Giuseppe Angelelli

Hepatic involvement in hereditary hemorrhagic telangiectasia

Hereditary hemorrhagic telangiectasia (HHT), also known as Rendu-Osler-Weber disease, is an autosomal-dominant vascular disease characterized by mucocutaneous or visceral angiodysplastic lesions (telangiectases and arteriovenous malformations) that may be widely distributed throughout the cardiovascular system. The recognition of mucocutaneous telangiectases, the occurrence of spontaneous and recurrent episodes of epistaxis, the presence of visceral involvement, and a family history of this disease are the clinical criteria that allow diagnosis. In comparison with skin, lungs, gastrointestinal tract, and brain involvement, hepatic involvement defined by clinical criteria alone has long been considered uncommon. Our experience with a large group of HHT patients, even those asymptomatic for liver involvement, demonstrates that it is more frequent than reported and is characterized by the presence of intrahepatic shunts, disseminated intraparenchymal telangiectases, and other vascular lesions. Congestive cardiac failure, portal hypertension, portosystemic encephalopathy, cholangitis, and atypical cirrhosis have been reported as possible serious complications related to this condition. Thus, a correct diagnosis is important, and diagnostic imaging has a fundamental role in detecting alterations involving the liver. The possibilities to perform a multiphasic study and to provide high-quality multiplanar and angiographic reconstructions, gives multidetector row helical computed tomography the ability to detect and characterize the complex anatomopathologic alterations typical of this disease.

Abdominal wall hernias: imaging with spiral CT

Computed tomography is an accurate method of identifying the various types of abdominal wall hernias, especially if they are clinically occult, and of distinguishing them from other diseases such as hematomas, abscesses and neoplasia. In this study we examined the CT images of 94 patients affected by abdominal wall hernias observed over a period of 6 years. Computed tomography clearly demonstrates the anatomical site of the hernial sac, the content and any occlusive bowel complications due to incarceration or strangulation. Clinical diagnosis of external hernias is particularly difficult in obese patients or in those with laparotic scars. In these cases abdominal imaging is essential for a correct preoperative diagnosis and to determine the most effective treatment.

Accuracy of transvaginal sonography and contrast‐enhanced magnetic resonance‐colonography for the presurgical staging of deep infiltrating endometriosis

To investigate the accuracy of transvaginal sonography (TVS) and contrast‐enhanced magnetic resonance‐colonography (CE‐MR‐C) for the presurgical assessment of deep infiltrating endometriosis (DIE).

Prognostic value of multidetector computed tomography in bowel infarction

PurposeThis study aimed to correlate computed tomography (CT) findings and outcomes in patients affected by bowel infarction.Materials and methodsTwenty-seven patients with bowel infarction due to vascular obstruction were evaluated with multidetector CT (MDCT) to establish the prognostic value of CT findings and their correlation with the origin of the ischaemia. The chi-square test was used to analyse the results (p≤0.05).ResultsMDCT images allowed recognition of the nature of ischaemia in all cases. In particular, arterial occlusion was found in 67% of patients and venous obstruction in 33%. The overall mortality rate was 63%. Outcome closely correlated with the kind of vascular obstruction, with a mortality rate of 89% in arterial forms and 11% in venous forms. Bowel-wall hyperdensity (2/9 venous occlusions), loss of wall enhancement (1/9 venous occlusions, 2/18 arterial occlusions) and wall thickening (8/9 venous obstructions, 2/18 arterial occlusions) were predictive of good outcome. Bowel-loop dilatation (4/9 venous occlusions, 13/18 arterial occlusions), intramural pneumatosis (1/9 venous occlusions, 17/18 arterial occlusions), mesenteric venous gas (2/9 venous occlusions, 11/18 arterial occlusions), portal venous gas (1/9 venous occlusions, 4/18 arterial occlusions), pneumoperitoneum (8/18 arterial occlusions) and pneumoretroperitoneum (1/18 arterial occlusions) were predictive of poor outcome. Ascites (6/9 venous occlusions, 12/18 arterial occlusions) did not add any prognostic information.ConclusionsMDCT is able to detect the nature of bowel ischaemia and provide important prognostic information.RiassuntoObiettivoRicercare eventuali correlazioni tra informazioni ottenute con tomografia computerizzata (TC) e prognosi nell’infarto intestinale.Materiali e metodiSono state valutate le immagini TC multidetettore (TCMD) di 27 pazienti con infarto intestinale da occlusione vascolare e sono state ricercate: significatività prognostica delle alterazioni evidenziate, correlazioni con la natura dell’ischemia. È stato applicato il test statistico del χ2 (p≤0,05).RisultatiLa TCMD ha riconosciuto sempre la natura dell’ischemia, secondaria ad occlusione arteriosa nel 67% dei casi e venosa nel 33%. Il tasso di mortalità complessivo è stato del 63%. L’eziologia della patologia in rapporto alla prognosi è risultata altamente significativa, con mortalità del 89% nelle forme arteriose e del 11% in quelle venose. L’iperdensità parietale (2/9 occlusioni venose), l’assenza di enhancement (1/9 occlusioni venose, 2/18 occlusioni arteriose), l’ispessimento di parete (8/9 occlusioni venose, 2/18 occlusioni arteriose) sono risultati significativi di evoluzione benigna, mentre la dilatazione delle anse (4/9 occlusioni venose, 13/18 occlusioni arteriose), la pneumatosi parietale (1/9 occlusioni venose, 17/18 occlusioni arteriose), l’aria nelle vene mesenteriche (2/9 occlusioni venose, 11/18 occlusioni arteriose), l’aria nei rami portali (1/9 occlusioni venose, 4/18 occlusioni arteriose), lo pneumoperitoneo (8/18 occlusioni arteriose) e il retropneumoperitoneo (1/18 occlusioni arteriose) sono risultati indici prognostici sfavorevoli. L’ascite (6/9 occlusioni venose, 12/18 occlusioni arteriose) non ha fornito indicazioni di tipo prognostico.ConclusioniLa TCMD consente di definire la natura dell’ischemia intestinale e fornisce importanti valutazioni prognostiche.

Deep pelvic endometriosis: accuracy of pelvic MRI completed by MR colonography

PurposeThis study assessed the diagnostic accuracy of pelvic magnetic resonance (MR) imaging completed by MR colonography for the preoperative evaluation of deep pelvic endometriosis in patients undergoing laparoscopic surgery.Materials and methodsA total of 143 patients (mean age 34.3±5.1 years) with a clinical suspicion of deep pelvic endometriosis were assessed by pelvic MR and MR colonography. All patients underwent laparoscopic surgery 3–10 weeks after the MR examination. The presence, location, number and extent of endometriotic lesions were evaluated. Data obtained with MR were compared with surgical findings. MR sensitivity, specificity, positive (PPV) and negative (NPV) predictive values and diagnostic accuracy values were calculated for each site by considering the laparoscopic and histological findings as the reference standard.ResultsLaparoscopy confirmed the presence of endometriosis in 119/143 patients (83%); in 76/119 (64%) deep pelvic endometriosis was diagnosed, whereas in the remaining 43/119 (36%), superficial peritoneal implants and endometriomas were found. In 32/119 (27%) patients, intestinal lesions were detected. MR had sensitivity, specificity, PPV, NPV and diagnostic accuracy values of 67–100%, 85–100%, 83–100%, 84–100% and 84–100%, respectively, in recognising lesions located in different pelvic sites.ConslucionsMR imaging combined with colonography is a highly accurate tool for characterising deep endometriotic lesions in patients scheduled for laparoscopic surgery. In particular, MR colonography has very high accuracy in detecting colorectal involvement.RiassuntoObiettivoScopo del presente lavoro è stato valutare l’accuratezza diagnostica della risonanza magnetica (RM) pelvica associata a colonografia-RM nella valutazione preoperatoria della endometriosi pelvica profonda in pazienti sottoposte ad intervento per via laparoscopica.Materiali e metodiCentoquarantatre pazienti (età media 34,3±5,1 anni) con sospetto clinico di endometriosi pelvica profonda sono state valutate mediante RM pelvica completata con colonografia-RM. Tutte le pazienti sono state sottoposte a laparoscopia con un intervallo di 3–10 settimane dall’esame RM. Sono stati valutati presenza, sede, numero ed estensione delle lesioni endometriosiche. I dati ottenuti dalla RM sono stati confrontati con quelli chirurgici. Sensibilità, specificità, valore predittivo positivo (VPP) e negativo (VPN) ed accuratezza diagnostica della RM sono stati calcolati per ciascuna sede esaminata, considerando i reperti laparoscopici e istologici quale gold standard.RisultatiLa laparoscopia ha confermato la presenza di endometriosi in 119/143 pazienti (83%); in 76/119 (64%) era evidente endometriosi pelvica profonda, mentre nelle rimanenti 43/119 (36%) erano presenti endometriomi e impianti peritoneali superficiali. In 32/119 (27%) pazienti, sono state riscontrate lesioni intestinali. La RM ha presentato valori di sensibilità, specificità, VPP, VPN e accuratezza diagnostica rispettivamente compresi tra 67%–100%, 85%–100%, 83%–100%, 84%–100%, 84%–100% nel riconoscimento delle diverse sedi di impianto della patologia.ConclusioniLa RM associata a colonografia rappresenta una metodica accurata per lo studio delle pazienti con endometriosi pelvica profonda da sottoporre ad intervento chirurgico laparoscopico e per la caratterizzazione delle lesioni endometriosiche. In particolare la colonografia-RM consente elevati valori di accuratezza nell’identificazione delle lesioni intestinali.

Breast MRI background parenchymal enhancement (BPE) correlates with the risk of breast cancer

OBJECTIVES To investigate whether background parenchymal enhancement (BPE) and breast cancer would correlate searching for any significant difference of BPE pattern distribution in case of benign or malignant lesions. METHODS 386 patients, including 180 pre-menopausal (group 1) and 206 post-menopausal (group 2), underwent MR examination. Two radiologists evaluated MR images classifying normal BPE as minimal, mild, moderate or marked. The two groups of patients were subdivided into 3 categories based on MRI findings (negative, benign and malignant lesions). The distribution of BPE patterns within the two groups and within the three MR categories was calculated. The χ2 test was used to evaluate BPE type distribution in the three patient categories and any statistically significant correlation of BPE with lesion type was calculated. The Student t test was applied to search for any statistically significant difference between BPE type rates in group 1 and 2. RESULTS The χ2 test demonstrated a statistically significant difference in the distribution of BPE types in negative patients and benign lesions as compared with malignant ones (p<0.05). A significantly higher prevalence of moderate and marked BPE was found among malignant lesions (group 1: 32% and 42%, respectively; group 2: 31% and 46%, respectively) while a predominance of minimal and mild BPE among negative patients (group 1: 60% and 36%, respectively; group 2: 68% and 32%, respectively) and benign lesions (group 1: 54% and 38%, respectively; group 2: 75% and 17%, respectively) was found. The Student t test did not show a statistically significant difference between BPE type rates in group 1 and 2 (p>0.05). CONCLUSION Normal BPE could correlate with the risk of breast cancer being such BPE patterns as moderate and marked associated with patients with malignant lesions in both pre and post-menopausal women.

Multi-detector CT features of acute intestinal ischemia and their prognostic correlations.

Acute intestinal ischemia is an abdominal emergency occurring in nearly 1% of patients presenting with acute abdomen. The causes can be occlusive or non occlusive. Early diagnosis is important to improve survival rates. In most cases of late or missed diagnosis, the mortality rate from intestinal infarction is very high, with a reported value ranging from 60% to 90%. Multi-detector computed tomography (MDCT) is a fundamental imaging technique that must be promptly performed in all patients with suspected bowel ischemia. Thanks to the new dedicated reconstruction program, its diagnostic potential is much improved compared to the past and currently it is superior to that of any other noninvasive technique. The increased spatial and temporal resolution, high-quality multi-planar reconstructions, maximum intensity projections, vessel probe, surface-shaded volume rending and tissue transition projections make MDCT the gold standard for the diagnosis of intestinal ischemia, with reported sensitivity, specificity, positive and negative predictive values of 64%-93%, 92%-100%, 90%-100% and 94%-98%, respectively. MDCT contributes to appropriate treatment planning and provides important prognostic information thanks to its ability to define the nature and extent of the disease. The purpose of this review is to examine the diagnostic and prognostic role of MDCT in bowel ischemia with special regard to the state of art new reconstruction software.

MR evaluation of breast lesions obtained by diffusion-weighted imaging with background body signal suppression (DWIBS) and correlations with histological findings

OBJECTIVES Diffusion imaging represents a new imaging tool for the diagnosis of breast cancer. This study aims to investigate the role of diffusion-weighted MRI with background body signal suppression (DWIBS) for evaluating breast lesions. METHODS 90 patients were prospectively evaluated by MRI with STIR, TSE-T2, contrast enhanced THRIVE-T1 and DWIBS sequences. DWIBS were analyzed searching for the presence of breast lesions and calculating the ADC value. ADC values of ≤1.44×10(-3)mm(2)/s were considered suspicious for malignancy. This analysis was then compared with the histological findings. Sensitivity, specificity, diagnostic accuracy (DA), positive predictive value (PPV) and negative (NPV) were calculated. RESULTS In 53/90 (59%) patients, DWIBS indicated the presence of breast lesions, 16 (30%) with ADC values of >1.44 and 37 (70%) with ADC≤1.44. The comparison with histology showed 25 malignant and 28 benign lesions. DWIBS sequences obtained sensitivity, specificity, DA, PPV and NPV values of 100, 82, 87, 68 and 100%, respectively. CONCLUSION DWIBS can be proposed in the MRI breast protocol representing an accurate diagnostic complement.

Unenhanced breast MRI (STIR, T2-weighted TSE, DWIBS): An accurate and alternative strategy for detecting and differentiating breast lesions☆

PURPOSE To assess the role of STIR, T2-weighted TSE and DWIBS sequences for detecting and characterizing breast lesions and to compare unenhanced (UE)-MRI results with contrast-enhanced (CE)-MRI and histological findings, having the latter as the reference standard. MATERIALS AND METHODS Two hundred eighty consecutive patients (age range, 27-73 years; mean age±standard deviation (SD), 48.8±9.8years) underwent MR examination with a diagnostic protocol including STIR, T2-weighted TSE, THRIVE and DWIBS sequences. Two radiologists blinded to both dynamic sequences and histological findings evaluated in consensus STIR, T2-weighted TSE and DWIBS sequences and after two weeks CE-MRI images searching for breast lesions. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and diagnostic accuracy for UE-MRI and CE-MRI were calculated. UE-MRI results were also compared with CE- MRI. RESULTS UE-MRI sequences obtained sensitivity, specificity, diagnostic accuracy, PPV and NPV values of 94%, 79%, 86%, 79% and 94%, respectively. CE-MRI sequences obtained sensitivity, specificity, diagnostic accuracy, PPV and NPV values of 98%, 83%, 90%, 84% and 98%, respectively. No statistically significant difference between UE-MRI and CE-MRI was found. CONCLUSION Breast UE-MRI could represent an accurate diagnostic tool and a valid alternative to CE-MRI for evaluating breast lesions. STIR and DWIBS sequences allow to detect breast lesions while T2-weighted TSE sequences and ADC values could be useful for lesion characterization.

Diagnostic imaging in the study of visceral involvement of hereditary haemorrhagic telangiectasia

Hereditary haemorrhagic telangiectasia (HHT), also known as Rendu-Osler-Weber disease, is an autosomal-dominant vascular disease characterised by mucocutaneous or visceral angiodysplastic lesions. Its diagnosis is exclusively based on clinical criteria. The brain, lungs and liver, in growing order of prevalence, are the most frequently involved organs. Diagnostic imaging based on ultrasound (US), computed tomography (CT), magnetic resonance imaging (MRI) and digital subtraction angiography (DSA) has a fundamental role in detecting visceral involvement in HHT patients and is therefore crucial for the prognostic assessment and therapeutic approach. Arteriovenous shunts are the most common cerebrovascular malformations (CVMs). MRI and CT angiography are the methods of choice for diagnosing cerebral involvement, and it is debated whether MRI could be considered as a screening examination on account of its noninvasiveness. Pulmonary arteriovenous malformations, diffuse telangiectases or high-flow, low-pressure shunts between pulmonary arteries and veins can be studied with contrast-enhanced US, but multidetector CT seems to provide the most comprehensive evaluation of their angioarchitecture, whereas angiography has a predominant role in treatment. Liver involvement is frequent and characterised by the presence of intrahepatic shunts, disseminated intraparenchymal telangiectases and other vascular lesions. US is useful for detecting hepatic lesions but should be completed by more accurate imaging methods such as multidetector CT and MRI.RiassuntoLa telangiectasia emorragica ereditaria (HHT), o malattia di Rendu-Osler-Weber, è un disordine vascolare ereditario, caratterizzato dalla comparsa di lesioni angiodisplasiche mucocutanee e viscerali, la cui diagnosi si basa esclusivamente su criteri clinici. L’encefalo, i polmoni ed il fegato sono, in ordine crescente di prevalenza, le sedi viscerali più frequentemente coinvolte. La diagnostica per immagini, mediante gli ultrasuoni (US), la tomografia computerizzata (TC), la risonanza magnetica (RM) e la angiografia (DSA), ha un ruolo cruciale nella diagnosi del coinvolgimento viscerale nei pazienti affetti da HHT ed è, pertanto, fondamentale nella valutazione prognostica e nella impostazione terapeutica. Tra le malformazioni vascolari cerebrali gli shunt arterovenosi costituiscono l’alterazione più frequente. La RM e la angio-TC sono le metodiche di scelta nella diagnosi dell’interessamento cerebrale, ed è dibattuto se, per la scarsa invasività, la RM sia da proporre come metodica di screening. Le malformazioni arterovenose polmonari, telangiectasie diffuse o fistole tra arterie e vene polmonari, possono essere ricercate con US con MdC, ma la TC multidetettore appare l’indagine più completa per la valutazione della loro angioarchitettura mentre l’angiografia mantiene un ruolo prevalentemente terapeutico. L’interessamento epatico è frequente e caratterizzato dalla comparsa di fistole arterovenose, telangiectasie intraparenchimali ed altre alterazioni vascolari. Gli US sono utili nella ricerca delle lesioni epatiche, ma devono essere integrati da indagini più accurate quali la TC multidetettore e la RM.