Alessandra Di Sibio

Early assessment of sub-clinical cardiac involvement in systemic sclerosis (SSc) using delayed enhancement cardiac magnetic resonance (CE-MRI)

OBJECTIVES Systemic sclerosis heart involvement (SHI) is one of systemic sclerosis (SSc) most frequent complications, both in diffuse (dcSSc) and limited (lcSSc) cutaneous forms of disease. Nowadays, SHI is a major factor decreasing SSc survival rate because, when clinically evident, is associated with 70% of mortality at 5 years. SHI shows different forms, primary and/or secondary. Primary myocardial SHI is characterized by fibrosis. Aim of our study is to assess the presence and pattern of fibrosis as detected by cardiac magnetic resonance (CMR) in systemic sclerosis. METHODS In this study, we used CE-MRI (contrast enhanced-MRI) in 58 female SSc patients. Images were evaluated to obtain functional parameters and to see presence, location and pattern (nodular, linear or diffuse) of myocardial LE, sign of fibrosis. CE-MRI findings were correlated with patients clinical setting. RESULTS Myocardial fibrosis was detected in 25 of 58 patients (43%). The main finding observed in 16 of these 25 patients was a late enhancement showing a linear pattern, without coronary distribution and sparing the sub-endocardial myocardial layers. A patchy nodular enhancement pattern was observed in 9 patients (36%). Patients with linear pattern presented dcSSc, on the contrary patients with nodular LE displayed the lcSSc form. CONCLUSIONS This study shows that CE-MRI is a reliable technique to detect SHI earlier than other methods. SHI increase passive myocardial stiffness, proportional to collagen deposition degree, leading to cardiac remodelling with possible development of heart failure, even with normal ejection fraction. An early treatment of SHI might improve SSc patients outcome.

Image quality and radiation dose of single heartbeat 640-slice coronary CT angiography: A comparison between patients with chronic Atrial Fibrillation and subjects in normal sinus rhythm by propensity analysis

OBJECTIVES To evaluate image quality and radiation dose of single heartbeat 640-slice coronary CT angiography (CCTA) in patients with chronic Atrial Fibrillation (cAF) in comparison with subjects in normal sinus rhythm. METHODS A cohort of 71 patients with cAF was matched with 71 subjects in normal sinus rhythm (NSR) and HR≤65 bpm using a matched by propensity analysis. All subjects underwent a single heartbeat CCTA with prospective gating. In subjects with cAF, we manually established the acquisition of data only from a single heartbeat. Mean effective dose and image quality, with both objective and subjective measures, were assessed. RESULTS 96.4% of all segments in the cAF group had diagnostic image quality. The rate of subjects with at least one non-diagnostic segment was 14% and 2.8% (p=0.031) in the cAF and NRS groups, respectively. In the cAF group, the percentage of patients with at least one non-diagnostic segment for acquisition HR≤72 was 1.8% (1/55), and it did not significantly differ from the NSR group (2.8%; 2/71) (p=1.0). Objective quality parameters did not show a statistically significant difference between the two groups. The mean effective dose was 4.24±1.24 mSv in the cAF group and 2.67±0.5 mSv in the sinus rhythm group (p<0.0001) with an increase by 59% in the cAF group with respect to the SNR group. CONCLUSIONS A single heartbeat acquisition protocol with a 640-slice prospectively ECG-triggered CT angiography may be feasible in patients with cAF and HR below 72 bpm at the CT acquisition, although mean effective dose of this protocol in cAF group was 59% higher than in sinus rhythm one. In patients with cAF and a heart rate higher than 72 bpm, CCTA tends to have more movement-associated artefacts.

Progressive Multifocal Leukoencephalopathy Following Treatment with Rituximab in an HIV-Negative Patient with Non-Hodgkin Lymphoma: A Case Report and Literature Review

Progressive multifocal leukoencephalopathy (PML) is a rare rapidly progressive demyelinating disease of the central nervous system caused by reactivation of latent John Cunningham (JC) polyomavirus (JCV) infection. We describe an unusual case of PML in a 54-year-old patient with follicular non-Hodgkin lymphoma who received rituximab plus cyclophosphamide, hydroxydaunorubicin, oncovicin and prednisolone (R-CHOP) therapy. She started to notice gradual progressive neurological symptoms about two months after completion of rituximab treatment and was therefore admitted to hospital. On admission, brain CT and MRI showed widespread lesions consistent with a demyelinating process involving the subcortical and deep white matter of the cerebral and cerebellar hemispheres. CT and MRI findings were suggestive of PML, and JC virus DNA was detected by polymerase chain reaction assay of the cerebrospinal fluid and serum. The patient was treated supportively but reported a progressive worsening of the clinical and radiological findings. Our report emphasizes the role of CT and MRI findings in the diagnosis of PML and suggests that PML should be considered in patients with progressive neurological disorders involving the entire nervous system and mainly the white matter, especially in the presence of previous immunomodulatory treatment or immunosuppression.

Pediatric Stroke: Clinical Findings and Radiological Approach

This paper focuses on radiological approach in pediatric stroke including both ischemic stroke (Arterial Ischemic Stroke and Cerebral Sinovenous Thrombosis) and hemorrhagic stroke. Etiopathology and main clinical findings are examined as well. Magnetic Resonance Imaging could be considered as the first-choice diagnostic exam, offering a complete diagnostic set of information both in the discrimination between ischemic/hemorrhagic stroke and in the identification of underlying causes. In addition, Magnetic Resonance vascular techniques supply further information about cerebral arterial and venous circulation. Computed Tomography, for its limits and radiation exposure, should be used only when Magnetic Resonance is not available and on unstable patients.

Magnetic resonance imaging and magnetic resonance spectroscopy in a young male patient with anti-N-methyl-D-aspartate receptor encephalitis and uncommon cerebellar involvement: A case report with review of the literature

We report a case of a 17-year-old man presenting with new onset psychiatric symptoms. Magnetic resonance imaging (MRI) and proton magnetic resonance (MR) spectroscopy revealed some lesions in the right cerebellar hemisphere and ipsilateral cerebellar tonsil suggestive of encephalitis. An extensive workup was negative for both infectious and neoplastic diseases and he was afterward diagnosed with anti-N-methyl-D-aspartate receptor (anti-NMDAR) encephalitis. This disorder is an autoimmune encephalitis, highly lethal but curable, predominantly found in young female with ovarian teratoma. He received methylprednisolone. His clinical findings gradually improve and he made a complete recovery. Accordingly, repeated brain MRI and proton MR spectroscopy showed a gradual reduction of the lesions; MRI taken six months after starting therapy showed complete resolution of the lesions. Our case shows that, although rare, anti-NMDAR encephalitis should be considered also in young men for whom a rapid onset of psychiatric neurological disorders cannot be explained by more frequent causes. Our report underlines also the usefulness of MRI and proton MR spectroscopic findings in the diagnosis and follow-up of this disease.

Diagnostic accuracy of proton magnetic resonance spectroscopy and perfusion-weighted imaging in brain gliomas follow-up: a single institutional experience

Objectives The objective of this study was to evaluate whether proton magnetic resonance spectroscopy and perfusion magnetic resonance imaging (MRI) are able to increase diagnostic accuracy in the follow-up of brain gliomas, identifying the progression of disease before it becomes evident in the standard MRI; also to evaluate which of the two techniques has the best diagnostic accuracy. Methods Eighty-three patients with cerebral glioma (50 high-grade gliomas (HGGs), 33 low-grade gliomas (LGGs)) were retrospectively enrolled. All patients underwent standard MRI, H spectroscopic and perfusion echo-planar imaging MRI. For spectroscopy variations of choline/creatine, choline/N-acetyl-aspartate ratio, and lipids and lactates peak were considered. For perfusion 2.0 was considered the cerebral blood volume cut-off for progression. The combination of functional parameters gave a multiparametric score (0–2) to predict outcome. Diagnostic performance was determined by the receiver operating characteristic curve, with sensitivity, specificity, positive predictive and negative predictive values. Results In patients with LGGs a combined score of at least 1 was the best predictor for progression (odds ratio (OR) 3.91) with 8.4 months median anticipation of diagnosis compared to standard MRI. The individual advanced magnetic resonance technique did not show a diagnostic accuracy comparable to the combination of the two. Overall diagnostic accuracy area under the curve (AUC) was 0.881. In patients with HGGs the multiparametric score did not improve diagnostic accuracy significantly. Perfusion MRI was the best predictor of progression (OR 3.65), with 6.7 months median anticipation of diagnosis. Overall diagnostic accuracy AUC was 0.897. Then spectroscopy and perfusion MRI are able to identify tumour progression during follow-up earlier than standard MRI. Conclusion In patients with LGGs the combination of the functional parameters seems to be the best method for diagnosis of progression. In patients with HGGs perfusion is the best diagnostic method.

Pharmacological stress, rest perfusion and delayed enhancement cardiac magnetic resonance identifies very early cardiac involvement in systemic sclerosis patients of recent onset

To evaluate occult cardiac involvement in asymptomatic systemic sclerosis (SSc) patients by pharmacological stress, rest perfusion and delayed enhancement cardiac magnetic resonance (CMR), for a very early identification of patients at higher risk of cardiac‐related mortality.

An Unusual Case of Ascending Pancreatitis with Mediastinal Involvement: A Case Report with CT and MRI Findings

Fluid collections are common findings of pancreatitis and spread, more often, along preferential drainage pathways in the abdomen. In some rare cases, fluid collections may spread towards extra-abdominal sites like the mediastinum leading to the formation of mediastinal collections. We present the case of a 52-years-old man with pain in the right upper quadrant of the abdomen and mid-epigastrium lasting for some hours. Laboratory tests suggested a diagnosis of pancreatitis. CT and subsequent MRI revealed changes consistent with acute exacerbation on chronic pancreatitis spreading to the mediastinum and to the greater omentum. The patient received medical treatment and reported gradual improvement in his laboratory results and CT findings.

Advanced neuroimaging of carbon monoxide poisoning

Carbon monoxide (CO) inhalation is nowadays the most common cause of fatal poisoning worldwide. CO binds to haemoglobin 230–270 times more avidly than oxygen, thus leading to formation of carboxyhaemoglobin with subsequent reduction of tissue oxygenation. Brain is mainly affected due to its high oxygen requirement. Up to two-thirds of patients who survive the acute phase of this pathology present a delayed leukoencephalopathy, usually in a period ranging from two to 40 days. White matter damage closely relates to long-term prognosis of these patients. On the other hand CO seems to play a fundamental role as a possible neuro-protective agent in ischaemic stroke. Diagnostic imaging, with computed tomography and magnetic resonance imaging, especially magnetic resonance spectroscopy, is very useful to depict the presence and extension of this pathology, in both acute and late phase. Nevertheless, a correlation of imaging studies with clinical history and laboratory data is fundamental to perform the correct diagnosis. The purpose of this article is to highlight the imaging features of brain CO poisoning in acute and late phase, describing a case report of a 56-year-old man found unconscious at home.

Magnetic Resonance Imaging of AMS (Aneurysm of the Membranous Septum), review of the literature and case report

Aneurysm of the Membranous Septum (AMS) is a rare cardiac disease, mostly associated with other cardiac anomalies, very rare in the absence of other congenital heart defects. A prompt diagnosis is important, due to severe potential complications, but remain challenging. Most of the cases were earlier diagnosed using ventriculography, but, with the availability of echocardiography and cardiovascular magnetic resonance (CMR), this disease can be accurately assessed non-invasively. We report a case of a 62 years old female patient, without other cardiac congenital disease, who was incidentally diagnosed, by means of CMR with a true and isolated AMS. Our report underlines CMR usefulness in AMS diagnosis, thanks to accurate evaluation (both morphologic and functional) provided by this diagnostic tool, which is able to demonstrate clearly the presence of AMS (aneurysm of the membranous septum) and depict its features.