Claudia Lucia Piccolo

Contrast-enhanced ultrasound (CEUS) in blunt abdominal trauma

Baseline ultrasound is essential in the early assessment of patients with a huge haemoperitoneum undergoing an immediate abdominal surgery; nevertheless, even with a highly experienced operator, it is not sufficient to exclude parenchymal injuries. More recently, a new ultrasound technique using second generation contrast agents, named contrast-enhanced ultrasound (CEUS) has been developed. This technique allows all the vascular phase to be performed in real time, increasing ultrasound capability to detect parenchymal injuries, enhancing some qualitative findings, such as lesion extension, margins and its relationship with capsule and vessels. CEUS has been demonstrated to be almost as sensitive as contrast-enhanced CT in the detection of traumatic injuries in patients with low-energy isolated abdominal trauma, with levels of sensitivity and specificity up to 95%. Several studies demonstrated its ability to detect lesions occurring in the liver, spleen, pancreas and kidneys and also to recognize active bleeding as hyperechoic bands appearing as round or oval spots of variable size. Its role seems to be really relevant in paediatric patients, thus avoiding a routine exposure to ionizing radiation. Nevertheless, CEUS is strongly operator dependent, and it has some limitations, such as the cost of contrast media, lack of panoramicity, the difficulty to explore some deep regions and the poor ability to detect injuries to the urinary tract. On the other hand, it is timesaving, and it has several advantages, such as its portability, the safety of contrast agent, the lack to ionizing radiation exposure and therefore its repeatability, which allows follow-up of those traumas managed conservatively, especially in cases of fertile females and paediatric patients.

Clinical and instrumental assessment of herniated discs after nucleoplasty: a preliminary study

Background and Aim: The therapy for low back pain boasts different approaches; one of these is nucleoplasty. We wanted to assess the effectiveness of nucleoplasty both by clinical response both by MR imaging evaluation, including even extrusions larger than one third of the spinal canal. Methods: Fifty-seven patients were treated with nucleoplasty in our hospital, 11 of these patients accepted both clinical and MRI evaluation after six months from treatment. The clinical evaluation was performed with Visual Analogue Scale (VAS) of pain, scored before and after the procedure. MRI evaluation consisted of analysing some imaging parameters of disc protrusions before and after the treatment. Results: In 10 out of 11 (91%) patients, VAS was reduced and only 1 out of 11 (9%) had the same pain after procedure. The mean of decrease of VAS score was 64%. In our population 8/11 (72%) patients had a herniation larger than 1/3 of the sagittal diameter of spinal canal and 100% of them had an improvement with a mean VAS reduction value of 75%. With MRI evaluation, the mean percentage of expulsion before and after treatment was respectively 40% and 34%. The expulsion decreased in 7/13 discs, remained equal in 4/13, and increased in 2/13 discs. Among the 9 larger protrusions, 3 didn’t change, 6 reduced with a decrease mean value of 13%. Other MRI parameters didn’t change significantly. Conclusions: Our preliminary experience supports the success of coblation on pain relief, aiming to show progressively that this treatment is suitable even in case of great extrusions, which are generally treated only with surgical approach. It’s not clear the usefulness of MRI control yet, even if in most of cases we could have found a certain reduction of expulsion degree. (www.actabiomedica.it)

Injuries of the Pleural Spaces

The presence of thoracic injuries in a multisystemic trauma can highly increase patient mortality; furthermore, injuries such as “flail chest,” lung contusion, hemothorax, and pneumothorax can complicate overall case management.

Role of contrast-enhanced ultrasound (CEUS) in the diagnosis and management of traumatic splenic injuries

Splenic injuries are common emergencies in the setting of abdominal trauma, as the spleen is the second most frequently injured abdominal organ after the liver. The treatment of splenic injuries underwent a severe shift from operative to non-operative due to an increased awareness of the double physiological function, both immunological and hematological, of the spleen. This, in turn, led to an increased application of splenic preservation techniques. The non-operative approach has been strengthened through radiological imaging and interventional radiology. While multidetector computed tomography is mandatory in the evaluation of hemodynamically stable patients after high-energy trauma, one ultrasound (US) can be used as a first-line technique to examine patients in cases of low-energy trauma. Unfortunately, baseline US has low sensitivity in the detection of traumatic injuries. With the introduction of contrast-enhanced ultrasound (CEUS) as a reliable alternative to baseline ultrasound for low-grade abdominal trauma, the sensitivity of the US technique in recognizing traumatic abdominal lesions has strongly increased, reaching levels of accuracy similar to those of the CT. It has also been strongly recommended for use with children, as it allows for the performance of imaging techniques with the lowest dose of radiation possible. In this review, the authors aim to present the typical appearance of traumatic splenic injuries, using enhanced CEUS capability to overcome baseline US limits, and to describe the different techniques applied according to the hemodynamic stability of the patient.SommarioLa milza è il secondo organo più comunemente sede di trauma nel contesto dei traumi chiusi dell’addome. Nel corso degli ultimi decenni il trattamento dei traumi splenici ha subito un rapido shift verso un approccio sempre meno aggressivo. Il razionale alla base di questo trend sta nel duplice ruolo svolto da quest’organo dal punto di vista fisiologico, sia immunologico che ematologico, che ha portato allo sviluppo di manovre terapeutiche sempre più conservative. Questo approccio nonoperativo è stato fortemente sostenuto dalle nuove metodiche di imaging e dal rapido evolversi delle tecniche di radiologia interventistica. Dal punto di vista dell’imaging, mentre la TC Multidetector è mandatoria nella valutazione del paziente che ha subito un trauma ad elevata energia e stabile emodinamicamente, nei traumi a bassa energia l’ecografia può essere utilizzata come metodica di primo approccio. Sfortunatamente essa è caratterizzata da una bassa sensibilità nell’ individuazione delle lesioni traumatiche a carico degli organi addominali. Con l’introduzione dell’ecografia con mezzo di contrasto (CEUS) come alternativa alla sola ecografia nella valutazione dei traumi a bassa energia, la sensibilità di tale metodica è notevolmente aumentata, raggiungendo livelli di accuratezza molto vicini a quelli della TC. Il suo utilizzo è stato fortemente sostenuto nella valutazione iniziale del paziente pediatrico al fine di ridurre il più possibile l’esposizione a radiazioni ionizzanti. In questo articolo gli autori si propongono di presentare una revisione dei traumi splenici, enfatizzando il ruolo della CEUS rispetto alla sola ecografia e di descrivere quali sono le metodiche da utilizzare in base alla stabilità emodinamica del paziente.

Hypertrophic Pyloric Stenosis (HPS)

The hypertrophic pyloric stenosis (HPS) is not a rare condition due to a lack of relaxation of the pyloric muscle caused by hypertrophy and hyperplasia of the antropyloric muscular ring. HPS is the most common surgical cause of vomiting in infants, and it is a very frequent cause of access in emergency hospital.

Ultrasound and Magnetic Resonance Imaging of Pediatric Musculoskeletal Injuries

Medical and diagnostic evaluation of musculoskeletal trauma is a complex issue for several aspects.