Carmela Visalli

Harmonic US imaging of vesicoureteric reflux in children: usefulness of a second generation US contrast agent

Background: Contrast-enhanced voiding urosonography (VUS) is largely accepted both for the diagnosis and follow-up of vesicoureteric reflux (VUR) in children. Objective: To evaluate the usefulness of contrast-enhanced second-harmonic VUS in the diagnosis and grading of VUR, using a second-generation contrast agent. Materials and methods: Eighty consecutive children were prospectively studied with contrast-enhanced second-harmonic VUS. All children received a second-generation contrast medium, constituted by phospholipid-stabilized microbubbles of sulphur-hexafluoride (SonoVue, Bracco, Milan, Italy). US monitoring of the bladder, of the retrovesical space and of the kidneys was performed using, alternatively, both tissue-harmonic and contrast-harmonic modes. In those young boys where VUR was depicted at VUS, examination was completed with transperineal, sagittal urethral exploration during micturition. VUR was graded in five steps and diagnoses were compared with voiding cystourethrography (VCUG). Results: VUR was diagnosed in 52 reno-ureteral units with VUS. In 49 of these reno-ureteral units, VCUG confirmed the presence of VUR. In comparison to VUS, sensitivity and negative predictive value of VCUG were inferior. The grade of VUR detected at VUS was higher than that detected at VCUG in three units. In no case was the grade of VUR detected at VCUG higher than the one detected at VUS. The differences between VUS and VCUG in grading VUR were statistically significant (p=0.02). Imaging of the normal posterior urethra was skilfully demonstrated with US in 15 young boys with VUR. No statistically significant differences were found between tissue-harmonic and contrast-harmonic mode (p=0.102). Conclusions: Contrast-enhanced second-harmonic VUS is a sensitive and easy technique for the evaluation of VUR. A second-generation US contrast medium such as SonoVue, if available, should be the first choice as the dose required for one examination is much lower and consequently significant reduction of contrast agent cost is possible.

Multiple hypervascular pancreatic metastases from renal cell carcinoma:Dynamic MR and spiral CT in three cases

Pancreatic metastases are rare. Melanoma, lung cancer and breast carcinoma are the most common origin of pancreatic metastases, whereas renal cell carcinoma is counted in only 1-2%. Renal cell carcinoma usually leads to a solitary pancreatic metastasis, whereas multiple pancreatic metastases are uncommon. We present three cases of multiple hypervascular pancreatic metastases from renal cell carcinoma, studied with spiral CT and dynamic MR.

Diagnostic imaging in athletes with chronic lower leg pain.

OBJECTIVE Our purpose is to describe the imaging features in athletes with chronic lower leg pain, emphasizing the role of MRI and CT, which are the diagnostic tools with the highest sensitivity and specificity in the differential diagnosis of lower leg pain. Moreover, a diagnostic algorithm in patients with chronic lower leg pain is proposed. CONCLUSION Plain radiography has a low sensitivity but may reveal tibial stress fractures, bone tumors, and soft-tissue calcification. CT and MRI may be useful to better evaluate the abnormalities shown by plain radiography.

Contrast-enhanced ultrasonography (voiding urosonography) of vesicoureteral reflux: State of the art

Three methods are currently used to identify vesicoureteral reflux (VUR) in children, namely, radiographic voiding cystourethrography, radionuclide voiding cystography and, more recently, echo-enhanced voiding urosonography (VUS). Recent advances in tissue-harmonic and contrast-specific imaging techniques, together with the development of second-generation contrast agents, have improved the potential of ultrasonography both in the diagnosis and grading of VUR in children. Today, VUS is able to accurately assess the grade of reflux and the state of the urethra, previously considered fundamental limitations to the extensive use of this technique. The aim of our paper is to review the role of ultrasonography in the diagnosis of VUR, from the initial experiences up to the recent use of second-generation microbubbles combined with contrast-specific low-mechanical-index software. We discuss the advantages and limits of VUS with respect to radiographic and radionuclide imaging in the light of an analysis of the most recent literature, and we described the new VUS study technique using second-generation contrast media. Growing requests by paediatric nephrologists and surgeons require that even general radiologists become familiar with this technique.RiassuntoLa diagnostica per immagini del reflusso vescico-ureterale (RVU) si avvale oggi di tre metodiche: la uretrocistografia minzionale, la cistoscintigrafia diretta e, più recentemente, la urosonografia con mezzo di contrasto (VUS). Il recente sviluppo tecnologico dell’imaging armonico tissutale e contrasto-specifico, unitamente alla disponibilità di mezzi di contrasto ecografici di seconda generazione, ha comportato un significativo miglioramento della ecografia nella diagnosi e nella stadiazione in gradi del RVU. Oggi la VUS consente un’accurata stadiazione in gradi del reflusso ed una valutazione dello stato dell’uretra, in passato considerate le principali limitazioni all’uso estensivo della metodica. Lo scopo di questo lavoro è quello di rivisitare il ruolo dell’ecografia nella diagnosi del RVU dalle esperienze iniziali sino ai più recenti sviluppi tecnologici costituiti dall’impiego di microbolle di ultima generazione accoppiato a sistemi contrasto-specifici a basso indice meccanico. Vengono discussi i vantaggi ed i limiti della VUS rispetto alle metodiche radiografica e radioisotopica, anche alla luce dell’analisi della più recente letteratura e viene descritta la tecnica di studio VUS con contrasto di ultima generazione. Considerata la crescente domanda da parte di nefrologi e chirurghi pediatri, riteniamo utile che anche il radiologo generale acquisisca familiarità con questa nuova tecnica.

Intrahepatic portal vein aneurysm: three-dimensional power Doppler demonstration in four cases.

Wedescribe four cases of portal vein aneurysm that were studied with ultrasonography, color Doppler, computed tomography, and magnetic resonance imaging as well as three-dimensional power Doppler. Three-dimensional ultrasonography showed the portal aneurysm and its relationship to its portal branches in all patients and showed the portosystemic communication in three. In all cases, computed tomography or magnetic resonance imaging confirmed the three-dimensional ultrasonographic findings.

Diagnostic approach to retromolar trigone cancer by multiplanar computed tomography reconstructions.

Neoplasms of retromolar trigone have important peculiarities due to their spatial relationships with the surrounding structures. Tumours that involve this area can extend to nearby muscles; adipose spaces; and other anatomic structures, such as the soft palate, the tonsillar fossa, the parapharyngeal space, and the floor of the mouth. In spite of a relatively quick diagnosis, the real extent of these tumours is typically underestimated at clinical examination. Our purpose was to propose a systematic approach to the use of multiplanar computed tomography reconstructions to evaluate normal retromolar trigone anatomy and the main pathways of spread for tumours that arise in this area. To our knowledge, only few reports exist in literature about this topic and none are about the usefulness of multidetector computed tomography and multiplanar reconstructions.

Subcapsular renal spread of a pancreatic pseudocyst

Abstract. In pancreatitis, the fluid collection may extend to unusual sites and organs and form a pseudocyst. We present US and CT findings of a pancreatic tail pseudocyst extending into the subcapsular space of the left kidney.

A new variant of cholecystohepatic duct: MR cholangiography demonstration

Magnetic resonance cholangiography used before laparoscopic cholecystectomy may reduce the incidence of post-operative complications related to the high anatomic variability of the biliary system. A number of anatomic variants of the biliary tree have been reported. We present a rare case in which magnetic resonance cholangiography demonstrated a new variant of the cholecystohepatic bile duct acting as a communication between the gallbladder fundus and an intrahepatic biliary duct.

Embolization of a Bronchial Artery Aneurysm in a Chronic Obstructive Pulmonary Disease (COPD) Patient with Non-Massive Hemoptysis

Summary Background Bronchial artery aneurysm (BAA) is a rare condition with a reported prevalence of less than 1% of all selective bronchial arterial angiograms. Despite its low incidence, BAA represents a potential cause of hemoptysis. Case Report We describe the case of a 63-year-old man suffering from chronic obstructive pulmonary disease (COPD), who presented with non-massive hemoptysis. CT angiography revealed a single bronchial artery aneurysm of 9 mm in diameter, abutting the esophageal wall. Other CT findings included hypertrophy of the bronchial arteries along the mediastinal course, diffuse thickening of the walls of numerous bronchial branches and a “ground glass” opacity in the anterior segment of the right upper pulmonary lobe suggestive of alveolar hemorrhage. The final diagnosis was established based on selective angiography, which was followed by transcatheter arterial embolization (TAE) of the BAA and of the pathological bronchial circulation. Follow-up CT scans revealed a total exclusion of the aneurysm from the systemic circulation, resolution of the parenchymal “ground glass” opacity and absence of further episodes of hemoptysis over a period of two years. Conclusions An incidental finding of a bronchial artery aneurysm necessitates prompt treatment. CT angiography and TAE represent the methods of choice for an appropriate diagnosis and treatment, respectively. In case of a BAA associated with chronic inflammatory diseases, such as COPD, in patients with hemoptysis, TAE of the BAA and of the pathological bronchial circulation, in association with the treatment of the underlying disease, represents a valid approach that can improve the pulmonary status and prevent further episodes of hemoptysis.

CT-MR integrated diagnostic imaging of the oral cavity: neoplastic disease

The oral cavity is a complex anatomical region consisting of different anatomical sites and subsites. Cancer undoubtedly represents the most frequent and relevant disease of this region. Clinical examination is often the first approach to oral cavity tumours. Cross-sectional computed tomography (CT) and magnetic resonance imaging (MRI) play a key role in staging locoregional disease by demonstrating submucosal spread and involvement of deep layers; evaluation of specific pathways of spread to peculiar anatomical subsites is also fundamental information that can be obtained with these techniques. The purpose of this paper is to illustrate CT and MRI findings of anatomical subsites involved by tumours of the oral cavity.RiassuntoIl cavo orale rappresenta una regione anatomica complessa, nella cui costituzione rientrano differenti aree e logge. Nell’ambito di tale distretto la patologia neoplastica rappresenta certamente l’evento più frequente e di maggiore rilevanza. L’approccio iniziale alle neoplasie del cavo orale è quasi sempre rappresentato dall’esame clinico. L’imaging panesplorante ottenuto con tomografia computerizzata (TC) e risonanza magnetica (RM) assume un ruolo fondamentale nella stadiazione locoregionale di malattia, dimostrando la possibile estensione sottomucosa e il coinvolgimento dei piani profondi; fondamentale è inoltre l’informazione ottenibile con tali indagini relativamente alla identificazione di peculiari vie di diffusione in alcune particolari sub-sedi anatomiche. Scopo del lavoro è illustrare i rilievi di semeiotica TC e RM nelle neoplasie del cavo orale relativamente al coinvolgimento delle diverse sub-sedi anatomiche.