Luciano Lupattelli

CT angiography versus colour-Doppler US in acute dissection of the vertebral artery.

AbstractPurpose.Conventional digital subtraction angiography (DSA) still represents the criterion standard for the diagnosis of vertebral artery dissection (VAD), but the main drawbacks of this technique include invasiveness, patient discomfort and risk of complications. We evaluated the potential of multidetector computed tomography angiography (CTA) as a noninvasive tool providing highresolution images of the arterial lumen and wall by comparing the diagnostic accuracy of CTA and colour-Doppler ultrasonography (CDUS) in detecting acute VAD.Materials and methods. We retrospectively reviewed 15 cases of VAD in 15 patients (five men and ten women, age range 28–58 years) who came to our attention between August 2001 and September 2005. The diagnosis was made on the basis of appropriate clinical presentation, absence of atherosclerotic disease in the cerebrovascular circulation and evidence of distinctive CT features, which were subsequently confirmed by conventional angiography used as reference standard. All patients with a clinical suspicion of VAD underwent CDUS of the neck vessels prior to CTA. Accuracy, sensitivity and specificity of CDUS and CTA were expressed as percentages of agreement with the reference angiographic procedure. Interreader concordance for detection of VAD by CTA was calculated with the Cohen K value.Results.The CDUS examinations revealed ten out of 15 VAD, with a sensitivity of 66%, a specificity of 60%, a positive predictive value of 55.5% and a negative predictive value of 70.5%. In five cases, CDUS revealed nonspecific wall and flow alterations; in eight patients, high resistance obstructive flow; and in two patients, intimal flap with demonstration of the true and false lumen. CTA enabled the correct identification of all 15 VAD. The reported sensitivity, specificity, positive predictive value and negative predictive value were 100%, 95%, 93.7% and 100%, respectively. With regard to localisation of VAD, CTA showed 100% correlation with DSA. The differences in CTA and CDUS sensitivity (100% vs 66%), specificity (95% vs 60%), and overall diagnostic accuracy (97% vs 62.8%), assessed by cross tabulations and compared by using the McNemars two-sided test, were significant (p<0.05).Conclusions.Multidetector CTA is a sensitive technique for the diagnosis of VAD. Used as a complement to unenhanced brain CT, it has the advantage of being readily available and easy to perform.

Outcome of abdominal aortic endografting in high-risk patients: a 4-year single-center study.

Purpose: To evaluate feasibility, safety, and effectiveness of endovascular abdominal aortic aneurysm (AAA) repair in patients whose fitness for surgery is questionable. Methods: Between April 1997 and December 2001, 389 consecutive patients underwent endovascular AAA repair. Of these, 51 (13.1%) were ASA grade IV. The perioperative and late outcomes of this group were compared to the remaining 338 patients with ASA grades <IV. Failure of AAA exclusion was defined as late conversion to open repair, AAA rupture, increased aneurysm diameter, or persisting graft-related endoleak. Gender, age, ASA grade IV, EUROSTAR class E, and AAA diameter were examined by logistic regression analysis for their influence on perioperative death, survival, and failure of AAA exclusion. Results: Four (7.8%) perioperative deaths occurred in the ASA IV group compared to 1 (0.3%) in the ASA <IV group (p=0.001). Median follow-up was 22 months (range 1–56). Failure of AAA exclusion occurred in 3 (5.9%) patients in ASA IV group and in 25 (7.4%) in ASA <IV group (p>0.05). Actuarial survival at 30 months was 62.9% in ASA IV group and 88.0% in ASA <IV group (p=0.001, log-rank test). There were no independent predictors for failure of AAA exclusion; ASA IV was independently associated with perioperative mortality (HR 17.8; 95% CI 1.6 to 188; p=0.016). Conclusions: Endovascular AAA repair in ASA IV patients is feasible and effective in preventing AAA rupture in the mid term. High-risk patients experience a worse prognosis than their good-risk counterparts. An individualized approach in selecting high-risk patients for endoluminal repair is mandatory.

Pulmonary congenital cystic disease in adults. Spiral computed tomography findings with pathologic correlation and management

PurposeThe aim of this study was to assess the computed tomography (CT) features of intrapulmonary congenital cystic diseases in adults and to correlate the imaging features with the pathological findings, with emphasis on the oncogenic potential of the lesions.Materials and methodsWe retrospectively reviewed the CT scans in three institutions from August 1996 to December 2008, of nine patients (six men, three women; mean age 48.6 years; range 26–75 years) who had histological diagnosis of pulmonary cystic disease after surgery. Six patients had a diagnosis of intrapulmonary bronchogenic cyst (IBC), and three had a type-I cystic adenomatoid malformation (CAM). In one case, intralobar sequestration (ILS) was associated with type-I CAM.ResultsThree patients were symptomatic and six were asymptomatic. On CT scans, IBCs showed homogeneous fluid attenuation (n=2), air-fluid level (n=2), air attenuation (n=1) or soft-tissue attenuation (n=1). The surrounding lung tissue showed areas of band-like linear attenuation in three IBCs, atelectasia in two and mucocele-like areas in one. On CT, type-I CAM appeared as a unilocular cystic lesion with air-fluid level (n=1) or air content (n=1). Both cases had thin walls surrounded by normal lung parenchyma. ILS appeared as a fluid-filled cyst with afferent and efferent vessels. Of the six IBCs, one occurred in the upper right lobe, two in the middle lobe and three in the lower right lobe. Of the three type-I CAMs, one was in the upper left lobe and one in the middle lobe. The type-I CAM associated with ILS was located in the left lower lobe.ConclusionsThe similar CT patterns preclude differentiation between IBC and type-I CAM. Surgical resection of all intrapulmonary cystic lesions detected in adults is mandatory because type-I CAM is a precursor of mucinous bronchioloalveolar carcinoma.RiassuntoObiettivoScopo di questo lavoro è stato valutare con tomografia computerizzata (TC) gli aspetti semeiologici delle malattie cistiche congenite intrapolmonari nell’adulto e correlarle con i reperti patologici, in riferimento al potenziale oncogenetico di tali lesioni.Materiali e metodiAbbiamo analizzato retrospettivamente gli esami TC di tre centri, da agosto 1996 a dicembre 2008, relativi a nove pazienti (sei maschi e tre femmine, età media 48,6 anni, range compreso tra 26-75 anni) trattati chirurgicamente per patologia cistica polmonare, in cui l’esame istologico del pezzo operatorio ha consentito di ottenere la diagnosi definitiva: in sei pazienti cisti broncogena intrapolmonare (CBI) e in tre malformazione adenomatoide cistica (MAC) di tipo I, associata in un caso a sequestro polmonare intralobare (SPI).RisultatiTre pazienti erano sintomatici e sei asintomatici. All’esame TC le CBI si presentavano: in due casi come lesioni completamente liquide, in due casi con livello idroaereo contestuale, in un caso come una formazione completamente ripiena di aria e in un caso come una formazione omogenea rispetto alla densità dei tessuti molli. Nel parenchima contiguo alle CBI erano presenti bande lineari di fibrosi in tre casi, atelettasia in due e lesione simile a mucocele in un caso. Le MAC di tipo I si presentavano una come lesione cistica uniloculata con livello fluido, e l’altra a contenuto aereo; entrambe erano delimitate da una parete sottile con parenchima adiacente normale. La MAC associata a SPI appariva come cisti completamente ripiena di liquido con un arteria bronchiale ectasica afferente ed una vena efferente. Delle sei CBI, una era localizzata nel lobo superiore di destra, due nel lobo medio, e tre in quello inferiore di destra. Le tre MAC di tipo I erano localizzate nel lobo superiore di sinistra, nel lobo medio e quella associata a SPI, nel lobo inferiore sinistro.ConclusioniL’aspetto TC analogo tra CBI e MAC di tipo I non consente una diagnosi differenziale tra queste due lesioni. Nell’adulto è sempre raccomandabile la resezione chirurgica di tutte le lesioni intrapolmonari cistiche poiché la MAC di tipo I è il precursore del carcinoma mucinoso bronchiolo-alveolare.

Selective thrombolysis with low-dose urokinase in chronic arteriosclerotic obstructions

Twenty-one patients, 15 males and 6 females aged 52–75 years, with angiographically demonstrated occlusions of the superficial femoral or popliteal arteries, were treated by low-dose urokinase intraarterial infusion. The obstructions were 2–12 months old and from 7 to 18 cm in length. Urokinase was infused at 50,000 U/h; heparin was simultaneously administered by intravenous route in doses of 800 U/h. The average duration of treatment was 18 h. Effective clot lysis was accomplished in 18 cases (85%); 15 patients had underlying stenoses treated by balloon dilatation to prevent rethrombosis. Of the primarily recanalized arteries, two reoccluted within 4 weeks.

Three–dimensional analysis of pulmonary nodules by MSCT with Advanced Lung Analysis (ALA1) software

Purpose.The purpose of this study was to test the reproducibility of the three–dimensional (3D) Advanced Lung Analysis software (3D–ALA, GE Healthcare) in the estimation of pulmonary nodule volume.Materials and methods.We retrospectively reviewed the unenhanced multislice CT scans (Lightspeed Pro 16 GE) of 77 patients with a solitary pulmonary nodule (n=71) or metastatic pulmonary disease (n=6). A total of 103 pulmonary nodules (19 well–circumscribed, 45 juxtavascular and 39 juxtapleural) were analysed grouped into five classes based on diameter: <5 mm, 10 nodules (9.7%); ≥5 to <10 mm, 25 nodules (24.2%); ≥10 mm to <15 mm, 41 nodules (39.8%); ≥ 5 to <18 mm, 14 nodules (13.6% ); ≥ 8 to <30 mm, 13 nodules (12.62%). The following acquisition parameters were used: slice thickness 0.625 mm, reconstruction interval 0.4 mm, pitch 0.562:1, 140 kV, 300 mAs, field of view 13 cm, bone kernel. For each of the 103 nodules three, 3D volume measurements were obtained by the 3D–ALA software. The reproducibility of nodule segmentation was evaluated according to a visual score (1=optimal, ≥95%; 2=fair, 90–95%; 3=poor, ≤90%) by three observers working in consensus. The reproducibility of volume estimation was evaluated by comparing all 3D volume measurements and all segmentations obtained for each pulmonary nodule using the ANOVA test.Results.ALA–1 software allowed segmentation in all nodules (type 1 segmentation n=43, type 2 n=35, type 3 segmentation n=25). ALA–1 provided an identical 3D volume measurement in 62 nodules: [16 out of 19 well circumscribed (84.2%), 31 out of 45 juxtavascular (68.8%), 15 out of 39 juxtapleural (38.4%)]. Repeatability of 3D volume measurement was not possible in 41 out of 103 nodules [3 out of 19 (15.7%) well–circumscribed, 14 out of 45 (31.1%) juxtavascular, 24 out of 39 (61.5%) juxtapleural]. Among the 41 nodules with nonrepeatable 3D volume measurement, segmentation was scored as 1 in 2 out of 41 (4.8%), as 2 in 15 out of 41 (36.5%) and as 3 in 24 out of 41 (58.5%). The difference between the mean volume on three measurements and each type of nodule was not statistically significant (p>0.05).Conclusions.Three–dimensional volume measurement with ALARiassunto 1 software is reproducible for all nodules as regards dimension and site. ALA–1 software provided a good and reproducible volume measurement in well–circumscribed and most juxtavascular nodules. Volumetric evaluation and reproducibility of volume estimation in juxtapleural pulmonary nodules, particularly those adjacent to diaphragmatic pleura, is inadequate, and software improvement is needed.

Small (≤2 cm) atypical hepatic haemangiomas in the non-cirrhotic patient: pattern-based classification scheme for enhancement at triple-phase helical CT

PurposeThe aim of this study was to determine by triplephase helical computed tomography (CT) the appearance of atypical small (≤2 cm) hepatic haemangiomas (HHs) in the non-cirrhotic patient.Materials and methodsWe retrospectively reviewed the hepatic arterial-dominant phase (HAP), portal venous phase (PVP) and delayed-phase (DP) helical CT images of 47 patients with 52 atypical small (≤2cm) HHs associated with 34 typical small HHs. Images were assessed to identify the patterns of enhancement of atypical HHs and correlate their appearance with that of typical small HHs in the delayed phase. Interobserver variability and kappa value were calculated. Statistical significance was calculated by the Fisher exact test.ResultsThe 52 atypical small HHs were categorised as follows: type 1a (hyperattenuating in the HAP, n=17), type 1b [hyperattenuating with transient hepatic attenuation difference (THAD) around the lesion in the HAP, n=12], type 2a (homogeneously hypoattenuating in the HAP or PVP, n=9), type 2b (hypoattenuating with “bright-dot” sign in the HAP or PVP, n=13) and type 3 (hypoattenuating with central enhancing area, n=1). Interobserver agreement was perfect for HHs of types 1a, 1b, 2a and 3. On DP images, the appearance of atypical small HHs was identical to that of typical small HHs in all cases (p<0.0001), with lesions showing homogeneous isoattenuation to the aorta or liver parenchyma without peripheral capsule.ConclusionsTriple-phase helical CT scans can distinguish several types of atypical small HHs. The demonstration of patterns similar to those of typical forms on DP CT is fundamental for the diagnosis.RiassuntoObiettivoDeterminare mediante tomografia computerizzata (TC) spirale trifasica l’aspetto degli emangiomi epatici (EE) atipici di piccole dimensioni (≤2 cm) in pazienti con fegato non-cirrotico.Materiali e metodiSono stati valutati retrospettivamente gli esami TC trifasici in fase dominante-arteriosa (FA), fase venosa portale (FVP) e fase tardiva (FT), di 47 pazienti con 52 emangiomi epatici (EE) atipici di piccole dimensioni (≤2 cm) associati a 34 EE tipici piccoli. Le immagini sono state esaminate al fine di individuare i patterns di enhancement degli EE atipici e correlare in FT il loro aspetto con quello degli EE piccoli tipici. Sono state calcolate la variabilita interosservatore e le differenze statistiche mediante il test esatto di Fisher.RisultatiI 52 EE atipici di piccole dimensioni erano così distribuiti: tipo 1a EE iperdenso in FA (n=17), tipo 1b EE iperdenso con transient hepatic attenuation difference (THAD) in FA (n=12), tipo 2a EE ipodenso in FA o FVP (n=9), tipo 2b EE ipodenso con puntiforme/i iperdensita periferica in FA o FVP (n=13), e tipo 3 EE ipodenso con iperdensità centrale ad enhancement centrifugo in FVP (n=1). È stata riscontrata completa concordanza tra i tre osservatori relativamente agli EE di tipo 1a, 1b, 2a, e 3. In FT l’aspetto degli EE atipici di piccole dimensioni (isodensità rispetto all’aorta o al parenchima epatico con assenza di capsula periferica) è risultato sovrapponibile a quello degli EE tipici di piccole dimensioni (p<0,0001).ConclusioniLa TC trifasica consente di distinguere diverse forme di EE atipici di piccole dimensioni che in FT presentano aspetto analogo alle forme tipiche di piccole dimensioni.

Chronic iliac artery occlusion: treatment with the Strecker stent after PTA

The purpose of this retrospective study was to evaluate the use of percutaneous transluminal angioplasty (PTA) and subsequent. Strecker stent implantation for the treatment of chronic iliac artery occlusions. A total of 39 patients were subjected to this procedure. The occluded vessels were catheterized, dilated and subjected to stenting in all patients: the length of occlusion varied from 4.5 to 10.5 cm (mean 5.9), lesions were located in common iliac arteries (25), external iliac arteries (10) and in combinations of both (4). Twenty-five patients presented stage II according to Fontaine classification, nine patients stage III and five patients stage IV. The stent was mounted on balloon catheter and introduced through a 9 French sheet (for 8-10 mm stent diameter). After this procedure, 37 out of 39 patients showed a statistically significant increase in the Doppler sonographic ankle-arm index (AAI) (P = 0.001) and improvement of clinical symptoms, while in two patients a complete occlusion resulted due to long dissection not covered by the stent in one case and to stent misplacement in the other case. After stenting, 27 patients improved to stage I, ten patients to stage IIa and two patients showed no changes. Two complications were observed: one groin hematoma and one distal embolization. At a 6-month follow-up, a 89.7% of patency was observed. This study shows that Strecker stent can be successfully employed in addition to PTA to treat occlusions of the iliac arteries.

Simultaneous Occurrence of Renal Oncocytoma and B Small Cell Lymphoma in the Same Kidney: Report of Two Cases

Two cases of simultaneous occurrence of oncocytoma (OC) associated with small B-cell lymphoma in the same kidney were investigated. Computed tomography, performed for staging purposes, incidentally revealed a small hypo- and hyperattenuating renal mass. Diagnosis of OC was performed on the specimen by morphology, immunohistochemistry and electron microscopy. The patients are in complete remission after a vaccinotherapy with follicular dendritic cells. The occurrence of OC and non-Hodgkin lymphoma in the same kidney has never been reported. These case reports outline that computerized tomography is a sensitive method in the staging of lymphoma. However, when some solid, small hyper- or hypoattenuating masses occur in the kidney, the diagnosis by computed tomography alone is always a challenge and other malignant neoplasms may be considered. Immunohistochemistry and electron microscopy allow a definitive diagnosis of OC.

Magnetic resonance imaging features of myxoid leiomyoma of the vagina: A case report

We report a rare case of a voluminous vaginal myxoid leiomyoma in a 27-year-old nulliparous woman. Magnetic Resonance Imaging (MRI) revealed a mass arising from the vagina, with inhomogeneous signal intensity on spin-echo T1W and T2W images. MRI accurately defined the tissue planes between the lesion and the adjacent structures and suggested its benign nature. The mass was completely resected by means of transvaginal approach and the diagnosis of myxoid leiomyoma was confirmed histologically. To the best of our knowledge, this is the first report describing the MRI features of vaginal myxoid leiomyoma.

Postpartum ovarian vein thrombosis with simultaneous pyelocaliectasis: diagnosis and follow-up by MR imaging. Case report and literature review

We describe the critical role of MR imaging in a case of postpartum ovarian vein thrombosis (OVT) with concomitant pyelocaliceal ectasia. MR imaging confirmed the diagnosis suspected on the basis of ultrasonography and computed tomography by demonstration of a subacute clot with high signal intensity within the right ovarian vein and its complete resolution after anticoagulant therapy. MR imaging is a useful noninvasive, accurate tool for the diagnosis and follow-up of this potentially life-threatening condition, providing information helpful for choosing a prompt medical treatment rather than a surgical therapy. To our knowledge, no previous case of OVT causing pyelocaliceal ectasia documented by MR imaging has been reported. However, even though our case is suggestive, a cause–effect relationship between OVT and hydronephrosis could not be demonstrated with certainty.