Gianluca Marrone

Multidisciplinary imaging of liver hydatidosis

Liver hydatidosis is a parasitic endemic disease affecting extensive areas in our planet, a significant stigma within medicine to manage because of its incidence, possible complications, and diagnostic involvements. The diagnosis of liver hydatidosis should be as fast as possible because of the relevant complications that may arise with disease progression, involving multiple organs and neighboring structures causing disruption, migration, contamination. The aim of this essay is to illustrate the role of imaging as ultrasonography (US), multi detector row computed tomography, and magnetic resonance imaging (MRI) in the evaluation of liver hydatidosis: the diagnosis, the assessment of extension, the identification of possible complications and the monitoring the response to therapy. US is the screening method of choice. Computed tomography (CT) is indicated in cases in which US is inadequate and has high sensitivity and specificity for calcified hydatid cysts. Magnetic resonance is the best imaging procedure to demonstrate a cystic component and to show a biliary tree involvement. Diagnostic tests such as CT and MRI are mandatory in liver hydatidosis because they allow thorough knowledge regarding lesion size, location, and relations to intrahepatic vascular and biliary structures, providing useful information for effective treatment and decrease in post-operative morbidity. Hydatid disease is classified into four types on the basis of their radiologic appearance.

Interventional Radiology Procedures in Pediatric Patients with Complications after Liver Transplantation

Interventional radiologists play a key role in treating vascular and nonvascular complications of pediatric liver transplantation, improving graft and patient survival and in most cases avoiding the need for surgical revision or repeat transplantation. The interventional radiology procedures most commonly used in this context include percutaneous and transjugular liver biopsies performed with ultrasonographic and fluoroscopic guidance for the diagnosis of graft disease; angioplasty and stent placement for treatment of vascular and biliary occlusion, stenosis, and stricture; and catheter placement for drainage of fluid collections. Since interventional radiology procedures themselves may lead to complications, it is important that the radiologist be familiar with the indications for a particular procedure, the technical considerations, and the expected results, as well as with normal and abnormal postintervention imaging appearances.

The role of 1.5T cardiac MRI in the diagnosis, prognosis and management of pulmonary arterial hypertension

Cardiovascular magnetic imaging is a noninvasive, three dimensional tomographic technique that allows for a detailed morphology of the cardiac chambers, the accurate quantification of right ventricle volumes, myocardial mass, and transvalvular flow. It can also determine whether right ventricular diastolic function is impaired through pulmonary hypertension. The aim of this article is to review the main kinetic, morphological and functional changes of the right ventricle that can occur in patients affected by pulmonary arterial hypertension (PAH) and to assess how the MRI findings can influence the prognosis, and guide the decision-making strategy. In those cases in which MRI shows a significant cardiac diastolic dysfunction, the prognosis is predictive of pharmacological treatment failure, and mortality. This leaves double lung-heart transplantation as the only therapeutic option. The coexistence of PAH and left ventricle impairment causes worse right ventricle function, leads to a poor prognosis, and may change the therapeutic strategies (for example, PAH associated with left ventricle dysfunction may require a double lung-heart transplant).

Ischemic mitral valve regurgitation in patients with depressed ventricular function: cardiac geometrical and myocardial perfusion evaluation with magnetic resonance imaging

OBJECTIVE To investigate geometrical and functional changes involving the left ventricle (LV) and mitral valve (MV) apparatus in patients with depressed LV ejection fraction (LVEF) and ischemic MV regurgitation (IMVR). METHODS A series of patients with three vessels coronary artery disease (CAD) and depressed LVEF underwent cardiac magnetic resonance imaging to investigate MV/LV geometry and function, and myocardial perfusion/vitality. Geometrical data were indexed by anterior MV leaflet length. Two groups were identified: CAD without IMVR (group CAD), and with IMVR (group IMV). RESULTS Eleven patients were enrolled in the CAD group and 13 in the IMV group. IMVR volume was significantly higher in the IMV group (24.0+/-12.0 vs 4.5+/-5.2; p<0.0001). LVEF% was comparable (IMV 34.6+/-13.0 vs CAD 31.5+/-13.0; p=ns). Indexed MV/LV geometrical variables were comparable in the two groups. Perfusion/vitality study showed inferior myocardial necrosis occurred more often in the IMV group (p=0.01). At Pearson test, MV regurgitation occurrence correlated with inferior myocardial necrosis (r=0.5; p=0.006), non-indexed systolic/diastolic annular inter-commissural diameters (r=0.4; p=0.04) and MV annular areas (r=0.4; p=0.04). Papillary muscles distance (PMD) and LV volumes inversely correlated with LVEF% (r=-0.6; p<0.05 and r=-0.8; p<0.001). At multivariable analysis, no independent determinants for IMVR were identified and LV volumes were the sole determinants for LVEF% (p<0.05). CONCLUSION In patients with depressed LVEF%, IMV cannot be explained by LV geometrical modifications alone. Although PMD, LV volumes, and LVEF% are correlated, they have no direct impact in the development of IMVR. In contrast, inferior myocardial necrosis and increased inter-commissural MV diameters may lead to deformity of MV complex and subsequent IMV.

Biliary cystadenoma with bile duct communication depicted on liver-specific contrast agent-enhanced MRI in a child

Biliary cystadenoma is a benign, but potentially malignant, cystic neoplasm of the biliary ducts occurring most commonly in middle-aged females and very rarely in children. We present a 9-year-old boy with biliary cystadenoma, diagnosed by MRI using a new liver-specific contrast agent (gadoxetic acid) that is eliminated by the biliary system. The images clearly demonstrate the communication between the multiloculated cystic mass and the biliary tree, suggesting the possibility of biliary cystadenoma. Due to the malignant potential of a cystadenoma, the lesion was resected. The resection was complete and the postoperative course was uneventful.

The role of ultrasound and magnetic resonance cholangiopancreatography for the diagnosis of biliary stricture after liver transplantation

PURPOSE To identify the diagnostic value of ultrasound (US) and magnetic resonance cholangiopancreatography (MRCP) in diagnosing biliary strictures after liver transplantation. MATERIALS AND METHODS Sixty patients with clinically suspected biliary strictures after liver transplantation were retrospectively evaluated. All patients underwent US and MRCP before the standard of reference (SOR) procedure: endoscopic retrograde cholangiopancreatography or percutaneous transhepatic cholangiography. Radiological images were analyzed for biliary dilatation and strictures. RESULTS By SOR, biliary dilatation was present in 55 patients, stricture in 53 (44 anastomotic, 4 intrahepatic, 5 both), and dilatation and/or stricture in 58. Dilatation was diagnosed by US and MRCP in 39 and 45, respectively (sensitivity 71% vs. 82%, p=0.18). Stricture was diagnosed by US and MRCP in 0 and 42, respectively (sensitivity 0% vs. 79%, p<0.0001). False positive stricture was diagnosed by MRCP in 2. Dilatation and/or stricture was diagnosed by US in 39 and MRCP in 50 (sensitivity 67% vs. 86%, p=0.01); however, using both techniques, sensitivity increased to 95%. CONCLUSIONS MRCP is superior to US for diagnosing biliary strictures after liver transplantation primarily because MRCP can detect stricture. The combination of US and MRCP seems superior to either method alone. Our data suggest that in patients with normal US and MRCP, direct cholangiography could be avoided.

Intracranial hemorrhage during extracorporeal membrane oxygenation: does family history play a role?

Extracorporeal membrane oxygenation (ECMO) is a lifesaving mechanical support for reversible severe heart or respiratory injury [1]. ECMO circuit causes a wide inflammatory response and coagulation disequilibrium due to the exposure of blood to a non-biological surface. Procoagulant state, consumption of clotting factors, impaired platelet function, thrombocytopenia, and fibrinolysis coexist. Therefore, systemic anticoagulation is required to prevent life-threatening thrombosis and excessive bleeding [2]. Over the past decade, the use of ECMO in adults has increased [3, 4]. Substantial technological improvements have made the circuit systems simpler and safer, causing less bleeding than in the past. ECMO can be associated with different neurological complications, such as seizures, ischemic or hemorrhagic stroke, and acute disseminated encephalomyelitis in H1N1affected patients. ECMO registries have reported a rate of intracranial hemorrhage of 4–15 %. In the majority the outcome is catastrophic [5–7]. Predictive scores proposed to achieve the best cost-effectiveness and individual patient’s prognosis do not involve neurological outcomes [8]. Because of the increasing indication for ECMO, the occurrence of neurological injuries will be likely an emergent phenomenon that should be understood better and monitored. Possibly, neurologists should be involved in the initial stages of the decision-making process and evaluation of prognosis and outcome. In the first 6 months of 2014, we managed 16 cases of ECMO for different causes of severe ARDS unresponsive to conventional treatment (7 H1N1 infection, 5 pneumonia of various origins, 3 end-stage respiratory failure as bridge to lung transplantation, and 1 primary graft failure PGF), with an overall survival of 65 %. Among these patients, we had two cases of intracranial hemorrhage, which caused death of both patients. We present them because of the fortuitous finding of a family history of vascular cerebral episodes: a bleeding cerebral vascular anomaly in one case and hemorrhagic stroke in the other one.

A Rare Case of Left Ventricular Intramural Hemangioma Diagnosed Using 1.5-T Cardiac MRI with Histopathological Correlation and Successfully Treated by Surgery

Hemangiomas are vascular tumors composed of blood vessels, frequently localized in the skin and subcutaneous muscles; their localization in the heart is exceptional. The most common localizations are the lateral walls of the left ventricle, the anterior wall, and the septum. Mostly, these tumors grow intracavitarily, rarely intramurally. We describe a singular case of left ventricular intramural hemangioma, detected and diagnosed using newer magnetic resonance imaging (MRI) modalities, confirmed by histopathological results, and treated successfully by surgery.

Liver Volume Restoration and Hepatic Microarchitecture in Small-for-Size Syndrome.

BACKGROUND We investigated preoperative parameters that could work as markers of liver regeneration (LR), and tried to create an algorithm for therapeutic decision-making, looking at the clinical setting of post-hepatectomy liver failure (PHLF) after major liver resection for malignancies (LRM) and of the small-for-size syndrome (SFSS) after adult-to-adult living related liver transplantation (LRLT), considering PHLF and SFSS a single clinical entity. MATERIAL AND METHODS The clinical data of 2 series of 10 consecutive patients who experienced liver-specific complications after LRLT or LRM between 2008 and 2013 were analyzed. LR was evaluated by multidetector computed tomography (MDCT) and hepatic parenchymal findings with specific re-examinations of liver biopsies. The analysis was done according to demographics, tumor characteristics, and postoperative complications occurring within 90 days of surgery and codified within the Clavien classification. RESULTS A total of 13 cases of SFSS occurred in 8 LRLT recipients (61.5%) and in 5 patients after LRM (38.5%). The incidence of SFSS was significantly associated with a greater spleen volume/future remnant liver volume ratio (1.08±0.5; P=0.02) and a reduced number of hepatic tumors (0.58±0.6; P=0.04). A greater degree of LR was not associated with a lesser likelihood of developing SFSS (P=0.31). SFSS incidence and re-examination of post-operative liver biopsies differed according to the evidence of focal endothelial denudation in the portal vein and centrilobular hepatocanalicular cholestasis. We found an association between SFSS incidence and the immunohistochemical overexpression of cytological proliferation marker Ki-67 (29.3±29.8%; P=0.007), which was a significant predictor of poor post-operative survival (OR=1.12, C.I.: 1.013; 1.242). CONCLUSIONS SFSS is a rare but dangerous clinical entity characterized by anarchic hepatic regeneration. We suggest focusing on early diagnosis in order to establish non-surgical modulation of the portal inflow, in conjunction with optimization of medical management.

Cirsoid Aneurysm of Coronary Arteries Associated with Arterioventricular Fistula Evaluated by 64-Multidetector CT Coronary Angiography: Depiction of a Case

A female patient with severe pulmonary hypertension was admitted for lung transplant evaluation. As an incidental finding, the chest CT showed diffuse and dilated coronaries, not detected at previous echocardiography. A coronary CT angiography was then performed using a 64-multidetector computed tomography (MDCT) scanner to better evaluate the coronary tree. The images obtained after postprocessing demonstrated tremendously aneurysmatic and tortuous coronary arteries and the presence of a septal branch deepening into the myocardium and penetrating the right ventricle cavity, forming an abnormal arterioventricular fistula. A causal relation between the aneurysms and the fistula is suspected.