Cyprian Olchowy

The presence of the gadolinium-based contrast agent depositions in the brain and symptoms of gadolinium neurotoxicity - A systematic review

Background and purpose Gadolinium based contrast agents (GBCAs) are widely used in magnetic resonance imaging, but recently, high signal intensity in the cerebellum structures was reported after repeated administrations of contrast- enhanced magnetic resonance images. The aim of this systematic review was to investigate the association between increased signal intensity in the dentate nucleus and globus pallidus in the brain and repeated administrations of GBCAs. Additionally, we focused on possible short- and long-term consequences of gadolinium use in those patients. Methods Systematic review of retrospective investigations in PubMed and Medline was performed in July 2016. Primary outcomes included the presence of increased signal intensity within the dentate nucleus and globus pallidus on unenhanced T1-weighted MR images in patients following administrations of GBCAs. Two independent reviewers were responsible for search and data extraction. Results 25 publications satisfied inclusion criteria (19 magnetic resonance images analyses, 3 case reports; 3 autopsy studies). Magnetic resonance images of 1247 patients with increased signal intensity on unenhanced T1-weighted MR images were analyzed as well as tissue specimens from 27 patients. Signal intensity correlated positively with the exposure to GBCAs and was greater after serial administrations of linear nonionic than cyclic contrast agents. Gadolinium was detected in all tissue examinations. Conclusions High signal intensity in the dentate nucleus and globus pallidus on unenhanced T1-weighted magnetic resonance images were associated with previous administration of GBCAs. Signal intensity correlated negatively with stability of contrast agents. Clinical significance of gadolinium deposition in the brain remains unclear. There is a strong need for further research to identify type of gadolinium deposited in the brain as well as to gather knowledge about long-term consequences.

The Snapping Elbow Syndrome as a Reason for Chronic Elbow Neuralgia in a Tennis Player – MR, US and Sonoelastography Evaluation

Summary Background Ulnar neuropathy is the second most common peripheral nerve neuropathy after median neuropathy, with an incidence of 25 cases per 100 000 men and 19 cases per 100 000 women each year. Skipping (snapping) elbow syndrome is an uncommon cause of pain in the posterior-medial elbow area, sometimes complicated by injury of the ulnar nerve. One of the reason is the dislocation of the abnormal insertion of the medial triceps head over the medial epicondyle during flexion and extension movements. Others are: lack of the Osboune fascia leading to ulnar nerve instability and focal soft tissue tumors (fibromas, lipomas, etc). Recurrent subluxation of the nerve at the elbow results in a tractional and frictional neuritis with classical symptoms of peripheral neuralgia. As far as we know snapping triceps syndrome had never been evaluated in sonoelastography. Case Report A 28yo semi-professional left handed tennis player was complaining about pain in posterior-medial elbow area. Initial US examination suggest golfers elbow syndrome which occurs quite commonly and has a prevalence of 0.3–0.6% in males and 0–3–1.1% in women and may be associated (approx. 50% of cases) with ulnar neuropathy. However subsequently made MRI revealed unusual distal triceps anatomy, moderate ulnar nerve swelling and lack of medial epicondylitis symptoms. Followed (second) US examination and sonoelastography have detected slipping of the both ulnar nerve and the additional band of the medial triceps head. Discussion Snapping elbow syndrome is a poorly known medical condition, sometimes misdiagnosed as the medial epicondylitis. It describes a broad range of pathologies and anatomical abnormalities. One of the most often reasons is the slipping of the ulnar nerve as the result of the Osborne fascia/anconeus epitrochlearis muscle absence. Simultaneously presence of two or more “snapping reasons” is rare but should be always taken under consideration. Conclusions There are no sonoelastography studies describing golfers elbow syndrome, additional triceps band and ulnar neuritis. Our data suggest that the sonoelastography signs are similar to those seen in well described lateral epicondylitis syndrome, Achilles tendinitis and medial nerve neuralgia.

Wrist ultrasound examination – scanning technique and ultrasound anatomy. Part 1: Dorsal wrist

Ultrasound imaging of the musculoskeletal system is superior to other imaging methods in many aspects, such as multidimensional character of imaging, possibility of dynamic evaluation and precise assessment of soft tissues. Moreover, it is a safe and relatively inexpensive method, broadly available and well-tolerated by patients. A correctly conducted ultrasound examination of the wrist delivers detailed information concerning the condition of tendons, muscles, ligaments, nerves and vessels. However, the knowledge of anatomy is crucial to establish a correct ultrasound diagnosis, also in wrist assessment. An ultrasound examination of the wrist is one of the most common US examinations conducted in patients with rheumatological diseases. Ultrasonographic signs depend on the advancement of the disease. The examination is equally frequently conducted in patients with pain or swelling of the wrist due to non-rheumatological causes. The aim of this publication was to present ultrasound images and anatomic schemes corresponding to them. The correct scanning technique of the dorsal part of the wrist was discussed and some practical tips, thanks to which highly diagnostic images can be obtained, were presented. The following anatomical structures should be visualized in an ultrasound examination of the dorsal wrist: distal radio-ulnar joint, radiocarpal joint, midcarpal joint, carpometacarpal joints, dorsal radiocarpal ligament, compartments of extensor tendons, radial artery, cephalic vein, two small branches of the radial nerve: superficial and deep, as well as certain midcarpal ligaments, particularly the scapholunate ligament and lunotriquetral ligament. The paper was distinguished in 2014 as the “poster of the month” (poster number C-1896) during the poster session of the European Congress of Radiology in Vienna.

Case Report of Fire Eater’s Pneumonia in Adolescent Female Patient – Evolution of Radiologic Findings

Summary Background We present a case of a 16-year-old girl with fire-eater’s pneumonia (hydrocarbon pneumonitis). The goal of this report was to assess evolution of radiological findings. Case Report The reported case was unique because that was the first completely described case of fire-eater’s pneumonia reported in an under-aged person. Moreover, this disease is very rare even in adults and only a few scientific reports can be found, mostly because of a small occupational group. Conclusions The aim of this report was to show that the problem of fire-eater’s pneumonia can occur in under-aged patients and should be taken into consideration in case of severe pneumonia. Another objective was to point out that chest radiograph is not sufficient to depict the evolution of radiological manifestations.

A Rare Case of Aggressive Fibromatosis Infiltrating Dorsal Muscles in a 6-Year-Old Patient - CT, MRI and Elastography Evaluation.

Summary Background The term fibromatosis or desmoid tumor refers to a group of benign fibrous growths without metastatic potential but with a significant risk of local recurrence. These lesions typically present infiltrative growth pattern with local invasion of adjacent tissues. This tendency is the reason for a relatively high rate of local recurrence, even after surgical removal. Fibromatosis is a very rare condition in general population but occurs more frequently in one of the familial cancer predispositions known as familial adenomatous polyposis (FAP) or Gardner syndrome. There are two main groups of fibromatosis: superficial (small, slow-growing lesions) and deep, also known as aggressive fibromatosis (large, rapid-growing lesions). Case Report We report a case of a 6-year-old boy suffering from an aggressive form of fibromatosis. The patient developed a large pathological mass extending from the neck to the loins. After incisional biopsy and histpoathological examination of the sample, a diagnosis of aggressive fibromatosis was established. During the whole diagnostic process, different imaging techniques including CT, MRI and sonoelastography were used. As the surgical treatment was not possible, the patient was finally qualified for chemotherapy. Conclusions Eventual diagnosis of aggressive fibromatosis is based on histopathological examination. However, it is an important condition that should be included in differential diagnosis of soft-tissue masses found in diagnostic imaging. Radiologists should be careful especially in defining the margins of infiltration in case of potential surgical treatment.

Modified sonoelastographic scale score for lymph node assessment in lymphoma - a preliminary report.

Elastography is a new method of assessment of lymph node consistency. The majority of papers focus on metastases detection of head and neck or breast tumors. The typical desmoplastic reaction in connective tissue stroma in cancer, which is responsible for tissues hardening, is seen in lymphoma less frequently. Material and methods Study of 15 patients with active Hodgkin and non-Hodgkin lymphomas and 16 previously treated patients with no evidence of recurrence. A total of 60 patients suffering from reactive lymphadenopathy was the control group. The size, appearance, vascularity and elastogram of lymph node was analyzed. Results Type C elastogram correlated strongly with lymph nodes which presented at least three pathologic features in 2D image. Large lymph nodes with long axis diameter over 3 cm may have ‘cheese with holes’ appearance rather than common type C elastogram. Conclusion According to our simplified sonoelastography scoring system, type C elastogram was present mainly in patients with active lymphoma affecting lymph nodes, which showed all four features that we analyzed using conventional ultrasonography. This elastogram was also present in reactive lymphadenopathies. Distinctive for large lymph nodes in patients with active forms of lymphoma “cheese with holes” appearance, can be considered as equal with type C image, although it is corresponding to type B sonoelastographic map.

Hounsfield units from unenhanced 18F-FDG-PET/CT are useful in evaluating supradiaphragmatic lymph nodes in children and adolescents with classical Hodgkin’s lymphoma

BACKGROUND The precise identification of the primarily-affected nodal regions in Hodgkins lymphoma(HL) is essential in determining the stage of the disease and the intensity of chemotherapy and radiotherapy. OBJECTIVES The aim of this study was to use the degree of X-ray attenuation (XRA) in Hounsfield units(HU) and the lymph node-to-muscle attenuation ratio (LN/M) in computed tomography (CT) unenhancedimaging, routinely performed with 18F-fluorodeoxyglucose positron emission tomography (18F-FDG-PET),to distinguish HL-affected supradiaphragmatic lymph nodes. MATERIAL AND METHODS The study included 52 patients with classical HL treated according to the EuroNet-PHL-C1 protocol. Patients received 2 chemotherapy cycles after 18F-FDG-PET/CT testing, followedby re-examination. The lymph nodes were evaluated according to the Society for Pediatric Oncology andHematologys GPOH-HD-2002 study and Lugano criteria as not-involved (NI-LN) and involved (I-LN). RESULTS A significant difference (p < 0.001) was found in the XRA and LN/M values between NI-LN andI-LN before treatment and after the 2 chemotherapy cycles. The optimal cut-off point for XRA (44.7 HU) andLN/M (0.79) values distinguishing I-LN from NI-LN nodes was determined by receiver operating characteristic(ROC) analysis. After 2 cycles of chemotherapy, higher XRA (p = 0.002) and LN/M (p = 0.001) values in thegroup with inadequate early CTx response were found. CONCLUSIONS The use of XRA in HU and LN/M, together with the existing standard, can improve the qualificationof supradiaphragmatic lymph nodes in HL.

Low-dose computed tomography in assessment of pulmonary abnormalities in children with febrile neutropenia suffering from malignant diseases

BACKGROUND Management of febrile neutropenia in pediatric patients is challenging. Chest X-ray and CT scan help to identify infective foci; however, exposure to radiation is a risk factor for development of secondary cancer. For this reason, attention is paid to reducing radiation exposure. OBJECTIVES The aim of the study was to define the role of LDCT examination in the early detection of pulmonary lesions in children during oncology or autoimmune treatment complicated by neutropenia-related fever. Additionally, we focused on the possibility to optimize image quality in low-dose protocols. MATERIAL AND METHODS The study included 138 pediatric patients (mean age 8.08 years) with fever of 38.2°C or higher with an absolute neutrophil count of 10 mm with or without surrounding GGO or cavitations was sensitive at 77% and specific at 65% for fungal infection insert after neutrophil count: < 500/pL who underwent chest X-ray and LDCT in the maximal interval of 24 h. CT findings were compared with initial and final diagnosis as well as with clinical information. RESULTS LDCT detected pulmonary abnormalities in 116 patients (84.06%) showing ground-glass opacities (GGO) (n = 79), nodules (n = 60) and air-space consolidations (n = 58). Radiologists correctly diagnosed infective lesions in 94 out of 116 patients (81.03%). The presence of random or pleural-based nodules. Diagnosis of pyogenic infection based on the presence of air-space consolidation, pleural effusion, GGO or centrilobular nodules showed a sensitivity of 78% and specificity of 67%, whereas patchy or diffuse GGO, interstitial thickening and/or air-space consolidation showed a high sensitivity of 81% and specificity of 68% for Pneumocystis jirovecii pneumonia. CONCLUSIONS LDCT is an excellent modality in the diagnostic algorithm in patients with febrile neutropenia. It allows early detection and detailed characterization of pulmonary abnormalities. Using contrast, unenhanced CT examinations can further reduce radiation dose and diminish the number of complications without a negative influence on the diagnostic process.

Ultrasonography in the diagnosis of hemorrhagic cystitis - a complication of bone marrow transplantation in pediatric oncology patients.

Objective The aim of this study was to evaluate the usefulness of ultrasonography in the diagnosis of hemorrhagic cystitis following bone marrow transplantation in children. Material and methods The study involved an analysis of clinical material and the results of imaging tests performed in 334 patients who underwent hematopoietic cell transplantation. Ultrasonographic findings in 42 patients with hemorrhagic cystitis were analyzed in detail. The ultrasound images served to assess the severity of hemorrhagic cystitis and the results were compared with the clinical assessment of the disease on the Droller scale, as well as the laboratory and endoscopic tests. Results In the studied group of patients hemorrhagic cystitis following allogeneic transplantation was diagnosed in 12.5% cases. 73.8% patients received transplants from unrelated donors, 26.2% – from compatible siblings. The study revealed a higher incidence of hemorrhagic cystitis in children above 10 years of age. Grade 3 according to the Droller was diagnosed in 42.9%, grade 2 – in 30.9%, grade 4 – in 14.3%, and grade 1 – in 11.9% patients. The number of ultrasound examinations depended on the clinical symptoms, severity, duration and co-occurrence of other complications following the transplantation and was within the 1–15 range (average: 4.6). Grades 3 and 4 were related to the poor clinical condition of the patients and to their longer hospitalization. During this period there was an increased risk of renal malfunction and acute renal failure, post-inflammatory narrowing of the ureters, hydronephrosis, and in grade 4 the fibrosis of the bladder with reduced bladder capacity. Analyses demonstrated a significant correlation between the ultrasound image of the bladder wall and the clinical severity. Conclusions Ultrasound with Doppler options remains the primary diagnostic tool in the evaluation of hemorrhagic cystitis, and is useful in terms of its diagnosis, determination of the severity, and monitoring of the treatment.