IgG4-related cranio-spinal hypertrophic pachymeningitis involving the internal auditory canal

Immunoglobulin G4 (IgG4)-related hypertrophic pachymeningitis, which is a focally or diffusely thickened dura mater and lymphoplasmacytic infiltration with increased IgG4 bearing plasma cells, is a rare disease, and cases involving the whole cervical spine are even rarer. Here, we describe a case of probable IgG4-related hypertrophic pachymeningitis involving the whole cervical spine and the auditory canals in an 18-year-old male. The patient, who had a history of paresthesia and had previously experienced weakness, presented with generalized tonic seizures. A decompressive laminectomy on cervical vertebrae was performed as a matter of urgency, removing intradural fibrous material. The patient responded well to treatment and was discharged walking independently, with no strength deficit to any of the 4 limbs, and with normal blood tests.

Glide video laryngoscope for the management of foreign bodies impacted at the hypopharyngeal level in adults

BACKGROUND

Cricopharyngeal foreign bodies (FBs) impaction in adults is a common clinical problem; without treatment, the sequelae may be lethal due to local and/or mediastinal infection. When direct laryngoscopy and flexible fiberoptic endoscopy are ineffective, rigid endoscopy is the method of choice requiring general anesthesia. The new video laryngoscopes represent a great advancement in the assessment of the laryngeal inlet. Aim of the study was to assess the feasibility of identifying and removing FBs impacted at crycofaringeal and upper oesophageal sphincter by the video laryngoscope.

METHODS

In a period of 30 months, on an urgent basis, we systematically assessed by GlideScope® video laryngoscope all adult patients with a diagnosis of impacted crycofaringeal upper esophageal FB, after unsuccessful removal attempts in the otolaryngology or gastroenterology unit.

RESULTS

Twenty-six consecutive patients were evaluated. In conscious sedation by video laryngoscope 17 FBs were identified and removed from the hypopharynx or upper esophageal sphincter. In 9 patients rigid endoscopy in general anesthesia and tracheal intubation was necessary to remove FBs impacted beyond the upper esophageal sphincter.

CONCLUSION

In our experience video laryngoscope, because of the magnified vision, the better patient comfort and no requirement of general anesthesia, represents a great improvement in identifying and removing in conscious sedation even small and thin foreign bodies not recognized by radiological and otolaryngology examination and not readily detected by direct endoscopy.

Prophylactic arterial catheterization in the management of high risk patients for obstetric haemorrhage

OBJECTIVES

Post-partum haemorrhage still remains one of the major causes of maternal morbidity and mortality. In case of abnormal placentation it is possible to carry out preventive and therapeutic actions. To maintain fertility in reproductive-aged women and to avoid a more radical surgery, embolization has been introduced in patients at high risk for haemorrhage. To describe a new option in the management of patients with abnormal placentation by an elective, preventive arterial catheterization and selective embolization of pelvic arteries.

PATIENTS AND METHODS

A retrospective study including thirty six patients with abnormal placental invasion. All patients were prepared in the angiographic room and preventive arterial catheterization was performed before elective caesarean delivery. Materials for interventional angiography were transferred to the operating room. During surgery, selective embolization of pelvic arteries was realized in case of uncontrolled bleeding.

RESULTS

Thirty-six elective arterial catheterizations were performed: 4 cases (11.1%) required embolization, haemorrhage was stopped in 2 patients. Hysterectomy was performed in two cases (5.5%). No death was reported. Two humeral thrombosis (5.5%) were registered.

CONCLUSIONS

Prophylactic arterial catheterization appears to be safe. The main advantage is the reduction of the interval between the onset of bleeding and the embolization. This new option of management may contribute to reduce the risk of hysterectomy and maternal death.

Femoroacetabular impingement: role of imaging

The femoroacetabular impingement (FAI) is an impingement characterized by repetitive abutment between the femur and the acetabular rim during hip motion due to loss of joint clearance (Imam and Khanduja in Int Orthop 35(10):1427-1435, 2011; James et al. in AJR Am J Roentgenol 187(6):1412-1419, 2006). Femoroacetabular impingement (FAI) can be classified as either cam or pincer type, and it can be differentiated on the basis of a predominance of either a femoral or an acetabular abnormality (Pfirrmann et al. in Radiology 244(2):626, 2007; Ganz et al. in Clin Orthop Relat Res 466(2):264-272, 2008). In cases of cam FAI, the nonspherical shape of the femoral head at the femoral head-neck junction and reduced depth of the femoral waist lead to abutment of the femoral head-neck junction against the acetabular rim. In cases of pincer FAI, acetabular overcoverage limits the range of motion and leads to a conflict between the acetabulum and the femur. The most important role of preoperative MR evaluation in patients affected by FAI is the accurate assessment of the damage's extension.

Giant benign solitary fibrous tumour of the pleura (> 15 cm): role of radiological pathological correlations in management. Report of 3 cases and review of the literature

OBJECTIVES

Solitary fibrous tumour pleura (SFTP) is a localized tumour arising from the submesothelial areolar mesenchyme. In the present study, we defined "giant" lesions with diameter greater than 15 cm. We have studied the role of radiological-histological correlations of three cases in the management of the disease with review of the literature.

METHODS

We conducted a retrospective review of the clinical records of three patients who had undergone surgical resection for giant benignant SFTP between 2007 and 2011.

RESULTS

Three symptomatic patients (all woman, mean age 80 years) with a giant benign SFTP (mean diameter 19.3 cm and mean weight 1290 gm) underwent surgery with full excision of the tumour. All tumours showed histological features of benignancy and intense immunopositivity for CD34.

CONCLUSIONS

The integration of CT and pathological findings is essential in the optimal management of giant benign SFTP. Chest radiograph and CT cannot differentiate between benign and malignant giant SFTP. Surgical resection is necessary to determine the nature of tumour. The immunohistochemical staining pattern assists in differentiating SFTPs from other spindle cell neoplasms of the pleura including diffuse malignant mesothelioma. The choice of surgical approach is determined by the location of the tumour and by spatial relations in the imaging study rather than by the radiologist's impressions. Recurrence after complete resection is possible in giant benign SFTP, as a consequence of incomplete excision. Long-term follow-up is highly recommended because of the possibility of late recurrence. Due to rarity of these tumours, further studies and multicentre trials are needed to confirm these preliminary findings.

Questions and answers: what can be said by diagnostic imaging in neuroendocrine tumors?

The neuroendocrine tumors (NET) of the gastro-entero-pancreatic area (GEP) represent a heterogeneous group of malignancies from the histologic, clinico-laboratoristic (functioning and non-functioning variants), and therapeutic point of view. It is an issue becoming more frequent for the diagnostic imager, being radiologist as well as nuclear physician. Imaging (together with biopsy) plays a key role in the diagnostic assessment and staging (including grading and prognostic definition), in evaluating response to treatment, and in follow-up of GEP-NET. Multislice computed tomography (MSCT), octreoscan and PET-CT are the most widely diffuse and accurate imaging modalities employed in this setting. Other methods, such as Magnetic Resonance and Endoscopic Ultrasound, may also play a significant role.

Pulmonary congenital cystic disease in adults. Spiral computed tomography findings with pathologic correlation and management

PURPOSE

The aim of this study was to assess the computed tomography (CT) features of intrapulmonary congenital cystic diseases in adults and to correlate the imaging features with the pathological findings, with emphasis on the oncogenic potential of the lesions.

MATERIALS AND METHODS

We retrospectively reviewed the CT scans in three institutions from August 1996 to December 2008, of nine patients (six men, three women; mean age 48.6 years; range 26-75 years) who had histological diagnosis of pulmonary cystic disease after surgery. Six patients had a diagnosis of intrapulmonary bronchogenic cyst (IBC), and three had a type-I cystic adenomatoid malformation (CAM). In one case, intralobar sequestration (ILS) was associated with type-I CAM.

RESULTS

Three patients were symptomatic and six were asymptomatic. On CT scans, IBCs showed homogeneous fluid attenuation (n=2), air-fluid level (n=2), air attenuation (n=1) or soft-tissue attenuation (n=1). The surrounding lung tissue showed areas of band-like linear attenuation in three IBCs, atelectasia in two and mucocele-like areas in one. On CT, type-I CAM appeared as a unilocular cystic lesion with air-fluid level (n=1) or air content (n=1). Both cases had thin walls surrounded by normal lung parenchyma. ILS appeared as a fluid-filled cyst with afferent and efferent vessels. Of the six IBCs, one occurred in the upper right lobe, two in the middle lobe and three in the lower right lobe. Of the three type-I CAMs, one was in the upper left lobe and one in the middle lobe. The type-I CAM associated with ILS was located in the left lower lobe.

CONCLUSIONS

The similar CT patterns preclude differentiation between IBC and type-I CAM. Surgical resection of all intrapulmonary cystic lesions detected in adults is mandatory because type-I CAM is a precursor of mucinous bronchioloalveolar carcinoma.

Three-dimensional analysis of pulmonary nodules by MSCT with Advanced Lung Analysis (ALA1) software

PURPOSE

The purpose of this study was to test the reproducibility of the three-dimensional (3D) Advanced Lung Analysis software (3D-ALA, GE Healthcare) in the estimation of pulmonary nodule volume.

MATERIALS AND METHODS

We retrospectively reviewed the unenhanced multislice CT scans (Lightspeed Pro 16 GE) of 77 patients with a solitary pulmonary nodule (n=71) or metastatic pulmonary disease (n=6). A total of 103 pulmonary nodules (19 well-circumscribed, 45 juxtavascular and 39 juxtapleural) were analysed grouped into five classes based on diameter: <5 mm, 10 nodules (9.7%); >or=5 to <10 mm, 25 nodules (24.2%); >or=10 mm to <15 mm, 41 nodules (39.8%); >or=5 to <18 mm, 14 nodules (13.6% ); >or=8 to <30 mm, 13 nodules (12.62%). The following acquisition parameters were used: slice thickness 0.625 mm, reconstruction interval 0.4 mm, pitch 0.562:1, 140 kV, 300 mAs, field of view 13 cm, bone kernel. For each of the 103 nodules three, 3D volume measurements were obtained by the 3D-ALA software. The reproducibility of nodule segmentation was evaluated according to a visual score (1=optimal, >or=95%; 2=fair, 90-95%; 3=poor, <or=90%) by three observers working in consensus. The reproducibility of volume estimation was evaluated by comparing all 3D volume measurements and all segmentations obtained for each pulmonary nodule using the ANOVA test.

RESULTS

ALA-1 software allowed segmentation in all nodules (type 1 segmentation n=43, type 2 n=35, type 3 segmentation n=25). ALA-1 provided an identical 3D volume measurement in 62 nodules: [16 out of 19 well circumscribed (84.2%), 31 out of 45 juxtavascular (68.8%), 15 out of 39 juxtapleural (38.4%)]. Repeatability of 3D volume measurement was not possible in 41 out of 103 nodules [3 out of 19 (15.7%) well-circumscribed, 14 out of 45 (31.1%) juxtavascular, 24 out of 39 (61.5%) juxtapleural]. Among the 41 nodules with nonrepeatable 3D volume measurement, segmentation was scored as 1 in 2 out of 41 (4.8%), as 2 in 15 out of 41 (36.5%) and as 3 in 24 out of 41 (58.5%). The difference between the mean volume on three measurements and each type of nodule was not statistically significant (p>0.05).

CONCLUSIONS

Three-dimensional volume measurement with ALARiassunto 1 software is reproducible for all nodules as regards dimension and site. ALA-1 software provided a good and reproducible volume measurement in well-circumscribed and most juxtavascular nodules. Volumetric evaluation and reproducibility of volume estimation in juxtapleural pulmonary nodules, particularly those adjacent to diaphragmatic pleura, is inadequate, and software improvement is needed.

Pancreatic carcinoma versus chronic focal pancreatitis: contrast-enhanced power Doppler ultrasonography findings

BACKGROUND

We assessed the potential usefulness of contrast-enhanced power Doppler ultrasonography (US) for differentiating pancreatic carcinoma from chronic focal pancreatitis.

METHODS

Twenty-six consecutive patients with ductal carcinoma (n=16) and chronic focal pancreatitis (n=10) underwent power Doppler US examinations before and after intravenous injection of an air-based contrast agent (Levovist, Schering, Berlin, Germany). Final diagnosis was obtained by surgery in all patients. The following parameters before and after intravenous administration of contrast agent were evaluated for each lesion: number, morphology and course of the vessels within the lesion and time to maximum detectable enhancement. Number of the lesion vessels and time to maximum enhancement for each lesion were compared by with Student t test.

RESULTS

After injection of contrast agent, nine of 16 (56.2%) carcinomas showed a larger total number of vessels (p<0.005) and faster enhancement (p<0.0001) compared with chronic focal pancreatitis. Irregular vessels with a serpiginous course that penetrated the tumor was predominant in carcinoma (eight of 16 cases), whereas focal pancreatitis presented mostly as avascular masses (five of 10 cases).

CONCLUSION

Contrast-enhanced power Doppler US provides useful findings for differentiating pancreatic carcinoma from chronic focal pancreatitis.

Emergencies in the retroperitoneum: assessment of spread of disease by helical CT

Acute pancreatitis, leaking abdominal aortic aneurysm, and renal trauma frequently occur in the setting of patients with abdominal nontraumatic and traumatic injury; it represents the most urgent conditions that may determine the presence of fluid collections or haematoma in the retroperitoneum. Single spiral CT and multidetector-row CT (MDCT) play an important role in diagnosis of retroperitoneal emergencies, providing useful informations on the type, site, extent and management of the fluid collections. An accurate CT assessment requires the awareness of the existence of dissectable retroperitoneal fascial planes. Fluid collections or haematoma tends to escape the retroperitoneal site of origin into planes extend from the diaphragm to the pelvic floor. We assess the multicompartimental anatomy of the retroperitoneum and the pathway of spread of the most frequent retroperitoneal fluid collections or haematoma by helical CT.

MR findings in a case of exogastric stromal tumor of the stomach

A case of gastrointestinal stromal tumor of stomach investigated with US, CT, and MRI is reported. On imaging, the neoplasm arises from the wall of the gastric fundus and appears well circumscribed and sharply demarcated from the adjacent structures. MRI provides an excellent means of evaluating the site and extension of this neoplasm and enables accurate surgical planning. The authors stress that there has been recently widespread scientific and clinical interest in GIST (gastrointestinal stromal tumor) because its principal pathogenetic defect has been identified and a specific molecular inhibitor of GIST has been developed.

Primary retroperitoneal angiosarcoma: MR imaging features

We report a rare case of retroperitoneal angiosarcoma in a 72-year-old man who presented with abdominal pain. Diagnosis was obtained histologically after radical excision of the tumour. Fat-suppression MRI after intravenous administration of the contrast agent gadolinium-DTPA was able to define tissue planes between the lesion and the adjacent structures, suggesting the vascular nature of the lesion, and provided useful information for an accurate surgical approach. To the best of our knowledge, this is the first report that illustrates the MRI characteristics of a retroperitoneal angiosarcoma.

Small renal masses: assessment of lesion characterization and vascularity on dynamic contrast-enhanced MR imaging with fat suppression

OBJECTIVE

The aim of our study was to characterize renal lesions equal to or smaller than 3.0 cm using dynamic contrast-enhanced MR imaging with fat suppression by means of quantitative analysis of signal intensity.

MATERIALS AND METHODS

We retrospectively reviewed the MR imaging examinations of 35 patients (20 with renal cell carcinoma, eight with angiomyolipoma, and seven with complicated cysts) who were studied with spin-echo and dynamic fat-suppressed gradient-recalled echo MR sequences, before and after the administration of gadopentetate dimeglumine. Every 30 sec after contrast injection, we measured the lesion percentage of enhancement and the ratio of contrast (lesion-renal cortex signal intensity difference) to noise.

RESULTS

Ten renal cell carcinomas were classified as hypervascular (enhancement greater than that of renal cortex) and 10 as hypovascular. The percentage of enhancement of hypervascular carcinomas was similar to that of renal cortex until 150 sec and greater in the late sequences (180-210 sec, p < 0.01). Hypovascular carcinomas had a lower percentage of enhancement than hypervascular carcinomas (60-210 sec, p < 0.005). Angiomyolipomas, after an early enhancement peak, showed values similar to those of hypovascular carcinomas. Complicated cysts had very low enhancement (p < 0.001). The baseline contrast-to-noise ratio was negative for all lesions (hypointensity with respect to renal cortex). After gadolinium injection, the contrast-to-noise ratio of hypervascular carcinomas rose, becoming positive after 150 sec. Until 60 sec, the contrast-to-noise ratio of hypovascular carcinomas declined slightly, whereas that of angiomyolipomas and cysts fell sharply; then the three curves remained stable (60-210 sec, p < 0.05 for all matches except angiomyolipomas versus cysts).

CONCLUSION

Quantitative analysis of signal intensity variations during dynamic contrast-enhanced MR imaging with fat suppression can be useful in the characterization of small renal lesions.

[Aortic intramural hematoma: aspects with spiral computerized tomography]

PURPOSE

To evaluate the signs of aortic intramural hematoma with helical CT and the diagnostic role of this technique in patients with this condition.

MATERIAL AND METHODS

We reviewed the CT findings of 396 patients submitted to emergency examinations for suspected aortic dissection from 1995 to 1999. Only 18 patients (6 women and 12 men) had CT signs of aortic intramural hematoma. Helical CT studies were carried out with the following parameters: slice thickness 10 mm, reconstruction index 10, feed 1.5 mm, conventional algorithm with minimum values of 130 kV and 125 mA. All patients were examined with dynamic contrast-enhanced CT, before and after a power injection of 130 mL ionic contrast material. We studied: hematoma localization and longitudinal extension; thickness and density of aortic wall; presence and location of intimal calcifications; integrity of intimal wall; hemomediastinum and/or hemothorax.

RESULTS

Aortic wall thickening appeared as a high density crescent-shaped area at baseline CT and had low density on enhanced images in all patients. Thickening was eccentric in 14/18 patients and concentric in 4/18 only; it always exceeded 4 mm. We found some intimal calcifications in 8 patients and hemothorax and/or hemomediastinum in 9 patients. A patient with type A hematoma died of cardiac tamponade a few hours after CT diagnosis. Six patients (5 type B and 1 type A) underwent anti-hypertensive treatment and radiological follow-up. Eleven patients (6 type A and 5 type B) underwent prosthesis replacement and 5 of them (3 type A and 2 type B) died of postoperative complications. In the 5 type B patients surgery was performed because of treatment-resistant pain and of the onset of ischemic complications to abdominal organs caused by involvement of the main collateral branches of the aorta. One patient with type A hematoma was submitted to drug treatment because it was judged unresectable.

DISCUSSION AND CONCLUSIONS

Intramural hematoma of the aorta is a distinct pathological entity, which should not be confused with aortic dissection. The imaging techniques (TEE, CT, MRI) have an important role in the final diagnosis of aortic hematoma. Presently Helical CT and MR angiography are the main tools in the early diagnosis of this condition before the development of complications. In our experience helical CT, before and after the administration of contrast material, was accurate in identifying the hematoma localization and extension.

[Gunshot wounds of the cranium studied with computerized tomography. Personal experience in 23 cases]

INTRODUCTION

Gunshot wounds to the head are usually mortal injuries. Their frequency has been increasing in the last years because of increasing crime rates. Gunshot wounds to the head require close clinical and diagnostic cooperation of the neurosurgeon and radiologist, detailed assessment of skull and brain damage, and finally prompt treatment. Emergency Computed Tomography (CT) makes a useful tool for depicting bullet course and brain damage, and thus helps plan treatment. We investigated the CT signs of subdural hematoma, lacerocontusive focus, subarachnoid hemorrhage, hemoencephalus, skull bone fracture and thecal hollow and report them as an aid to the neurosurgeon and the radiologist, for best treatment planning, and in an attempt to establish useful prognostic criteria.

MATERIAL AND METHODS

We retrospectively reviewed 23 cases of gunshot injuries to the head studied with CT at the Emergency Unit of Loreto Mare Hospital in Naples, Italy. Twenty patients were men and 3 women; their mean age was 31 years (range: 18-49). Three women and 2 men had been injured accidentally by wandering bullets, and one case was an attempted suicide; all the other cases resulted from shootings. CT slices were 10 mm thick, with 8 mm gap (5 mm in complex injuries and when posterior cranial fossa was involved); all scans were unenhanced.

RESULTS

We found 22 penetrating gunshot wounds: 13 of them with thecal entry hole and intracranial bullet retention and 9 with an entry and an exit hole. One case was a superficial wound. Crash skull fractures were seen in 22 cases and they were fragmented in 12, with overlapping thecal fragments in 4, and with deep fragments in 2 cases. There were scattered bone splinters in 3 cases and the bullet was retained in the mastoid bone in one case. Lacerocontusive foci were assessed in 22 cases, brain swelling in 20, subarachnoid hemorrhage in 19, brain hematoma in 15, blood in the ventricular system in 9, pneumoencephalus in 7, air bubbles along the bullet course in 7, impression on ventricula and linear structures in 7, interhemispheric blood in 5, and finally blood effusion in Sylvian scissure in 4 cases.

DISCUSSION AND CONCLUSIONS

Gunshot wounds to the head are complex and severe traumas with high mortality rates because of both early and late effects and complications. CT provides the neurosurgeon with abundant findings for diagnosis and surgical planning, which may result in improved survival rates. In these patients emergency CT plays a fundamental diagnostic role in depicting brain damage and thus remains the method of choice for thorough, rapid and accurate brain and skull studies, as well as to detect possible injury to the chest and abdomen.

[The topicality and use of the radiological exam in gunshot wounds of the limbs. An assessment of 132 cases]

INTRODUCTION

Gunshot wounds of limbs are frequent injuries especially in Western countries. They can be single or associated with other penetrating gunshot wounds, for instance to the chest, abdomen and skull.

PURPOSE

We investigated the current role and usefulness of conventional radiography in the assessment of gunshot injuries to limbs because, despite major advances in diagnostic imaging, this method remains the examination of choice in this condition. We stress the valuable contribution of conventional radiography to detection of bone blow-out fractures, multifocal traumatic bone changes, bone and joint injuries, bullet retention, and finally subcutaneous emphysema.

MATERIAL AND METHODS

We retrospectively reviewed 132 cases of firearm injuries of limbs submitted to radiography March 1996 to July 1999. All the patients were men ranging in age 17-66 years (mean: 35). Radiography followed a preliminary physical examination, and follow-ups were carried out in the following days after orthopedic reduction of bone fractures or surgery with metal osteosynthesis. Emergency CT was performed first when chest, abdomen, or skull were involved.

RESULTS

The lower limbs were involved three times as much as the upper ones; the leg was most frequently involved (61%), followed by thigh (61%), forearm and hands (24%), and feet (15%). The right lower limb was wounded in 65% of cases, especially tibia (55 cases) and femur (46 cases). Spiral injuries to bone diaphysis were the most frequent ones, followed by mixed fractures caused by cortical bone sinking from bullet impact. Bullets were retained in 60% of cases; subcutaneous emphysema was found in 78% of cases and vascular injuries in 25 cases in relation to disarranged fractures. We observed 4 arteriovenous fistulas during 3 years' follow-up.

DISCUSSION AND CONCLUSIONS

Gunshot wounds to the limbs need a different clinical, diagnostic and therapeutic approach than thoracoabdominal and skull injuries, which require immediate and quick diagnosis and emergency treatment. The cases with injury to a primary artery from open and splintered fractures require emergency surgical reconstruction with vascular anastomosis and reduction of compound fractures, to prevent necrosis and amputation. Conventional radiography does depict the bullet and its site, subcutaneous emphysema, blow-out fractures, and the location of bone splinters. This permits adequate emergency surgery and an efficacious orthopedic approach, as well as selection of the cases to be submitted to clinical monitoring.

[Gunshot wounds of the abdomen studied by computed tomography. The authors' personal experience in 30 cases]

INTRODUCTION

CT plays an important role in depicting gunshot wounds in parenchymal and hollow organs in the abdomen. Relative to other techniques and to emergency laparotomy, CT permits good assessment of abdominal content, major injuries and changes in other districts, such as chest, pelvis and skull. We investigated the yield and role of CT in diagnosing abdominal gunshot wounds, with their rich and varied radiological signs and associated injuries.

MATERIAL AND METHODS

We retrospectively reviewed the findings of 30 patients with abdominal gunshot wounds examined in 4 years at Loreto-Mare Hospital, Naples. All patients were men, age ranging 19-54 years (mean: 35); 6 of them were not from the European Union. Examinations were carried out from diaphragm to pubis with i.v. contrast injection and the CT angiography technique. CT was integrated with chest studies in 6 cases and with skull studies in 5. Subsequent CT follow-ups were necessary in 12 cases submitted to conservative treatment.

RESULTS

Liver was the most damaged parenchyma, with hemorrhage and lacerocontusion in 7 cases and mashed in 1 case; spleen was involved in 4 cases; hemoperitoneum was found in 18 cases. Diaphragm was involved in 5 cases and pancreas in 2; gallbladder, stomach and duodenum were involved in 1 case each and jejunum-ileum and colon in 3 and 6 cases, respectively. CT showed renal injury in 3 cases and bladder injury in 2. Eight patients had vertebral gunshot damage. Pneumothorax, hemothorax and lacerocontusion were found in 7 cases; brain was injured in 4 cases and limbs in 16.

DISCUSSION AND CONCLUSIONS

Tissue damage extent depends on the speed and kinetic energy the bullet carries into the abdomen. Abdominal radiography shows the bullet and its site, pneumoperitoneum from gastrointestinal perforation, crash bone injuries, vertebral trauma and subcutaneous emphysema. Instead, CT depicts early parenchymal damage and vascular injury and thus becomes a complete and necessary tool for imaging gunshot wounds. CT provides early diagnostic information which help plan emergency treatment and thus decrease mortality. As for angiography and US, we suggest they be used subsequently because in emergency they may delay the diagnosis. Moreover, vessel rupture and active intraabdominal bleeding are easily detected with spiral CT, which appears the best tool for prompt assessment of the injuries associated with gunshot wounds in other districts such as, the skull. To conclude, CT permits adequate planning of emergency surgery and helps select the cases for follow-up, intensive care and conservative treatment.

Duodenal duplication cyst: MR imaging appearance

The MR imaging appearance of a duodenal duplication cyst is reported. MR imaging confirmed the diagnosis suggested by ultrasound and CT scans. Fat-suppressed MR imaging before and after oral administration of the positive contrast agent Gd-DTPA was able to define tissue planes between the lesion and adjacent structures, such as the head of the pancreas, providing useful information for an accurate surgical approach. To our knowledge this is the first reported case of a duodenal duplication cyst in an adult demonstrated by MR imaging.

Water enema transvaginal ultrasound for local staging of stenotic rectal carcinoma

BACKGROUND

To increase the value of ultrasound in the staging of stenotic rectal carcinoma.

METHODS

Water enema transvaginal ultrasound (WE-TVUS) was performed in 21 consecutive female patients with severely stenotic rectal tumor (adenocarcinoma histologically proved) who were selected on the basis of clinical and double-contrast barium enema study. All patients underwent surgery, and histopathologic correlation was possible.

RESULTS

Rectal tumors were well demonstrated in all cases, and a good correlation between perirectal neoplastic infiltration, and lymph node involvement at WE-TVUS and histologic data were observed. Compared with histologic results, WE-TVUS correctly staged 19 of 21 tumors (overall accuracy = 90%); one case was understaged (T4 as T3) and one case was overstaged (T3 as T4). In the detection of lymph node involvement, the sensitivity was 50% and specificity was 78%.

CONCLUSION

WE-TVUS is a potentially valuable technique for defining the local extension of severely stenotic rectal tumors in women.

[Computerized tomography findings in intestinal carcinoid]

INTRODUCTION

We studied the CT patterns of abdominal carcinoid tumors.

MATERIAL AND METHODS

Eight patients with carcinoid tumors were examined with CT. The tumors were in the ileum (2 patients), duodenum (1), colon (1), and mesentery (4). Pathologic confirmation was obtained at surgery in all patients. The symptoms were the carcinoid syndrome in 2 patients, abdominal pain in 4, jaundice in 1 patient and a right lower quadrant mass in 1. All patients were examined with(out) i.v. contrast agent administration; 6 patients received oral contrast material and 2 were submitted to water enema, to enhance visualization of the distal ileum and colon.

RESULTS

CT identified the tumor in all patients but correctly defined its site in 7 cases only. CT showed a small mass in the distal common bile duct in 1 case, which postoperative histology diagnosed as a malignant carcinoid tumor of the duodenum. The CT findings of carcinoid tumors were a rounded mesenteric mass displacing bowel loops in 4 cases, an infiltrating colonic tumor in 1 case, an apparently intracholedochal mass in 1, a large necrotic mesenteric mass in 1 case. CT showed lymph node involvement in 2 cases, but no liver metastases were found. A carcinoid tumor was diagnosed in 4 patients based on the typical CT finding of a mesenteric mass with radiating soft-tissue density bands resulting in a stellate pattern. No preoperative diagnosis was possible in some other cases because the CT patterns were aspecific and mimicked those of other lesions, namely of tumor of the distal common bile duct, adenocarcinoma of the right colon, submucosal tumor of the distal ileum, large necrotic mesenteric mass.

CONCLUSIONS

CT is a useful tool in the detection of carcinoid tumors. The correct diagnosis can be made based on the characteristic CT finding of a rounded mesenteric mass. In our experience, however, carcinoid tumors may present with other CT patterns mimicking those of other tumors.

Thoracic CT findings at hypovolemic shock

PURPOSE

To describe and discuss the thoracic CT features of hypovolemic shock.

MATERIAL AND METHODS

From a group of 18 patients with signs of hypovolemia on contrast-enhanced abdominal CT, 11 were selected for our study as having also undergone a complete chest examination. Pulse rate, blood pressure, trauma score value, Glasgow coma scale value, surgical result, and final outcome were retrospectively evaluated. The CT features analyzed were: decreased cardiac volume, reduced caliber of the thoracic aorta, aortic branches and caval venous system, increased enhancement of the aorta, and increased enhancement of the pulmonary collapses/contusions.

RESULTS

All 11 subjects presented severe injuries and hemodynamic instability; 7 were stable enough to undergo surgery; only 1 of the 11 survived. Two patients showed none of the features of thoracic hypovolemia. All the other patients presented at least two signs: reduced caliber of the thoracic aorta in 7 cases; decreased volume of the cardiac chambers and increased aortic enhancement in 6; decreased caliber of the aortic vessels in 4; decreased caliber of the caval veins in 3; and increased enhancement of the pulmonary collapses/contusions in 3.

CONCLUSIONS

In patients with hypovolemia, CT may show several thoracic findings in addition to abdominal ones. Knowledge of these features is important for distinguishing them from traumatic injuries.

Segmental pulmonary arteries: two-dimensional and three-dimensional time-of-flight magnetic resonance angiography

The authors compared two-dimensional (2D) and three-dimensional (3D) time-of-flight (TOF) magnetic resonance angiography in ten healthy volunteers to establish which of two techniques is more effective in representing the pulmonary segmental arteries. No respiratory trigger or electrocardiogram gating was used. Presaturation pulses were used to eliminate venous flow. Images acquired in the sagittal planes were processed using maximum intensity projection. A total of 200 segmental arteries were evaluated with each technique by three observers (M.S., C.S., A.R.) in terms of vessel visibility. There was no significant difference among the observers' interpretations (p > 0.05). On average, 2D fast, low-angle shot breath-hold TOF sequences showed 136.1 of 200 (68%) segmental arteries, 74.1 of 100 in the right lung and 62 of 100 in the left lung. Three-dimensional fast imaging with steady state precession showed 171.6 of 200 (85.8%) segmental arteries, 94 of 100 in the left lung and 77.6 of 100 in the left lung. Three-dimensional imaging appeared to be better than 2D MRA for demonstration of segmental pulmonary arteries.

[Computerized tomography in craniocerebral, maxillofacial, cervical, and spinal gunshot wounds. Part II--Clinical contribution and medico- legal aspects]

To assess the diagnostic and medicolegal contribution of Computed Tomography (CT) in patients with craniocerebral, maxillofacial, neck and spine gunshot wounds, we submitted to CT 106 patients with gunshot wounds examined over a 7-year period (February, 1988 to December, 1994). Twenty-four of them had craniocerebral injuries (23%), 9 maxillofacial (8%), 8 neck (8%) and 10 vertebral (9%) injuries. Emergency CT demonstrated the mechanism of the injury, the bullet path and site, the site of bone and/or metallic fragments, and damage extent. In all perforating cranioencephalic injuries (n = 7) intracerebral or extrathecal bone fragments were demonstrated adjacent to the bullet entrance and exit holes, respectively. In injury monitoring. CT showed injury evolution, retained fragments and complications, thus enabling damage extent assessment. High Resolution Computed Tomography (HRCT) was useful in locating minute orbitary retrobulbar and intraspinal fragments. Magnetic Resonance (MR) Imaging in postoperative patients proved a valuable tool to assess the extent of spinal cord damage. To conclude, CT is a useful technique to examine the patients with gunshot wounds, which helps plan adequate treatment and solve complex medicolegal problems.

A new method for study of the rectum using transvaginal ultrasound with water enema

BACKGROUND

To propose a new method for the ultrasound study of the rectum.

METHODS

Twenty-one healthy female patients, 58-72 years old, were examined. To achieve optimal filling and distention of the rectum, the examination was performed with the patient in the right lateral decubitus position. After placing the probe into the vagina, 1000-1500 mL of water warmed to 35 degrees C was introduced into the rectum through a cannula. After the rectum was completely full, the cannula was extracted. Images were obtained before and after rectum distention on the transverse plane by using a 5.0-MHz convex radial endocavitary probe.

RESULTS

Using water eliminated air and fecal artifacts, so rectal wall layers were reliably demonstrated, with the rectal ampulla well distended. In addition, the rectum in whole circumferential extension and the perirectum fat were clearly visualized.

CONCLUSION

This new method is useful for study of the rectum.

[Computed tomography in gunshot trauma. I. Ballistics elements and the mechanisms of the lesions]

The knowledge of wound ballistics and of wounding mechanisms is mandatory for the radiologist to interpret the CT findings of gunshot wounds. The severity of a bullet wound depends on the characteristics of the tissue it goes through, i.e., tissue elasticity, density, thickness of the wounded body part, the type of tissue, its specific gravity, internal cohesiveness and anatomical relationships, as well as on missile characteristics, i.e., mass, shape, fragmentation and deformation. Bullet velocity is certainly a major factor in wounding, but it is only one factor. Two major wounding mechanisms exist the crushing of the bullet-struck tissue (forming the permanent cavity) and radial stretching (forming a temporary cavity). Bullet "yaw" is defined as the angle between the long axis of the bullet and its flight path. The yaw is directly proportional to tissue crushing and stretching: the wider the yaw, the most severe tissue crushing and stretching and, therefore, the more severe tissue damage. The basic knowledge of these concepts is of the utmost importance to understand the CT findings of gunshot wounds and can help physicians study and treat gunshot wounds.

Rectal carcinoma: preoperative staging and detection of postoperative local recurrence with transrectal and transvaginal ultrasound

Transrectal ultrasound (TRUS) was performed preoperatively in 35 patients with rectal carcinoma and the results were compared to histologic findings. In the same group, postoperative studies were performed in 22 patients; in women, transvaginal ultrasound (TVUS) was added to the transrectal study. According to Duke's classification modified by Astler-Coller, in relation to the "T" parameter, TRUS correctly staged 33 of 35 neoplasms (accuracy, 94.3%); one was overstaged and one was understaged. In detection of lymph node involvement, accuracy was 74% (sensitivity 69%, specificity 73.9%). Recurrent local tumors, histologically confirmed, developed in two of 22 postoperative patients who had undergone curative anterior resection. This study demonstrates that TRUS is an accurate method in preoperative staging of rectal carcinoma. In the prospective study, the role of follow-up TRUS and TVUS in detection of local recurrences is evaluated.

[Transvaginal echography in the study of the rectum. A new method with rectal distension with water]

Transrectal sonography (TRUS) accurately assesses the depth of invasion in the staging of rectal carcinomas. However, the method is limited in the evaluation of upper rectal and highly stenotic rectal cancers. These conditions can be demonstrated in female patients by transvaginal sonography (TVUS) with a 5-MHz convex probe. Conventional TVUS becomes even more accurate when the rectum is distended with water. Twenty-one asymptomatic female patients were examined in a prospective study to assess the value of conventional versus water-distended TVUS. Water improves rectal depiction because it eliminates air and fecal artifacts. In our series, the rectum was demonstrated from anum to rectosigmoid junction in all cases. The whole rectal outline could also be demonstrated. Besides rectal lumen evaluation, the method allowed rectal wall layers and perirectal fat to be detailed. Subsequently, 14 female patients were examined--8 during the preoperative staging and 6 during the follow-up. In preoperative patients, the extent of stenosing rectal cancer and perirectal fat infiltration were assessed; in postoperative patients rectal recurrences were excluded. In conclusion, TVUS with rectal distension by means of water is a new diagnostic procedure which can markedly improve the US imaging of highly stenosing rectal cancers.

[Opportunistic infections in AIDS. The pulmonary manifestations]

The initial and follow-up chest radiographs of 31 patients with the acquired immunodeficiency syndrome (AIDS) were reviewed to assess the spectrum and frequency of opportunistic pulmonary infections. In our series, the most common pulmonary infections seen on chest films were: Pneumocystis carinii pneumonia (PCP) (n = 17), PCP associated with Cytomegalovirus (CMV) (n = 2), PCP associated with Mycobacterium avium-intracellulare (MAI) (n = 1), Mycobacterium tuberculosis (n = 7), CMV (n = 2), MAI (n = 1) and Cryptococcus neoformans (n = 1). Diffuse or focal interstitial infiltrate is the most common finding in PCP; bilateral focal or multilobar interstitial infiltrates are also frequently observed: they are usually caused by PCP or by PCP associated with CMV. Infiltrating cavitating lesions and multiple interstitial well-defined nodules < 10 mm diameter were seen only in Mycobacterium tuberculosis infections. Normal chest findings and/or pleural effusions were uncommon; no case exhibited pulmonary cysts on initial radiographs. In this retrospective study we emphasize the high incidence of Mycobacterium tuberculosis infections; other pulmonary infections are emerging in AIDS. The X-ray patterns of pulmonary infections in AIDS must be known for a prompt and accurate diagnosis and to plan the appropriate treatment.

[A rare case of idiopathic staghorn urolithiasis in childhood. Imaging diagnosis]

The authors describe one case of kidney staghorn lithiasis in a little patient 1 1/2 years old, as complication of a megacalycosis with associated pyelo-ureteral junction dysplasia. They underline the value of ultrasound both as a first examination and, particularly, in the follow up because of the non invasivity of the technique and the correct information about the persistence of calculi and dilatation.

[Echography in the study of the neonatal hip: the diagnostic-therapeutic implications of type-IIa (borderline) findings]

Sonography (US) is a useful method in the early diagnosis of congenital hip dislocation; X-ray examination exhibits limitations due to high false-positive and false-negative rates. The advantages of US include: non-invasiveness, direct visualization of muscle and cartilage, dynamic demonstration of anatomical structures, and possible diagnosis in neonatal age. Therefore, US can be used as a screening or targeted diagnostic technique in selected newborns with clinical suspicion and/or risk factors. In this paper the authors report their experience in 1271 patients (721 females, 550 males), aged 1 day to 7 months, who were examined with US for the diagnosis of congenital hip dislocation. The newborns were divided into two groups at first examination: a) the screening group included 524 consecutive newborns (F = 266, M = 258) from S. Chiara Regional Hospital in Trento, and b) a selected group of 747 newborns (F = 455, M = 292) with clinical suspicion and/or risk factors, who had been selected in the Trento area. According to Graf's classification, the results of US in 2542 neonatal hips, were: 2346 (92.3%) normal hips, 171 (6.1%) type IIa hips, and 24 (1.6%) pathological hips. In the selected group (1494 hips) we observed: 1351 (90.4%) normal, 119 (8%) type IIa, and 24 (1.6%) pathological hips (IIb, IIc, D, III). In the screening group (1048 hips) we detected: 995 (95%) normal hips (Ia/Ib), 52 (4.9%) type IIa, and 1 (0.1%) pathological hips (D). Our experience suggests that US is a useful method in selected newborns with clinical suspicion of congenital hip dislocation and/or risk factors. US limitations consists in the dispersion of type IIa hips. Moreover, the need emerged for complete cooperation between pediatrician, radiologist, and orthopedist to optimize the cost/benefit ratio.