Giuseppe Mamone

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.

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.

Real-time spatial compound sonography of Achilles tendon in patients with heterozygous familial hypercholesterolaemia and normal physical examination

PurposeThis study was undertaken to assess the prevalence and ultrasound features of Achilles tendon xanthomas (ATX) in patients with heterozygous familial hypercholesterolemia (HFH) and normal physical examination studied with high-resolution ultrasonography (HRUS) and, secondarily, to evaluate the role of real-time spatial compound sonography (CS) in terms of image quality.Materials and methodsBoth Achilles tendons of 40 patients with HFH were studied with HRUS and CS. Two experienced radiologists evaluated by consensus the presence of ATX described as (1) tendon thickening and/or (2) focal hypoechoic areas and the quality of images obtained with the two techniques.ResultsTen out of 80 tendons showed thickening (mean: 11.2 mm). Twelve xanthomas 4.1–9.8 mm were identified in 9/80 tendons of five patients. In 5/80 tendons, both tendon thickening and focal hypoechoic areas were observed. There was no difference in the number of xanthomas detected at conventional US or CS. With respect to image quality, the performance of CS was considered significantly higher than HRUS in 72/80 (90%) cases and equal to HRUS in the remaining 8/80 (10%) (p<0.001).ConclusionsCS is an effective tool in the assessment of ATX in patients with HFH and normal physical examination, and provides a better image quality when compared with HRUS.RiassuntoObiettivoValutare l’incidenza e gli aspetti ecografici degli xantomi del tendine d’Achille (XTA) in pazienti con ipercolesterolemia familiare eterozigotica (IFE) ed esame clinico negativo, studiati con ecografia ad elevata risoluzione (HRUS) e, secondariamente, l’apporto fornito dalla “real-time spatial compound sonography” (CS) in termini di qualità dell’immagine.Materiali e metodiEntrambi i tendini d’Achille di 40 pazienti con IFE sono stati studiati con HRUS e CS. Due esperti radiologi hanno valutato in consenso sia la presenza di XTA intesi come: a) incremento dello spessore e/o b) presenza di aree focali ipoecogene, sia la qualità delle immagini ottenute con entrambe le tecniche.RisultatiDieci su 80 tendini erano ispessiti (media: 11,2 mm). In 9/80 tendini di 5 pazienti sono stati identificati 12 xantomi (media: 7,1 mm). In 5/80 tendini si è osservato l’ispessimento associato alla presenza di aree ipoecogene. Il numero di xantomi identificati si è rivelato uguale con HRUS o CS. Riguardo la qualità dell’immagine, la CS è stata valutata significativamente superiore in 72/80 (90%) casi o, nei rimanenti 8/80 (10%), pari all’HRUS (p<0,001).ConclusioniL’ecografia CS è in grado di individuare XTA in pazienti con IFE ed esame clinico negativo, offrendo una migliore qualità dell’immagine rispetto all’HRUS.

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.

The “Target sign” and the “Lollipop sign” in hepatic epithelioid hemangioendothelioma

The ‘‘Target sign’’ and the ‘‘Lollipop sign’’ are characteristic radiological findings of Hepatic Epithelioid Hemangioendothelioma (HEH) described in contrastenhanced CT and MR imaging. HEH is a rare liver tumor of vascular origin, with relatively specific imaging characterized by peripheral location of the nodules, capsular retraction, coalescence of multiple lesions, a target-like appearance, and the ‘‘Lollipop sign.’’ The ‘‘Target sign’’ is generated by a more scleroticfibrous center, a layer of cellular proliferation, and a peripheral narrow avascular zone between the tumor nodules and liver parenchyma caused by tumor infiltration and occlusion of hepatic sinusoids and small vessels (Fig. 1). This configuration with concentric rings of varying attenuation/intensity gives a stratified pattern to the hepatic lesion which resembles a ‘‘target’’ [1]. MRI is the best technique for lesion characterization with evidence of the target sign in particular on T2weighted images as well as the dynamic study [2]. On T2 images, a target appearance consists of a core with high signal intensity (similar to fluid), a thin ring with low signal intensity, and a peripheral halo with slight hyperintense signal. On dynamic study, it consists of an hypodense/hypointense core, surrounded by a layer of enhancement and a thin peripheral hypodense/hypointense halo (Figs. 2,3). The ‘‘Lollipop sign’’ (Fig. 4) is a combination of two structures: the well-defined tumor mass on enhanced images (the candy in the lollipop) and the adjacent occluded vein (the stick), because HEH has the tendency to spread within the portal and hepatic vein branches (Fig. 5) [3]. The vein should terminate smoothly at the

Hepatic morphology abnormalities: beyond cirrhosis

The diagnosis of cirrhosis can be reached on the basis of established hepatic morphological changes. However, some other conditions can mimic cirrhosis. The aim of this pictorial essay is to review the CT and MRI appearances of hepatic morphology abnormalities in the cirrhotic liver and other diseases, describing pathologic conditions that can mimic cirrhosis, with useful tips for the differential diagnosis. Mimickers of cirrhosis include congenital hepatic fibrosis, Caroli disease, Budd–Chiari Syndrome, hepatoportal sclerosis, cavernous transformation of the portal vein, pseudocirrhosis from metastatic disease, acute liver failure, post-therapeutic morphologic changes in the liver, and infective conditions including schistosomiasis and oriental cholangiohepatitis. Recognizing the hepatic morphological changes in images can help radiologists to diagnose cirrhosis and other diseases in early stages.

Complete spontaneous regression of giant focal nodular hyperplasia of the liver: Magnetic resonance imaging evaluation with hepatobiliary contrast media

Focal nodular hyperplasia (FNH) of the liver is a benign lesion occurring in 0.6%-3% of the general population that probably reflects a local hyperplastic response of hepatocytes to a vascular abnormality. Most lesions are diagnosed incidentally and the natural history of the disease remains largely unknown. It has been shown that most FNH remain stable, or even regress, over a long follow-up period. We present a patient with FNH of the liver who was followed up for 7 years. A 26-year-old woman with a 5-year history of oral contraceptive use was referred to our hospital in February 2005 for further examination of a liver tumour. The diagnosis of FNH was made using magnetic resonance (MR) imaging with hepatospecific contrast media; this technique allows a correct diagnosis, in particular distinguishing FNH from hepatic adenoma, avoiding an invasive procedure such as the lesion biopsy. After 7-year from the diagnosis, we observed the complete spontaneous regression of the lesion by enhanced MR scanning. In this patient, discontinuation of oral contraceptive use and two childbirths may have influenced the natural history of FNH. To our knowledge, in the English literature there is no report illustrating a complete regression of giant FNH but only studies of decreasing in size. The present case suggests that a young patient with giant FNH should be managed conservatively rather than by resection, because FNH has the potential for spontaneous regression.

Percutaneous treatment of aortic coarctation to manage severe hypertension in a 66-year-old patient.

Percutaneous treatment of aortic coarctation to manage severe hypertension in a 66-year-old patient