Canan Cimsit

Diffusion-weighted MR imaging in postoperative follow-up: Reliability for detection of recurrent cholesteatoma

INTRODUCTION Cholesteatoma is a progressively growing process that destroy the neighboring bony structures and treatment is surgical removal. Follow-up is important in the postoperative period, since further surgery is necessary if recurrence is present, but not if granulation tissue is detected. This study evaluates if diffusion-weighted MR imaging alone can be a reliable alternative to CT, without use of contrast agent for follow-up of postoperative patients in detecting recurrent cholesteatoma. MATERIALS AND METHODS 26 consecutive patients with mastoidectomy reporting for routine follow-up CT after mastoidectomy were included in the study, if there was loss of middle ear aeration on CT examination. MR images were evaluated for loss of aeration and signal intensity changes on diffusion-weighted sequences. Surgical results were compared with imaging findings. RESULTS Interpretation of MR images were parallel with the loss of aeration detected on CT for all 26 patients. Of the 26 patients examined, 14 were not evaluated as recurrent cholesteatoma and verified with surgery (NPV: 100%). Twelve patients were diagnosed as recurrent cholesteatoma and 11 were surgically diagnosed as recurrent cholesteatoma (PPV: 91.7%). Four of these 11 patients had loss of aeration size greater than the high signal intensity area on DWI, which were surgically confirmed as granulation tissue or fibrosis accompanying recurrent cholesteatoma. CONCLUSION Diffusion-weighted MR for suspected recurrent cholesteatoma is a valuable tool to cut costs and prevent unnecessary second-look surgeries. It has the potential to become the MR sequence of choice to differentiate recurrent cholesteatoma from other causes of loss of aeration in patients with mastoidectomy.

A rare cause of hyperprolactinemia: persistent trigeminal artery with stalk-section effect.

Abstract The primitive trigeminal, otic, hypoglossal, and proatlantal intersegmental arteries are fetal anastomoses between the carotid and vertebrobasilar systems. Persistent trigeminal artery (PTA) is the most frequent embryonic communication between the vertebrobasilar and carotid systems in adults. We report a case of PTA compressing the left side of the pituitary gland and stalk, in a patient with elevated blood prolactin level.

Susceptibility-weighted magnetic resonance imaging for the evaluation of deep infiltrating endometriosis: preliminary results

Background Knowledge of the precise sites of deep infiltrating endometriosis (DIE) lesions is essential for preoperative workup and treatment. Susceptibility-weighted imaging (SWI) has high sensitivity for blood products and have recently been applied in abdominal imaging. Purpose To determine the value of SWI in the diagnosis of DIE. Material and Methods Forty-three clinically suspected DIE patients with sonographically diagnosed ovarian endometriomas who had tenderness or palpable nodule(s) on rectovaginal examination were referred to pelvic magnetic resonance imaging (MRI) including SWI. Two patients were excluded from the study because of low quality of SWI series. Twenty-eight patients who were offered laparoscopic endometriosis surgery (LES) preferred medical treatment over surgical approach. Thirteen out of 41 participants had LES. Lesions were evaluated for their locations, signal intensities on T1-weighted (T1W) and T2-weighted (T2W) images, and presence of signal voids on SWI using 3T MRI and correlated with LES findings. Results A total of 18 endometriosis foci were laparoscopically removed from 13 patients. DIE lesions removed at laparoscopy were located at the uterosacral ligament (9/18), rectovaginal region (4/18), retrocervical region (2/18), and fallopian tubes (3/18). Eleven out of 18 (61%) DIE foci were detected by their high-signal intensities on T1W images whereas 16 out of 18 (89%) DIE foci were detected by signal voids on SWI. Conclusion SWI imaging with its high sensitivity to blood products, contributes to the diagnosis of DIE by depicting different phases of hemorrhage not seen by conventional MRI sequences.

Prevalence of dynamic magnetic resonance imaging-identified pelvic organ prolapse in pre- and postmenopausal women without clinically evident pelvic organ descent

Background Dynamic magnetic resonance imaging (dMRI) is an imaging tool that can be used to evaluate and stage pelvic organ prolapse (POP). Greater understanding of the incidental detection of POP in asymptomatic patients is needed. Purpose To evaluate the prevalence of dMRI-detected POP in pre-and postmenopausal women who were imaged for reasons unrelated to pelvic floor dysfunction. Material and Methods A total of 227 women who had diagnoses that did not include POP underwent abdominal/pelvic dMRI. Patients with a positive gynecological examination for or a clinical history of POP (n = 11), hysterectomy (n = 4), or gynecologic-oncology surgery (n = 2) were excluded, as well as patients who were unable to strain during MRI (n = 11). A total of 199 patients without visible prolapse were enrolled in the study. An H-line, M-line, pubococcygeal line (PCL), and mid-pubic line (MPL) were used to detect and grade prolapse. Results The prevalence of dMRI-identified POP was higher in postmenopausal subjects. The PCL led to a greater frequency of prolapse detection than the MPL. The frequency of middle compartment descent was similar regardless of whether the PCL or MPL was used as a reference line. There was a higher incidence of prolapse in the posterior compartment. Using an H-line and PCL as references, the anterior and posterior compartments were found to significantly differ between pre- and postmenopausal subjects. The MRI parameters that were used to define POP were not correlated with parity, vaginal birth, BMI, or fetal birth weight. With respect to the MPL, age was correlated with both the presence of an elongated H-line and with descent. Conclusion Dynamic MRI identified incidental pelvic organ prolapse in asymptomatic patients. The prevalence of dMRI-detected POP was higher in postmenopausal women without visible prolapse. These findings suggest the need for further studies to identify how to modify the currently used dMRI thresholds for postmenopausal women.

Sciatic neuroendometriosis: Magnetic resonance imaging defined perineural spread of endometriosis

Catamenial sciatic radiculopathy resulting from endometriosis is a rare presentation of a common disease in which the pathogenesis of pain is still under debate. A 32‐year‐old woman presented complaining of infertility, catamenial sciatica, and pelvic and gluteal pain. Magnetic resonance imaging showed endometriotic infiltration of the left proximal lumbosacral plexus, sacral nerve track, sciatic nerve at the sciatic notch and pudendal nerve along the iliococcygeus muscle, together with left endometrioma and deep infiltrating endometriosis lesions. Laparoscopic endometriosis surgery was performed after all of the complications and possible outcomes of the surgery were discussed with the patient. Our case report highlights the importance of magnetic resonance imaging evidence of perineural spread, outlining the pathophysiology of the pelvic pain associated with neuroendometriosis.

Parenchymal density changes in acute pulmonary embolism: Can quantitative CT be a diagnostic tool? A preliminary study

PURPOSE Determine the ability of quantitative CT (QCT) in defining parenchymal density changes in acute pulmonary embolism (PE). MATERIAL & METHODS Mean lung density (MLD) and percentage distribution values (PDV) were calculated in 34 patients suspected of PE using software application based on computerized volumetric anatomical segmentation. RESULTS Total, left, and right MLD differed significantly between emboli positive(n=23) and negative(n=11) groups(p<0.006, p<0.009, p<0.014). PDVs differed between groups (p<0.05) except for LUZ and RLZ. When PE was present in lobe &/segment branches, PDVs were significantly lower except RUZ. CONCLUSION QCT is a promising application for defining parenchymal density changes in PE revealing potential functional impact of emboli. This preliminary study suggests QCT could provide added value to CTPA in peripheral PE.

Correlation of clot distribution with morphometric measurements and pleuroparenchymal findings in acute pulmonary embolism: experience with 692 cases

PURPOSE The aim of the study is to determine if clot distribution in acute pulmonary embolism (PE) correlates with morphometric measurements of right heart function, reflux in inferior vena cava (IVC), and pleuroparenchymal findings. MATERIALS AND METHODS A total of 692 computed tomography pulmonary angiographies with PE were enrolled, and patients were grouped according to clot localization. Parenchymal findings, morphometric measurements of right heart function, and contrast reflux in IVC were noted. RESULTS Differences were found between groups for most measurements, and central PE was associated with significantly higher right ventricle (RV) and pulmonary artery diameters, ratio of RV diameter to left ventricle (LV) diameter (RV/LV) ≥ 1, and IVC reflux. CONCLUSIONS Significant association was present among clot distribution in PE, morphometrics, IVC reflux, and pleuroparenchymal findings.

Diaphragmatic Thickness Fraction in Subjects at High-Risk for COPD Exacerbations

BACKGROUND: Ultrasound-based diaphragmatic thickness fraction is a reflection of the size and function of the diaphragm. This study aimed to examine the value of this measurement in identifying patients with COPD who are at high risk for the development of symptoms and exacerbations. METHODS: This cross-sectional study included 53 subjects with COPD. Respiratory function test results, ultrasonography-based diaphragmatic thickness, symptom scores (modified Medical Research Council dyspnea scale); COPD Assessment Test results, and number of previous exacerbations and admissions were recorded. RESULTS: Only age showed an inverse and weak relation with percent thickness fraction (r = −0.37, P = .006). None of the other variables tested correlated significantly with percent thickness fraction. No association was found between percent thickness fraction and exacerbation frequency, modified Medical Research Council dyspnea scale and COPD Assessment Test symptom scores, or Global Initiative for Chronic Obstructive Lung Disease ABCD risk/symptom assessments. CONCLUSIONS: Diaphragmatic thickness fraction measurements based on diaphragmatic ultrasound assessment in subjects with COPD seemed to be unable to identify subjects at high risk of symptoms and exacerbations as defined by the Global Initiative for Chronic Obstructive Lung Disease ABCD composite disease index.

Evaluation of sacroiliac joint MRI for pelvic venous congestion signs in women clinically suspected of sacroiliitis.

Background Pelvic congestion syndrome (PCS) is a commonly overlooked condition which is a potential cause of chronic pelvic pain. Magnetic resonance imaging (MRI) of the sacroiliac joint (SIJ) may demonstrate unexpected conditions that can mimic sacroiliitis (SI). Awareness of MRI-defined pelvic venous congestion (PVC) may help in identifying PCS, where vascular abnormality may be the sole manifestation of SIJ pain. Purpose To detect incidental MRI-defined PVC in patients who underwent SIJ-MRI for presumed SI and define the variance of its incidence. Material and Methods A total of 870 women who underwent SIJ-MRI were retrospectively evaluated. Incidental findings of PVC and other genitourinary and musculoskeletal system disorders were documented. Results Of the 774 included patients, 37% demonstrated incidentally detected imaging findings related to the genitourinary system, musculoskeletal system, and PVC. The prevalence of MRI-defined PVC signs was higher in patients without SI than with SI. The prevalence of musculoskeletal disorders was higher in patients with SI whereas prevalence for genitourinary disorders was similar. Binary logistic regression analysis revealed a statistically significant correlation between SI–PVC and SI–genitourinary disorders but not between SI–musculoskeletal disorders pairs (P = 0.001, 0.001, and 0.057 > 0.05). The probability of observing SI in SIJ-MRI is positively correlated with the absence of PVC or genitourinary disorders. Conclusion Patients who underwent MRI for presumed SI demonstrated incidental PVC as well as other genitourinary and musculoskeletal findings. An awareness of these imaging findings can help identify PVC and may draw clinicians’ attention to the possibility of PCS.

Clarification of strain ratio in sonoelastography.

Strain elastography (SE) or real-time sonoelastography calculates the relative hardness of tissue by measuring mechanically induced deformation of the structures in order to estimate the elasticity of the targeted area and the surrounding tissues (Wells and Liang, 2011). Elasticity is the ratio of the strain (pressure) required to induce relative elongation or distention. Quantification of elastography is measured in strain values defined by an elasticity index (EI) and is displayed in an elastogram. The strain ratio (target EI-to-reference tissue EI) is calculated to provide a semiquantitative analysis which indirectly depicts the elasticity (Bamber et al., 2013). The strain ratio reflecting the property of stiffness of the target lesion is automatically calculated on the sonography machine (Tan et al., 2013). In our study we aimed to define the placental stiffness differences between normal and preeclamptic pregnancies. First ROI was set for subcutaneous fat and Elasticity Index (EI) is automatically calculated as E1. Second ROI was placed on the placental tissue and EI was calculated for placenta as E2. The strain ratio (placenta-to-fat) is calculated as E2/E1. We found that the strain ratio of the placenta was higher in early-onset preeclamptic pregnancies than normal pregnancies indicating increased tissue stiffness (Cimsit et al., 2015). Lau et al. reported a new study on mechanical testing of the human placenta complicated by IUGR. They have measured and found differences between the mechanical properties of IUGR and normal placenta samples (Lau et al., 2015). They have cited our study and stated that higher strain ratio in the preeclamptic patients indicated less stiffness when compared to normal placenta which is actually just the opposite of our findings (Cimsit et al., 2015). Our study results were in line with the study of Sugitani et al. as we cited in our article where significant difference in firmness between placentas of normal and pregnancy induced hypertension pregnancies has been shown in an ex-vivo analysis (Sugitani et al. 2013). They used shear wave elastography, acoustic radiation force impulse (ARFI) imaging, involving a short acoustic push pulse to displace the target tissue generating a shear wave where the velocity (Vs) reflects elasticity index. Increased shear wave speed (Vs) was reported which was associated with firmer placentas in hypertensive pregnancies.