Marcelo Souto Nacif

Cardiac magnetic resonance imaging in clinical practice

Resumo Objective: To evaluate and describe indications, mainly diagnoses and cardiac magnetic resonance imaging findings observed in clinical practice. Materials and Methods: Retrospective and descriptive study of cardiac magnetic resonance performed at a private hospital and clinic in the city of Niterói, RJ, Brazil, in the period from May 2007 to April 2011. Results: The sample included a total of 1000 studies performed in patients with a mean age of 53.7 ± 16.2 years and predominance for male gender (57.2%). The majority of indications were related to assessment of myocardial perfusion at rest and under pharmacological stress (507/1000; 51%), with positive results in 36.2% of them. Suspected myocarditis was the second most frequent indication (140/ 1000; 14%), with positive results in 63.4% of cases. These two indications were followed by study of arrhythmias (116/1000; 12%), myocardial viability (69/1000; 7%) and evaluation of cardiomyopathies (47/1000; 5%). In a subanalysis, it was possible to identify that most patients were assessed on an outpatient basis (58.42%). Conclusion: Cardiac magnetic resonance has been routinely performed in clinical practice, either on an outpatient or emergency/ inpatient basis, and myocardial ischemia represented the main indication, followed by investigation of myocarditis, arrhythmogenic right ventricular dysplasia and myocardial viability.Barranhas AD, Santos AASMD, Coelho-Filho OR, Marchiori E, Rochitte CE, Nacif MS. Cardiac magnetic resonance imaging in clinical practice. RadiolBras. 2014 Jan/Fev;47(1):1–8.AbstractResumoObjective: To evaluate and describe indications, mainly diagnoses and cardiac magnetic resonance imaging findings observed in clinicalpractice.Materials and Methods: Retrospective and descriptive study of cardiac magnetic resonance performed at a private hospital and clinic inthe city of Niteroi, RJ, Brazil, in the period from May 2007 to April 2011.Results: The sample included a total of 1000 studies performed in patients with a mean age of 53.7 ± 16.2 years and predominancefor male gender (57.2%). The majority of indications were related to assessment of myocardial perfusion at rest and under pharm acologicalstress (507/1000; 51%), with positive results in 36.2% of them. Suspected myocarditis was the second most frequent indication ( 140/1000; 14%), with positive results in 63.4% of cases. These two indications were followed by study of arrhythmias (116/1000; 12% ),myocardial viability (69/1000; 7%) and evaluation of cardiomyopathies (47/1000; 5%). In a subanalysis, it was possible to ident ify thatmost patients were assessed on an outpatient basis (58.42%).Conclusion: Cardiac magnetic resonance has been routinely performed in clinical practice, either on an outpatient or emergency/inpatient basis, and myocardial ischemia represented the main indication, followed by investigation of myocarditis, arrhythmoge nic rightventricular dysplasia and myocardial viability.Keywords: Cardiac magnetic resonance; Health profile; Evidence-based medicine; Diagnostic methods – policies.Objetivo: Avaliar e descrever as indicacoes, os principais diagnosticos e os achados de imagem de ressonâncias magneticas cardiacasrealizadas na pratica clinica.Materiais e Metodos: Estudo descritivo e retrospectivo dos exames de ressonância magnetica cardiaca realizados em um hospital euma clinica particulares do municipio de Niteroi, RJ, no periodo de maio de 2007 a abril de 2011.Resultados: Um total de 1000 exames foi incluido, com pacientes apresentando media de idade de 53,7 ± 16,2 anos e predominiono sexo masculino (57,2%). A maioria das indicacoes foi para pesquisa de isquemia miocardica com estresse farmacologico (507/1000; 51%), que teve resultado positivo em 36,2% das avaliacoes. A pesquisa de miocardite (140/1000; 14%) foi a segundaindicacao mais frequente, com resultados positivos em 63,4% dos casos. Estas duas principais indicacoes foram seguidas de avali acaode arritmias (116/1000; 12%), viabilidade miocardica (69/1000; 7%) e cardiomiopatias diversas (47/1000, 5%). Em uma subanalise,foi possivel identificar que a grande maioria dos exames foi realizada pela via ambulatorial (58,42%).Conclusao: A ressonância magnetica cardiaca esta sendo realizada de rotina na pratica clinica, tanto via ambulatorial ou pela viaemergencial/intra-hospitalar, e a pesquisa de isquemia miocardica foi a principal indicacao, seguida de miocardite, displasia a rritmoge-nica do ventriculo direito e viabilidade miocardica.Unitermos: Ressonância magnetica cardiaca; Perfil de saude; Medicina baseada em evidencias; Exames medicos – politicas.

Cardiac magnetic resonance imaging and computed tomography in ischemic cardiomyopathy: an update

Ischemic cardiomyopathy is one of the major health problems worldwide, representing a significant part of mortality in the general population nowadays. Cardiac magnetic resonance imaging (CMRI) and cardiac computed tomography (CCT) are noninvasive imaging methods that serve as useful tools in the diagnosis of coronary artery disease and may also help in screening individuals with risk factors for developing this illness. Technological developments of CMRI and CCT have contributed to the rise of several clinical indications of these imaging methods complementarily to other investigation methods, particularly in cases where they are inconclusive. In terms of accuracy, CMRI and CCT are similar to the other imaging methods, with few absolute contraindications and minimal risks of adverse side-effects. This fact strengthens these methods as powerful and safe tools in the management of patients. The present study is aimed at describing the role played by CMRI and CCT in the diagnosis of ischemic cardiomyopathies.

Anomalous Origin of Coronary Artery (ALCAPA) in 64-Channel TC Scanner

Multidetector computed tomography (MDCT) with 64 channels provides to clinical practice an excellent method to detect coronary artery anomalies. The diagnosis of coronary anomalies consisting of origin of left coronary artery in the pulmonary trunk in adults with no history of congenital disease has few reports in literature. We report a case in a 30-year old female patient complaining of fatigue on major efforts and positive scintigraphy for ischemia. The diagnosis was made through 64-channel MDCT and thus it appears that the method can be used as baseline.

Intestinal malrotation associated with duodenal obstruction secondary to Ladd's bands

A 38-year-old male sought treatment in the emergency room, complaining of abdominal pain and bloating, accompanied by an inability to pass gas or eliminate feces. The patient underwent multidetector computed tomography of the abdomen and pelvis, with and without the administration of intravenous iodinated contrast media, which showed significant fluid distension of the stomach and duodenum, with abrupt narrowing of the duodenal lumen at the transition from the second to the third portion of the duodenum (Figure 1A). The duodenal arch was short, with a vertical angle of Treitz and all of the loops shifted to the right, together with intestinal malrotation, the cecum and ascending colon appearing in the anterior and medial positions, occupying the mesogastrium (Figure 1B). Those aspects are found in classical malrotation with duodenal obstruction secondary to Ladd’s bands (Figure 2A). The patient underwent laparoscopy Ladd’s procedure (Figure 2B) and was subsequently discharged in good condition, thereafter reporting no episodes of recurrence. The evaluation of the musculoskeletal system by imaging methods has been the subject of a number of recent studies in the radiology literature of Brazil. Intestinal malrotation is a rare congenital condition, occurring in 1 out of every 200–500 live births. Most cases are diagnosed during the neonatal period, only 0.2% being diagnosed in adulthood. The condition can lead to chronic nonspecific symptoms in young adults, making it difficult to diagnose. Intestinal malrotation typically manifests as nonspecific abdominal discomfort, occasionally provoking abdominal pain related to obstruction of acute onset. Generally, the obstructions occur during the neonatal period and should be considered in all infants presenting with bilious vomiting and abdominal pain. The use of multidetector computed tomography in the emergency room has facilitated the diagnosis of malrotations, primarily in the context of congenital diseases that go undiagnosed until adulthood. This method, in addition to facilitating the evaluation of the loops, can aid in the assessment of the vasculature, which can be affected. Another important imaging method is radiological study with contrast, which can reveal a vertical duodenum and the absence of a duodenojejunal angle, as are observed in 80% of cases. The typical treatment for intestinal malrotation is Ladd’s procedure, first described in 1936, which involves classical laparotomy. It is considered the gold-standard surgical treatment in cases of intestinal malrotation and can currently be performed safely by laparoscopy, as in the case presented here. The procedure consists in mobilization of the duodenum and right colon; the sectioning of adhesions (Ladd’s bands, sometimes near the superior mesentery); and appendectomy. This aim of the treatment is to reduce the risk of acute-onset volvulus by placing the small intestine in a nonrotating position and broadening the base of the mesentery. Appendectomy is performed because of potential difficulty in diagnosing appendicitis in the future, given that the appendix would be far from the correct position. The diagnosis of intestinal malrotation associated with duodenal obstruction secondary to Ladd’s bands should be considered in adult patients presenting with duodenal obstruction, a vertical duodenum, and malrotation of the small intestine with the cecum in the medial position. We believe that computed tomography is now the method of choice for the diagnosis of such malrotations.

Optimized three-dimensional sodium imaging of the human heart on a clinical 3T scanner.

Optimization of sequence and sequence parameters to allow three‐dimensional (3D) sodium imaging of the entire human heart in vivo in a clinically reasonable time.

Caseous calcification of the mitral annulus: computed tomography features.

. Nevertheless, because for-eign bodies of vegetable origin do not produce hyperintense im-ages, the diagnosis is not usually obtained by CT. Upper gas-trointestinal endoscopy is a useful tool in the study of gastric le-sions and allows the collection of material for histopathologicalevaluation. However, endoscopic biopsies are usually small andsuperficial, which can make it difficult to confirm the diagnosis ofgranuloma pulse

Identificação de calcificação coronariana utilizando tomografia computadorizada do tórax não sincronizada ao eletrocardiograma

Objective To evaluate the accuracy of visual analysis and of the coronary artery calcium (CAC) score in nontriggered computed tomography (CT), in comparison with that of the CAC score in electrocardiogram-triggered CT, in identifying coronary calcification. Materials and Methods A total of 174 patients for whom CT was indicated for CAC scoring underwent nontriggered and triggered CT in a 64-channel multislice scanner, in a single session without a change in position. The images were interpreted by a radiologist with seven years of experience in thoracic and cardiovascular radiology. The measurement of coronary calcium was carried out by three methods: CAC score with dedicated software in nontriggered CT, CAC score with dedicated software in triggered CT, and visual analysis without dedicated software in nontriggered CT. Results In nontriggered CT, the CAC score presented an accuracy of 95.98% (95% CI: 91.93-98.04). The visual analysis showed an accuracy of 97.13% (95% CI: 93.45-98.77). Conclusion Nontriggered CT showed excellent accuracy in the identification and exclusion of coronary calcification, either the CAC score was determined with dedicated software or through visual analysis.

Prevalence of pancreatic cystic neoplasms on imaging exams: association with signs of malignancy risk

Objective To analyze the prevalence of cystic lesions of the pancreas on imaging exams and their association with signs of malignancy risk. Materials and methods This was an observational cross-sectional study, in which we evaluated 924 sequential computed tomography and magnetic resonance imaging scans of the abdomen. For all of the patients included in the study, we reviewed the demographic data available in the medical records and evaluated the images. Results Cysts were observed in 4.5% of patients, the prevalence of cysts being highest (7.6%) in patients over 60 years of age. Lesions were detected at higher rates on magnetic resonance imaging and in patients with pancreatic symptoms (6.1% and 42.9%, respectively). Signs of malignancy risk were observed in 26.3% of the patients, more frequently in those who were male and over 60 years of age. Conclusion The prevalence of pancreatic cysts was 4.5%. Signs of malignancy risk were observed in 26.3% of the cystic neoplasms identified.Objective To analyze the prevalence of cystic lesions of the pancreas on imaging exams and their association with signs of malignancy risk. Materials and methods This was an observational cross-sectional study, in which we evaluated 924 sequential computed tomography and magnetic resonance imaging scans of the abdomen. For all of the patients included in the study, we reviewed the demographic data available in the medical records and evaluated the images. Results Cysts were observed in 4.5% of patients, the prevalence of cysts being highest (7.6%) in patients over 60 years of age. Lesions were detected at higher rates on magnetic resonance imaging and in patients with pancreatic symptoms (6.1% and 42.9%, respectively). Signs of malignancy risk were observed in 26.3% of the patients, more frequently in those who were male and over 60 years of age. Conclusion The prevalence of pancreatic cysts was 4.5%. Signs of malignancy risk were observed in 26.3% of the cystic neoplasms identified.

Tumor de células gigantes do seio frontal: típico e improvável

1. Documenta – Hospital São Francisco, Ribeirão Preto, SP, Brazil. 2. Hospital Israelita Albert Einstein, São Paulo, SP, Brazil. 3. Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo (HCFMRP-USP), Ribeirão Preto, SP, Brazil. Mailing address: Dr. Rodolfo Mendes Queiroz. Documenta – Centro Avançado de Diagnóstico por Imagem. Rua Bernardino de Campos, 980, Centro. Ribeirão Preto, SP, Brazil, 14015-130. E-mail: rod_queiroz @hotmail.com. edema is also common, being seen in 77–90% of cases. On CT scans, CNS lymphomas are typically hyperdense, because they are hypercellular and have a high nucleus-cytoplasm ratio. On MRI, they often demonstrate a hypointense or isointense signal in T1-weighted sequences and an isointense or hyperintense signal in T2-weighted sequences. After intravenous administration of contrast medium, they show homogeneous (90%) or, in rare cases, annular enhancement. They also exhibit signs of restricted water diffusion. Perfusion-weighted imaging shows less vascularization than that seen in other malignant brain tumors. On magnetic resonance spectroscopy, CNS lymphomas show elevated lipid and choline peaks, as well as a reduction in N-acetyl-aspartate levels. The definitive diagnosis is made by biopsy. Such lymphomas respond to chemotherapy and radiotherapy, the surgical option being used for tumor mass reduction. Overall survival ranges from 15% to 80%, depending on the age of the patient, as well as on the characteristics and stage of the disease. The list of differential diagnoses of expansile CNS lesions in imaging studies is extensive, including glioma, acute ischemia, inflammatory processes, and infectious diseases. When such lesions appear in an intraventricular location and are hyperdense on CT, they can be confused with colloid cysts, which are common at that site and exhibit similar density. Burkitt-like lymphomas are highly malignant, with cellular characteristics intermediate between those of diffuse non-Hodgkin large B-cell lymphoma and those of Burkitt lymphoma. Burkitt-like lymphomas are typically associated with infection— HIV or the Epstein-Barr virus. They account for 2–3% of nonHodgkin lymphomas in immunocompetent adults, being most common among the elderly. Burkitt-like lymphomas can affect the brain, intestines, skin, ovaries, kidneys, liver, and bone marrow. Chemotherapy is the most widely used treatment, although, even with treatment, survival is less than one year. The term “vanishing tumor” refers to a tumor that shows marked regression or disappears, with or without nonspecific therapy, and can recur or progress to new forms. In the brain, lymphomas often occur after corticosteroid therapy, demyelinating diseases, or inflammatory disorders.

Defecography by digital radiography: experience in clinical practice

Objective The objective of this study was to profile patients who undergo defecography, by age and gender, as well as to describe the main imaging and diagnostic findings in this population. Materials and Methods This was a retrospective, descriptive study of 39 patients, conducted between January 2012 and February 2014. The patients were evaluated in terms of age, gender, and diagnosis. They were stratified by age, and continuous variables are expressed as mean ± standard deviation. All possible quantitative defecography variables were evaluated, including rectal evacuation, perineal descent, and measures of the anal canal. Results The majority (95%) of the patients were female. Patient ages ranged from 18 to 82 years (mean age, 52 ± 13 years): 10 patients were under 40 years of age; 18 were between 40 and 60 years of age; and 11 were over 60 years of age. All 39 of the patients evaluated had abnormal radiological findings. The most prevalent diagnoses were rectocele (in 77%) and enterocele (in 38%). Less prevalent diagnoses were vaginal prolapse, uterine prolapse, and Meckels diverticulum (in 2%, for all). Conclusion Although defecography is performed more often in women, both genders can benefit from the test. Defecography can be performed in order to detect complex disorders such as uterine and rectal prolapse, as well as to detect basic clinical conditions such as rectocele or enterocele.