Jean Pierre Laissy

Measurement of aortic valve calcification using multislice computed tomography: correlation with haemodynamic severity of aortic stenosis and clinical implication for patients with low ejection fraction

Background Measurement of the degree of aortic valve calcification (AVC) using electron beam computed tomography (EBCT) is an accurate and complementary method to transthoracic echocardiography (TTE) for assessment of the severity of aortic stenosis (AS). Whether threshold values of AVC obtained with EBCT could be extrapolated to multislice computed tomography (MSCT) was unclear and AVC diagnostic value in patients with low ejection fraction (EF) has never been specifically evaluated. Methods Patients with mild to severe AS underwent prospectively within 1 week MSCT and TTE. Severe AS was defined as an aortic valve area (AVA) of less than 1 cm2. In 179 patients with EF greater than 40% (validation set), the relationship between AVC and AVA was evaluated. The best threshold of AVC for the diagnosis of severe AS was then evaluated in a second subset (testing set) of 49 patients with low EF (≤40%). In this subgroup, AS severity was defined based on mean gradient, natural history or dobutamine stress echocardiography. Results Correlation between AVC and AVA was good (r=−0.63, p<0.0001). A threshold of 1651 arbitrary units (AU) provided 82% sensitivity, 80% specificity, 88% negative-predictive value and 70% positive-predictive value. In the testing set (patients with low EF), this threshold correctly differentiated patients with severe AS from non-severe AS in all but three cases. These three patients had an AVC score close to the threshold (1206, 1436 and 1797 AU). Conclusions In this large series of patients with a wide range of AS, AVC was shown to be well correlated to AVA and may be a useful adjunct for the evaluation of AS severity especially in difficult cases such as patients with low EF.

Infective Endocarditis with Symptomatic Cerebral Complications: Contribution of Cerebral Magnetic Resonance Imaging

Background: Cerebral complications are well-identified causes of morbidity and mortality in patients with infective endocarditis (IE). Few studies have analysed the impact of brain magnetic resonance imaging (MRI) in IE patients with neurological manifestations. Objectives: The aims of this study were to assess the MRI contribution to the management of patients with IE neurological manifestations and to compare cerebral CT and MRI findings. Material and Methods: Patients with definite or probable IE and neurological manifestations were prospectively enrolled from 2005 to 2008, in a university hospital (Bichat Claude Bernard Hospital, Paris). Clinical and radiological characteristics and echocardiographic findings were systematically recorded. Brain MRI with angiography was performed and compared to available CT scans. The contribution of MRI results to cerebral involvement staging and to therapeutic plans was evaluated. Results: Thirty patients, 37-89 years old, were included. Nineteen suffered from pre-existing heart disease. Blood cultures were positive in 29 cases and the main micro-organisms were streptococci (n = 14) and staphylococci (n = 13). The IE was mainly located on mitral (n = 15) and aortic valves (n = 13). Neurological events were strokes (n = 12), meningitis (n = 5), seizures (n = 1), impaired consciousness (n = 11) and severe headache (n = 1). MRI findings included ischaemic lesions (n = 25), haemorrhagic lesions (n = 2), subarachnoid haemorrhage (n = 5), brain abscess (n = 6), mycotic aneurysm (n = 7), vascular occlusion (n = 3) and cerebral microbleeds (n = 17). In 19/30 cases, neurological manifestations were observed before the diagnosis of IE. MRI was more sensitive than CT scan in detecting both clinically symptomatic cerebral lesions (100 and 81%, respectively) and additional asymptomatic lesions (50 and 23%, respectively). Therapeutic plans were modified according to MRI results in 27% of patients: antibiotherapy regimen modifications in 7% (switch for molecules with high cerebral diffusion) and surgical plan modifications in 20% (indication of valvular replacement due to the embolic nature of the vegetations revealed by MRI or postponement of surgery due to haemorrhagic lesions). None of the 16/30 (51%) operated-on patients experienced postoperative neurological worsening. In-hospital death occurred in 4 patients. Conclusion: In patients with IE neurological manifestations, MRI revealed a broader involvement of the brain (type and number of lesions) than indicated by clinical signs and/or CT scan. With a better disease staging of neurological manifestations, MRI brain imaging may help in patient management and the decision-making process especially for cardiac surgery indication and timing of valve replacement.

Impact of a Combined Intravenous/ Intra-Arterial Approach in Octogenarians

Background: Intravenous (IV) alteplase is not currently recommended in octogenarian patients, and the benefit/risk ratio of endovascular (intra-arterial, IA) therapy remains to be determined. The aim of this study was to determine the impact of a combined IV-IA approach in octogenarians. Methods: From a single-centre interventional study, we report age-specific outcomes of patients treated by a combined IV-IA thrombolytic approach. Patients ≧80 years with documented arterial occlusion treated by conventional IV thrombolysis constituted the control group. Results: Among 84 patients treated by the IV-IA approach, those ≧80 years (n = 25) had a similar rate of early neurological improvement to that of patients <80 years, whereas the 90-day favourable outcome rate was lower in octogenarians (adjusted odds ratio, OR, 0.21; 95% confidence interval, CI, 0.06–0.75). No difference in symptomatic intracranial haemorrhage was observed whereas a higher rate of 90-day mortality (adjusted OR, 3.27; 95% CI, 0.76–14.14) and asymptomatic intracranial haemorrhage (adjusted OR, 6.39; 95% CI, 1.54–26.63) were found in patients ≧80 years old. Among octogenarians, and compared to IV-thrombolysis-treated patients (n = 24), patients treated by the IV-IA approach had a higher rate of recanalization (76 vs. 33%, p = 0.003) associated with increased early neurological improvement (32 vs. 8%, p = 0.07). Although there was a higher rate of asymptomatic intracranial haemorrhage (44 vs. 8%, p = 0.005) observed in the IV-IA group, no difference existed in symptomatic intracranial haemorrhage rates and 90-day favourable outcome. Conclusion: The IV-IA approach in octogenarians was associated with lower efficacy at 3 months and higher mortality and asymptomatic haemorrhagic complications than in patients <80 years old. Definite recommendations cannot be given, but an endovascular approach may cause more harm than positive effects in patients over 80 years and should not be considered outside an approved protocol.

Myocardial infarction after blunt chest trauma: usefulness of cardiac ECG-gated CT and MRI for positive and aetiologic diagnosis

Myocardial infarction after blunt chest trauma has been reported in only few cases, and mechanisms of this complication have rarely been described. We report two cases of coronary artery lesions, one parietal hematoma of right coronary artery and one dissection of the left main coronary artery, which resulted in acute myocardial infarction following a blunt chest trauma. In these two cases, cardiac CT and MRI were useful to noninvasively explore these lesions.

Reversibility of experimental acute renal failure in rats: Assessment with USPIO-enhanced MR imaging

The purpose of this study was to evaluate the potential reversibility of kidney lesions in an experimental model of acute renal failure using ultra‐small particles of iron oxide (USPIO)‐enhanced magnetic resonance (MR) imaging. This study was conducted in 21 uninephrectomized rats using a model of iodinated contrast media‐induced renal failure. Thirteen rats received selective intraarterial renal administration of diatrizoate (370 mg/ml) and were compared with two control groups, including six animals injected with saline and two noninjected animals.

Imaging Features of Fabry Disease

OBJECTIVE Our objective was to describe the various imaging patterns of Fabry disease, including cerebrovascular, renal, cardiac, and other organ involvement. Fabry disease, an X-linked inborn error of glycosphingolipid catabolism resulting from a deficient activity of the hydrolase alpha-galactosidase A, displays more complications in men than in heterozygous women. CONCLUSION It is up to radiologists to evoke the diagnosis, help practitioners in treating patients early with enzyme replacement therapy, and monitor its efficacy.

Intramedullary spinal cord abscess associated with cervical spondylodiskitis and epidural abscess.

A 50-year-old man presented a cervical vertebral osteomyelitis and epidural abscess due to Staphylococcus aureus. There were significant changes in the cervical region, as revealed by CT scan and MRI, leading to the diagnosis of associated intramedullary abscess of the spinal cord, which was confirmed by anatomopathological study.

Anévrisme poplité veineux

es anevrismes poplites veineux sont des lesions rares mais dangereuses du fait de leur potentiel emboligene. Ils doivent etre recherches par un echoDoppler devant toute embolie pulmonaire associee ou non a une thrombose veineuse profonde. L’angio-scanner est un excellent examen pour l’etude arterielle des membres inferieurs mais a ete peu utilise specifiquement pour le reseau veineux, son utilite semble certaine. La prise en charge therapeutique, en dehors des petits anevrismes fusiformes asymptomatiques qui necessitent une surveillance par echo-Doppler, est chirurgicale et repose le plus souvent sur une endoanevrysmorraphie.

Effect of a speculum blade on dynamic MRI evaluation of pelvic organ prolapse

We aimed to evaluate whether the use of a speculum blade modifies the evaluation of pelvic organ prolapse (POP) as assessed by dynamic magnetic resonance imaging (MRI). Twenty‐seven women with POP Quantification (POPQ) stage II or greater, scheduled for POP surgery, were evaluated using MRI. The procedure was repeated using the posterior blade of a standard plastic Graves speculum to successively retract the anterior and posterior vaginal walls. Standard POPQ was 15% stage II (n =4), 59% stage III (n =16) and 26% stage IV (n =7). The use of a blade evidenced hidden pelvic prolapsed compartments in 59% (n =16) of cases. For 48% of patients (n =13), the variation of the leading edge of at least one additional prolapsed compartment was diagnosed as more than 20 mm. In this series, the use of a speculum blade during dynamic MRI modified the POP evaluation in a large proportion of patients with POP stage ≥II.

Ostéosarcome extrasquelettique d'emblée métastatique révélé par une masse occipitale

BACKGROUND Extraskeletal osteosarcoma is a rare mesenchymatous tumour occurring in adults aged over 50 years and is located mainly in the limbs or retroperitoneum. We report a case of metastatic extraskeletal osteosarcoma revealed by a cutaneous occipital tumour site. CASE-REPORT A 53-year-old woman was admitted for dyspnea and weight loss. An occipital tumour, noticed for one year by the patient, was discovered. It was freely movable on the bone, of hard consistency and responsible for alopecia. In addition to left-sided pleural effusion, a chest CAT revealed a large mass in the left lung, including areas of necrosis and calcifications with intracardiac extension. Histological examination of biopsies of the skin and of pulmonary and intracardiac lumps showed an osteosarcomatous proliferation. No primary osteosarcoma was found in the bones. A diagnosis was made of metastatic extraskeletal osteosarcoma. Intravenous chemotherapy was given followed by radiotherapy. After a six-month stabilization period, the disease progressed. DISCUSSION Extraskeletal cutaneous locations of osteosarcoma are extremely rare. They may comprise either the primary tumour or a metastatic lesion. In this patient, the immediately metastatic nature of the disease was a poor prognostic factor for this high-grade sarcoma.