 1/5 patients, a sinuous distal tract of the Wharton duct; in 2/5 patients, a stenosis of the proximal tract of the Wharton duct. In our series, the incidence of wharton duct evagination was 1.6% incidence. It may represent a form of duct wall weakness although its cause is uncertain. It is, however, a condition that needs to be highlighted on sialograms for eventual inflammatory consequences or in guiding sialoendoscopy to avoid eventual ductal perforation.

A rare case of pedunculated bronchial hemangioma

We describe a rare case of pedunculated endobronchial hemangioma observed in a 60-years-old patient complaining of chronic productive cough and accessional dyspnea which had been progressively worsening over 20 years. The lesion was first noticed at fiberoptic bronchoscopy; then computed tomography scan was performed and integrated with tridimensional reconstruction techniques. Pathology showed the picture of a vascular neoplasm, compatible with capillary hemangioma. The lesion was submitted to laser-assisted endoscopic removal in order to relieve the obstruction, leading to remission of symptoms.

Morbidity of salivary gland digital sialography using a non-ionic dimeric contrast medium

AIM

Sialography is considered a low invasive procedure, due to cannulation of salivary duct orifice. The aim of this study was to evaluate the morbidity of sialography using a nonionic dimeric contrast medium.

METHODS

A questionnaire was proposed to 90 patients who underwent parotid and submandibular sialography to reveal related symptoms as: pain, swelling, impairment to daily activities and taste alteration. Pain and swelling intensity was assessed using a visual analogue scale (VAS).

RESULTS

Fifty-two out of ninety questionnaires were returned. Sialography was performed in 30/52 patients in the submandibular gland, 22/52 in the parotid gland. Pain during sialography was complained by 28/52 patients with a 2.4 mean VAS score. Pain after sialography, was reported by 17/52 patients with a 1.3 mean VAS score. Swelling was reported by 25/52 patients with a 2.4 mean VAS score; 48/52 patients returned immediately to daily activities; 8/52 complained different taste alterations.

CONCLUSION

Main related symptoms for submandibular and parotid sialography are pain and swelling, spontaneously resolving after 24-48 hours in most of cases. The statistical analysis also demonstrated in patients who underwent submandibular sialography the onset of pain during the procedure is significantly related to an increase of pain after the examination. Thus in patients, who referred severe pain during sialography, antiinflammatory drugs are recommended to control the onset of pain after sialography.

Bisphosphonate-related osteonecrosis of the jaw (BRONJ): run dental management designs and issues in diagnosis

Recently, jawbone osteonecrosis has been largely reported as a potential adverse effect of bisphosphonate (BP) administration. Because of the peculiar pharmacokinetic and pharmacodynamic features of the BF (mainly for i.v. administration), their efficacy and large use, some major issues have to be taken into account extendedly both by oncologists and by dentists: 1) therapeutic dental protocol for patients with diagnosis of bisphosphonate-related osteonecrosis of the jaw (BRONJ); 2) dental strategies for patients in former or current i.v. BF treatment and in absence of BRONJ signs; 3) strategies for patients before i.v. BF treatment. Clinical features and guidelines for the management of this condition have been investigated and reported, sometimes with unclear indications; hence, on the basis of the literature and our clinical experience, major end points of this paper are providing our run protocols for the issues above described and, finally, focusing on a crucial, but not extensively investigated point: the early and correct diagnosis of BRONJ versus metastatic jaw lesions in cancer patients.

Sialodochoplasty in the treatment of salivary-duct stricture in chronic sialoadenitis: technique and results

PURPOSE

This study was undertaken to investigate peroral balloon angioplasty of salivary-duct strictures (sialodochoplasty) in chronic sialadenitis, analysing the technique, results and limitations.

MATERIALS AND METHODS

Nine patients underwent sialodochoplasty: seven for Stensen's-duct strictures and two for Wharton's-duct strictures. One patient had a double stricture of Stensen's duct and another a salivary stone associated with a Wharton's-duct stricture. All patients were subjected to preliminary sialography to evaluate stricture site, length and grade. Sialodochoplasty was performed after local anaesthesia and progressive dilation of the salivary-duct orifice.

RESULTS

The stricture was successfully dilated in 7/9 patients. The stricture was unchanged after dilatation in one patient, and in another, it recurred after 13 months. In the patient with a double stricture of Stensen's duct, one was resolved and the other was only partially dilated, with significant symptom improvement. One patient developed a new episode of sialadenitis after 3 months, which resolved with medical therapy. Five out of seven patients were asymptomatic at follow-up.

CONCLUSIONS

Sialodochoplasty is an effective procedure in the treatment of salivary-duct strictures, improving symptoms in the majority of patients. The procedure is repeatable and can be proposed as a first-line treatment for symptomatic salivary-duct stricture.

MRI findings in lingual venous malformations

OBJECTIVES

To describe the plain and enhanced MRI findings of lingual venous malformations and to discuss the importance of contrast medium in the differential diagnosis of high intensity lesions of the tongue on T(2) weighted images.

METHODS

The clinical records and MR images of eight patients affected by a lingual venous malformation were retrospectively reviewed. Patients presented with a palpable submucosal bluish-red soft mass in the tongue. MRI examinations were performed on a 0.5 T superconducting unit. Plain and enhanced SE (spin echo) T(1) weighted and FSE (fast spin echo) T(2) weighted images were acquired in axial, sagittal and coronal planes. Axial SPGR (spoiled gradient recalled echo) T(1) weighted images were also obtained before and after intravenous (i.v.) injection of paramagnetic contrast medium.

RESULTS

Five of eight venous malformations were located at the tip of the tongue. The other three involved the whole tongue and had an extralingual extent; two extended into the submandibular space and one into the glossoepiglottic valleculae. The largest diameter ranged from 2.5 cm to 8 cm. All lingual venous malformations presented as lobulated masses that were slightly hyperintense or isointense on T(1) weighted images and highly hyperintense on T(2) weighted images with respect to normal tongue and/or surrounding muscles. They showed a slow and homogeneous filling following iv injection of contrast medium. Millimetre-sized hypointense foci and linear hypointense strands were sometimes noticed, which were owing to phleboliths, flow void or septation.

CONCLUSION

Knowledge of MRI findings of lingual venous malformations is useful for differential diagnosis with other high intensity lingual lesions on T(2) weighted images. This discrimination is achievable using iv paramagnetic contrast medium.

Isolated hydatid disease of the spleen: CT findings in 4 patients and differential diagnosis

AIM

To report our experience with four cases of isolated hydatid disease of the spleen studied by spiral Computed Tomography (CT) and to review the literature with special attention to the differential diagnosis with other focal lesions of the spleen.

MATERIALS AND METHODS

The spiral CT images and clinical records of four patients (1 man, 3 women; age range 26-45 yrs) affected by isolated hydatid disease of the spleen were retrospectively evaluated. None of the patients had a history of hydatid disease. All the patients were evaluated by plain and enhanced spiral CT of the abdomen. All patients underwent preoperative chest X-ray and surgery; all surgical specimens were studied by histology.

RESULTS

Spiral CT depicted all the hydatid lesions of the spleen. It showed the location, size, low density of their content without enhancement after iv contrast medium injection, the possible presence of daughter cysts, the appearance of the wall with calcifications, and excluded the presence of complications. The preoperative chest X-ray was negative for focal pulmonary lesions in all cases. Pathology confirmed the diagnosis of hydatid disease in all cases.

CONCLUSIONS

According to our results and to the literature, spiral CT plays an important role in the pre-surgical evaluation of patients with hydatid disease of the spleen, and provides useful information for differentiating the disease from other isolated cyst-like lesions of the spleen.

Intra-articular osteoid osteoma: diagnostic imaging in three cases

PURPOSE

To report our experience pertaining to three cases of intra-articular osteoid osteoma assessed by means of integrated imaging and review of literature.

MATERIALS AND METHODS

Medical records, radiologic and nuclear medicine findings pertaining to three cases of intra-articular osteoid osteoma were retrospectively evaluated and compared with those of surgery. All the patients (2 males, one female; age range 8-38 ys) affected by intra-articular osteoid osteoma respectively of the elbow, tibio-talar joint and hip were evaluated by means of radiographic examination and Magnetic Resonance Imaging (MRI). SE T1-w and T2-w, GRE T2*-w, GRE 3D T1-w and STIR pulse sequences were used and axial, coronal and sagittal images were acquired. Two patients underwent CT scan. One patient underwent skeletal scintigraphy. All the patients underwent surgery.

RESULTS

In 2 out of 3 cases plain radiography allowed the radiologist to suspect the presence of the lesion. In the remaining one, plain radiography failed to detect both the nidus and the perilesional osteosclerosis; nevertheless, a small osteochondral erosion of the humeral condyle suggested the presence of joint inflammation, thus leading to further investigation. CT scan well depicted the presence of the nidus and, in one case, the presence of joint effusion. MRI was always able to detect the nidus, which presented as lesion of low to intermediate signal in T1-w images, low signal in the T2-w images in one patient and high signal in the remaining two; in these latter STIR images showed high intensity nidus and edema of neighbouring cancellous bone. Furthermore, in all patients MRI clearly depicted joint effusion. Skeletal scintigraphy demonstrated both the lesion and the inflammatory involvement of neighbouring soft tissue. In all patients histologic specimen confirmed the diagnosis of osteoid osteoma with joint inflammation and synovitis.

CONCLUSIONS

According to our results and literature data the pre-surgical diagnosis of osteoid osteoma is very difficult to achieve. Indeed, only the combination of clinical information and radiologic and nuclear medicine findings enables the radiologist to make the right diagnosis.

Interventional treatment of sialoliths in main salivary glands

PURPOSE

The aim of our study was to demonstrate the effectiveness of interventional radiology in the treatment of sialolithiasis, as the first-choice treatment for the removal of stones located in the middle and proximal tracts of the main salivary ducts, and to assess its limitations and contraindications.

MATERIAL AND METHODS

Between February 1998 and May 2001 eleven interventional removals of sialoliths were performed for recurrent obstruction of the main salivary duct associated with chronic sialadenitis. Patients were selected on the basis of a preliminary sialogram, designed to determine the location and size of the stone. Exclusion criteria were location of the stone in the gland hilum or intraglandular stone, maximum stone diameter >20% of the duct calibre, signs of adherence of the stone to the duct wall. Stone removal, performed after obtaining informed consent, involved administering antibiotic therapy and local anaesthesia, and dilatating the duct ostium to enable introduction of the basket catheter. The basket was then advanced along the duct under fluoroscopic guidance and suitably manoeuvred so as to capture and extract the stone. On completing the procedure a sialogram was taken to ensure the complete patency of the duct. Patients were prescribed a short course of antibiotics and were followed up at 1, 3 and 6 months.

RESULTS

In 10/11 patients the stone was located in Wharton's duct and in 1/11 in Stensen's duct. Removal of the calculus was successful in 10/11 patients; in 2 of these it was necessary to reintroduce the basket after extraction of the stone, in order to eliminate small stone fragments and salivary sand; in 1 patient a preliminary balloon-catheter sialoplasty was performed prior to the procedure to dilatate a distal stenosis caused by chronic sialadenitis; in 3 patients it was necessary to make a small incision in the orifice to introduce the dilator. Removal of the sialolith was unsuccessful in 1/11 of the patients treated, as it proved impossible to capture the calculus, even after repeated attempts. 8/11 patients reported pain during the procedure and swelling in the gland region immediately after the procedure, which resolved spontaneously within 24-48 hours. 9/11 patients remained asymptomatic in the follow-up; only 1/11 patients experienced a recurrence of sialadenitis after a short time, with pus secretion, which resolved with antibiotic treatment.

CONCLUSIONS

The interventional removal of sialoliths in the salivary glands is an effective alternative to the conventional treatment of obstructive diseases of the glandular ducts.

Analysis of radioactive pollution in the Gulf of Palermo

PURPOSE

Sea water represents more than three quarters of the whole world. The radioactive fall out caused by nuclear experiments, radioactive drosses from nuclear power plants and other pollution sources, are able to contaminate the world ecosystems, and especially the sea water. The aim of this work is the evaluation of a possible radioactive pollution in the Gulf of Palermo.

MATERIAL AND METHODS

The Gulf of Palermo was divided into 5 homogeneous hydrological parts, in which fish and water were collected. The dosage of 131I e del 137Cs was mainly assessed because they have a long half-life and their presence in the water can be due to nuclear accidents but also to a wrong removal of the waste materials of nuclear medicine procedures; the other radioisotopes assessed (144Ce, 106Rh, 140La) are due only to nuclear fall-out. Gamma spectrometry technique was used for the evaluation of the radioisotopes' concentration after an adequate treatment of the samples.

RESULTS AND CONCLUSIONS

The concentration of the examined radionuclides was below the instrumental capability apart from the 137Cs, whose dose was increased, and can be due to nuclear accidents and explosions. The radionuclide levels detected do not determine a higher risk than normal for the population's health even regard the eatablity of ittical species.

[Adult intestinal intussusception: comparison between CT features and surgical findings]

PURPOSE

To report our experience in the use of CT in the evaluation of adult intestinal intussusception. A correlation between radiologic findings and surgery was attempted in order to verify our diagnostic hypothesis.

MATERIAL AND METHODS

Intestinal intussusception was diagnosed by CT between September 1993 and December 2000 in 10 patients (6 men and 4 women, age range 18-82 years). For 9/10 patients the diagnosis was confirmed by surgery; in one patient the condition resolved spontaneously as confirmed by a follow-up CT performed 24 hours after the first. Six patients were studied by a third generation CT and four by a helical CT unit. Five patients were administered iodinated oral contrast medium and in seven i.v. iodinated contrast medium. Diagnosis was hypothesized at CT on the basis of the following aspects: target, sausage, and pseudokidney.

RESULTS

Surgery confirmed the CT diagnosis of intussusception in 9/10 patients; in the patient with transient intussusception a spontaneous resolution was confirmed at follow up CT after 24 h. In the 10 patients studied the following CT aspects were observed in the bowel involved by intussusception: a target aspect in 4 patients; a sausage aspect in 4 patients; in one of them a peritoneal effusion was also present; a pseudokidney aspect was observed in 2 patients, with a long tract intussusception and peritoneal adipose tissue; in both a hyperdensity of the peritoneal adipose tissue and enlarged vessels, that were herniated within the lumen of the bowel, were recognized. At surgey the causes of intestinal intussusception were: malignant tumors of the colon (4 cases), hamartomatous polyps of the small bowel (2 cases), mixoid fibrolipoma of the colon (one case), leiomyoma of the distal ileum (one case). In one patient no cause could be identified at CT, but the condition was found to co-exist with acute appendicitis at surgery.

CONCLUSIONS

CT is an accurate technique in the evaluation of intestinal intussusception in adults. It allows to identify the condition, its site, and sometimes the type of the lesion causing the intussusception, and any vascular alteration, thus playing an important role in establishing the most appropriate therapeutic strategy.

[Anastomosis between the left internal spermatic and splanchnic veins. Retrospective analysis of 305 patients]

PURPOSE

To investigate the presence and the rate of anastomoses between the internal spermatic vein (ISP) and visceral veins in patients with idiopathic varicocele.

MATERIAL AND METHODS

We retrospectively reviewed the venographic findings of 305 patients (age range 14-40 years; mean age 28 years) with a US diagnosis of varicocele who were submitted to sclerotherapy from 1991 to 1997. All the venographic examinations had been carried out with selective injection of the ISP for complete mapping of gonadal vessels.

RESULTS

The most frequent venographic patterns (type I) was identified in 139/305 patients (45.5%), type III was found in 86/305 (28.2%), type V in 37/305 (12.1%). Type IVb was found in 32 cases (10.4%) and type IVa in 9 (2.9%). Type II was seen in 2/305 patients only (0.6%). Single or double anastomoses between the ISP and portal or systemic veins were found in 34 patients (11.1%); a single or double communication with the left colic vein was observed in 24 cases (7.8%) and a communication with the paravertebral venous system in 10 patients (3.2%). Other anastomoses with the inferior mesenteric veins and splenic veins were seen in 7 and 4 patients (2.2% and 1.3%, respectively).

DISCUSSION AND CONCLUSION

The presence of vascular variants and of communications of the ISP with the visceral veins needs accurate venographic studies preliminary to sclerotherapy and a skilled interventional radiologist in order to reduce the number of recurrences.

The value of magnetic resonance imaging in a fistula of Wharton's duct

A 30-year-old woman developed a fistula of the Wharton's duct following excision of the submandibular gland. The contribution of conventional fistulography, MRI and MRI fistulography in detecting the exact extent of the fistula is discussed.

MR imaging of pancreatic changes in patients with transfusion-dependent beta-thalassemia major

OBJECTIVE

The aim of this study was to evaluate MR imaging changes of the pancreas in patients with transfusion-dependent beta-thalassemia major.

SUBJECTS AND METHODS

Twenty patients with transfusion-dependent beta-thalassemia major were examined using MR imaging at 0.5 T, with spin-echo T1-weighted, fast spin-echo T2-weighted, and gradient-echo T2*-weighted sequences. Image analysis was performed to assess pancreas-to-fat signal intensity ratios for all pulse sequences. Pancreatic exocrine and endocrine function and serum ferritin levels were assessed. Twenty healthy volunteers underwent MR imaging with the same three sequences and served as a control group.

RESULTS

The pancreas-to-fat signal intensity ratio was significantly decreased in 17 (85%) of the 20 patients on spin-echo T1-weighted images (p < .05), fast spin-echo T2-weighted images (p < .01), and gradient-echo T2*-weighted images (p < .01) when compared with the 20 volunteers in the control group. The pancreas-to-fat signal intensity ratio was significantly increased in three (15%) of the 20 patients on spin-echo T1-weighted images (p < .01) and fast spin-echo T2-weighted images (p < .05). In addition, in the 20 patients, we found a significant correlation between increased pancreas-to-fat signal intensity ratios and decreased serum trypsin levels (r = -.77, p < .01 for spin-echo T1-weighted sequences; r = -.75, p < .05 for fast spin-echo T2-weighted sequences; and r = -.74, p < .05 for gradient-echo T2*-weighted sequences). Likewise, for the 20 patients, we found a significant correlation between decreased pancreas-to-fat signal intensity ratios and increased serum ferritin levels for gradient-echo T2*-weighted images (r = -.65, p < .01). No correlation was found for the other clinical parameters evaluated.

CONCLUSION

MR imaging revealed signal intensity changes in the pancreas of patients with transfusion-dependent beta-thalassemia major. Patients with a major impairment of the exocrine pancreatic function had higher signal intensity of the pancreas because of fatty replacement of the parenchyma.

Static magnetic fields generated by a 0.5 T MRI unit affects in vitro expression of activation markers and interleukin release in human peripheral blood mononuclear cells (PBMC)

PURPOSE

To investigate the effects of the static magnetic field (SMF) generated by a 0.5 T superconducting MRI unit on in vitro activation marker expression and interleukin release in human peripheral blood mononuclear cell (PBMC) samples from healthy volunteers.

MATERIALS AND METHODS

PBMC samples were split into two groups: exposed and sham-exposed under isothermal conditions. PBMC were exposed for 2 h at 24 degrees C to the SMF of a 0.5 T superconducting MRI unit. Immediately after exposure, both samples were cultured for 24 h at 37 degrees C with or without mitogenic stimulation by phytohaemagglutinin (PHA). PBMC were examined for expression of CD25, CD69 and CD71 by immunofluorescence analysis and supernatants were assayed to quantify IFN-gamma, TNF-alpha and IL-4 by ELISA.

RESULTS

The 0.5 T SMF produced, after 24 h of culture, a reduced expression of CD69 from PBMC in vitro, that was enhanced after PHA stimulation. An increased release of IFN-gamma and IL-4 was also found, which was reduced after PHA stimulation. The release of TNF-alpha, IL-6 and IL-10 was not modified.

CONCLUSIONS

The SMF generated by a 0.5 T superconducting MRI unit modified in vitro activation marker expression and interleukin release from human PBMC.

[Biologic effects of the static magnetic field generated by a 0.5 T magnetic resonance tomograph on the enzyme activity of catalase and creatine kinase in the rat]

PURPOSE

We investigated possible alterations in the enzyme activity of catalase and isozyme MB-creatine kinase induced by prolonged exposure of laboratory rodents to a static magnetic field generated by a .5 T Magnetic Resonance unit.

MATERIAL AND METHODS

Thirty Wistar albino mice were divided into two groups of 15 mice, one to be exposed to the static magnetic field for 12 hours and the other to be kept in the same environmental conditions as a control group. Immediately after the exposure a peripheral venous blood sample was collected, the cardiac muscle was removed from the mice and the enzyme activity of catalase and MB-creatine kinase were assayed using the spectrophotometric analysis.

RESULTS

No statistically significant variation was detected between the enzyme activity of catalase and MB-creatine kinase in the serum and cardiac muscle of the exposed versus the control mice. In the mice exposed to the static magnetic field the enzyme activity of serum and cardiac muscle catalase were respectively .2154 U/L and .0707 U/L after 10 minutes; they were; .2699 U/L and .0946 U/L after 160 minutes. In the control mice the enzyme activity of serum and cardiac muscle catalase were respectively .1941 U/L and .0707 U/L after 10 minutes; they were .2061 U/L and .1068 U/L after 160 minutes. The enzyme activity of MB-creatine kinase in mice was measured in the exposed (80.8 U/L) versus the control (79.6 U/L) group: the difference does not exceed standard deviation.

DISCUSSION AND CONCLUSION

Our results seem to exclude any alteration in the activity of catalase and MB-CK after 12 hours' exposure to the static magnetic field. However some homeostatic mechanisms peculiar to pluricellular organisms might act in vivo to adapt to the effects of the static magnetic field during exposure.

[Closed loop intestinal obstruction: role of computerized tomography]

PURPOSE

The obstruction of a bowel segment at both ends results in a closed loop obstruction. Progression to strangulation frequently occurs if surgical intervention is delayed. The role of plain radiography in the diagnosis of closed loop obstruction and strangulation has been shown to be limited, while the recent literature has demonstrated the growing role of computed tomography (CT). This paper reports our experience in the study of closed loop obstruction by CT.

MATERIAL AND METHODS

The CT studies of 12 patients with surgically confirmed closed loop obstruction were retrospectively reviewed. The following CT signs were used for the diagnosis: a) fluid-filled distended loops, b) C-shaped incarcerated loop, c) radial distribution of several dilated bowel loops and mesenteric vessels converging toward the point of obstruction, d) triangular or fusiform tapering of the closed loop and/or whirl sign in the site of obstruction.

RESULTS

On the basis of these signs, the diagnosis was made in 11 of 12 patients. Only 1 patient, who had a negative CT study, was positive at a subsequent enteroclysis. CT findings of strangulation were associated in 3 cases: slight wall thickening with vascular congestion and mesenteric ascites, confirmed at surgery.

DISCUSSION AND CONCLUSIONS

Small bowel obstruction can be distinguished into simple and closed loop obstructions. The latter is a more severe condition which is often complicated by strangulation with vascular impairment, edema and intramural and mesenteric hemorrhage. Consequent arterial insufficiency rapidly leads to ischemia, infarction and necrosis. The radiologist plays a role in the early recognition of the closed loop obstruction and of any sign of strangulation. The role of CT in the diagnosis and workup of patients with suspected intestinal occlusion has been analyzed in the literature with reported 63% sensitivity, 78% specificity and 66% accuracy. CT is also capable of revealing the causes of occlusion in 73-95% of cases. The above CT signs, as confirmed in our experience, allow to identify closed loop obstruction and also small bowel strangulation, thus supplying a valuable contribution to diagnosis and accurate preoperative evaluation. We conclude that CT can accurately demonstrate the presence of closed loop obstruction and can be the technique of choice in patients in whom obstruction is associated with clinical signs suggestive of strangulation.

Serum and fecal pancreatic enzymes in beta-thalassemia major

CONCLUSION

This study, using indirect tests, demonstrated that exocrine pancreatic function is impaired in a proportion of patients with beta-thalassemia major (TM), though this impairment is generally mild or moderate.

BACKGROUND

Impaired structure and function of the exocrine pancreas has been reported in patients with Beta-thalassemia major.

METHODS

In this study we measured fecal fats and serum and fecal pancreatic enzymes in 30 patients (13 M, 17 F) with TM, mean age 22.1 yr (range 14-39) and compared them with those of a matched group of healthy controls. Results were correlated with age, serum ferritin, blood transfusion, and various nutritional parameters. Enzymes assays included: serum pancreatic amylase (PA), lipase (L), trypsin (T), fecal chymotrypsin (FCT), and fecal elastase (FE).

RESULTS

No patient was positive for steatorrhea. Comparison of the mean values showed a significant difference only for FE (p < 0.002). Using only the fecal tests as a reference, we found that 12 patients had FE values below the cutoff limit; of these, five had values between 100 and 185 micrograms/g, three between 50 and 99 micrograms/g and four below 50 micrograms/g. Ten patients had FCT values below the cutoff limit; seven presented impairment in both tests and six of them had FE values below 100 micrograms/g (including four diabetics). No correlations were found between enzyme values and mean serum ferritin values or mean blood consumption over the previous 3 yr. No correlation was found between FE and FCT levels or between enzymes and age.

Hydatid cyst of the liver communicating with the left colon

Rupture and secondary infection are common complications of hydatid cyst in the liver. Ultrasound and CT findings are reported in a case of hydatid cyst which has ruptured directly into the left colon. Rupture of hydatid cyst into a hollow viscus is extremely rare. CT demonstrated partial drainage of the cyst contents with the creation of an air-fluid level.

[Server World-Wide Web on the Internet for the provision of clinical cases and digital radiologic images for training and continuing education in radiology]

The Internet, as a global computer network, provides opportunities to make available multimedia educational materials, such as teaching files and image databases, that can be accessed using "World-Wide Web" client browser to provide continuing medical education. Since August, 1995, at the Institute of Radiology-University of Palermo, we developed a World-Wide Web server on the Internet to provide a collection of interactive radiology educational resources such as teaching files and image database for continuing medical education in radiology. Our server is based on a UNIX workstation connected to the Internet via our campus Ethernet network and reachable at the uniform resource locator (URL) address: http:/(/)mbox.unipa.it/approximately radpa/ radpa.html. Digital CT and MR images for teaching files and image database are downloaded through an Ethernet local area network from a GE Advantage Windows workstation. US images will be acquired on-line through a video digitizing board. Radiographs will be digitized by means of a Charge Coupled Device (CCD) scanner. To set up teaching files, image database and all other documents, we use the standard "HyperText Markup Language" (HTML) to edit the documents, and the Graphics Interchange Format (GIF) or Joint Photographic Expert Group (JPEG) format to store the images. Nine teaching files are presently available on the server, together with 49 images in the database, a list of international radiological servers, a section devoted to the museum of radiology hosted by our Institute, the electronic version of the Journal Eido Electa. In the first 12 months of public access through the Internet, 12,280 users accessed the server worldwide: 45% of them to retrieve teaching files; 35% to retrieve images from the database; the remaining 20% to retrieve other documents. Placing teaching files and image database on a World-Wide Web server makes these cases more available to residents and radiologists to provide continuing medical education in radiology.

[Chronic osteomyelitis of the long bones: magnetic resonance imaging]

To investigate MR capabilities in assessing the extent of disease in chronic osteomyelitis of long bones, we examined 6 consecutive patients, 4 men and 2 women (age range: 27-67 years; mean: 42 years), with posttraumatic chronic osteomyelitis diagnosed at clinics, US, CT and radiography. The diagnosis had surgical or bioptical confirmation. MR studies were performed with an 0.5 T superconducting magnet, a surface coil and T1-weighted SE sequences-before and after Gd-DTPA administration-STIR and T2-weighted SE sequences, on the axial and coronal or sagittal planes. The signal intensity of the inflammation area was hypointense on short TR and TE images and hyperintense on long TR and TE images. After Gd-DTPA administration, granulation tissue surrounding the infection was enhanced in all cases and also the areas of vascularized inflammation within bone marrow were enhanced in two cases. MRI provided accurate and detailed information as to soft tissue and medullary canal involvement depicted sinus tracts in 5 cases and confirmed the presence of sequestrum in 5 cases, in agreement with previous CT findings. In our experience, MRI proved to be a reliable tool to assess the intramedullary and extracompartmental extent of osteomyelitis and also to plan surgery. MR specificity, which is often affected by post-traumatic or postoperative changes, improves markedly if some morphological features typical of the condition are also considered, such as sequestrum and sinus tracts.

[A computer system for the systematization of MR findings in knee joint diseases]

An inexpensive, easy-access computer-based system is proposed, which was developed for the systematization of the clinical series of knee joint disorders studied with Magnetic Resonance Imaging (MRI). The system is based upon the integration of multimedia technology and Data Base Management Systems (DBMS). The hardware configuration for this project included an Apple Macintosh workstation based on a Motorola 68040 microprocessor and a customized application developed by the authors with the 4th Dimension software. The MR images available only on film were digitized off-line with a solid-state Charge Coupled Device (CCD) scanner with back-light cover for transparency. Otherwise, MR images were acquired on-line through an Ethernet-based local area network from the MR unit or from a SparcStation-Advantage Windows workstation connected with the MR unit. Image post-processing was performed with the Adobe PhotoShop software. The system was devoted to the systematization and analysis of a clinical series of 800 MR studies of the knee. A mean of 10 significant MR images were stored for each examination with a standard image compression algorithm--the Joint Photographic Experts Group (JPEG). This permitted us to save the system's storage space and at the same time to preserve image quality for consultation and teaching purposes, not for diagnosis which is made on the backboard or on the MR unit's or Advantage Window's monitor. Finally, MR findings were indexed with a customized check-list specific for knee joint disorders. On the basis of stored and selected information, it was thus possible to carry out a statistical analysis and to make detailed reports which are useful for scientific purposes, such as the preparation of lectures and papers. Moreover, the system was very useful for patients' follow-up and for the preparation of hypermedia teaching applications on knee joint disorders which are available on the Internet at our World-Wide Web server (URL: http://mbox.unipa.it/radpa/radpa ++ +.html). In conclusion, the system is a cost-effective and user-friendly solution for the multipurpose management of radiologic series.

[Biomechanical correlations of lesions associated with traumatic diseases of the anterior cruciate ligament. Analysis with magnetic resonance]

To investigate the correlations between traumatic injuries of the anterior cruciate ligament and other ligamentous, meniscal and bone traumatic injuries, a series of 193 patients with anterior cruciate ligament injuries studied with MRI between January 1992 and December 1994, was retrospectively reviewed. MR results were compared with arthroscopic and/or surgical findings in most (181) patients; in the remaining 12 patients, clinical follow-up was performed. We used two 0.5 superconductive MR units, with dedicated coils and T1-weighted spin-echo and T2*-weighted gradient-echo sequences on the axial, sagittal and coronal planes. Anterior cruciate ligament injuries were associated with other ligamentous, meniscal and bone injuries in 78% of patients. The patients were classified in 5 groups depending on biomechanics and the association of injuries: -group I: isolated injury of the anterior cruciate ligament (41 patients), most frequently caused by forced extension stress associated with "kissing contusions" of the anterior portion of the lateral femoral condyle and of the lateral tibial plateau; this type of injury is less frequently caused by forced flexion stress associated with avulsion fracture of the tibial eminence; -group II: associated injury of the anterior cruciate ligament and medial compartment (62 patients), caused by forced flexion-external rotation stress (abduction, valgism and external rotation). The classic association of this mechanism was the injury of the anterior cruciate ligament, medial collateral ligament and medial meniscus (O'Donoghue triad) (9 patients). Valgus stress and the pivot-shift phenomenon can impact the tibial and femoral articular surfaces, with consequent osteochondral contusion; -group III: associated injury of the anterior cruciate ligament and lateral compartment (26 patients), caused by forced flexion-internal rotation stress (adduction, varism and internal rotation). This mechanism can cause, as a typical bone lesion, Segond fractures; -group IV: associated injury of the anterior cruciate ligament, lateral and medial compartments observed in 52 patients with different associations of varus-valgus and rotatory stress; -group V: in 5 patients, anterior cruciate ligament injury was associated with traumatic injury of the posterior cruciate ligament; in this case, posterior displacement of the tibia and knee hyperextension were the most common mechanisms of injury. In conclusion, our results demonstrate that anterior cruciate ligament injuries due to traumatic sprains of the knee are rarely isolated (21%). Thus, it is important to know the biomechanics of knee trauma to read MR images in order to detect possibly associated injuries. The final goal is to assess the actual extent of the traumatic damage for best subsequent clinical-therapeutic management.

[A quantitative in-vitro analysis of the effects of magnetic fields and radiofrequencies on amino acid metabolism]

The extensive use of magnetic resonance imaging in medical diagnosis needs experimental confirmation of the real biological harmlessness of magnetic fields and radiofrequencies in the imaging process. To date, no unquestionable conclusions have been drawn and experimental results differ in various literature reports. We investigated the effects of radiofrequencies and magnetic fields on the amino acid content of plasma samples from 10 healthy volunteers aged 25 to 30 years; the samples were exposed for 60 minutes to MR fields at 0.5 T with the sequences commonly used in clinical practice. After exposure to magnetic fields, the samples were analyzed with chromatography and the results compared with those of plasma samples not exposed to MR fields. Thirty-four different amino acids were investigated and no significant changes were observed in the total concentration of any of them. Our results show that, at least in a cell-free system, exposure to a magnetic field at 0.5 T causes no significant quantitative changes in amino acid composition, at least no changes demonstrable at chromatography. On the other hand, our preliminary observation does not exclude that exposure to nonionizing radiation may modify in vivo enzyme kinetics with transient qualitative, but not quantitative, changes.

[An experimental in-vitro evaluation of membrane antigen expression and of interleukin production by monocytes exposed to magnetic resonance]

The interactions of magnetic fields and radiofrequency with biological systems have been described by several authors. However, no definitive conclusions have been drawn yet as to the safety of the magnetic fields and radiofrequencies used in clinical examinations. The immune system is one of the most complex biological systems, in which a network of intracellular signals regulates the immune response. Interleukins are released by an activation process which involves, at least in part, intra- and/or extracellular calcium mobilization. The latter step can be influenced by the in vitro effect of this type of nonionizing radiations produced by an MR system on peripheral blood mononuclear cells. Our results show that the 2-hour exposure to magnetic fields (0.5 T) and radiofrequency caused an increase in the spontaneous release of IL2, IL4, IL10, TNF alpha and INF gamma, while the amount of the same cytokines induced by PHA stimulation was decreased. No differences were observed in the spontaneous or PHA-induced release of IL6 by exposure to magnetic fields (MRI). Furthermore, the expression of the CD 11b molecule was increased at the same time. These results may be useful for us to understand the interactions between magnetic fields and radiofrequencies and the immune system.

[Biomechanics and semeiotics of traumatic lesions of the posterior cruciate ligament using magnetic resonance]

The authors reviewed 458 MR examinations of the knee to assess the potentials of this technique in the study of traumatic injuries of the posterior cruciate ligament (PCL) and to investigate the frequency of their association with injuries of other knee joints. MR images were acquired with an 0.5-T super-conductive unit with an extremity coil. T1-weighted spin-echo (SE) and T2*-weighted gradient-echo (GE) sequences were used on sagittal, coronal and, in some cases, axial planes, with 3-mm slice thickness and 0-1 mm slice gap. The following parameters were studied to diagnose partial or complete PCL tears: PCL thickness and outline, disruption of ligamentous fasci and signal intensity features. The injuries were classified as proximal, intermediate and distal according to their site. Thirteen PCL tears were detected, 5 of them complete and 8 partial. Complete tears were found in 4/5 patients in the middle third and one patient had a distal intersection tear with tibial bone avulsion. Partial tears were found in the distal tract in 5/8 patients, in the proximal tract in one patient and in the middle third in 2 patients. In 12/13 patients capsuloligamentous knee tears were associated. Overall MR rate of PCL tears was 2.8%; of them, 92.3% were associated with other capsuloligamentous injuries. MR diagnosis was confirmed at arthroscopy in 12/13 patients. The sagittal plane was best in optimally demonstrating the whole PCL and its injuries. GE T2* sagittal sequences demonstrated the site of PCL tears better than SE sagittal ones. Relative to other authors, we found MRI an extremely reliable method to distinguish partial from complete PCL tears. This was probably due to the thinner slices (3 mm) we used. MRI can accurately assess the extent of traumatic injuries of the PCL and of other capsuloligamentous parts of the knee, which is relevant from the clinical point of view. Indeed, MRI allows useless diagnostic arthroscopy to be avoided and yields major indications to choose the correct treatment.

[Comparison of echography and magnetic resonance in sprains of the external compartment of the ankle]

In most cases ankle sprains involve external compartment ligaments. In particular, the anterior talofibular ligament is involved alone in 70% of cases and together with calcaneofibular and posterior talofibular ligaments in the remaining 30% of cases. To investigate the potentials and the possible limitations of high-frequency US (7.5-13 MHz) for the preliminary assessment of the extent of damage of the capsulo-ligamentous lesions of the external ankle compartment, 25 athletes with clinical diagnosis of sprain trauma were examined with conventional radiology. Morphology and structure were studied from the semiologic point of view. US findings were compared with MR results. In all patients, US showed anterior talofibular ligament lesions alone in 13 patients and associated with calcaneofibular ligament lesions in 12 patients. The posterior talofibular and the interosseous talocalcaneal ligaments were never demonstrated by US. In 4/13 patients diagnosed by US as having isolated anterior talofibular lesions, MRI demonstrated a coexisting calcaneofibular lesion (4/13) and, in one of them, a posterior talofibular and interosseous talocalcaneal ligaments lesion. The comparison of US and MR findings in the patients US had diagnosed as having associated anterior talofibular and calcaneofibular ligaments lesions, showed 100% agreement; MRI allowed the demonstration of the lesions in the posterior talofibular and interosseous talocalcaneal ligaments in 2/12 patients. Considering the statistical prevalence of the anterior peroneal-astragalic lesions caused by ankle sprains, the use of high-frequency US as the first diagnostic approach seems justified. Nevertheless, MRI is a fundamental complement for accurately assessing damage extent.