Carmelo Lacognata

Diffusion-weighted magnetic resonance for assessing ileal Crohn's disease activity

Background:Endoscopy and imaging objectively assess Crohns disease (CD) activity. Magnetic resonance enterography (MRE) uses no ionizing radiation, carries no significant morbidity, and is highly sensitive in revealing soft tissues inflammation. Diffusion-weighted imaging can distinguish intestinal inflammation from a lower diffusion of water molecules giving rise to a reduced apparent diffusion coefficient. The magnetic resonance index of activity score and, more recently, the Clermont score were recently developed for staging CD activity. The aim of this study was to compare the MRE scores and the Simple Endoscopic Score for CD in identifying ileal CD activity. Methods:Fifty-five patients with ileal and ileocolonic CD were consecutively enrolled between June 2012 and June 2013. All patients underwent clinical examination, biochemical tests, MRE, and colonoscopy to assess disease activity. Results:MRE assessed active ileal disease in 31 patients (56.3%). The Clermont score significantly correlated with the magnetic resonance index of activity score (r = 0.91; P < 0.0001) and the Simple Endoscopic Score for CD (r = 0.76; P < 0.0001). The apparent diffusion coefficient correlated with the Simple Endoscopic Score for CD (r = −0.63; P < 0.0001) especially in unoperated patients. Conclusions:The Clermont score and the apparent diffusion coefficient value can stage ileal CD, avoiding the need to use contrast agents.

Magnetic Resonance Enterography for Crohn’s Disease: What the Surgeon Can Take Home

BackgroundCrohn’s disease (CD) is a life-long, chronic, relapsing condition requiring often morphological assessment. MR enterography (MRE) offers advantages of not using ionizing radiation and yielding intraluminal and intra-abdominal informations. The aim of our study was to identify how MRE can be useful in planning surgical procedures.Patients and MethodsIn this retrospective study, 35 patients who underwent MRE and then surgery for CD were enrolled from 2006 to 2010. MRE findings were compared to intraoperative findings. Histology of operative specimens, systemic inflammatory parameters, and fecal lactoferrin were also evaluated. Cohen’s κ agreement test, sensitivity and sensibility, uni-/multivariate logistic regression, and non-parametric statistics were performed.ResultsMRE identified bowel stenosis with a sensitivity of 0.95 (95% CI 0.76–0.99) and a specificity of 0.72 (95% CI 0.39–0.92). The concordance of MRE findings with intraoperative findings was high [Cohen’s κ = 0.72 (0.16)]. Abscesses were detected at MRE with a sensitivity of 0.92 (95% CI 0.62–0.99) and a specificity of 0.90 (95% CI 0.69–0.98) with a Cohen’s κ = 0.82 (0.16). The grade of proximal bowel dilatation resulted to be a significant predictor of the possibility of using strictureplasty instead of/associated to bowel resection either at univariate or at multivariate analysis.ConclusionOur study confirmed that MRE findings correlate significantly with disease activity. Detailed information about abscess could suggest percutaneous drainage that could ease the following surgery or avoid emergency laparotomy. Proximal bowel dilatation can suggest the possibility to perform bowel sparing surgery such as strictureplasty.

Relationship between myocardial blush grades, staining, and severe microvascular damage after primary percutaneous coronary intervention: a study performed with contrast-enhanced magnetic resonance in a large consecutive series of patients

BACKGROUND Although angiographic perfusion has been traditionally evaluated by myocardial blush grade (MBG), pathophysiologic features underlying different MBG and the persistent blush, traditionally called staining, have been poorly explained. The aim of the study was to evaluate the correlation between MBG and morphologic aspects on cardiac magnetic resonance (CMR). METHODS Myocardial blush grade and morphologic aspects on contrast-enhanced CMR, with special reference to staining phenomenon and persistent microvascular damage (PMD), were evaluated in a consecutive series of patients with acute myocardial infarction (AMI) treated by primary percutaneous coronary intervention. RESULTS A total number of 294 AMI patients were enrolled and classified into 2 groups, that is, MBG 0/1 (115, 39%) and MBG 2/3 (179, 61%), according to the angiographic profile. By comparing MBG 0/1 versus MBG 2/3 patients, the former exhibited a larger enzymatic infarct size (P < .001) and a greater infarct size index (P < .001) and PMD (P < .001). In the MBG 0/1 group, a subgroup of 51 patients with staining phenomenon (MBG 0 staining) was also identified, with a worse CMR profile as PMD (P < .001). Multivariate analysis confirmed the strong association between MBG 0/1 and mean number of segments with transmural necrosis (odds ratio 1.62, 95% CI 1.17-2.24, P = .003) and PMD index (odds ratio 3.13, 95% CI 1.19-8.29, P = .021). CONCLUSIONS In AMI patients treated by primary percutaneous coronary intervention, angiographic parameters of impaired reperfusion correlate with PMD as detected by contrast CMR. Among patients with MBG 0, the presence of the so-called staining phenomenon identifies a subgroup of patients with more severe PMD.

Morphofunctional Abnormalities of Mitral Annulus and Arrhythmic Mitral Valve Prolapse

Background—Arrhythmic mitral valve prolapse (MVP) is characterized by myxomatous leaflets and left ventricular (LV) fibrosis of papillary muscles and inferobasal wall. We searched for morphofunctional abnormalities of the mitral valve that could explain a regional mechanical myocardial stretch. Methods and Results—Thirty-six (27 female patients; median age: 44 years) arrhythmic MVP patients with LV late gadolinium enhancement on cardiac magnetic resonance and no or trivial mitral regurgitation, and 16 (6 female patients; median age: 40 years) MVP patients without LV late gadolinium enhancement were investigated by morphofunctional cardiac magnetic resonance. Mitral annulus disjunction (median: 4.8 versus 1.8 mm; P<0.001), end-systolic mitral annular diameters (median: 41.2 versus 31.5; P=0.004) and end-diastolic mitral annular diameters (median: 35.5 versus 31.5; P=0.042), prevalence of posterior systolic curling (34 [94%] versus 3 [19%]; P<0.001), and basal to mid LV wall thickness ratio >1.5 (22 [61%] versus 4 [25%]; P=0.016) were higher in MVP patients with late gadolinium enhancement than in those without. A linear correlation was found between mitral annulus disjunction and curling (R=0.85). A higher prevalence of auscultatory midsystolic click (26 [72%] versus 6 [38%]; P=0.018) was also noted. Histology of the mitral annulus showed a longer mitral annulus disjunction in 50 sudden death patients with MVP and LV fibrosis than in 20 patients without MVP (median: 3 versus 1.5 mm; P<0.001). Conclusions—Mitral annulus disjunction is a constant feature of arrhythmic MVP with LV fibrosis. The excessive mobility of the leaflets caused by posterior systolic curling accounts for a mechanical stretch of the inferobasal wall and papillary muscles, eventually leading to myocardial hypertrophy and scarring. These mitral annulus abnormalities, together with auscultatory midsystolic click, may identify MVP patients who would need arrhythmic risk stratification.

Concealed Metastatic Lung Carcinoma Presenting as Acute Coronary Syndrome With Progressive Conduction Abnormalities

A 70-year-old diabetic woman with recent onset of cough was admitted to the emergency room for acute chest pain with evidence of T-wave abnormalities in the V2 through V6, L1, and aVL leads (Figure 1A). Her coronary arteries were angiographically normal, and her troponin I was elevated at 0.3 μg/L. Two-dimensional echocardiography revealed a hypertrophic left ventricle without kinetic abnormalities. Three weeks later, the patient was readmitted for chest pain and a complete left bundle-branch block on 12-lead ECG (Figure 1B) with a peak troponin I of 0.429 μg/L. To exclude a myocarditis, a cardiac magnetic resonance (CMR) was performed. On early scout images, diffuse multiple nodules with irregular epicardial borders were evident (Figure 2A–2C), which were also present on CMR T1 cine balanced images, indicating an irregular tissue composition (Movies I and II in the online-only Data Supplement). A moderate pericardial effusion was also detected. On T2-weighted images, the nodules presented a signal intensity higher than skeletal muscle (Figure 3A). First-pass contrast …

Relationship between T-wave inversion and transmural myocardial edema as evidenced by cardiac magnetic resonance in patients with clinically suspected acute myocarditis: clinical and prognostic implications.

BACKGROUND The pathophysiologic mechanisms and the prognostic meaning of electrocardiographic (ECG) T-wave inversion (TWI) occurring in a subgroup of patients with clinically suspected acute myocarditis remain to be elucidated. Contrast-enhanced cardiac magnetic resonance (CMR) offers the potential to identify myocardial tissue changes such as edema and/or fibrosis which may underlie TWI. METHODS AND RESULTS We studied 76 consecutive patients (median age 34years) with clinically suspected acute myocarditis, using a comprehensive CMR protocol which included T2 weighted sequences for myocardial edema. At the time of CMR, TWI was observed in 21 (27%) patients. There was a statistically significant association of TWI with the median number of left ventricular (LV) segments showing both any pattern of myocardial edema (transmural and non-transmural) [5 (3-7) vs. 3 (2-4); p=0.015] and myocardial late-gadolinium-enhancement [4 (3-7) vs. 3 (2-4); p=0.002]. Transmural myocardial edema involving ≥2 LV segments was found in 17/21 (81%) patients with TWI versus 13/55 (24%) patients without TWI (p<0.001) and remained the only independent predictor of TWI at multivariable analysis (OR=9.96; 95%CI=2.71-36.6; p=0.001). Overall, topographic concordance between the location of TWI across the ECG leads and the regional distribution of transmural myocardial edema was 88%. There was no association between acute TWI and reduced LV ejection fraction (<55%) at 6-months of follow-up. CONCLUSIONS This is the first study to demonstrate an association between LV transmural myocardial edema as evidenced by CMR sequences and TWI in clinically suspected acute myocarditis. As an expression of reversible myocardial edema, development of TWI during the acute disease phase was not a predictor of LV systolic dysfunction at follow-up.

Spine and sacroiliac joints on magnetic resonance imaging in patients with early axial spondyloarthritis: prevalence of lesions and association with clinical and disease activity indices from the Italian group of the SPACE study

Our aim was to determine the prevalence of spine and sacroiliac joint (SIJ) lesions on magnetic resonance imaging (MRI) in patients with early axial spondyloarthritis (axSpA) and their correlation with disease activity indices. Sixty patients with low back pain (LBP) (≥3 months, ≤2 years, onset ≤45 years), attending the SpA-clinic of the Unità Operativa Complessa Reumatologia of Padova [SpondyloArthritis-Caught-Early (SPACE) study], were studied following a protocol including physical examination, questionnaires, laboratory tests, X-rays and spine and SIJ MRI. Positive spine and SIJ MRI and X-rays images were scored independently by 2 readers using the SPARCC method, modified Stoke ankylosing spondylitis spine score and New York criteria. The axial pain and localization of MRI-lesions were referred to 4 sites: cervical/thoracic/lumbar spine and SIJ. All patients were classified into three groups: patients with signs of radiographic sacroiliitis (r-axSpA), patients without signs of r-axSpA but with signs of sacroiliitis on MRI (nr-axSpA MRI SIJ+), patients without signs of sacroiliitis on MRI and X-rays (nr-axSpA MRI SIJ-). The median age at LBP onset was 29.05±8.38 years; 51.6% of patients showed bone marrow edema (BME) in spine-MRI and 56.7% of patients in SIJ-MRI. Signs of enthesitis were found in 55% of patients in the thoracic district. Of the 55% of patients with BME on spine-MRI, 15% presented presented a negative SIJMRI. There was a significant difference between these cohorts with regard to the prevalence of radiographic sacroiliitis, active sacroiliitis on MRI and SPARCC SIJ score. The site of pain correlated statistically with BME lesions in thoracic and buttock districts. Since positive spine-MRI images were observed in absence of sacroiliitis, we can hypothesize that this finding could have a diagnostic significance in axSpA suspected axSpA.

Prediction of N0 Irradiated Rectal Cancer Comparing MRI Before and After Preoperative Chemoradiotherapy

BACKGROUND: The prediction of lymph node status using MRI has an impact on the management of rectal cancer, both before and after preoperative chemoradiotherapy. OBJECTIVE: The purpose of this study was to maximize the negative predictive value and sensitivity of mesorectal lymph node imaging after chemoradiotherapy because postchemoradiation node-negative patients may be treated with rectum-sparing approaches. DESIGN: This was a retrospective study. SETTINGS: The study was conducted at a tertiary care hospital. PATIENTS: Sixty-four patients with locally advanced rectal cancer who underwent preoperative chemoradiotherapy and MRI for staging and the assessment of response were evaluated. MAIN OUTCOME MEASURES: The sums of the sizes of all mesorectal lymph nodes in each patient on both prechemoradiotherapy and postchemoradiotherapy imaging data sets were calculated to determine the lymph node global size reduction rates, taking these to be the outcomes of the histopathologic findings. Other included measures were interobserver agreement regarding the prediction of node status based on morphologic criteria and the diagnostic performance of contrast-enhanced images. RESULTS: Using a cutoff value of a 70% lymph node global size reduction rate with only 15 node-positive patients on histopathology, the sensitivity in the prediction of nodal status and negative predictive value were 93% (95% CI, 70.2%–98.8%) and 97% (95% CI, 82.9%–99.8%) for observer 1 and 100% (95% CI, 79.6%–100%) and 100% (95% CI, 62.9%–100%) for observer 2. The areas under the receiver operating characteristic curves for the 2 observers were 0.90 (95% CI, 0.82–0.98; p < 0.0001) for observer 1 and 0.65 (95% CI, 0.50–0.79; p = 0.08) for observer 2. The efficacy of the morphologic criteria and contrast-enhanced images in predicting node status was limited after chemoradiotherapy. LIMITATIONS: This study is limited by its small sample size and retrospective nature. CONCLUSIONS: Assessing the lymph node global size reduction rate value reduces the risk of undetected nodal metastases and may be helpful in better identifying suitable candidates for the local excision of early stage rectal cancer. See Video Abstract at http://links.lww.com/DCR/A412.

Activation Energies for the Longitudinal Relaxation Rates of the Water in Normal and Neoplastic Lung

Abstract Variable temperature water T1 relaxation times have been measured on some normal and neoplastic human lung tissues. The corresponding activation energies have been derived and a short discussion of the experimental results is given.

Ovarian Teratoma or Uterine Malformation? PET/MRI as a Novel Useful Tool in NMDAR Encephalitis

This is a case report of a 17-year-old girl affected by N-methyl-D-aspartate-receptor (NMDAR) encephalitis suspected for a paraneoplastic syndrome. Ultrasound (US) and computed tomography (CT) imaging identified an ovarian lesion compatible with teratoma. 18F-fluorodeoxyglucose (FDG) positron emission tomography/magnetic resonance imaging (PET/MRI), performed to evaluate metabolic activity of the brain and of the ovarian mass, correctly changed the diagnosis to uterine malformation that was later histologically proven.