Laura Oleaga

Staging of uterine cervical cancer with MRI: guidelines of the European Society of Urogenital Radiology

Objective: To design clear guidelines for the staging and follow-up of patients with uterine cervical cancer, and to provide the radiologist with a framework for use in multidisciplinary conferences. Methods: Guidelines for uterine cervical cancer staging and follow-up were defined by the female imaging subcommittee of the ESUR (European Society of Urogenital Radiology) based on the expert consensus of imaging protocols of 11 leading institutions and a critical review of the literature. Results: The results indicated that high field Magnetic Resonance Imaging (MRI) should include at least two T2-weighted sequences in sagittal, axial oblique or coronal oblique orientation (short and long axis of the uterine cervix) of the pelvic content. Axial T1-weighted sequence is useful to detect suspicious pelvic and abdominal lymph nodes, and images from symphysis to the left renal vein are required. The intravenous administration of Gadolinium-chelates is optional but is often required for small lesions (<2 cm) and for follow-up after treatment. Diffusion-weighted sequences are optional but are recommended to help evaluate lymph nodes and to detect a residual lesion after chemoradiotherapy. Conclusions: Expert consensus and literature review lead to an optimized MRI protocol to stage uterine cervical cancer. MRI is the imaging modality of choice for preoperative staging and follow-up in patients with uterine cervical cancer.

Single-Center Experience of Cerebral Artery Thrombectomy Using the TREVO Device in 60 Patients With Acute Ischemic Stroke

Background and Purpose— We sought to explore the safety and efficacy of the new TREVO stent-like retriever in consecutive patients with acute stroke. Methods— We conducted a prospective, single-center study of 60 patients (mean age, 71.3 years; male 47%) with stroke lasting <8 hours in the anterior circulation (n=54) or <12 hours in the vertebrobasilar circulation (n=6) treated if CT perfusion/CT angiography confirmed a large artery occlusion, ruled out a malignant profile, or showed target mismatch if symptoms >4.5 hours. Successful recanalization (Thrombolysis In Cerebral Infarction 2b–3), good outcome (modified Rankin Scale score 0–2) and mortality at Day 90, device-related complications, and symptomatic hemorrhage (parenchymal hematoma Type 1 or parenchymal hematoma Type 2 and National Institutes of Health Stroke Scale score increment ≥4 points) were prospectively assessed. Results— Median (interquartile range) National Institutes of Health Stroke Scale score on admission was 18 (12–22). The median (interquartile range) time from stroke onset to groin puncture was 210 (173–296) minutes. Successful revascularization was obtained in 44 (73.3%) of the cases when only the TREVO device was used and in 52 (86.7%) when other devices or additional intra-arterial tissue-type plasminogen activator were also required. The median time (interquartile range) of the procedure was 80 (45–114) minutes. Good outcome was achieved in 27 (45%) of the patients and the mortality rate was 28.3%. Seven patients (11.7%) presented a symptomatic intracranial hemorrhage. No other major complications were detected. Conclusions— The TREVO device was reasonably safe and effective in patients with severe stroke. These results support further investigation of the TREVO device in multicentric registries and randomized clinical trials.

Relevance of Blood–Brain Barrier Disruption After Endovascular Treatment of Ischemic Stroke Dual-Energy Computed Tomographic Study

Background and Purpose— Computed tomographic (CT) high attenuation (HA) areas after endovascular therapy for acute ischemic stroke are a common finding indicative of blood–brain barrier disruption. Dual-energy CT allows an accurate differentiation between HA areas related to contrast staining (CS) or to brain hemorrhage (BH). We sought to evaluate the prognostic significance of the presence of CS and BH after endovascular therapy. Methods— A prospective cohort of 132 patients treated with endovascular therapy was analyzed. According to dual-energy CT findings, patients were classified into 3 groups: no HA areas (n=53), CS (n=32), and BH (n=47). The rate of new hemorrhagic transformations was recorded at follow-up neuroimaging. Clinical outcome was evaluated at 90 days with the modified Rankin Scale (poor outcome, 3–6). Results— Poor outcome was associated with the presence of CS (odds ratio [OR], 11.3; 95% confidence interval, 3.34–38.95) and BH (OR, 10.4; 95% confidence interval, 3.42–31.68). The rate of poor outcome despite complete recanalization was also significantly higher in CS (OR, 9.7; 95% confidence interval, 2.55–37.18) and BH (OR, 15.1; 95% confidence interval, 3.85–59.35) groups, compared with the no-HA group. Patients with CS disclosed a higher incidence of delayed hemorrhagic transformation at follow-up (OR, 4.5; 95% confidence interval, 1.22–16.37) compared with no-HA patients. Conclusions— Blood–brain barrier disruption, defined as CS and BH on dual-energy CT, was associated with poor clinical outcomes in patients with stroke treated with endovascular therapies. Moreover, isolated CS was associated with delayed hemorrhagic transformation. These results support the clinical relevance of blood–brain barrier disruption in acute stroke.

Vessel Wall Enhancement and Blood–Cerebrospinal Fluid Barrier Disruption After Mechanical Thrombectomy in Acute Ischemic Stroke

Background and Purpose— Less than half of acute ischemic stroke patients treated with mechanical thrombectomy obtain permanent clinical benefits. Consequently, there is an urgent need to identify mechanisms implicated in the limited efficacy of early reperfusion. We evaluated the predictors and prognostic significance of vessel wall permeability impairment and its association with blood–cerebrospinal fluid barrier (BCSFB) disruption after acute stroke treated with thrombectomy. Methods— A prospective cohort of acute stroke patients treated with stent retrievers was analyzed. Vessel wall permeability impairment was identified as gadolinium vessel wall enhancement (GVE) in a 24- to 48-hour follow-up contrast-enhanced magnetic resonance imaging, and severe BCSFB disruption was defined as subarachnoid hemorrhage or gadolinium sulcal enhancement (present across >10 slices). Infarct volume was evaluated in follow-up magnetic resonance imaging, and clinical outcome was evaluated with the modified Rankin Scale at day 90. Results— A total of 60 patients (median National Institutes of Health Stroke Scale score, 18) were analyzed, of whom 28 (47%) received intravenous alteplase before mechanical thrombectomy. Overall, 34 (57%) patients had GVE and 27 (45%) had severe BCSFB disruption. GVE was significantly associated with alteplase use before thrombectomy and with more stent retriever passes, along with the presence of severe BCSFB disruption. GVE was associated with poor clinical outcome, and both GVE and severe BCSFB disruption were associated with increased final infarct volume. Conclusions— These findings may support the clinical relevance of direct vessel damage and BCSFB disruption after acute stroke and reinforce the need for further improvements in reperfusion strategies. Further validation in larger cohorts of patients is warranted.

Utilidad de la biopsia cilindro guiada por control ecográfico en el diagnóstico y manejo de los tumores renales

Resumen Antecedentes La biopsia guiada por control ecografico esta siendo utilizada de manera creciente en los ultimos anos como aproximacion diagnostica inicial en los tumores renales, aunque su aceptacion entre radiologos y patologos aun no es generalizada. Metodos Durante un periodo de 6 anos (2000-2005), se han biopsiado por este metodo y con agujas 18G un total de 48 tumores renales en 47 pacientes. Resultados Se observo un predominio de varones (34V/13M) y la edad promedio se situo en 51,7 anos (rango 1-92). Treinta y siete (77,1%) casos correspondieron a neoplasias, incluyendo adenocarcinomas renales (25 casos), oncocitomas (3 casos), linfomas (3 casos), tumores de Wilms (2 casos), un tumor carcinoide metastasico, un carcinoma epidermoide metastatico, un nefroma quistico y un sarcoma fusocelular. Cinco casos (10,4%) correspondieron a pseudotumores (3 quistes renales y 2 pielonefritis cronicas). La biopsia proporciono tejido renal normal en 4 casos y tejido fibroadiposo en 2. Se detectaron minimas discrepancias en la adjudicacion de la variante histologica del cancer en 2 casos. Conclusiones La biopsia cilindro guiada por ecografia es un metodo muy util y fiable para el diagnostico de los tumores renales, y deberia ser incluida como herramienta de primera linea en su manejo. Sin embargo, para la obtencion de optimos resultados que puedan llevar a un tratamiento individualizado, se precisa una estrecha colaboracion entre clinicos, radiologos y patologos.

Diagnóstico por angiorresonancia magnética del síndrome del estrecho torácico superior

Objetivo Valorar las secuencias y las maniobras recomendadas para el estudio del sindrome del estrecho toracico superior (SETS) y la utilidad de la resonancia magnetica (RM) a la hora de demostrar su etiologia. Material y metodo Presentamos un estudio de 8 pacientes con clinica sugerente de SETS. En todos ellos se realizo estudio anatomico de RM, angio-RM con gadolinio, con los brazos extendidos a lo largo del cuerpo y con maniobras posturales de abduccion y elevacion de los brazos, radiografia de torax y angiografia digital. Se analizaron las caracteristicas anatomicas del estrecho toracico superior bilateralmente antes y durante las maniobras posturales. Asi mismo, se estudio la permeabilidad de los vasos y la integridad del plexo braquial. Resultados En dos casos se demostro trombosis de la arteria y vena subclavias respectivamente producida por una costilla cervical, confirmada en la radiografia de torax. En una paciente se demostro estenosis de la arteria subclavia con maniobra de abduccion secundaria a hipertrofia del musculo escaleno anterior; la angiografia digital demostro los mismos hallazgos. En dos casos la angio-RM mostro trombosis vascular, arterial en un caso y venosa en otro, sin evidencia de anomalias anatomicas, este hallazgo se confirmo en el estudio de angiografia digital. En dos pacientes la RM, angio-RM y angiografia digital no mostraron hallazgos patologicos. En un caso la RM puso de manifiesto la presencia de una costilla cervical sin repercusion vascular. Conclusion La angio-RM con gadolinio es util para valorar el SETS. Es importante evaluar los pacientes en reposo y con maniobras posturales, pudiendo en muchos casos demostrar la causa responsable de la compresion vascular.

Localized scleroderma of the breast

Abstract. We report a 44-year-old patient with right-breast morphea. Mammography, MRI and needle biopsy were used for assessment of the case. Mammography demonstrated thickening of the skin and the subcutaneous tissue. The MRI showed replacement of the subcutaneous and breast fat by a low signal intensity, non-enhancing tissue. Skin biopsy confirmed the histological features of scleroderma.

Brain hemorrhage after endovascular reperfusion therapy of ischemic stroke: a threshold-finding whole-brain perfusion CT study

Endovascular reperfusion therapy is increasingly used for acute ischemic stroke treatment. The occurrence of parenchymal hemorrhage is clinically relevant and increases with reperfusion therapies. Herein we aimed to examine the optimal perfusion CT-derived parameters and the impact of the duration of brain ischemia for the prediction of parenchymal hemorrhage after endovascular therapy. A cohort of 146 consecutive patients with anterior circulation occlusions and treated with endovascular reperfusion therapy was analyzed. Recanalization was assessed at the end of reperfusion treatment, and the rate of parenchymal hemorrhage at follow-up neuroimaging. In regression analyses, cerebral blood volume and cerebral blood flow performed better than Delay Time maps for the prediction of parenchymal hemorrhage. The most informative thresholds (receiver operating curves) for relative cerebral blood volume and relative cerebral blood flow were values lower than 2.5% of normal brain. In binary regression analyses, the volume of regions with reduced relative cerebral blood volume and/or relative cerebral blood flow was significantly associated with an increased risk of parenchymal hemorrhage, as well as delayed vessel recanalization. These results highlight the relevance of the severity and duration of ischemia as drivers of blood-brain barrier disruption in acute ischemic stroke and support the role of perfusion CT for the prediction of parenchymal hemorrhage.

Pseudoprogression as an adverse event of glioblastoma therapy

We explored predictive factors of pseudoprogression (PsP) and its impact on prognosis in a retrospective series of uniformly treated glioblastoma patients. Patients were classified as having PsP, early progression (eP) or neither (nP). We examined potential associations with clinical, molecular, and basal imaging characteristics and compared overall survival (OS), progression‐free survival (PFS), post‐progression survival (PPS) as well as the relationship between PFS and PPS in the three groups. Of the 256 patients studied, 56 (21.9%) were classified as PsP, 70 (27.3%) as eP, and 130 (50.8%) as nP. Only MGMT methylation status was associated to PsP. MGMT methylated patients had a 3.5‐fold greater possibility of having PsP than eP (OR: 3.48; 95% CI: 1.606–7.564; P = 0.002). OS was longer for PsP than eP patients (18.9 vs. 12.3 months; P = 0.0001) but was similar for PsP and nP patients (P = 0.91). OS was shorter–though not significantly so—for PsP than nP patients (OS: 19.5 vs. 27.9 months; P = 0.63) in methylated patients. PPS was similar for patients having PsP, eP or nP (PPS: 7.2 vs. 5.4 vs. 6.7; P = 0.43). Neurological deterioration occurred in 64.3% of cases at the time they were classified as PsP and in 72.8% of cases of eP (P = 0.14). PsP confounds the evaluation of disease and does not confer a survival advantage in glioblastoma.

Displasia renal multiquística segmentaria: hallazgos radiológicos y diagnóstico diferencial

La displasia renal multiquistica constituye la segunda causa mas frecuente de masa renal en neonatos tras la hidronefrosis y la causa mas frecuente de masa quistica en la infancia. Presentamos un caso de una masa quistica renal en un lactante cuyo diagnostico anatomopatologico definitivo fue de displasia quistica segmentaria. Esta entidad, en su forma segmentaria es rara, ya que habitualmente la displasia quistica renal se presenta como una afectacion unilateral de todo el rinon. Revisamos la etiopatogenia de esta entidad, los hallazgos radiologicos y su principal diagnostico diferencial con el fin de establecer un correcto diagnostico y su diferenciacion con otras lesiones focales quisticas renales de la infancia.