Alfredo D’Andrea

US in the assessment of acute scrotum

BackgroundThe acute scrotum is a medical emergency . The acute scrotum is defined as scrotal pain, swelling, and redness of acute onset. Scrotal abnormalities can be divided into three groups , which are extra-testicular lesion, intra-testicular lesion and trauma. This is a retrospective analysis of 164 ultrasound examination performed in patient arriving in the emergency room for scrotal pain.The objective of this article is to familiarize the reader with the US features of the most common and some of the least common scrotal lesions.MethodsBetween January 2008 and January 2010, 164 patients aged few month and older with scrotal symptoms, who underwent scrotal ultrasonography (US), were retrospectively reviewed. The clinical presentation, outcome, and US results were analyzed. The presentation symptoms including scrotal pain, painless scrotal mass or swelling, and trauma.ResultsOf 164 patients, 125 (76%) presented with scrotal pain, 31 (19%) had painless scrotal mass or swelling and 8 (5%) had trauma. Of the 125 patients with scrotal pain, 72 had infection,10 had testicular torsion, 8 had testicular trauma, 18 had varicocele, 20 had hydrocele, 5 had cryptorchidism, 5 had scrotal sac and groin metastases, and 2 had unremarkable results. In the 8 patients who had history of scrotal trauma, US detected testicular rupture in 1 patients, scrotal haematomas in 2 patients .Of the 19 patients who presented with painless scrotal mass or swelling, 1 6 had extra-testicular lesions and 3 had intra-testicular lesions. All the extra-testicular lesions were benign. Of the 3 intra-testicular lesions, one was due to tuberculosis epididymo-orchitis, one was non-Hodgkin’s lymphoma, and one was metastasis from liposarcomaConclusionsUS provides excellent anatomic detail; when color Doppler and Power Doppler imaging are added, testicular perfusion can be assessed

Split-bolus versus triphasic multidetector-row computed tomography technique in the diagnosis of hepatic focal nodular hyperplasia: a case report

IntroductionComputed tomography and magnetic resonance imaging are able to demonstrate and to diagnose hepatic focal nodular hyperplasia when a typical pattern of a well-circumscribed lesion with a central scar is present.Our aim is to propose the split-bolus multidetector-row computed tomography technique as an alternative to the conventional triphasic technique in the detection and characterization of focal nodular hyperplasia to reduce the radiation dose to the patient.To the best of our knowledge, this is the first report regarding the application of the split-bolus computed tomography technique in the evaluation of hepatic focal nodular hyperplasia.Case presentationWe describe a case of focal nodular hyperplasia of the liver in a 53-year-old Caucasian woman (weight 75Kg) with a colorectal adenocarcinoma histologically confirmed. An innovative split-bolus multidetector-row computed tomography technique was used that, by splitting intravenous contrast material in two boli, combined two phases (hepatic arterial phase and portal venous phase) in a single pass; a delayed (5 minutes) phase was obtained to compare the findings with that of triphasic multidetector-row computed tomography.ConclusionsSplit-bolus multidetector-row computed tomography was able to show the same appearance of the lesion as the triphasic multidetector-row computed tomography technique.This is the first case demonstrating the effectiveness of the split-bolus multidetector-row computed tomography technique in the detection and characterization of focal nodular hyperplasia with a significant reduction in radiation dose to the patient with respect to triphasic multidetector-row computed tomography technique.

Ultrasonography (US) in the assessment of pediatric non traumatic gastrointestinal emergencies.

BackgroundNon traumatic gastrointestinal emergencies in the children and neonatal patient is a dilemma for the radiologist in the emergencies room and they presenting characteristics ultrasound features on the longitudinal and axial axis. The most frequent emergencies are : appendicitis, intussusceptions, hypertrophic pyloric stenosis, volvulus due to intestinal malrotation. The aim of this article is to familiarize the reader with the US features.MethodsA retrospective analysis of 200 ultrasound examinations performed in neonatal and children patients with fever, abdominal pain, leukocytosis, vomiting and diarrhea were evaluated.ResultsOf 200 exame 50 cases of intussusceptions, 100 cases of appendicitis, 20 cases associated with abscess;10 gangrenous appendicitis with absence a color Doppler , and 10 cases of perforated appendicitis at tomography computer integration and 10 cases of volvulus was found.ConclusionsUltrasonography (US) is therefore rapidly becoming an important imaging modality for the evaluation of acute abdominal pain, particularly in pediatric patients, where satisfactory examination is often not achievable for the attending clinicians. US provides excellent anatomic detail on the longitudinally and axial axis .

Biparametric MRI: a further improvement to PIRADS 2.0?

Dear Editor, We have read with great interest the short communication by Turkbey and Choyke (1) in the September–October 2015 issue of Diagnostic and Interventional Radiology. The authors reported that Prostate Imaging Reporting and Data System (PIRADS) 2.0 provides extensive information on how to acquire, interpret, and report multiparametric magnetic resonance imaging (mpMRI) of the prostate and the highlights of the changes compared with PIRADS 1.0. However, there are some concerns to be discussed regarding the role of mpMRI and its limits in PIRADS. Current PIRADS 2.0 appears to have good diagnostic accuracy in prostate cancer (PCa) detection and localization, but standardizing the reporting of mpMRI exams and correlating it with tumor aggressiveness remain controversial (2). Dynamic contrast-enhanced (DCE)-MRI is a specific modality to detect PCa in the peripheral and transition zones and to correlate tumor aggressiveness and type of enhancement curves (3). DCE-MRI plays only a minor role in determining PIRADS assessment category, and each lesion gets a positive or negative score based on DCE-MRI (2). The gold standard for assessment of PCa aggressiveness is the Gleason score obtained from prostate biopsy or radical prostatectomy specimens. Furthermore, other limits to be considered for the mpMRI include the cost and the time required to complete the study, such as the use of gadolinium-based contrast agents requiring intravenous access and different technical parameters (e.g., field strength and b values). In the diagnosis of PCa, it is essential to consider that: 1) Histopathology remains the gold standard method for diagnosis of PCa; 2) Dominant sequences in the lesion detection are diffusion-weighted imaging (DWI) and T2-weighted MRI; 3) DCE-MRI has a secondary role to T2-weighted MRI and DWI, and it is often difficult to differentiate focal enhancement of small PCa (especially in the transition zone) from adjacent normal prostatic tissues; and 4) T2-weighted MRI alone or with DWI is sufficient for MRI-ultrasonography fusion to direct biopsy needles under transrectal ultrasound guidance. Considering the abovementioned points, in patients suspected of having PCa, the goals of MRI are essentially detection, localization, and staging of the lesions suspected for PCa. We use biparametric MRI (bpMRI) at 3.0 T with nonendorectal coil incorporating axial fat suppression T1-weighted MRI, axial, sagittal, and coronal T2-weighted MRI and DWI series with apparent coefficient diffusion (ADC) maps. In our experience, we consider DWI as the dominant sequence in lesion detection both in the peripheral and transition zones and in the anterior fibromuscular stroma (Fig.), as reported (4). In addition to DWI/ADC, we consider the appearance of the lesions on T2-weighted MRI to prevent overcalling in the transition zone. Figure. a–c. Biparametric prostate 3.0 T MRI of a 59-year-old male with a serum prostate specific antigen of 10.31 ng/mL (two negative transrectal ultrasound-guided biopsies prior to MRI). The lesion affects anterior fibromuscular stroma in the left at the prostate ... Currently, there is no prospective randomized study that evaluates role of bpMRI for detection of PCa. The current limited experience is all based on retrospectively evaluated data. The real impact of DCE-MRI and/or use of endorectal coil is unknown. BpMRI offers diagnostic scan in approximately 15 min at a reduced cost, an accurate sector map of the prostate, detection, localization and tumor staging allowing direct biopsy needle under MRI-ultrasound or MRI-guided endorectal prostate biopsy (4–6). A further improvement of PIRADS 2.0 would be its simplification and the introduction of bpMRI, considering that assigned DWI/ADC and T2-weighted MRI score can be sufficient for the stratification of patients for further diagnostic workup.

Sharp penetrating wounds: spectrum of imaging findings and legal aspects in the emergency setting

The main cause of severe civilian trauma is not the same all over the world; while in Europe the majority of cases are due to blunt traumatic injury, in the United States, penetrating gunshot wounds are the most common. Penetrating wounds can be classified into two different entities: gunshot wounds, or more technically ballistic traumas, and sharp penetrating traumas, also identifiable with non-ballistic traumas. Sharp penetrating injuries are mainly caused by sharp pointed objects such as spears, nails, daggers, knives, and arrows. The type of injuries caused by sharp pointed objects depends on the nature and shape of the weapon, the amount of energy in the weapon or implement when it strikes the body, whether it is inflicted upon a moving or a still body, and the nature of the tissue injured. In the assessment of hemodynamically stable patients with sharp penetrating wounds, the main imaging procedure is Multidetector Computed Tomography (MDCT), especially used in complicated cases of penetrating injuries with an important impact on the final therapeutic choice. The diagnostic approach has been changed by MDCT due to its technical improvements, in particular, faster data acquiring and upgraded image reconstructions.

Split-Bolus Multidetector-Row Computed Tomography Technique for Characterization of Focal Liver Lesions in Oncologic Patients

Background In oncologic patients, the liver is the most common target for metastases. An accurate detection and characterization of focal liver lesions in patients with known primary extrahepatic malignancy are essential to define management and prognosis. Objectives To assess the diagnostic accuracy of the split-bolus multidetector-row computed tomography (MDCT) protocol in the characterization of focal liver lesions in oncologic patients. Patients and Methods We retrospectively analyzed the follow-up split-bolus 64-detector row CT protocol in 36 oncologic patients to characterize focal liver lesions. The split-bolus MDCT protocol by intravenous injection of two boluses of contrast medium combines the hepatic arterial phase (HAP) and hepatic enhancement during the portal venous phase (PVP) in a single-pass. Results The split-bolus MDCT protocol detected 208 lesions and characterized 186 (89.4%) of them: typical hemangiomas (n = 9), atypical hemangiomas (n = 3), cysts (n = 78), hypovascular (n = 93) and hypervascular (n = 3) metastases. Twenty two (10.6%) hypodense lesions were categorized as indeterminate (≤5 mm). The mean radiation dose was 24.5±6.5 millisieverts (mSv). Conclusion The designed split-bolus MDCT technique can be proposed alternatively to triphasic MDCT and in a single-pass to PVP in the initial staging and in the follow-up respectively in oncologic patients.

Biparametric MRI of the prostate

Biparametric Magnetic Resonance Imaging (bpMRI) of the prostate combining both morphologic T2-weighted imaging (T2WI) and diffusion-weighted imaging (DWI) is emerging as an alternative to multiparametric MRI (mpMRI) to detect, to localize and to guide prostatic targeted biopsy in patients with suspicious prostate cancer (PCa). BpMRI overcomes some limitations of mpMRI such as the costs, the time required to perform the study, the use of gadolinium-based contrast agents and the lack of a guidance for management of score 3 lesions equivocal for significant PCa. In our experience the optimal and similar clinical results of the bpMRI in comparison to mpMRI are essentially related to the DWI that we consider the dominant sequence for detection suspicious PCa both in transition and in peripheral zone. In clinical practice, the adoption of bpMRI standardized scoring system, indicating the likelihood to diagnose a clinically significant PCa and establishing the management of each suspicious category (from 1 to 4), could represent the rationale to simplify and to improve the current interpretation of mpMRI based on Prostate Imaging and Reporting Archiving Data System version 2 (PI-RADS v2). In this review article we report and describe the current knowledge about bpMRI in the detection of suspicious PCa and a simplified PI-RADS based on bpMRI for management of each suspicious PCa categories to facilitate the communication between radiologists and urologists.

MDCT and MRI Protocols in Pediatric Non-traumatic Abdominal Emergencies

Accurate and tempestive diagnosis is essential in pediatric patients with non-traumatic abdominopelvic diseases (Singh et al. Radiographics 27(5):1419–31, 2007). In emergency management of these conditions, ultrasonography (US) and multidetector-row computed tomography (MDCT) represent the methods of the choice to identify and treat any life-threatening medical or surgical disease condition and relief from pain. Magnetic resonance (MR) imaging is a promising alternative to MDCT in the evaluation of acute abdominal pain and does not involve the use of ionizing radiation exposure (Singh et al. Radiographics 27(5):1419–31, 2007; Stoker et al. Radiology 253(1):31–46, 2009).

SPLIT-BOLUS SINGLE-PASS MULTIDETECTOR-ROW CT PROTOCOL FOR DIAGNOSIS OF ACUTE PULMONARY EMBOLISM

Background: Currently computed tomography pulmonary angiography (CTPA) has become a widely accepted clinical tool in the diagnosis of acute pulmonary embolism (PE). Objectives: To report split-bolus single-pass 64-multidetector-row CT (MDCT) protocol for diagnosis of PE. Patients and Methods: MDCT split-bolus results in 40 patients suspicious of PE were analyzed in terms of image quality of target pulmonary vessels (TPVs) and occurrence and severity of flow-related artifact, flow-related artifact, false filling defect of the pulmonary veins and beam hardening streak artifacts. Dose radiation to patients was calculated. Results: MDCT split-bolus protocol allowed diagnostic images of high quality in all cases. Diagnosis of PE was obtained in 22 of 40 patients. Mean attenuation for target vessels was higher than 250 HU all cases: 361 ± 98 HU in pulmonary artery trunk (PAT); 339 ± 93 HU in right pulmonary artery (RPA); 334 ± 100 HU in left pulmonary artery (LPA). Adequate enhancement was obtained in the right atrium (RA):292 ± 83 HU; right pulmonary vein (RPV): 302 ± 91 HU, and left pulmonary vein (LPV): 291 ± 83 HU. The flow related artifacts and the beam hardening streak artifacts have been detected respectively in 4 and 25 patients. No false filling defect of the pulmonary veins was revealed. Conclusion: MDCT split-bolus technique by simultaneous opacification of pulmonary arteries and veins represents an accurate technique for diagnosis of acute PE, removes the false filling defects of the pulmonary veins, and reduces flow related artifacts.

Imaging of Gastrointestinal Tract Perforation in the Elderly Patient

There are multiple etiologies of gastrointestinal perforation in children. It occurs most frequently in the newborn. The most common causes of perforation include necrotizing enterocolitis (NEC), gastric perforation, Hirschsprung’s disease, meconium ileus, imperforate anus, and neonatal small left colon syndrome. Other causes of intestinal perforation are intussusception, volvulus/malrotation, appendicitis, inflammatory bowel disease, and foreign object.