Mesut Sivri

Importance of imaging and recent developments in diagnosis of nonalcoholic fatty liver disease

Nonalcoholic fatty liver disease (NAFLD) is one of the most common causes of chronic liver disease and is a major public health problem worldwide. It is a spectrum that includes simple steatosis, nonalcoholic steatohepatitis (NASH), fibrosis and cirrhosis. Recently, NAFLD prevalence in children and adolescents has increased too. The increasing prevalence has resulted in NASH-related chronic liver disease. Therefore, early diagnosis and treatment is quite important. Although liver biopsy is still the gold standard for diagnosis and staging of NAFLD, particularly for the diagnosis of NASH, imaging methods such as ultrasonography, computed tomography, magnetic resonance imaging with chemical shift imaging and especially magnetic resonance spectroscopy and elastography have been increasingly approved as noninvasive alternative methods. The aim of this review is to analyze the diagnostic accuracy and limitations of the imaging methods and recent developments in the diagnosis of NAFLD.

High-sensitivity C-reactive protein, lipoprotein-related phospholipase A2, and acute ischemic stroke.

Background Serum biomarkers may be useful for early diagnosis of acute ischemic stroke, exclusion of other diseases that may mimic stroke, and prediction of infarct volume. We evaluated serum high-sensitivity C-reactive protein (hs-CRP) and lipoprotein-related phospholipase A2 (Lp-PLA2) in patients who had acute ischemic stroke. Methods In 200 patients who presented to an emergency service (acute ischemic stroke, 102 patients; control with no stroke, 98 patients), stroke patients were evaluated with the Canadian neurological scale and diffusion-weighted magnetic resonance imaging, and all patients were evaluated with the Glasgow coma scale and their serum hs-CRP level and Lp-PLA2 activity were assessed. The volume of stroke lesions was calculated from magnetic resonance images. Results Patients who had stroke had higher mean serum hs-CRP level (stroke, 7±6 mg/dL; control, mean ± standard deviation 1±1 mg/dL; P≤0.001) and Lp-PLA2 activity (stroke, mean ± standard deviation 113±86 nmol/min/mL; control, mean ± standard deviation 103±50 nmol/min/mL; P≤0.001) than control patients who did not have stroke. The mean hs-CRP level and Lp-PLA2 activity were higher in patients who had greater stroke severity (lower Canadian neurological scale score) and were higher in patients who had larger volume strokes. Conclusion Higher hs-CRP level and Lp-PLA2 activity are significantly associated with more severe neurologic impairment and larger infarct size in patients who have acute ischemic stroke. These biomarkers may be useful for rapid diagnosis and prediction of ischemic tissue volume in the early stage of ischemic stroke. These findings may be important for health care facilities that have limited access to emergency computed tomography scanning for the diagnosis of stroke.

Diagnostic efficacy of diffusion‐weighted MRI for pre‐operative assessment of myometrial and cervical invasion and pelvic lymph node metastasis in endometrial carcinoma

To determine the diagnostic accuracy of diffusion‐weighted magnetic resonance imaging (DW‐MRI) for the pre‐operative assessment of patients with endometrial carcinoma and to assess myometrial and cervical invasion as well as pelvic lymph node metastasis.

Prospective ECG-gated high-pitch dual-source cardiac CT angiography in the diagnosis of congenital cardiovascular abnormalities: Radiation dose and diagnostic efficacy in a pediatric population.

PURPOSE The goal of this study was to investigate the radiation dose and diagnostic efficacy of cardiac computed tomography angiography (CCTA) using prospective ECG-gated high-pitch dual-source computed tomography (DSCT) in the diagnosis of congenital cardiovascular abnormalities in pediatric population. MATERIALS AND METHODS One hundred five pediatric patients who were clinically diagnosed with congenital heart disease with suspected extracardiac vascular abnormalities were included in the study. All CCTAs were performed on a 128×2-section DSCT scanner. CCTA findings were compared with surgical and/or conventional cardiac angiography findings. Dose-length product (DLP) and effective doses (ED) were calculated for each patient. Patients were divided into 4 groups by age, and ED and DLP values were compared among groups. The image quality was evaluated using a five-point scale. RESULTS CCTA showed 173 abnormalities in 105 patients. There were 2 patients with false positive and 3 with false negative findings. The sensitivity and specificity of CCTA were 98.3% and 99.9%, respectively. The positive predictive value and negative predictive value of CCT were 98.9% and 99.9%, respectively. The average DLP and ED values were 15.6±9.6 (SD) mGy.cm and 0.34±0.10 (SD) mSv, respectively. The mean image quality score was 4.8±0.5 (SD) in all patients. The inter-observer agreement for the image quality scores was good (κ=0.80). CONCLUSION CCTA is an excellent imaging modality for evaluation of cardiovascular abnormalities and provides excellent image quality with very low radiation exposure when low-dose prospective ECG-triggered high-pitch DSCT is used.

Our Experience with MR Imaging of Perianal Fistulas

Summary Magnetic resonance imaging (MRI) depicts infectious foci in the perianal region better than any other imaging modality. MRI allows definition of the fistula, associated abscess formation and its secondary extensions. Accurate information is necessary for surgical treatment and to obtain a decrease in the incidence of recurrence and complications. Radiologists should be familiar with anatomical and pathological findings of perianal fistulas and classify them using the MRI – based grading system. The purpose of this article was to provide an overview for evaluation of perianal fistulas, examples of various fistula types and their classification.

Ectopic Pregnancy in a Cesarean Section Scar: Successful Management Using Vacuum Aspiration under Laparoscopic Supervision—Mini Review of Current Literature

A cesarean scar ectopic pregnancy (CSEP) is a fairly uncommon presentation wherein the conceptus is implanted deep in the myometrium and at the exact scar site of the previous cesarean section. There are various CSEP management options that range from medical treatment to surgical interventions such as dilatation and curettage, laparoscopic excision, resection by laparotomy, or, sometimes, a combination of these modalities. Establishing a diagnosis of CSEP can be challenging. Given the relatively rare incidence of CSEP, its management is controversial and current standards of therapy have been derived from data obtained from a limited number of patients. Herein, we present transvaginal ultrasonography (TVUS) imaging findings and management strategies used in a case of CSEP along with the short review of current literature.

Comparison Between Prospectively Electrocardiogram-Gated High-Pitch Mode and Retrospectively Electrocardiogram-Gated Mode for Dual-Source CT Coronary Angiography

Summary Background We aimed to report the image quality, relationship between heart rate and image quality, amount of contrast agent given to the patients and radiation doses in coronary CT angiography (CTA) obtained by using high-pitch prospectively ECG-gated “Flash Spiral” technique (method A) or retrospectively ECG-gated technique (method B) using 128×2-slice dual-source CT. Material/Methods A total of 110 patients who were evaluated with method A and method B technique with a 128×2-detector dual-source CT device were included in the study. Patients were divided into three groups based on their heart rates during the procedure, and a relationship between heart rate and image quality were evaluated. The relationship between heart rate, gender and radiation dose received by the patients was compared. Results A total of 1760 segments were evaluated in terms of image quality. Comparison of the relationship between heart rate and image quality revealed a significant difference between heart rate <60 beats/min group and >75 beats/min group whereas <60 beats/min and 60–75 beats/min groups did not differ significantly. The average effective dose for coronary CTA was calculated as 1.11 mSv (0.47–2.01 mSv) for method A and 8.22 mSv (2.19–12.88 mSv) for method B. Conclusions Method A provided high quality images with doses as low as <1 mSv in selected patients who have low heart rates with a high negative predictive value to rule out coronary artery disease. Although method B increases the amount of effective dose, it provides high diagnostic quality images for patients who have a high heart rate and arrhythmia which makes it is difficult to obtain images.

A Novel Pipeline for Adrenal Tumour Segmentation

BACKGROUND AND OBJECTIVE Adrenal tumours occur on adrenal glands surrounded by organs and osteoid. These tumours can be categorized as either functional, non-functional, malign, or benign. Depending on their appearance in the abdomen, adrenal tumours can arise from one adrenal gland (unilateral) or from both adrenal glands (bilateral) and can connect with other organs, including the liver, spleen, pancreas, etc. This connection phenomenon constitutes the most important handicap against adrenal tumour segmentation. Size change, variety of shape, diverse location, and low contrast (similar grey values between the various tissues) are other disadvantages compounding segmentation difficulty. Few studies have considered adrenal tumour segmentation, and no significant improvement has been achieved for unilateral, bilateral, adherent, or noncohesive tumour segmentation. There is also no recognised segmentation pipeline or method for adrenal tumours including different shape, size, or location information. METHODS This study proposes an adrenal tumour segmentation (ATUS) pipeline designed to eliminate the above disadvantages for adrenal tumour segmentation. ATUS incorporates a number of image methods, including contrast limited adaptive histogram equalization, split and merge based on quadtree decomposition, mean shift segmentation, large grey level eliminator, and region growing. RESULTS Performance assessment of ATUS was realised on 32 arterial and portal phase computed tomography images using six metrics: dice, jaccard, sensitivity, specificity, accuracy, and structural similarity index. ATUS achieved remarkable segmentation performance, and was not affected by the discussed handicaps, on particularly adherence to other organs, with success rates of 83.06%, 71.44%, 86.44%, 99.66%, 99.43%, and 98.51% for the metrics, respectively, for images including sufficient contrast uptake. CONCLUSIONS The proposed ATUS system realises detailed adrenal tumour segmentation, and avoids known disadvantages preventing accurate segmentation.

Microcystic meningioma: difficulties in diagnosis and magnetic resonance imaging findings

A 45-year-old woman was referred to our hospital with the complaints of dizziness, blurring vision and subsequent syncope. Diffusion and conventional magnetic resonance imaging (MRI) were performed to the patient. The patient’s MRI showed an extra-axial mass of 4 9 2.5 cm in size in the left frontoparietal region. The mass was starting from centrum semiovale level and continuing through the vertex. The mass was hypointense on T1-weighted (W) images, hyperintense on T2W images containing pointwise hypointense areas. It was having microcystic components and minimal peritumoral edema (Fig. 1). After contrast injection, central mild enhancement with reticular appearance and peripheral thin enhancement was revealed (Fig. 2). Diffusion-weighted (DW) imaging showed increased diffusion (Fig. 3). Pathological examination of totally excised lesion was reported as microcystic meningioma. Meningiomas are common intracranial tumors. However, as a very rare subtype of meningiomas, microcystic meningiomas constitute for 1.6% of all intracranial meningioma cases. Typical, atypical or anaplastic meningiomas should be regarded in differential diagnosis of microcystic meningiomas. Computed tomography (CT), conventional MRI, DW images and ADC maps are useful in diagnosis and differential diagnosis of microcystic meningiomas. Typically meningiomas are defined as extraaxially located lesions, having dural tail, and showing strongly homogeneous contrast enhancement without edema around brain parenchyma. The microcystic meningiomas are reported as low-density lesions at CT examinations. They usually show high-contrast enhancement. Half of the cases may show hyperostosis. Microcystic meningiomas are reported as hypointense on T1W images, and as hyperintense on T2W images of MRI and very often they show signal intensity compatible with peritumoral edema. The serious peritumoral edema findings are more frequent and more characteristic MRI findings of microcystic meningiomas compared with the classical meningiomas [1, 2]. However, in the recent studies, more aggressive atypical and anaplastic meningiomas were reported to have similar findings. In the study of Avetis et al. [3], ADC maps were shown to be more effective in differentiation of microcystic meningiomas from more aggressive atypical or anaplastic meningiomas. Tumors with high grade and cellularity show significantly lower ADC values compared with normal brain tissue. In addition, Terada et al. [4] described that a reticular appearance on gadolinium-enhanced T1-weighted MRI and DW imaging and relatively low ADC values might be the diagnostic markers of microcystic meningiomas. These findings are important for the accurate diagnosis and surgery planning. In conclusion, microcystic meningiomas must be kept in mind in the differential diagnosis of extra-axially located tumors showing contrast enhancement with reticular appearance, containing pointwise hypointense areas at T2W images and displaying increased diffusion with peritumoral edema. & Mustafa Koplay koplaymustafa@hotmail.com

Cervical giant pseudomeningocele presented with neck pain: conventional MRI and MR myelography findings.

A 12-year-old boy with neck pain was admitted to our clinic. He had a history of head and neck trauma 3 years before presentation. Laboratory and neurologic examination was unremarkable. Conventional magnetic resonance imaging of cervical spine showed a giant multiloculated cystic lesion with the size of 7.5 cm×2.5 cm. The lesion was hypointense on T1weighted images and hyperintense on T2-weighted images such as cerebrospinal fluid (Fig. 1A, B). The cystic lesion was extending through neural foramens around the spinal nerve roots (Fig. 1C, D). Magnetic resonance myelography demonstrated the pseudomeningocele in detail anterior to spinal cord and thecal sac (Fig. 2). The spinal nerves of cervical and brachial plexus were intact. Conservative management of the lesion was decided because the patient showed no evidence of progressive neurologic deficit. Pseudomeningocele is defined as an extradural collection of cerebrospinal fluid that results from a tear in dura and arachnoid layer. It becomes encapsulated in a fibrous sac. Common etiologic factors are congenital, traumatic, and iatrogenic [1–3]. References