Flávia Pegado Junqueira

MR Imaging in Deep Pelvic Endometriosis: A Pictorial Essay

Deep pelvic endometriosis is an important gynecologic disorder that is responsible for severe pelvic pain and is defined as subperitoneal invasion that exceeds 5 mm in depth. Deep pelvic endometriosis can affect the retrocervical region, uterosacral ligaments, rectum, rectovaginal septum, vagina, urinary tract, and other extraperitoneal pelvic sites. It is commonly associated with dysmenorrhea, dyspareunia, pelvic pain, urinary tract symptoms, and infertility. Because surgery remains the best therapeutic option for affected patients, the accurate preoperative assessment of the extension of endometriotic disease is extremely important. Pelvic magnetic resonance (MR) imaging is a noninvasive method with high spatial resolution that allows multiplanar evaluation of deep pelvic endometriosis and good tissue characterization, but without the use of ionizing radiation or iodinated contrast agents. MR imaging yields important findings that help grade the disease and identify subperitoneal lesion extension and other associated disease entities, thereby facilitating accurate diagnosis and adequate treatment. Radiologists should be familiar with the MR imaging findings of deep infiltrating endometriosis in various anatomic locations so that they can provide information that allows adequate presurgical counseling.

Right and left ventricular function and myocardial scarring in adult patients with sickle cell disease: a comprehensive magnetic resonance assessment of hepatic and myocardial iron overload

BackgroundPatients with Sickle cell disease (SCD) who receive regular transfusions are at risk for developing cardiac toxicity from iron overload. The aim of this study was to assess right and left cardiac volumes and function, late gadolinium enhancement (LGE) and iron deposits in patients with SCD using CMR, correlating these values with transfusion burden, ferritin and hemoglobin levels.MethodsThirty patients with SCD older than 20 years of age were studied in a 1.5 T scanner and compared to age- and sex-matched normal controls. Patients underwent analysis of biventricular volumes and function, LGE and T2* assessment of the liver and heart.ResultsWhen compared to controls, patients with SCD presented higher left ventricular (LV) volumes with decreased ejection fraction (EF) with an increase in stroke volume (SV) and LV hypertrophy. The right ventricle (RV) also presented with a decreased EF and hypertrophy, with an increased end-systolic volume. Although twenty-six patients had increased liver iron concentrations (median liver iron concentration value was 11.83 ± 9.66 mg/g), only one patient demonstrated an abnormal heart T2* < 20 msec. Only four patients (13%) LGE, with only one patient with an ischemic pattern.ConclusionsAbnormal heart iron levels and myocardial scars are not a common finding in SCD despite increased liver iron overload. The significantly different ventricular function seen in SCD compared to normal suggests the changes in RV and LV function may not be due to the anemia alone. Future studies are necessary to confirm this association.

Ressonância magnética na síndrome da interseção do antebraço: ensaio iconográfico

Magnetic resonance imaging plays a relevant role in the assessment of patients with pain on the dorsal aspect of the distal forearm and wrist. Among the causes of pain, intersection syndrome is highlighted, corresponding to an inflammatory process affecting the tendons of the second compartment of the forearm extensor (extensor carpi radialis brevis and extensor carpi radialis longus), usually caused by direct trauma or repetitive activities requiring wrist flexion and extension. The present essay is aimed at illustrating the typical findings in intersection syndrome of the forearm and discuss the main differential diagnoses.

Pulmonary arterial hypertension: an imaging review comparing MR pulmonary angiography and perfusion with multidetector CT angiography.

Pulmonary hypertension (PH) is a progressive disease that leads to substantial morbidity and eventual death. Pulmonary multidetector CT angiography (MDCTA), pulmonary MR angiography (MRA) and MR-derived pulmonary perfusion (MRPP) imaging are non-invasive imaging techniques for the differential diagnosis of PH. MDCTA is considered the gold standard for the diagnosis of pulmonary embolism, one of the most common causes of PH. MRA and MRPP are promising techniques that do not require the use of ionising radiation or iodinated contrast material, and can be useful for patients for whom such material cannot be used. This review compares the imaging aspects of pulmonary MRA and 64-row MDCTA in patients with chronic thromboembolic or idiopathic PH.

Avaliação por ressonância magnética das fístulas perianais: ensaio iconográfico

Fistula in ano is an uncommon condition that has a tendency to recur despite seemingly appropriate surgery. Recurrent fistula in ano is usually caused by infection that was missed during surgical exploration. Magnetic resonance imaging has been shown to accurately demonstrate the anatomy of the perianal region as well as the fistulas relationship with the pelvic diaphragm and ischiorectal fossa, allowing the classification of fistulas into five types. Magnetic resonance imaging depicts infectious foci in the perianal region better than any other investigation modality, including surgical exploration. Magnetic resonance image-guided surgery helps to reduce postoperative recurrence by 75% in patients with complex disease.

Myocardial iron quantification using modified Look-Locker inversion recovery (MOLLI) T1 mapping at 3 Tesla

Background Quantification of myocardial iron overload is critical for the management of patients with hemochromatosis. The effects of excess iron on T1 and T2* relaxation times correlate directly with tissue iron concentration. T2* became the clinical standard at 1.5T as it can be easily obtained in a fast one breath-hold ECG gated multi-echo GRE sequence. At 3T, however, T2* quantification can be limited by pronounced susceptibility artifacts and signal sampling restraints due to shorter T2* times at higher iron concentrations . Since myocardial T1 time is up to thirty times longer than T2*, it can be quantified with short echo-time inversionrecovery sequences even at high iron concentrations, and is less sensitive to susceptibility artifacts. We aimed to validate a recently developed modified LookLocker inversion recovery (MOLLI) sequence to quantify myocardial T1 in healthy controls and patients with iron overload at 3T, comparing to standard GRE based multi-echo T2* times at 1.5T. Methods A total of 15 normal volunteers and 7 chronic anemia patients (with a myocardial T2* measure <20 ms at 1.5T in the last 2 years, five of these on iron chelating therapy) were prospectively enrolled. Myocardial T2* and T1 times were quantified in the same day, the former using a breath-hold multi-echo GRE sequence at 1.5T (Symphony, Siemens, Erlangen, Germany) and the latter using the T1 mapping -MOLLI sequence at 3T (Verio, Siemens, Erlangen, Germany). All ROIs were placed at mid-interventricular septum, carefully avoiding the blood pool (Fig 1). All analyses were blinded. Results All patients had regular heart rhythm and all MRI exams showed diagnostic image quality. Volunteers and patients had significantly different mean myocardial T2* (27.2 ms +/- 3.9 vs. 15.4 ms +/- 6.3 p<0.05 respectively) and T1 times 1175.7 ms +/- 22.8 vs. 952.1 ms +/- 173.2 p<0.05 respectively). 3T T1 times strongly correlated with 1.5T T2* times (r=0.95 and Fig 2). Using the 3T T1 cut-off of 1130 ms, sensitivity and specificity for 3T

Ressonância magnética na endometriose do trato urinário baixo: ensaio iconográfico

Endometriosis is defined as the presence of functional endometrial tissue outside the endometrial cavity and myometrium. Although this is a frequent disease with multifactorial causes, involvement of the lower urinary tract is rare. Magnetic resonance imaging is highly sensitive, specific and accurate in the diagnosis of endometriosis in the lower urinary tract, especially for allowing the identification of lesions obscured by adhesions or with subperitoneal extension. The present iconographic essay presents the main magnetic resonance imaging findings of the lower urinary tract involvement by endometriosis.

Cardiac magnetic resonance imaging in the current practice

Radiol Bras. 2014 Jan/Fev;47(1):V Because of increasing scientific and technological advances, the use of cardiac magnetic resonance imaging (MRI) keeps exponentially increasing over at least 30 years, and for many years has been utilized as a routine in the clinical practice both on outpatient and emergency/inpatient bases, particularly in centers where the clinical staff could remain updated, following the advances in the technology applied to cardiac imaging. Even being the most recent diagnostic method in terms of cardiac imaging if compared with scintigraphy and echocardiography, cardiac MRI has its high value demonstrated as a one-stop-shop imaging method with innumerable advantages over other methods because of its high spatial resolution associated with capacity of tissue characterization by means of conventional and contrast-enhanced MRI sequences. With such characteristics, morphology, biventricular function, perfusion at rest or under pharmacological stress for investigation of ischemia, areas of injury and myocardial viability can be evaluated in a single procedure. Additionally, cardiac MRI is an increasingly promising method in the assessment of coronary arteries. New high-field 3T magnets have added even higher spatial resolution and tissue contrast, improving the imaging quality in procedures such as myocardial perfusion scan, so the definitive inclusion of this method in the algorithm of cardiac evaluation is inevitable. Cardiac MRI is currently considered a gold standard to quantify cardiac mass and volume, because of its low variability, high reproducibility and better accuracy when compared with other imaging methods utilized in cardiology. In Brazil, the first guideline on the utilization of such method was published in 2006 and the number of quali-

Myocardial iron quantification using T2-prepared SSFP parametric images at 3 Tesla

Background Quantification of myocardial iron overload is critical for the management of patients with hemochromatosis. The effects of excess iron over T2 and T2* relaxation times are well known and both measures strongly correlate with iron concentration. Due to its lower sensitivity to B0 inhomogeneities, T2 has theoretical advantages over T2*, but the latter became the clinical standard as it can be easily obtained in a fast one breath-hold ECG gated multi-echo GRE sequence. T2* is especially challenging at 3T due to greater B0 inhomogeneities at higher field strengths. We aimed to validate a recently developed T2-prepared SSFP sequence that quantifies myocardial T2 times at 3T, compared to standard GRE based multi-echo T2* times at 1.5T. Methods A total of 15 normal volunteers and 7 chronic anemia patients (with a myocardial T2* measure <20 ms in the last 2 years, five of these on iron chelating therapy) were prospectively enrolled. Myocardial T2* and T2 times were quantified in the same day, the former using a breath-hold multi-echo GRE sequence at 1.5T (Symphony, Siemens, Erlangen, Germany) and the latter using a recently developed T2 mapping technique based on a breath-hold T2-prepared SSFP sequence at 3T (Verio, Siemens, Erlangen, Germany). All ROIs were placed at mid-interventricular septum, carefully avoiding the blood pool (Figure 1). All analyses were blinded. Results All patients had regular heart rhythm and all MRI exams showed diagnostic image quality. Volunteers and patients had significantly different mean myocardial T2* (27.2 ms +/- 3.9 vs. 15.4 ms +/- 6.3 p<0.05 respectively) and T2 times (44.9 ms +/- 2.2 vs. 37.9 ms +/- 6.6 p<0.05 respectively). 3T T2 times strongly correlated with 1.5T T2* times (r=0.91 and Figure 2). C-statistic of 3T T2 times for the prediction of a 1.5T T2* <20 ms was 0.97. Using the 3T T2 cut-off of 40 ms and the standard 1.5T T2* of 20 ms, sensitivity and specificity for 3T T2 were 80% and 100% respectively.