Ioannis Chryssogonidis

Contrast-enhanced ultrasound of the carotid system: a review of the current literature

Carotid disease is a major current health problem accounting for a significant part of stroke patients. Ultrasound with colour Doppler and spectral analysis is the primary imaging technique used for screening and diagnostic evaluation of the extracranial part of carotid arteries offering identification and grading of carotid disease. However, inherent limitations of this technique include flow-related artefacts like Doppler angle dependence and aliasing artefact which may sometimes hinder complete assessment of a stenotic part of the vessel, potentially failing to address clinically significant differential diagnosis issues. The intravenous use of microbubbles as an US contrast agent has been introduced for the supplementation of conventional technique. The value of contrast-enhanced ultrasound (CEUS) has been investigated in the evaluation of carotid disease leading to promising results. CEUS provides improved flow visualization free of artefacts and detailed plaque surface delineation, thus being able to accurately grade stenosis, identify carotid plaque ulcerations, differentiate occlusion from highly stenotic plaques and identify carotid dissection. Furthermore, microbubbles can be used to identify and grade intraplaque neovascularization, carotid wall inflammation in patients with arteritis, follow-up patients after carotid intervention and assist interventional procedures reducing the need for nephrotoxic contrast agents. The purpose of this review is to present and discuss the current literature regarding the various uses of CEUS in carotid arteries.RiassuntoLa malattia carotidea rappresenta un grosso problema attuale di una parte significativa dei pazienti con ictus. L’ecografia con color Doppler e l’analisi spettrale è la metodica di imagine di prima istanza utilizzata per lo screening e la valutazione diagnostica della parte extracraniale delle arterie carotidee che offre l’identificazione e la classificazione della malattia carotidea. Tuttavia le limitazioni intrinseche di questa tecnica includono gli artefatti connessi al flusso, come dipendenza dall’angolo Doppler e l’artefatto aliasing che talvolta possono ostacolare la valutazione totale di una parte stenotica del vaso, avendo ad affrontare potenzialmente significativi problemi clinici di diagnosi differenziale. L’ uso endovenoso di microbolle come agente di contrasto nell’ecografia è stato introdotto per la supplementazione della tecnica convenzionale. Il valore del mezzo di contrasto nell’ ecografia (CEUS) è stato studiato per la valutazione della patologia carotidea e sta portando risultati promettenti. CEUS offre una migliore visualizzazione dettagliatta, libera da artefatti di flusso della placca e la delineazione della superficie essendo così in grado di precisare il grado di stenosi ed identificare ulzerazioni della placca carotidea, differenziare l’occlusione dalle placche altamente stenotiche e identificare la dissezione carotidea. Inoltre, le microbolle possono essere utilizzate per l’identificazione del grado di neovascolarizzazione intraplacca, l’infiammazione della parete carotidea in pazienti con l’arterite, di eseguire il follow-up dei pazienti dopo l’intervento carotideo e assistere le procedure interventistiche riducendo la necessità di mezzi di contrasto nefrotossici. Lo scopo di questa rassegna è quello di presentare e discutere la letteratura attuale per quando riguarda i vari usi di CEUS nelle arterie carotidee.

Bone Quality Assessment as Measured by Trabecular Bone Score in Patients With End-Stage Renal Disease on Dialysis

Patients with end-stage renal disease (ESRD) on maintenance hemodialysis (HD) exhibit osteoporosis and increased fracture risk. Dual-energy X-ray absorptiometry scan measurements and calculation of fracture risk assessment toll score underestimate fracture risk in these patients and do not estimate bone quality. Trabecular bone score (TBS) has been recently proposed as an indirect measure of bone microarchitecture. In this study, we investigated alterations of bone quality in patients with ESRD on HD, using TBS. Fifty patients with ESRD on HD, with a mean age 62 years, and 52 healthy individuals matched for age, body mass index, and gender, were enrolled. All participants had a bone mineral density (BMD) measurement by dual-energy X-ray absorptiometry scan at the lumbar spine, femoral neck, total hip, and 1/3 radius. TBS was evaluated using TBS iNsight. Serum fetuin-A and plasma fibroblast growth factor-23 (FGF-23) (C-terminal) were also measured. Patients on dialysis had significantly lower BMD values at all skeletal sites measured. Plasma FGF-23 levels significantly increased and serum fetuin-Α significantly decreased in patients on dialysis compared with controls. TBS was significantly reduced in patients on dialysis compared with controls (1.11 ± 0.16 vs 1.30 ± 0.13, p < 0.001, respectively) independently of age; BMD; duration of dialysis; and serum levels of alkaline phosphatase, 25-OH-vitamin D, parathyroid hormone, fetuin-A, or plasma FGF-23. Patients on HD who were diagnosed with an osteoporotic vertebral fracture had numerically lower TBS values, albeit without reaching statistical significance, compared with patients on dialysis without a fracture (1.044 ± 0.151 vs 1.124 ± 0.173, respectively, p = 0.079). Bone microarchitecture, as assessed by TBS, is significantly altered in ESRD on patients on HD independently of BMD values and metabolic changes that reflect chronic kidney disease-mineral and bone disorder.

Imaging of the ulcerated carotid atherosclerotic plaque: a review of the literature

Carotid atherosclerotic disease constitutes a major modern health problem whose diagnosis primarily relies on imaging. Grading of stenosis has been long used as the main factor for risk stratification and guiding of management. Nevertheless, increasing evidence has shown that additional plaque characteristics such as plaque composition and surface morphology play an important role in the occurrence of symptoms, justifying the term “vulnerable plaque”. Carotid plaque surface characteristics either in the form of surface irregularities or ulceration represent an important factor of vulnerability and are associated with the occurrence of neurologic symptoms. The delineation of the carotid plaque surface can be performed with virtually all imaging modalities including ultrasound, contrast-enhanced ultrasound, multi-detector computed tomography angiography, magnetic resonance angiography and the traditional reference method of angiography. These techniques have shown varying levels of diagnostic accuracy for the identification of ulcerated carotid plaques or plaque surface irregularities. As a consequence and given its high clinical significance, radiologists should be familiar with the various aspects of this entity, including its definition, classification, imaging findings on different imaging modalities and associations. The purpose of this review is to present the current literature regarding carotid plaque ulcerations and present illustrative images of ulcerated carotid plaques.Teaching Points• Plaque surface and ulceration represent risk factors for stroke in carotid disease.• Characterisation of the plaque surface and ulcerations can be performed with every modality.• US is the first-line modality for carotid disease and identification of ulcerations.• The administration of microbubbles increases US accuracy for diagnosis of carotid ulceration.• MDCTA and MRA are valuable for diagnosing ulceration and evaluating plaque composition.

ASSESSMENT OF SENTINEL LYMPH NODE METASTASIS IN CANINE MAMMARY GLAND TUMORS USING COMPUTED TOMOGRAPHIC INDIRECT LYMPHOGRAPHY

In the staging process of the breast cancer, demonstrating metastasis of the sentinel lymph node (SLN) has an important prognostic value, in both humans and animals. The aim of this prospective case-control study was to determine the diagnostic value of computed tomographic indirect lymphography (CT-LG) for detecting SLN metastasis in dogs with mammary cancer. Thirty-three female dogs with tumors in the abdominal and inguinal mammary glands were prospectively selected and subjected to CT-LG, 1 and 5 min after injection of 1 ml of contrast agent (iopamidol) in the subareolar tissue of the neoplastic and the contralateral normal mammary glands. The pattern of postcontrast opacification, degree of postcontrast enhancement, and size and shape were assessed in 65 SLNs in total and were correlated with histopathological findings. The absence of opacification or heterogeneous opacification 1 min after contrast medium injection showed the highest sensitivity, specificity, and accuracy (93%, 100%, and 98.4%, respectively). In images taken 1 min after injection, an absolute density value lower than 444 Hounsfield units (HU) in the center of the SLN also provided significant sensitivity and specificity (93.8% and 75%, respectively). The size and shape of the SLN (maximum and minimum diameter, maximum/minimum diameter ratio, maximum diameter/height of fifth thoracic vertebral body ratio) showed the lowest sensitivity and specificity. Results of this study support the hypothesis that CT-LG could help in the assessment of SLN metastasis in cases of mammary gland tumors in dogs.

Radiographic and Ultrasonographic Findings of Uterine Neoplasms in Nine Dogs

The records of nine female intact dogs with histologically confirmed uterine tumors were reviewed retrospectively, and the related radiographic and ultrasonographic signs of the lesions detected were recorded. Radiography revealed a soft-tissue opacity between the urinary bladder and colon in six of seven dogs with uterine body and/or cervical tumors, and a soft-tissue opacity in the midventral abdomen in two dogs with uterine horn tumors. Ultrasonography revealed masses in all dogs with uterine body/cervical tumors and could delineate the origin of the mass in one of two dogs with uterine horn tumors. The mass was characterized ultrasonographically as solid in three dogs (all leiomyomas), solid with cystic component in four dogs (two adenocarcinomas, one leiomyoma, and one fibroleiomyoma), and cystic in two (both leiomyomas). Hyperechoic foci in the mass were observed in three dogs. Ultrasonography was a useful method for demonstrating uterine body and/or cervical tumors. However, it was not possible to ascertain sonographically that a mass originated in a uterine horn unless there was associated evidence of uterine horn to which the mass could be traced. The ultrasonographic appearance of uterine tumors was variable, and the type of neoplasm could only be determined by taking biopsies of the mass.

Homocysteine and carotid intima-media thickness in ischemic stroke patients are not correlated

Introduction Hyperhomocysteinemia has been linked to cardiovascular morbidity and mortality by numerous authors. Whether this association is causal or not remains uncertain. The aim of the study was to investigate the association of hyperhomocysteinemia with the degree of carotid atherosclerosis in stroke patients. Methods We studied 97 Greek patients in our stroke unit who were hospitalized as a result of ischemic stroke between March 2006 and May 2007. The patients were divided into two groups: the first (52 patients) included stroke patients with serum levels of homocysteine below 15 μmol/L, but in the second group (45 patients) serum homocysteine exceeded this value. We measured carotid intima-media thickness (cIMT) in all patients and correlated it with serum homocysteine. Results The mean homocysteine concentration was 11.5 μmol/L in the first group and 21.5 μmol/L in the second group. Carotid IMT was 1.012 mm in the first group, and 1.015 mm in the second group, an insignificant difference. On the contrary, serum folate concentration was 21.3 nmol/L in the first group compared with 16.7 nmol/L in the second group (p < 0.001). VitB12 was 401 pmol/L in the first group and 340 pmol/L in the second group, a statistically significant difference (p < 0.001). Conclusions Serum levels of homocysteine were not correlated with cIMT in ischemic stroke patients. Both folate and vitB12 were decreased in hyperhomocysteinemic ischemic stroke patients.

Fatal pulmonary and cerebral aspergillosis after a short course of corticosteroids for idiopathic thrombocytopenic purpura.

Dear Editor,Aspergillosis constitutes a well-known complication inpatients receiving long-term corticosteroid treatment [1].On the contrary, until now, there are only two publishedcases of pulmonary and cerebral aspergillosis in patientsreceiving a short-term course of steroids for idiopathicthrombocytopenic purpura (ITP) [2, 3]. Fortunately, in bothcases, the patient survived without any clinical sequela. Inthis paper, we present a case of pulmonary and cerebralaspergillosis in a patient receiving a short course ofcorticosteroids for ITP. However, in contrast to the twoaforementioned cases, the infection in our patient was fatal.A 24-year-old man presented in our department withepistaxis, gingival bleeding, and purpura due to severethrombocytopenia (2,000/

Swirling of microbubbles: Demonstration of a new finding of carotid plaque ulceration on contrast-enhanced ultrasound explaining the arterio-arterial embolism mechanism.

Carotid plaque ulceration is a well-established feature of vulnerability, associated with high risk for neurological symptoms. From a pathogenetic point of view, the mechanism responsible for occurrence of symptomatology relies on the aggregation of platelets within the ulcer cavity, activation of coagulation mechanism, formation of thrombus and arterio-arterial embolization of thrombotic material in the central nervous system. Many imaging modalities including unenhanced ultrasound, computed tomographic angiography and magnetic resonance angiography have been used to image and diagnose carotid plaque ulceration with varying success. Contrast-enhanced ultrasound has been recently introduced in the study of carotid disease offering improved flow visualization and better plaque surface delineation. We present a case where contrast-enhanced ultrasound visualized the swirling pattern of movement of the microbubbles within the ulcer cavity. These findings illustrate the underlying hemodynamic mechanism of arterio-arterial embolization and can be proposed as a new finding of plaque ulcerations on contrast-enhanced ultrasound.

Multimodality Imaging and Endovascular Treatment Options of Subclavian Steal Syndrome

AHEPA University Hospital of Thessaloniki, Aristotle University of Thessaloniki, Thessaloniki, Greece University Hospitals, Case Western Reserve University, Cleveland, Ohio, USA Diagnostic and Interventional Radiology, University Hospital Heidelberg, Heidelberg, Germany University of Texas Southwestern Medical Center, Dallas, Texas, USA Department of Vascular and Endovascular Surgery, University Hospital Heidelberg, Heidelberg, Germany Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA Section of Interventional Radiology, Department of Radiology, Cleveland Clinic Foundation, Cleveland, Ohio, USA

Multiple variations of the coeliac axis, hepatic and renal vasculature as incidental findings illustrated by MDCTA

Vascular anatomical variations are not uncommon and may affect any organ’s arterial or venous vasculature. The coexistence of variations in different organic systems is less commonly found, but of great clinical significance in a series of clinical conditions like organ transplantation and surgical preoperative planning. Multidetector computed tomography angiography (MDCTA) has emerged as a valuable alternative to the conventional angiography for accurate evaluation of vascular anatomy and pathology. Radiologists should be familiar with each organ’s vascular variations and always report them to the clinician, even if they represent an incidental finding. This case report presents a 52-year-old female patient undergoing abdominal MDCTA for characterization of a renal lesion. This examination revealed the presence of three hilar arteries on the left kidney, a main renal vein in combination with an additional renal vein in both sides along with a replaced right hepatic artery originating from the superior mesenteric artery. Moreover, both inferior phrenic arteries were found originating from the coeliac axis. 3D volume rendering technique images were used in the evaluation of vascular anatomy as illustrated in this case report.