Antonio Gennarelli

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.

Advances in imaging and in non-surgical salvage treatments after radiorecurrence in prostate cancer: what does the oncologist, radiotherapist and radiologist need to know?

ObjectivesIn this article the state of art the of prostate cancer (Pca) imaging and non-surgical salvage treatments (STs) is surveyed in order to explore the impact of imaging findings on the identification of radiorecurrent Pca after external beam radiotherapy (EBRT).MethodsA computerised search was performed to identify all relevant studies in Medline up to 2012. Additional articles were extracted based on recommendations from an expert panel of authors.ResultsDefinitive EBRT for Pca is increasingly used as treatment. After radiorecurrent Pca, non-surgical STs are emerging and shifting from investigational status to more established therapeutic options. Therefore, several scientific societies have published guidelines including clinical and imaging recommendations, even if the timing, efficacy and long-term toxicity of these STs have to be established. In some measure, accurately delineating the location and the extent of cancer is critical in selecting target lesions and in identifying patients who are candidates for STs. However, there is increasing awareness that anatomical approaches based on measurements of tumour size have substantial limitations, especially for tumours of unknown activity that persist or recur following irradiationConclusionsTo date, the main focus for innovations in imaging is the combination of excellence in anatomical resolution with specific biological correlates that depict metabolic processes and hallmarks at the tumour level. The emergence of new molecular markers could favour the development of methods that directly determine their presence, thereby improving tumour detection.Key Points• Imaging may influence therapeutic decisions during non-surgical STs.• MRI findings correlate with parametric maps derived from multiple functional techniques.• Non-surgical salvage treatments allow local tumour control in patients with radiorecurrent PCa.

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.

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.

AB0630 Cardiac Magnetic Resonance Imaging with Pharmacological Stress Perfusion in Asymptomatic Patients with Systemic Sclerosis

Background Systemic Sclerosis (SSc)-heart disease (SSc-HD), although often clinically silent, significantly reduces the life-expectancy in these patients [1]. The cardiac magnetic resonance (CMR) is recognized useful tool for the diagnosis of SSc-HD and cardiac stress tests might be a helpful technique to highlight the occult myocardial involvement, which cannot be detected at rest due to compensatory mechanisms [2,3]. Objectives To evaluate the possible occult cardiac involvement in asymptomatic SSc patients by pharmacological stress, rest perfusion and delayed enhancement CMR, to identify as earlier as possible those patients at higher risk of cardiac related mortality and needing specific cardiovascular treatments. Methods Sixteen consecutive patients with definite SSc fulfilling the ACR/EULAR 2013 classificative criteria [4] in less than 1 year from the onset of Raynauds phenomenon underwent pharmacological stress, rest perfusion and delayed enhancement CMR. No enrolled patient showed signs and/or symptoms suggestive for cardiac involvement, confirmed by both the 12-lead ECG examination and echocardiography. No patient showed traditional cardiovascular risk factors. Patients, in which CMR technique showed occult cardiac involvement, underwent to heart computed tomography (CT) scan to evaluate a possible coronary disease. Results Stress perfusion defects, in the left ventricle, were detected in 6 out of 16 (37.5%) patients. A sub-endocardial defects and/or a ventricular mid-myocardial layer stress perfusion defects were observed. Our results confirmed, in these 6 patients, a normal flow distribution of the explored coronary arteries by CT scan. The presence of CMR stress perfusion defects did not correlate with any clinical feature of patients. Conclusions Myocardial stress perfusion defects may be early detected, by pharmacological stress perfusion CMR, a reliable and sensitive technique for the non-invasive evaluation of SSc-HD, in patients with SSc of recent onset. These defects seems to be independent from traditional risk factors and associated comorbidities, suggesting that are a specific hallmark of the disease. An early detection of myocardial involvement might suggest starting of vasodilatative therapies in these patients. References Allanore Y, et al. Primary myocardial involvement in systemic sclerosis: evidence for a microvascular origin. Clin Exp Rheumatol 2010;28:S48–53. Di Cesare E, et al. Early assessment of sub-clinical cardiac involvement in systemic sclerosis (SSc) using delayed enhancement cardiac magnetic resonance (CE-MRI). Eur J Radiol. 2013;82:e268–73. Hachulla AL, et al. Cardiac magnetic resonance imaging in systemic sclerosis: a cross-sectional observational study of 52 patients. Ann Rheum Dis. 2009;68:1878–84. van den Hoogen F, et al. 2013 Classification Criteria for Systemic Sclerosis An American College of Rheumatology/European League Against Rheumatism Collaborative Initiative. Arthritis Rheum. 2013;65:2737–47. Disclosure of Interest None declared

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.