Nevada Cioffi Squitieri

The role of US examination in the management of acute abdomen

Acute abdomen is a medical emergency, in which there is sudden and severe pain in abdomen of recent onset with accompanying signs and symptoms that focus on an abdominal involvement. It can represent a wide spectrum of conditions, ranging from a benign and self-limiting disease to a surgical emergency. Nevertheless, only one quarter of patients who have previously been classified with an acute abdomen actually receive surgical treatment, so the clinical dilemma is if the patients need surgical treatment or not and, furthermore, in which cases the surgical option needs to be urgently adopted. Due to this reason a thorough and logical approach to the diagnosis of abdominal pain is necessary. Some Authors assert that the location of pain is a useful starting point and will guide a further evaluation. However some causes are more frequent in the paediatric population (like appendicitis or adenomesenteritis) or are strictly related to the gender (i.e. gynaechologic causes). It is also important to consider special populations such as the elderly or oncologic patients, who may present with atypical symptoms of a disease. These considerations also reflect a different diagnostic approach. Today, surely the integrated imaging, and in particular the use of multidetector Computed Tomography (MDCT) has revolutionised the clinical approach to this condition, simplyfing the diagnosis but burdening the radiologists with the problems related to the clinical management. However although CT emerging as a modality of choice for evaluation of the acute abdomen, ultrasonography (US) remains the primary imaging technique in the majority of cases, especially in young and female patients, when the limitation of the radiation exposure should be mandatory, limiting the use of CT in cases of nondiagnostic US and in all cases where there is a discrepancy between the clinical symptoms and negative imaging at US.

Magnetic resonance imaging: is there a role in clinical management for acute ischemic colitis?

AIM To validate the utility of magnetic resonance imaging (MRI) for the clinical management of acute ischemic colitis (IC). METHODS This is a magnetic resonance (MR) prospective evaluation of 7 patients who were proved to have acute IC on the basis of clinical, endoscopic and computed tomography (CT) findings and who were imaged in our institution between February 2011 and July 2012. The mean age of the patients was 72.28 years. Abdominal CTs were obtained using a 64-detector row configuration for all patients with un-enhanced and contrast-enhanced scans, in the late arterial phase (start delay 45-50 s) and in the portal venous phase (start delay 70-80 s). The MR examinations were performed using a 1.5T superconducting magnet, using Fast Imaging Employing Steady State Acquisition and T2-weighted fast-recovery fast-spin echo sequences in axial and coronal plane. CT and MRI examinations were analysed for the presence of colonic abnormalities and associated findings. RESULTS Segmental involvement was seen in 6 patients (85.71%), with a mean length of involvement of 412 mm (range 145.5-1000 mm). Wall thickness varied between 6 mm and 17.5 mm (mean 10.52 mm) upon CT examinations and from 5 to 15 mm (mean 8.8 mm) upon MR examinations. The MRI appearance of the colonic wall varied over the time: Type I appearance with a 3 layer sandwich sign was seen in 5 out of 12 examinations (41.66%), patients underwent MR within a mean of 36 h (ranging from 1 to 54 h) after the CT examination. Type II and III appearance with a 2 layer sign, was seen in 4 examinations (33.33%), patients underwent MR within a mean of 420.5 h (ranging from 121 to 720 h) after the CT examination. In the remaining three MRI examinations, performed within a mean of 410 h (ranging from 99.5 to 720 h) the colonic wall appeared normal. CONCLUSION MRI, only using precontrast images, may be used as a substitute for invasive procedures in diagnosis and follow-up of acute IC.

Sigmoid diverticulitis: US findings

Acute diverticulitis (AD) results from inflammation of a colonic diverticulum. It is the most common cause of acute left lower-quadrant pain in adults and represents a common reason for acute hospitalization, as it affects over half of the population over 65 years with a prevalence that increases with age. Although 85% of colonic diverticulitis will recover with a nonoperative treatment, some patients may have complications such as abscesses, fistulas, obstruction, and /or perforation at presentation. For these reasons, different classifications were introduced through times to help clinicians to develop a correct diagnosis and guide the treatment and for the same reasons imaging is used in most cases both to realise a differential diagnosis and to guide the therapeutic management. US and CT are both usefull in diagnosis of diverticolitis, and their sensibility and specificity are similar. However CT scanning is essential for investigating complicated diverticular disease especially where there are diffuse signs and clinical suspicion of secondary peritonitis; instead in most uncomplicated cases the experienced sonographer may quickly confirm a diagnosis guided by the clinical signs. US is to be recommended in premenopausal women, and in young people to reduce dose exposure.

Bowel and mesenteric injuries from blunt abdominal trauma: a review

The bowel and the mesentery represent the third most frequently involved structures in blunt abdominal trauma after the liver and the spleen. Clinical assessment alone in patients with suspected intestinal and/or mesenteric injury from blunt abdominal trauma is associated with unacceptable diagnostic delays. Multi-detector computed tomography, thanks to its high spatial, time and contrast resolutions, allows a prompt identification and proper classification of such conditions. The radiologist, in fact, is asked not only to identify the signs of trauma but also to provide an indication of their clinical significance, suggesting the chance of conservative treatment in the cases of mild and moderate, non-complicated or self-limiting injuries and focusing on life-threatening conditions which may benefit from immediate surgical or interventional procedures. Specific and non-specific CT signs of bowel and mesenteric injuries from blunt abdominal trauma are reviewed in this paper.

Differences in perfusion CT parameter values with commercial software upgrades: a preliminary report about algorithm consistency and stability.

Background Computed tomographic perfusion (CTp) imaging is a promising technique that allows functional imaging, as an adjunct to a morphologic CT examination, that can be used as an aid to carefully evaluate the response to therapy in oncologic patients. Considering this statement, it could be desirable that the measurements obtained with the CT perfusion software, and their upgrades, are consistent and reproducible. Purpose To determine how commercial software upgrades impact on algorithm consistency and stability among the three version upgrades of the same platform in a preliminary study. Material and Methods Blood volume (BV), blood flow (BF), mean transit time (MTT), and permeability surface area product (PS) were calculated with repeated measurements (n = 1119) while truncating the time density curve at different time values in six CT perfusion studies using CT perfusion software version 4D (CT Perfusion 4D), then repeated with the previous version (CT Perfusion 3.0 and CT Perfusion 4.0), using a fixed ROI both for arterial input and target lesion. The software upgrades were compared in pairs by applying a Kolmogorov-Smirnov test to all the parameters measured. Stability and reliability of the three versions were verified through the variation of the truncated parameters. Results The three software versions provided different parent distributions for approximately 80% of the 72 parameters measured. A complete agreement was found only for one patient in version 3.0 vs. 4.0 and 3.0 vs. 4D. Perfusion 4.0 vs. 4D: a complete agreement was found only in two cases. Parameters obtained with Perfusion 4D always showed the lowest standard deviation in all temporal intervals and also for all individual parameters. Conclusion The three versions of the same platform tested yield different perfusion measurements. Thus, our preliminary results show that Perfusion 4D version uses a stable deconvolution algorithm to provide more reliable measurements.

Reperfusion in non-occlusive mesenteric ischaemia (NOMI): effectiveness of CT in an emergency setting.

OBJECTIVE To investigate the CT features of reperfusion (presence/absence) in non-occlusive mesenteric ischaemia (NOMI) and their prognostic value in an emergency setting. METHODS A revision was undertaken of imaging from 20 patients (16 males/4 females) with a dismissal summary of NOMI. All patients had previously undergone a minimum of one multidetector CT examination, and consequently underwent surgery (n = 8), autopsy (n = 2), angiography (n = 1) or endoscopy (n = 9). An evaluation of the CT scans was conducted to determine vessels, mesentery, bowel and peritoneal cavity features. The superior mesenteric artery (SMA) average diameter of NOMI cases were compared with 30 controlled cases. Kappa, Kolmogorov-Smirnov (K-S) and Fishers exact tests were used for statistical analysis. RESULTS A mean SMA diameter significantly smaller than that of the controlled cases was found for patients with NOMI (K-S test: D = 0.75, p = 3.7 × 10-08). Fishers exact tests showed a strong connection between the presence of reperfusion and mesenteric fat stranding (p = 0.026), bowel wall thickening (p = 3.2 × 10-05) and a high attenuation of the bowel wall on unenhanced CT images (p = 2.8 × 10-04). A reduction in mortality was significantly linked to the combination of normal mesenteric vessels and wall thickening (p = 0.034). CONCLUSION Analysis of not only vessels findings but also mesentery and bowel CT features will support the identification of NOMI with or without a reperfusion event in an emergency setting. A strong correlation between some CT features and lower mortality exists. ADVANCES IN KNOWLEDGE CT features of NOMI with or without reperfusion are demonstrated. Correctly assessing the presence of reperfusion in NOMI, may allow better management of these conditions in the emergency setting.

CT Perfusion in the Characterisation of Renal Lesions: An Added Value to Multiphasic CT

Objective. To prospectively evaluate if computed tomography perfusion (CTp) could be a useful tool in addition to multiphasic CT in renal lesion characterisation. Materials and Methods. Fifty-eight patients that were scheduled for surgical resection of a renal mass with a suspicion of renal cell carcinoma (RCC) were enrolled. Forty-one out of 58 patients underwent total or partial nephrectomy after CTp examination, and a pathological analysis was obtained for a total of 49 renal lesions. Perfusion parameters and attenuation values at multiphasic CT for both lesion and normal cortex were analysed. All the results were compared with the histological data obtained following surgery. Results. PS and MTT values were significantly lower in malignant lesions than in the normal cortex (P < 0.001 and P = 0.011, resp.); PS, MTT, and BF values were also statistically different between oncocytomas and malignant lesions. According to ROC analysis, the accuracy, sensitivity, and specificity to predict RCC were 95.92%, 100%, and 66.7%, respectively, for CTp whereas they were 89.80%, 93.35%, and 50%, respectively, for multiphasic CT. Conclusion. A significant difference between renal cortex and tumour CTp parameter values may suggest a malignant renal lesion. CTp could represent an added value to multiphasic CT in differentiating renal cells carcinoma from oncocytoma.

MR lymphangiography: a practical guide to perform it and a brief review of the literature from a technical point of view

We propose a practical approach for performing high-resolution MR lymphangiography (MRL). We shall discuss and illustrate the technical approach for the visualization of lymphatic vessels in patients suffering from lymphedema, how to distinguish lymphatic vessels from veins, and MRL role in supermicrosurgery treatment planning. A brief review of literature, from a technical point of view, is also reported.

Reduced Time CT Perfusion Acquisitions Are Sufficient to Measure the Permeability Surface Area Product with a Deconvolution Method

Objective. To reduce the radiation dose, reduced time CT perfusion (CTp) acquisitions are tested to measure permeability surface (PS) with a deconvolution method. Methods and Materials. PS was calculated with repeated measurements (n = 305) while truncating the time density curve (TDC) at different time values in 14 CTp studies using CTp 4D software (GE Healthcare, Milwaukee, WI, US). The median acquisition time of CTp studies was 59.35 sec (range 49–92 seconds). To verify the accuracy of the deconvolution algorithm, a variation of the truncated PS within the error measurements was searched, that is, within 3 standard deviations from the mean nominal error provided by the software. The test was also performed for all the remaining CTp parameters measured. Results. PS maximum variability happened within 25 seconds. The PS became constant after 40 seconds for the majority of the active tumors (10/11), while for necrotic tissues it was consistent within 1% after 50 seconds. A consistent result lasted for all the observed CTp parameters, as expected from their analytical dependance. Conclusion. 40-second acquisition time could be an optimal compromise to obtain an accurate measurement of the PS and a reasonable dose exposure with a deconvolution method.

Incidental and Underreported Pleural Plaques at Chest CT: Do Not Miss Them—Asbestos Exposure Still Exists

Pleural plaques (PPs) may be a risk factor for mortality from lung cancer in asbestos-exposed workers and are considered to be a marker of exposure. Diagnosing PPs is also important because asbestos-exposed patients should be offered a health surveillance that is mandatory in many countries. On the other hand PPs are useful for compensation purposes. In this study we aimed to evaluate the prevalence, as incidental findings, and the underreporting rate of PPs in chest CT scans (CTs) performed in a cohort of patients (1512) who underwent chest CT with a slice thickness no more than 1.25 mm. PPs were found in 76 out of 1482 patients (5.1%); in 13 out of 76 (17,1%) CTs were performed because of clinical suspicion of asbestos exposure and 5 of them (38%) were underreported by radiologist. In the remaining 63 cases (82.9%) there was no clinical suspicion of asbestos exposure at the time of CTs (incidental findings) and in 38 of these 63 patients (60.3%) PPs were underreported. Reaching a correct diagnosis of PPs requires a good knowledge of normal locoregional anatomy and rigorous technical approach in chest CT execution. However the job history of the patient should always be kept in mind.