Elif Peker

Deciphering cardiac involvement in systemic inflammatory diseases: noninvasive tissue characterisation using cardiac magnetic resonance is key to improved patients’ care

ABSTRACT Introduction: Cardiac involvement in systemic inflammatory diseases (SID) has a major impact on patients’ morbidity and mortality, yet the pathways to its recognition and management remain poorly established. Areas covered: Overall clinical management in SID patients is primarily guided by systemic symptoms. Cardiovascular disease goes largely undetected, as it evolves through years of a protracted and subclinical course. Despite the increased awareness and insights into the mechanistic role of the inflammatory pathways, clinical management of cardiac involvement continues to rely on diagnostic means, which are frequently insensitive, invasive and rely on radiation exposure. Advanced tissue characterisation with cardiovascular magnetic resonance (CMR) offers an accurate, non-invasive and radiation-free diagnostic method with obvious advantages: it is able to inform on a range of cardiovascular pathophysiology, as well as support safe serial examinations, informing on the disease presence, progress and response to treatment. Expert commentary: We summarise the recent advances in non-invasive imaging, and bridge the novel insights into pathophysiology with future posibilities in diagnosis and manangement of SID patients. We propose an interdisciplinary framework to screening of cardiac involvement in SID using an indepth phenotyping of evolution of cardiovascular disease, to decipher the opportunities to improve patients’ cardiac care.

Diagnostic accuracy and safety of CT-guided fine needle aspiration biopsy of pulmonary lesions with non-coaxial technique: a single center experience with 442 biopsies

PURPOSE We aimed to evaluate the diagnostic accuracy and safety of computed tomography (CT)-guided biopsy of pulmonary lesions with fine needle aspiration (FNA) using non-coaxial technique. METHODS We analyzed 442 patients who underwent CT-guided lung biopsy with FNA and non-coaxial technique to determine the diagnostic outcomes, complication rates, and independent risk factors for diagnostic failure and pneumothorax. RESULTS Diagnostic accuracy, sensitivity, and specificity were 97.6%, 97.3%, and 100%, respectively. Age and >35 mm lesion size were significant risk factors for diagnostic failure. The rates of pneumothorax and chest tube placement were 19% and 2.9%, respectively. Middle and lower lobe location, lesion to pleura distance >7.5 mm, and >45° needle trajectory angle were significant risk factors for pneumothorax. CONCLUSION CT-guided FNA of pulmonary lesions with non-coaxial technique is a safe and reliable method with a relatively low pneumothorax rate and an acceptably high diagnostic accuracy.

Trifurcation of the Left Common Carotid Artery.

Summary Background Trifurcation of the common carotid artery is an unusual variation. Case Report We report a case of left common carotid artery trifurcation in a 74-year-old man. The left common carotid artery divided into the internal carotid, external carotid and facial arteries. Herein, the anatomy of the carotid arteries and the Doppler sonography and CT angiography findings of the left common carotid artery trifurcation were described with images. Conclusions The variations of the carotid arteries should be known to avoid and reduce the complications during the invasive procedures.

A rare cause of small bowel obstruction

Magnetic resonance (MR) imaging performed at our hospital revealed that the ileal segments were clustered and encapsulated within a thick oval sac in the lower abdomen (Figure 1a). Small bowel dilatation with air-fluid levels, mural enhancement, and a small amount of intraperitoneal free fluid were associated with this finding (Figure 1b). The patient underwent exploratory laparotomy with a presumptive diagnosis of bowel obstruction.

Diagnostic performance of multiparametric MR imaging at 3.0 Tesla in discriminating prostate cancer from prostatitis: Histopathologic correlation

Objective To investigate the diagnostic performance of multiparametric magnetic resonance imaging (mpMRI) in differentiating prostate cancer (PCa) from prostatitis foci. Materials and Methods This retrospective analysis included 81 biopsy-proven lesions (44 prostatitis and 37 PCa). Normalized T2-signal intensity (nT2SI) and SI on diffusion-weighted imaging (b=1000 and 2000 mm2/s), apparent diffusion coefficient (ADC) values, peak SI, SI at the end of the dynamic curves, mean peak time, mean enhancement percentage, and washout percentage obtained from dynamic contrast-enhanced imaging (DCEI) were measured. Results nT2SI (3.8 vs. 3.2, p=0.003) and ADC values (0.685×10-3 mm2/s vs. 0.874×10-3 mm2/s, p<0.001) were significantly higher in the prostatitis group than in the PCa group. The washout percentage was the only DCEI parameter that was significantly different between the two groups (12% vs. 4%, respectively, p=0.003). The ADC values alone showed higher sensitivity (80.5%) and specificity (75%) than all of the single criteria and most of the combined criteria. The combination of nT2SI, ADC values, and washout percentage (at least two positive criteria were sufficient for a diagnosis of PCa) yielded the highest sensitivity (77.7%) and specificity (85.7%) among all combinations. Conclusion PCa and prostatitis can be discriminated using mpMRI with high sensitivity and specificity.

The Significance and Reliability of Imaging Findings in Pseudotumor Cerebri

ABSTRACT The objective of our study was to provide a comparative assessment of previously reported magnetic resonance imaging (MRI) parameters in primary and secondary pseudotumor cerebri (PTC) patients, to examine their diagnostic contribution, and to evaluate their association with symptoms, neuro-ophthalmological findings, laboratory results, and cerebrospinal fluid characteristics. Twenty-eight consecutive patients with PTC were included in the study. Age- and sex-matched 20 individuals with normal neurologic examination served as the control group. Modified Dandy Criteria were used for the diagnosis of PTC. Orbital and cranial MRI and MR venography of all patients and controls were assessed by three radiologists. According to our study, posterior flattening of the globe (64% sensitive, 100% specific), optic nerve sheath distention (46% sensitive, 100% specific), vertical tortuosity of the optic nerve (30% sensitive, 95% specific), and partial empty sella (43% sensitive, 100% specific) emerged as particularly valuable markers for a diagnosis of PTC.

Structure of corona radiata and tapetum fibers in ventricular surgery

In this study the three-dimensional anatomy of the corona radiata and tapetum via the fiber dissection and diffusion tensor imaging of the brain for ventricular surgery was demonstrated. Ten formalin-fixed cerebral hemispheres were dissected for corona radiata and tapetum via Klinglers fiber dissection method under an operating microscope. The corona radiata and tapetum were dissected through lateral and medial surfaces of the cerebral hemisphere, respectively. All surgical routes for ventricular lesions were evaluated for white matter fibers during and after dissections. Corona radiata and tapetum fibers were demonstrated by dissecting hemispheres through lateral and medial aspects of the brain. The internal capsule contains all fibers that extend from thalamus to cortex and cortex to thalamus, brainstem, and spinal cord. These fan-shaped fibers extending from cortex to internal capsule were named the corona radiata. The corona radiata is not a specific pathway, and it is composed of several different fiber pathways. The tapetum contains splenium and body fibers of the corpus callosum. Tapetum is located immediately medial to the ependymal line of the ventricular wall and forms a fiber layer in the medial optical radiation on the coronal and axial sections. Surgical planning for ventricular lesions requires detailed information regarding white matter fibers that can be obtained by the fiber dissection and diffusion tensor imaging of the brain to decrease surgical complications.

Intestinal Behçet Disease: Evaluation With MR Enterography—A Case-Control Study

OBJECTIVE The purposes of this study were to discern imaging findings that distinguish Behçet disease from small-bowel Crohn disease, to find initial performance estimates for these findings, and to evaluate the diagnostic value of MR enterography (MRE) for detecting intestinal Behçet disease. MATERIALS AND METHODS The MRE examinations of 30 consecutively registered patients with established intestinal Behçet disease were reviewed by two blinded readers. The frequencies of MRE findings were compared with those obtained for 30 control subjects with small-bowel Crohn disease who were matched for sex and age. The performance estimates were generated with ileocolonoscopic and histopathologic findings as the reference standard. RESULTS Polypoid pattern and homogeneous mural enhancement were the findings seen more frequently in Behçet disease (p = 0.000) than in Crohn disease (p = 0.003). Stricture formation, long-segment disease, and involvement of more proximal ileal segments favored small-bowel Crohn disease. The ROC AUCs for polypoid pattern and homogeneous mural enhancement in the detection of intestinal Behçet disease were 0.806 and 0.779. The accuracy of MRE was 70.00% (95% CI, 50.60-85.27%); sensitivity, 57.14% (95% CI, 34.02-78.18%), and specificity, 100% (95% CI, 66.37-100%). CONCLUSION MRE has potential for use as a radiation-free alternative for clarifying the cause of nonspecific gastrointestinal symptoms in patients with known Behçet disease. However, additional studies are needed to determine the actual value of MRE in patients with Behçet disease and to validate the clinical usefulness of the technique in the detection of unknown intestinal Behçet disease.

T1 mapping and magnetic resonance elastography: potential new techniques for quantification of parenchymal changes in hepatic amyloidosis

We read with interest the pictorial essay by Özcan et al. (1) entitled “Imaging for abdominal involvement in amyloidosis” in the recent issue of Diagnostic and Interventional Radiology. In this article, the authors provide both textual and visual portrayals of abdominal amyloidosis, which is difficult to diagnose because of nonspecific imaging findings and frequent subclinical presentation. Both computed tomography and magnetic resonance imaging (MRI) findings, in combination with clinical history, anatomic location and patient’s primary disease can help to limit the differential diagnosis. In this context, we would like to share our experience with two newly emerging imaging techniques that could be of interest to radiologists. A 46-year-old woman with biopsy-proven liver amyloidosis underwent liver and heart MRI examination with T1 mapping. Using modified look-locker inversion recovery (MOLLI) sequence, liver T1 values were higher (855 ms at MOLLI 5(3)3(3) and 880 ms at MOLLI 3(3)3(3)5) compared with the mean values (550±70 ms at MOLLI 5(3)3(3) and 615±35 ms at MOLLI 3(3)3(3)5) obtained in healthy volunteers (Fig. a). Many studies proved that T1-mapping values are informative for the presence of myocardial amyloidosis and normal T1 values can exclude cardiac amyloidosis (2, 3). Although we have found hepatic T1 values more than 4 times the standard deviation in our case, further investigations are needed to confirm our observations regarding the utility of mapping techniques in liver amyloidosis. The patient was also evaluated with magnetic resonance elastography (MRE) during liver MRI and very high liver shear stiffness values (mean, 8.5 kPa) were detected (Fig. b, c). A recent report has documented increased liver stiffness measured by MRE in liver amyloidosis (4). T1 mapping and MRE may be new tools to visualize and quantify liver changes in amyloidosis.

CT and MRI Findings in a Rare Case of Renal Primitive Neuroectodermal Tumor

Summary Background Primary renal primitive neuroectodermal tumor/extraskeletal Ewing’s sarcoma (PNET/EES) is a very rare renal tumor. Case Report We report a case of primary renal PNET/EES of the kidney in an adult patient and describe its computed tomography and magnetic resonance imaging findings, including diffusion weighted images along with a review of the current medical literature. Conclusions Although very rare, a relatively large renal mass which shows very infiltrative growth pattern on CT and MR imaging and striking diffusion restriction should raise the suspicion of a renal primitive neuroectodermal tumor, in a young adult.