Henrique Simão Trad

Revisão radiológica de 173 casos consecutivos de paracoccidioidomicose

OBJECTIVE: To determine the incidence of most significant radiological findings of paracoccidioidomycosis and to verify its possible variants. MATERIALS AND METHODS: One hundred and seventy-three cases of paracoccidioidomycosis presented between 1970 and 1980 were reviewed, including their radiological workup reanalysis by at least two experienced radiologists. RESULTS: Ninety-four cases were pulmonary only and 38 were pulmonary associated with ganglial, visceral and osseous lesions or in association with tuberculosis. There was no pulmonary involvement in 41 cases, presenting small bowel, viscera, bone lesions, or a combination of these. Most significant radiological findings in cases of pulmonary involvement were bilateral, diffuse reticular and nodular interstitial infiltrate, followed by the diffuse bilateral alveolar form. Visceral and gastrointestinal tract lesions presented predominantly with liver, jejunum and ileum involvement. Lymph nodal involvement was predominantly diffuse, abdominal or peripheral. In bones, osteolytic lesions affected predominantly long bones and clavicle. CONCLUSION: Paracoccidioidomycosis is a granulomatous disease commonly found in Brazil, primarily affecting lungs, caused by inhalation of fungus spores. Other rare or less frequent forms of the disease should be taken into consideration for differential diagnosis.

Magnetic resonance imaging evaluation of cardiac masses

Background Cardiac tumors are extremely rare; however, when there is clinical suspicion, proper diagnostic evaluation is necessary to plan the most appropriate treatment. In this context, cardiovascular magnetic resonance imaging (CMRI) plays an important role, allowing a comprehensive characterization of such lesions. Objective To review cases referred to a CMRI Department for investigation of cardiac and paracardiac masses. To describe the positive case series with a brief review of the literature for each type of lesion and the role of cardiovascular magnetic resonance imaging in evaluation. Methods Between August 2008 and December 2011, all cases referred for CMRI with suspicion of tumor involving the heart were reviewed. Cases with positive histopathological diagnosis, clinical evolution or therapeutic response compatible with the clinical suspicion and imaging findings were selected. Results Among the 13 cases included in our study, eight (62%) had histopathological confirmation. We describe five benign tumors (myxomas, rhabdomyoma and fibromas), five malignancies (sarcoma, lymphoma, Richter syndrome involving the heart and metastatic disease) and three non-neoplastic lesions (pericardial cyst, intracardiac thrombus and infectious vegetation). Conclusion CMRI plays an important role in the evaluation of cardiac masses of non-neoplastic and neoplastic origin, contributing to a more accurate diagnosis in a noninvasive manner and assisting in treatment planning, allowing safe clinical follow-up with good reproducibility.

Evaluation of Right Ventricular Systolic Function in Chagas Disease Using Cardiac Magnetic Resonance ImagingCLINICAL PERSPECTIVE

Background— Right ventricular (RV) impairment is postulated to be responsible for prominent systemic congestion in Chagas disease. However, occurrence of primary RV dysfunction in Chagas disease remains controversial. We aimed to study RV systolic function in patients with Chagas disease using cardiac magnetic resonance. Methods and Results— This cross-sectional study included 158 individuals with chronic Chagas disease who underwent cardiac magnetic resonance. RV systolic dysfunction was defined as reduced RV ejection fraction based on predefined cutoffs accounting for age and sex. Multivariable logistic regression was used to verify the relationship of RV systolic dysfunction with age, sex, functional class, use of medications for heart failure, atrial fibrillation, and left ventricular systolic dysfunction. Mean age was 54±13 years, 51.2% men. RV systolic dysfunction was identified in 58 (37%) individuals. Although usually associated with reduced left ventricular ejection fraction, isolated RV systolic dysfunction was found in 7 (4.4%) patients, 2 of them in early stages of Chagas disease. Presence of RV dysfunction was not significantly different in patients with indeterminate/digestive form of Chagas disease (35.7%) compared with those with Chagas cardiomyopathy (36.8%) (P=1.000). Conclusions— In chronic Chagas disease, RV systolic dysfunction is more commonly associated with left ventricular systolic dysfunction, although isolated and early RV dysfunction can also be identified.

Congenital inferior vena cava anomalies: a review of findings at multidetector computed tomography and magnetic resonance imaging

Inferior vena cava anomalies are rare, occurring in up to 8.7% of the population, as left renal vein anomalies are considered. The inferior vena cava develops from the sixth to the eighth gestational weeks, originating from three paired embryonic veins, namely the subcardinal, supracardinal and postcardinal veins. This complex ontogenesis of the inferior vena cava, with multiple anastomoses between the pairs of embryonic veins, leads to a number of anatomic variations in the venous return from the abdomen and lower limbs. Some of such variations have significant clinical and surgical implications related to other cardiovascular anomalies and in some cases associated with venous thrombosis of lower limbs, particularly in young adults. The authors reviewed images of ten patients with inferior vena cava anomalies, three of them with deep venous thrombosis. The authors highlight the major findings of inferior vena cava anomalies at multidetector computed tomography and magnetic resonance imaging, correlating them the embryonic development and demonstrating the main alternative pathways for venous drainage. The knowledge on the inferior vena cava anomalies is critical in the assessment of abdominal images to avoid misdiagnosis and to indicate the possibility of associated anomalies, besides clinical and surgical implications.

Evaluation of Chagas heart disease by cardiac magnetic resonance after an aborted sudden cardiac death event

Background Chagas’ disease (CD) is caused by the protozoan parasite Trypanosoma cruzi leading to a lifelong infection, which is still recognized as one of the world’s most neglected tropical diseases. After an acute phase, which is commonly unapparent, 30-40% of the patients develop the chronic form and chronic Chagas ‘cardiomyopathy (CCC), its most serious complication, has three main clinical presentations: arrhythmic syndrome, heart failure, and thromboembolic phenomena. All of these forms can lead to the most important outcome in CCC: the sudden cardiac death (SCD). This dramatic event can affect even young and previously asymptomatic patients. Cardiac Magnetic Resonance (CMR) is becoming a valuable tool to evaluate and stratify patients regarding the risk of severe arrhythmic events in many clinical conditions. Little is known about its prognostic value in CCC. Our objective was to report a series of aborted SCD in CCC patients in order to clarify if CMR can detect a common imaging pattern in such cases.

Presence of scar by late gadolinium enhancement is a strong predictor of events in Chagas Heart Disease

Methods A total of 121 patients with CHD disease (52.1% female; 54.5 ± 13 years-old) from Ribeirao Preto Clinical Hospital (Sao Paulo, Brazil) were included. A CMR was performed at the enrollment from October/2009 to March/2013 in a single 1.5T scanner (Achieve, Phillips, the Netherlands), including SSFP cines at the vertical and horizontal long axis, and a stack of the short axis. LGE sequences were performed after 10.1 ± 1.5 min gadolinium contrast (0.2 mmol/kg) in the same cine positions, with positive LGE visually assessed and quantified for core and grey zone. All analysis was performed with Mass Research version software (Leiden University, the Netherlands). Any death, pacemaker (PC) implant and heart failure hospitalization (HFH) was considered an event during the follow-up. Kaplan-Meier curves, log-rank analysis and Cox regression models were utilized at the statistical analysis.

Derivando escore de cálcio coronariano da tomografia computadorizada torácica

1. Radiologist for Lotus Radiologia, Postgraduate Student at the Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo (FMRP-USP), Ribeirão Preto, SP, Brazil. E-mail: hsimtrad@gmail.com. There is no doubt regarding the importance and socioeconomic impact of cardiovascular diseases, especially coronary artery disease (CAD). That is not the case in scientific discussions on diagnosis, treatment, and, especially, coronary risk stratification, which is one of the pillars of cardiology. It is wellestablished clinical practice to use global risk scores as an initial tool in the evaluation of patients with CAD, the Framingham risk score being the most widely used. However, given the quite heterogeneous presentation of the disease, one of the main questions is whether such scores should be used alone(1). In the search for noninvasive complementary methods of evaluating CAD, initially with electron beam computed tomography (CT) and subsequently with new generations of multichannel CT scanners, the creation of a coronary artery calcium (CAC) score was a natural development. In addition to being noninvasive, determination of the CAC score is a robust, simple examination, its main drawbacks being the limited availability of specific equipment and the use of ionizing radiation. After years of constant accumulation of scientific data, the CAC score has proven to be solid, not only being considered useful for coronary risk stratification, with values higher than those of the clinical methods cited, but also providing important prognostic information for various clinical scenarios. According to the Second Guidelines on Cardiovascular Magnetic Resonance Imaging and Computed Tomography, issued jointly by the Brazilian Society of Cardiology and the Brazilian College of Radiology(2), determination of the CAC score is the most accurate tool for the detection of subclinical atherosclerosis, refining the risk stratification in asymptomatic patients. In those same guidelines, the use of the CAC score in asymptomatic patients in whom the overall coronary risk is deemed intermediate was categorized as having a grade I recommendation and an A level of evidence. Therefore, in that scenario, the usefulness of the CAC score is indisputable. The Brazilian National Health Insurance Agency does not include the use of the CAC score on its minimum coverage list. This suggests that legislators are not truly acting in the best interests of the population ́s health. It also leads us to believe that there is other, non-scientific, “knowledge” that pervades that decisionmaking process. Studies on the cardiovascular system have recently been prominent in the radiology literature of Brazil(3–6). One study published in this issue of Radiologia Brasileira represents an innovative step forward in the understanding of the CAC score within the literature of Brazil. In that study, Pelandré et al.(7) explored a current tendency for the CAC score to be extrapolated from chest CT scans that are not triggered by an electrocardiogram. Following a recent trend in the literature, cited in the article itself, the authors sought to determine whether data related to the relevance of the CAC score can be extracted from an examination that is much more common and comprehensive. It makes perfect sense, especially because the guidelines of the leading pulmonology, thoracic surgery, and oncology societies recommend chest CT with low-dose radiation for lung cancer screening(8). Although some technical questions remain, the robustness of the data is undeniable, because they are based on findings in which the fundamentals of CT have been shown to be solid: spatial resolution; temporal resolution; and, in the specific case of calcifications, contrast resolution. In a more distant future, is the CAC score as we know it today doomed to disappear? Is it within the realm of possibility that lung cancer or CAD could both be evaluated in a single screening? I do not believe that it makes sense for medicine to move in a direction in which, for technical convenience, the role of the physician is reduced or worse, abdicated. That is a perilous path that is known to have many shortcomings. The complexity of the question for the scientific method is enormous, the populations are extremely different, and the clinical settings are highly variable. Drawing the conclusion that individuals referred for coronary risk assessment might benefit, in the form of a reduction in lung cancer mortality, from a complementary screening that was not indicated for those individuals . . . well, you have an idea of where I am heading. It is better to imagine that, during a clinically indicated evaluation of the chest, we are also able to perform a coronary

Fistula between the abdominal aorta and a retroaortic left renal vein: a rare complication of abdominal aortic aneurysm

http://dx.doi.org/10.1590/0100-3984.2016.0083 Because of the high risk of massive systemic embolization, it is considered necessary to treat a free-floating thrombus in the aortic arch. However, the ideal treatment remains undefined. Although the use of a thrombolytic is considered one of the options, it carries the risk of selective lysis of the pedicle of the lesion, which would have catastrophic results. In selected patients, surgical treatment is thought to be the most acceptable option. The purpose of this report was to describe a rare case of floating thrombus in the aortic arch with systemic embolization. In the case reported here, the thrombus was treated successfully through surgery.

Pulmonary 64-MDCT angiography with 50 mL of iodinated contrast material in an unselected patient population: a feasible protocol

Objective To propose a protocol for pulmonary angiography using 64-slice multidetector computed tomography (64-MDCT) with 50 mL of iodinated contrast material, in an unselected patient population, as well as to evaluate vascular enhancement and image quality. Materials and Methods We evaluated 29 patients (22-86 years of age). The body mass index ranged from 19.0 kg/m2 to 41.8 kg/m2. Patients underwent pulmonary CT angiography in a 64-MDCT scanner, receiving 50 mL of iodinated contrast material via venous access at a rate of 4.5 mL/s. Bolus tracking was applied in the superior vena cava. Two experienced radiologists assessed image quality and vascular enhancement. Results The mean density was 382 Hounsfield units (HU) for the pulmonary trunk; 379 and 377 HU for the right and left main pulmonary arteries, respectively; and 346 and 364 HU for the right and left inferior pulmonary arteries, respectively. In all patients, subsegmental arteries were analyzed. There were streak artifacts from contrast material in the superior vena cava in all patients. However, those artifacts did not impair the image analysis. Conclusion Our findings suggest that pulmonary angiography using 64-MDCT with 50 mL of iodinated contrast can produce high quality images in unselected patient populations.

Aortic Regurgitation Quantification using Cardiac Magnetic Resonance. Is there a best imaging plane for flow quantification? A single center clinical trial

Background The precise quantification of aortic regurgitation (AR) is central to surgical planning. Some authors suggest early intervention in asymptomatic patients with severe AR. With the advent of transcatheter aortic valve implantation (TAVI), the identification and precise quantification of paravalvular regurgitation is also paramount. In routine clinical practice, the imaging plane used for flow analysis by phase contrast (PC) technique is the sinotubular junction (STJ) in the ascending aorta. However, this plane is not suitable in cases with TAVI. The other two used planes are the ascending aorta (AAo) and the left ventricle outflow tract (LVOT), but these are said to respectively, overestimate and underestimate the measurements. Objective: to compare the volumes of three different planes of measurement in the AAo, JST and LVOT, in patients with different degrees of AR.