Maryam Rahmani

Color and power Doppler US for diagnosing carpal tunnel syndrome and determining its severity: a quantitative image processing method.

PURPOSE To determine whether intraneural vascularity seen at color Doppler ultrasonography (US) can be used to diagnose carpal tunnel syndrome (CTS) and to evaluate an image processing method for quantifying the severity of CTS on the basis of this vascularity. MATERIALS AND METHODS This study was approved by the university ethics review committee. One hundred one patients with clinical evidence of CTS and 55 healthy control subjects were enrolled. Electrodiagnostic testing (EDT) was performed in all participants, and the presence of intraneural vascularity was evaluated with color Doppler US. An image processing program was designed by using software to determine the sum of pixels in the intraneural vascular area on power Doppler US scans of the median nerve. The relationship between the number of pixels and the severity of the abnormality at EDT was determined. RESULTS The sensitivity (83%) and specificity (89%) of intraneural vascularity in the diagnosis of CTS were similar to those of EDT (81% and 84%, respectively). Intraneural vascularity was seen in 91.4% of patients with mild CTS and 100% of patients with moderate or severe CTS. In participants with positive intraneural vascularity, the sum of pixels in the intraneural vascular area was significantly higher in patients than in control subjects and paralleled the severity of the abnormality at EDT (P < .01). CONCLUSION Color Doppler US can be used to accurately diagnose CTS. By processing the recorded power Doppler images and determining the number of pixels in the intraneural vascular area, the severity of CTS can be assessed. 2011 SUPPLEMENTAL MATERIAL: http://radiology.rsna.org/lookup/suppl/doi:10.1148/radiol.11110150/-/DC1.

COMBINATION OF HIGH-RESOLUTION AND COLOR DOPPLER ULTRASOUND IN DIAGNOSIS OF CARPAL TUNNEL SYNDROME

Background Ultrasound has recently emerged as a diagnostic tool in carpal tunnel syndrome (CTS). Purpose To evaluate the utility of a combination of high-resolution and color Doppler ultrasound as an alternative to electrodiagnostic tests (EDT), in CTS diagnosis, and to define an ultrasonographic prediction model for CTS. Material and Methods A total of 85 patients with certain clinical diagnosis of CTS and 49 healthy controls were enrolled. High-resolution and color Doppler ultrasound were performed and the cross-sectional area (CSA), hypoechogenicity, and hypervascularity of the median nerve were evaluated. Receiver-operating characteristic curves were used to determine the optimal cut-off point of median nerve CSA in diagnosis of CTS. Multivariate logistic regression analysis was used to formulate a prediction model for CTS. Results The optimal cut-off point of median CSA in wrist was 10.5 mm2. Hypervascularity (OR = 37.95), hypoechogenicity (OR = 12.30), and high CSA (OR = 34.79) of median nerve were significantly (P < 0.001) higher in CTS patients than in controls. No significant difference was found between the sensitivity and specificity of EDT and any of the above indices in prediction of CTS. An ultrasonographic model for prediction of CTS, comprised hypervascularity and/or high CSA of median nerve, could predict the CTS probability between 87–99%. The sensitivity and specificity of this model (86% and 84%) was not different from EDT (80% and 84%). Conclusion A combination of high-resolution and color Doppler ultrasound can be used as a non-invasive alternative to EDT in diagnosis of CTS.

Detection of bone erosion in early rheumatoid arthritis: ultrasonography and conventional radiography versus non-contrast magnetic resonance imaging

Nowadays, there is a trend toward early diagnosis and treatment of rheumatoid arthritis (RA) especially in patients with early signs of bone erosion which can be detected by magnetic resonance imaging (MRI). The aim of following study is to compare the sensitivity and specificity of ultrasonography (US) and conventional radiography (CR) compared to MRI for early detection of bone erosion in RA patients. In 12 patients with RA diagnosis, 120 first to fifth metacarpophalangeal joints and 96 second to fifth proximal interphalangeal joints were examined. Non-contrast MRI, US and CR were performed for bone erosion evaluation. For further analysis, the patients were divided in two equal groups according to disease activity score (DAS28). The overall sensitivity and specificity of US compared to MRI in detecting bone erosion were 0.63 and 0.98, respectively with a considerable agreement (kappa = 0.68, p < 0.001). Sensitivity and specificity of CR compared to MRI in detecting bone erosion were 0.13 and 1.00, respectively (kappa = 0.20, p < 0.001). In patients with more active disease, the sensitivity and specificity were 0.67 and 0.99 (kappa = 0.74, p < 0.001) compared to 0.59 and 0.97 (kappa = 0.61, p < 0.001) for the rest of patients according to DAS28. Conclusively, these findings reveal an acceptable agreement between US and MRI for detection of bone erosion in patients with early RA but not CR. US might be considered as a valuable tool for early detection of bone erosion especially when MRI is not available or affordable. Besides, it seems the US could be more reliable when the disease is more active.

Wide distribution of carbapenem resistant Acinetobacter baumannii in burns patients in Iran

Antimicrobial resistance in carbapenem non-susceptible Acinetobacter baumannii (CNSAb) is a major public health concern globally. This study determined the antibiotic resistance and molecular epidemiology of CNSAb isolates from a referral burn center in Tehran, Iran. Sixty-nine CNSAb isolates were tested for susceptibility to antimicrobial agents using the E test methodology. Multiple locus variable number tandem repeat analysis (MLVA), Multilocus sequence typing (MLST) and multiplex PCR were performed. PCR assays tested for ambler classes A, B, and D β-lactamases. Detection of ISAba1, characterization of integrons, and biofilm formation were investigated. Fifty-three (77%) isolates revealed XDR phenotypes. High prevalence of blaOXA-23-like (88%) and blaPER-1 (54%) were detected. ISAba1 was detected upstream of blaADC, blaOXA-23-like and blaOXA51-like genes in, 97, 42, and 26% of isolates, respectively. Thirty-one (45%) isolates were assigned to international clone (IC) variants. MLVA identified 56 distinct types with six clusters and 53 singleton genotypes. Forty previously known MLST sequence types forming 5 clonal complexes were identified. The Class 1 integron (class 1 integrons) gene was identified in 84% of the isolates. The most prevalent (33%) cassette combination was aacA4-catB8-aadA1. The IC variants were predominant in the A. baumannii lineage with the ability to form strong biofilms. The XDR-CNSAb from burned patients in Iran is resistant to various antimicrobials, including tigecycline. This study shows wide genetic diversity in CNSAb. Integrating the new Iranian A. baumannii IC variants into the epidemiologic clonal and susceptibility profile databases can help effective global control measures against the XDR-CNSAb pandemic.

Color Doppler ultrasound for evaluation of vasomotor activity in patients with carpal tunnel syndrome

BackgroundPatients with carpal tunnel syndrome (CTS) have a variety of vasomotor symptoms. Here, we aimed to study the vasomotor activity of the radialis indicis (RI) artery (median nerve territory) and the radial palmar digital (RPD) artery of the little finger (ulnar nerve territory) before and after sympathetic stimulation in CTS patients using color Doppler ultrasound.MethodsWe performed a cross-sectional study of 46 consecutive CTS patients plus 36 healthy controls. All patients underwent electromyography studies and were classified into mild and moderate/severe groups according to electrodiagnostic findings. Color Doppler examination of the RI artery and the RPD artery of the little finger were performed with the participants in a relaxed sitting position and after a deep breath followed by a cough (sympathetic stimulation). The pulsatility index (PI) was recorded at the point of maximal change in waveform, before and after this stimulus.ResultsThe PI of RI artery was significantly lower (p < 0.01) in CTS patients than healthy controls, both before and after stimulation. The changes in PI of RI artery after stimulation were significantly lower in CTS patients than healthy controls (1.18 ± 0.37 vs. 5.41 ± 0.87; p < 0.001). The same pattern was seen for PI of RI artery when comparing patients with mild vs. moderate/severe CTS. No difference was found in PI of RPD artery of the 5th finger between patients vs. controls and between patients with mild vs. moderate/severe CTS, both before and after stimulation.ConclusionsWe showed that color Doppler ultrasound can readily determine impaired vasomotor activity in CTS patients.

Differentiation of benign from malignant adnexal masses by functional 3 tesla MRI techniques: diffusion-weighted imaging and time-intensity curves of dynamic contrast-enhanced MRI.

BACKGROUND The aim of this study was to evaluate and compare the accuracy of diffusion-weighted imaging (DWI), apparent diffusion coefficient (ADC) value, and time-intensity curve (TIC) type analysis derived from dynamic contrast-enhanced MR imaging (DCE-MRI) in differentiating benign from malignant adnexal masses. MATERIALS AND METHODS 47 patients with 56 adnexal masses (27 malignant and 29 benign) underwent DWI and DCE-MRI examinations, prior to surgery. DWI signal intensity, mean ADC value, and TIC type were determined for all the masses. RESULTS High signal intensity on DWI and type 3 TIC were helpful in differentiating benign from malignant adnexal masses (p<0.001). The mean ADC value was significantly lower in malignant adnexal masses (p<0.001). An ADC value<1.20?10-3 mm2/s may be the optimal cutoff for differentiating between benign and malignant tumors. The negative predictive value for low signal intensity on DWI, and type 1 TIC were 100%. The pairwise comparison among the receiver operating characteristic (ROC) curves showed that the area under the curve (AUC) of TIC was significantly larger than the AUCs of DWI and ADC (p<0.001 for comparison of TIC and DWI, p<0.02 for comparison of TIC and ADC value). CONCLUSIONS DWI, ADC value and TIC type derived from DCE-MRI are all sensitive and relatively specific methods for differentiating benign from malignant adnexal masses. By comparing these functional MR techniques, TIC was found to be more accurate than DWI and ADC.

P09.05: Evaluation of ossification timing of sacral vertebrae by transabdominal sonography in the second trimester of pregnancy

Objectives Diastematomyelia is a rare form of spinal dysraphism in which the spinal cord is divided into two columns by a cartilaginous or osseous spur. Two types of diastematomyelia have been defined: Type 1, where each hemicord has its own dural sheath, and Type 2, where both hemicords are covered by a common dural sheath. We present nine cases of diastematomyelia diagnosed prenatally in our practice in last 10 years. We discuss the role of ultrasound in correctly diagnosing this condition prenatally. Methods: We analysed the ultrasound findings of diastematomyelia in 9 cases. The study was performed on Phillips HD 11 XE and IU 22 ultrasound machine using C 5-2 convex and V2-6 convex volume transducer. The ultrasonographic findings of widening of the spinal canal in the coronal view, an echogenic focus crossing the spinal canal in the axial view and intact skin and soft tissues overlying the affected spinal segment were analysed in each case. Results: The gestational age at diagnosis was 17-22 weeks. All cases showed widening of spinal canal. 8 cases showed echogenic spur and in 1 case fibrous spur was noted (detected on MRI and not seen on USG). Overlying skin was intact in all cases. In one fetus severe kyphoscoliotic deformity was seen, in one patient hemivartebra at single vertebra level was noted. In remaining 7 cases spine showed normal curvature. MRI was done in 2 cases. 3D of spine was done in all cases. 4 patients continued pregnancy and 5 patients terminated pregnancy. Echogenic spur was seen at lumbar level except one case in which fibrous spur was noted at high thoracic level. Conclusions: Diastematomyelia is a rare abnormality of the spinal canal which may be associated with other spinal anomalies. Isolated cases of diastematomyelia have a favourable prognosis. If associated spinal abnormalities are noted, like severe kyphoscoliosis then prognosis is poor. Intrauterine recognition of diastematomyelia should facilitate appropriate management of the disease, which is important for the prevention of neurological sequelae.

Sentinel lymph node in cervical cancer

Background: Cervical cancer is the second most common type of cancer among women. Effective screening programs can help cancer detection in early phases and reduce death. Metastasis to lymph nodes is one of the most prognostic factors in patients who underwent surgery. Also, a positive result from pathology report alert oncologist as a cause of death. Sentinel lymph node biopsy has been widely studied and clinically used for many types of cancer. Methods: Two techniques exist for detecting sentinel node in cervical cancer, which are Blue dye and gamma probe with radioactive isotope (99mTc). Moreover, lymphoscintigraphy has many advantages over the stain method. Detecting the sentinel node is performed via laparoscopy or laparotomy; former method is better and more accurate. Results: Various researchers have focused on this method and its positive results; its superiority against full lymphadenectomy has been declared in previous studies. Moreover, the role of sentinel lymph nodes biopsy in cervical cancer is still being extensively studied. Sentinel lymph nodes (SLN) method has a higher accuracy level to detect metastasis. Conclusion: Hence, it can be considered as a more appropriate alternative for pelvic lymph node dissection (PLND), which is a standard technique. Altering the method to a standard clinical method needs in-depth researches and studies.

Accuracy of Imaging in Preoperative Local Staging of Endometrial Cancer: Could Imaging Predict Low Risk Patients?

Endometrial cancer is the most common gynecological cancer in women and is considered the sixth most common malignancy in women (1,2). The incidence of endometrial carcinoma in Iran accounts for 17.6% of female genital tract carcinomas based on officially published female cancer statistics (3). Surgical staging is the current way of endometrial cancer treatment; it includes total abdominal hysterectomy and bilateral salpingo-oophorectomy. Nowadays, there are controversies about routine lymphadenectomy. Some studies suggest less extensive surgery for lowrisk patients, reserving para aortic lymphadenectomy for high-risk patients (4-6). Several studies showed only 5% positive lymph node metastasis with superficial myometrial invasion (1,7-9). Extra-uterine disease and lymph node metastasis cannot be evaluated via presurgical clinical examination; on the other hand, these are related to the depth of myometrial invasion, the most important and independent prognostic factor, cervical involvement and histopathological type and grade (1,10,11). Preoperative imaging assessment of myometrial invasion may help predict probable lymphadenopathies, especially in low grade tumors, and provide guidance for a better surgical approach in avoiding extensive surgery in low-risk patients with low-grade histopathology and myometrial invasion of less than 50%. Magnetic resonance imaging (MRI) and transvaginal sonography (TVS) are widely accepted as imaging choices in preoperative local staging of endometrial cancer (12) and accuracy of TVS in some recent studies was comparable with that of MRI, though there are still challenges (8,13,14). The use of Doppler sonography in the evaluation of endometrial cancer is a controversial issue (15). In this prospective study, we evaluated the diagnostic accuracy of MRI, TVS and Doppler for detecting the Abstract Objectives: In this study we aimed to evaluate diagnostic accuracy of magnetic resonance imaging (MRI) and transvaginal sonography (TVS) in identifying the depth of myometrial invasion and cervical involvement and also their relationship with the uterine arteries resistance index (RI) and pulsatility index (PI) in endometrial carcinoma. Materials and Methods: We performed a prospective study on 45 women with histologically confirmed diagnosis of endometrial carcinoma. The study was performed from October 2009 to December 2012. All the patients were evaluated by 3T MRI and TVS and transvaginal color Doppler sonography of uterine arteries. All the patients underwent hysterectomy and the result of imaging and pathologic studies were compared. Results: Mean age was 54.5 ± 10.8 years (33 to 77 years), mean gravid was 3.93 ± 2.8 and the mean parity was 3.9 ± 2.5. The pathology results indicated 29 patients (64.4%) in stage IA and 16 patients (35.6%) in stage IB. Mean endometrial thickness in stage IA patients was 18.4±14.4 mm and in stage IB patients was 38.5±11.5 mm. TVS also showed positive predictive value (PPV) of 76.5%, negative predictive value (NPV) of 88.9%, sensitivity of 81.3%, specificity of 85.7%, and accuracy of 84.1% for assessment of the depth of myometrial invasion in endometrial carcinoma. We found PPV of 86.7%, NPV of 92.3%, sensitivity of 86.7%, specificity of 92.3%, and accuracy of 90.2% for MRI study. Conclusions: TVS can evaluate the depth of myometrial invasion with an acceptable accuracy when MRI is not available or costeffective, or when MRI is contraindicated. Both preoperative MRI and TVS can predict low risk patients (less than 50% of myometrial invasion) accurately; thereby avoiding lymphadenectomy in these patients.