Carlo Masciocchi

Comparative evaluation of TEE, conventional MRI and contrast-enhanced 3D breath-hold MRA in the post-operative follow-up of dissecting aneurysms

Purpose: To verify the diagnostic potentialities of conventional magnetic resonance imaging (MRI), breath-hold 3D contrast enhanced MR angiography (C3D MRA) and transesophageal echocardiography (TEE) in patients surgically treated for type A aortic dissection. Materials and methods: Twenty-nine patients (21 males and 8 females), surgically treated for type A aortic dissection, were evaluated with MRI using a 1.5 T (GE Horizon Echospeed 8.2) with standard gated SE sequences and breath-hold 3D fast SPGR after intravenous Gd injection (0.2 mmol/kg). 3D MIP reconstruction was obtained. TEE evaluation was performed with a HP 2000 system and a biplane 5 MHz probe. The sizes of aortic root, distal anastomosis, descending aorta and periprosthetic thickening were measured. Regional false lumen and aortic branch involvement were also evaluated. Results: Concordance among TEE, conventional MRI and C3D MRA was observed in the evaluation of aortic root (MRI vs. C3D MRA r = 0.93; MRI vs. TEE r = 0.84; C3D MRA vs. TEE r = 0.84) and descending aorta (r = 0.94, 0.91 and 0.92, respectively). The interobserver variability was also very low. Inadequate agreement was observed for distal anastomosis. C3D MRA was inadequate in the evaluation of periprosthetic thickening; r = 0.73 was obtained between MRI and TEE. For qualitative data: TEE was inadequate in the evaluation of the abdominal aorta and branches. C3D MRA depicted supra-aortic vessel involvement in more cases than the other techniques. Conclusion: C3D MRA is a fast and accurate technique in the evaluation of the endoluminal alterations and involvement of the aortic branches. Conventional MRI allows a direct evaluation of the aortic wall and periaortic tissue. TEE is less accurate in the evaluation of aortic branches and abdominal aorta.

Mr-guided Focused Ultrasound (mrgfus) Ablation for the Treatment of Nonspinal Osteoid Osteoma: A Prospective Multicenter Evaluation

BACKGROUND Magnetic resonance-guided focused ultrasound (MRgFUS) is a novel imaging-guided surgical technique that allows the performance of noninvasive and radiation-free ablation. Presently, computed tomography (CT)-guided radiofrequency ablation, a minimally invasive percutaneous technique, is the standard for treating symptomatic osteoid osteomas. The purpose of this study was to evaluate the use of MRgFUS ablation for the treatment of nonspinal osteoid osteomas in terms of technical success, complications, and clinical success through one year of follow-up. METHODS In this prospective multicenter study, thirty consecutive patients with a nonspinal osteoid osteoma were enrolled between May 2010 and April 2012 at three different university centers; twenty-nine of the patients were treated with use of MRgFUS. Lesions had been previously diagnosed on the basis of imaging, including dynamic contrast-enhanced MR. The mean number of sonications and energy deposition were determined. Technical success was evaluated through an assessment of complications immediately after treatment. Clinical success was determined on the basis of pain reduction as measured with a visual analog scale (VAS), recurrence, and long-term complications through twelve months. RESULTS Technical success of MRgFUS was observed for all twenty-nine patients. The mean number of sonications (and standard deviation) was 7 ± 3, and the mean delivered acoustic energy was 1180 ± 736 J. At the twelve-month follow-up, complete clinical success was observed in twenty-six (90%) of the twenty-nine patients (95% confidence interval [CI] = 84 to 95; mean VAS, 0 ± 0 points). Partial success was observed in three (10%) of the twenty-nine patients (95% CI = 5 to 16; mean VAS score, 5 ± 0 points); two of these patients subsequently underwent CT-guided radiofrequency ablation, and one underwent open surgery. Pain score values showed a significant reduction (p < 0.001) between baseline (mean VAS score, 8 ± 1 points) and post treatment (mean VAS score, 1 ± 2 points). No complications were observed. CONCLUSIONS MRgFUS may be an effective and safe alternative approach in the treatment of nonspinal osteoid osteoma. A complete clinical success rate of 90% was demonstrated without adverse events. MRgFUS is totally noninvasive and eliminates radiation exposure.

Assessment of inflammatory activity in Crohn's disease by means of dynamic contrast-enhanced MRI.

PurposeOur aim was to perform a dynamic study of contrast enhancement of the intestinal wall in patients with Crohn’s disease to quantitatively assess local inflammatory activity.Materials and methodsWe studied a population of 50 patients with histologically proven Crohn’s disease. Magnetic resonance imaging (MRI) was performed using a 1.5-T magnet with a phased-array coil and acquisition of T2-weighted single-shot fast spin echo (SSFSE) half Fourier sequences before intravenous administration of gadolinium, and T1-weighted fast spoiled gradient (FSPGR) fat-saturated sequences before and after contrast administration. Before the examination, patents received oral polyethylene glycol (PEG) (1,000 ml for adults; 10 ml/Kg of body weight for children). Regions of interest (ROI) were placed on the normal and diseased intestinal wall to assess signal intensity and rate of increase in contrast enhancement over time. Data were compared with the Crohn’s Disease Activity Index (CDAI).ResultsThe diseased bowel wall showed early and intense uptake of contrast that increases over time until a plateau is reached. In patients in the remission phase after treatment, signal intensity was only slightly higher in diseased bowel loops than in healthy loops. There was a significant correlation between the peak of contrast uptake and CDAI.ConclusionsDynamic MRI is a good technique for quantifying local inflammatory activity of bowel wall in patients with Crohn’s disease.RiassuntoObiettivoStudiare dinamicamente l’accumulo di contrasto della parete intestinale in pazienti con morbo di Crohn per correlarlo quantitativamente con il grado di attività di infiammazione locale.Materiali e metodiAbbiamo studiato un campione di 50 pazienti con diagnosi istologica di morbo di Crohn (37 in fase attiva di malattia; 13 in remissione clinica); abbiamo utilizzato un magnete da 1,5 T, bobina phased array e sequenze T2 dipendenti SSFSE half Fourier in fase precontrastografica e T1 dipendenti FSPGR fat-sat in fase pre-e post-contrastografica. Prima di eseguire l’esame è stato somministrato per os glicole polietilenico (PEG) (1000 ml per adulti; 10 ml/Kg del peso corporeo per bambini). Abbiamo tracciato ROI (region of interest) per valutare l’intensit`a del segnale nella parete intestinale normale e patologica e la percentuale d’incremento nel tempo. Tali dati sono stati correlati con un indice di attività della malattia, il Crohn’s Disease Activity Index (CDAI).RisultatiAbbiamo osservato che la parete intestinale patologica ha un uptake contrastografico precoce ed elevato che aumenta nel tempo fino a una fase di plateau. In caso di remissione della malattia dopo terapia, per contro, si ha una significativa riduzione dell’incremento di segnale, di poco aumentato rispetto a quello delle anse normali. Inoltre abbiamo notato una buona correlazione tra il livello di massimo uptake contrastografico e il CDAI.ConclusioniLo studio dinamico con risonanza magnetica (RM) ci consente di quantificare l’attività infiammatoria locale della parete intestinale.

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.

Ankle impingement syndromes

The ankle impingement syndrome is a frequent condition in both athletes and the normal population. We investigated this painful syndrome from both a clinical and a diagnostic viewpoint. Depending on what ankle tissue impinges on the other, it is possible to distinguish bone impingement, soft tissue impingement and peripheral nerve entrapment. For each of these pathologic conditions we investigated the diagnostic role of conventional radiography, Computed Tomography and Magnetic Resonance Imaging. The evidence of osteophytes, exostosis and presence of the os trigonum on plain films make clinical diagnosis easy in both anterior and posterior bone impingement. CT can provide useful information about the component of the posterior ankle. MRI always adds important information about chondral or subchondral bone injuries, synovial reaction and adjacent soft tissue involvement. The anterolateral impingement syndrome is caused by repeated injuries in plantar flexion and ankle intrarotation. MRI well detects the meniscoid injury thanks to high contrast sequences; it can also distinguish this syndrome from painful chondral and/or bony lesions at this level. MRI is also the method of choice to study sinus tarsi impingement, especially thanks to fat suppression sequences which increase MR diagnostic capabilities in this important anatomic area. Deep peroneal nerve entrapment, the medial plantar nerve entrapment syndrome and the tarsal tunnel syndrome are the most important entrapment neuropathies of the ankle. US and MRI are very useful to study the tendon and soft tissue abnormalities causing the anterior tarsal tunnel syndrome. CT and particularly MRI can easily detect many pathologic conditions causing the medial plantar nerve entrapment and the tarsal tunnel syndromes.

MR imaging of white matter lesions in uncomplicated chronic alcoholism.

Chronic alcoholics may have CNS lesions, such as microvasculitis or glial, neural, and myelin degeneration, as documented in postmortem studies on subjects who had Wernicke encephalopathy, corpus callosum degeneration, or central pontine myelinolysis. One may also expect the presence of early white matter disease in patients who do not have neurologic complications of alcoholism. Thirty-five chronic alcoholics (Diagnostic and Statistical Manual III criteria) and 35 normal control subjects were studied by means of magnetic resonance (MR) imaging. Subjects >60 years old, or those with CNS involvement, or clinically evident systemic disorders were excluded. Of the remaining asymptomatic alcoholics, MR detected multiple round hyperintense areas in the white matter of 14 patients, in addition to a specific corticosubcortical and cerebellar atrophies. None of the normal control subjects showed such a finding. These results suggest an early involvement of the brain in asymptomatic alcoholic patients.

Talocalcaneal coalition : computed tomography and magnetic resonance imaging diagnosis

A correct evaluation of site and extension of the talocalcaneal coalition inducing biomechanical ankle alterations is very important for planning therapy. Four male patients were submitted to computed tomography (CT) and three of them were also examined by means of magnetic resonance imaging (MRI). In one patient, studied by CT only, a bilateral talocalcaneal coalition was present, while the other three patients, controlled with CT and MRI, were affected by monolateral talocalcaneal coalition which was of osseous type in one case and fibrocartilaginous in two cases. CT and MRI provided detailed information on type and extension of the coalition and both helped in distinguishing between osseous and fibrocartilaginous forms. Only MRI showed an area of subchondral ischemic disease of the posterior subtalar joint in one patient with monolateral fibrocartilaginous talocalcaneal coalition. Compared with CT, MRI proved to be more accurate in evaluation of the talocalcaneal coalition, due to its wider display capability.

Diagnostic imaging of malignant cartilage tumors

We compared the diagnostic capabilities of CT and MRI in the study of malignant cartilage tumors. Information about the characterization and the intra-/extraosseous spread of these lesions is of primary importance in the preoperative planning. Besides peripheral chondrosarcomas, arising from an osteochondroma and central chondrosarcomas, which are the most common malignant cartilaginous tumors, we also considered secondary, periosteal, dedifferentiated, clear cells and mesenchymal chondrosarcomas. Our study was performed using a standard MRI and CT protocol; in some cases, the examination was completed by the intravenous administration of a contrast agent. High contrast T2-weighted GE images can perfectly depict and differentiate the cartilage cap of an osteochondroma from the adjacent soft tissues. Evaluation of the growth of exostosis and of the thickness of its cap is essential in the assessement of malignant transformation. Both CT and MRI provide important information about peculiar aspects of the cartilaginous matrix such as the shape of calcifications-ossifications and lobulated growth, septa, septal enchancement and necrotic intratumoral areas, furthermore, CT perfectly shows the patterns of bone destruction. MRI should be considered as the most reliable imaging technique for the locoregional staging of malignant bone tumors thanks to its spatial and contrast resolution. CT plays a major role in the characterization of most bone tumors, especially those with a cartilaginous matrix.

Ultrasound enhanced with sulphur-hexafluoride-filled microbubbles agent (SonoVue) in the follow-up of mild liver and spleen trauma

PurposeThis study assessed the role of contrast-enhanced ultrasound (CEUS) in the follow-up of patients with a diagnosis of traumatic liver or spleen lesions.Materials and methodsBetween April 2006 and February 2008, 18 patients (13 males and five females, age range 8–42 years) with blunt abdominal trauma were evaluated with computed tomography (CT) and CEUS at the emergency department of our institution. Seven were diagnosed as surgical emergencies and were excluded from the study. The remaining 11 were treated conservatively and were monitored with CEUS at variable time intervals, depending on their clinical needs.ResultsCEUS confirmed lesion sites identified on presentation and allowed us to follow all phases of the repair process until complete resolution.ConclusionsThe conservative management of abdominal lesions in both adults and children is increasingly widespread but requires accurate follow-up over time. As a noninvasive, versatile, easy to perform and repeatable technique with a low rate of adverse reactions, CEUS is ideally suited for this purpose and allowed us to reduce the number of CT scans, especially in the follow-up of young patients.RiassuntoObiettivoValutare il ruolo dell’ecografia con mezzo di contrasto (CEUS) nel follow-up di pazienti traumatizzati con diagnosi di lesione parenchimale epatica e/o splenicaMateriali e metodiDiciotto pazienti (13 maschi e 5 femmine) di età compresa fra gli 8 e i 42 anni e con trauma addominale chiuso sono giunti alla nostra osservazione da aprile 2006 a febbraio 2008. La diagnosi all’ingresso è stata posta mediante esame CEUS e TC. Dopo esclusione di 7 pazienti di immediata pertinenza chirurgica, i restanti 11 sono stati sottoposti a CEUS e TC, trattati in modo conservativo e monitorizzati con CEUS ad intervalli variabili in base alle condizioni clinicolaboratoristiche.RisultatiLa CEUS ha confermato la sede delle lesioni documentate in prima diagnosi permettendo di seguirne le varie fasi riparative fino alla pressoché completa risoluzione.ConclusioniLa gestione conservativa delle lesioni addominali, nel paziente sia adulto che bambino, è sempre più diffusa ma richiede un monitoraggio stretto. A tal proposito, l’ecografia con MdC, in virtù della sua non invasività, facilità di esecuzione, ripetibilità del MdC e assenza di documentate reazioni avverse allo stesso, è la metodica ideale per la gestione del follow-up, riducendo il numero degli esami TC ai quali i pazienti, anche di giovane età, sono sistematicamente sottoposti.

Myxoid intraneural cysts of external popliteal ischiadic nerve. Report of 2 cases studied with ultrasound, computed tomography and magnetic resonance imaging

Peripheral neuropathy of the external popliteal ischiadic nerve caused by intraneural cysts is a very rare and peculiar pathological phenomenon compared with diseases associated with extraneural cysts or colliquative phenomena of solid nervous lesions. Two cases of peripheral neuropathy of the external popliteal ischiadic nerve caused by intraneural cysts and evaluated with ultrasound, computed tomography and magnetic resonance are described. The diagnostic efficacy of these imaging modalities is also evaluated with particular reference to MR capability to define the morphology of such lesions and their relationships to the surrounding structures. It is not yet possible to obtain a correct diagnosis about histopathologic features by means of the imaging techniques currently available. Nevertheless, they do provide information about the involvement of the neighboring areas, which are useful indications for possible surgical treatment of the disease.