Nicola Stagnaro

Multislice CT in congenital bronchopulmonary malformations in children

Congenital bronchopulmonary malformations encompass a wide spectrum of pathologies involving the lungs, trachea and bronchi, pulmonary vessels, and oesophagus. These developmental lesions are often isolated, but the association of two or more anomalies is not infrequent. Contrast-enhanced multidetector computed tomography (MDCT), thanks to multiplanar and 3D reconstructions, allows for detailed studies of these malformations, achieving better accuracy compared with conventional techniques such as chest X-ray, fluoroscopy, ventilation and perfusion scintigraphy and ultrasonography. MDCT is characterised by fast data acquisition and does not require sedation in the majority of cases. The main drawbacks of MDCT are the use of ionising radiation and — in many cases —contrast media. Recently, improved CT scanners and optimised CT protocols have made available to children all the benefits of MDCT, thanks to a significant reduction in radiation dose and an improved risk-benefit ratio. The aim of our paper was to evaluate MDCT in children with bronchopulmonary malformations by reporting our experience (about 2,400 studies in 30 months with a 64-slice MDCT scanner) and comparing it with the available literature.RiassuntoLe malformazioni congenite broncopolmonari rappresentano un ampio spettro di patologie che interessano il parenchima polmonare, il sistema vascolare, le vie aeree centrali e l’esofago. I pazienti affetti presentano quadri malformativi semplici o complessi, rispettivamente caratterizzati da una o più anomalie associate. La tomografia computerizzata (TC) volumetrica multidettetore (MDCT) con mezzo di contrasto permette di analizzare dettagliatamente le strutture toraciche coinvolte nelle malformazioni, con ricostruzioni multiplanari e 3D, con un’accuratezza superiore ad altre indagini tradizionalmente utilizzate tra cui il radiogramma toracico, gli studi fluoroscopici, l’ecografia e la scintigrafia ventilatoria perfusionale. Inoltre la rapidità di acquisizione dei dati consente di evitare nella maggior parte dei casi la sedazione del bambino. Lo svantaggio è rappresentato dall’utilizzo di radiazioni ionizzanti e dalla necessità di somministrare mezzo di contrasto per via endovenosa. Recentemente l’evoluzione tecnologica degli scanner TC e la definizione di protocolli pediatrici dedicati ha permesso una significativa riduzione della dose assorbita, pertanto oggi è possibile usufruire delle potenzialità della MDCT nello studio del torace del bambino con un rapporto rischio-beneficio ragionevolmente vantaggioso. Il nostro articolo si propone di valutare i differenti aspetti dell’impiego della TC sul bambino analizzando la letteratura e confrontandola con l’esperienza personale, unica in Italia: circa 2400 TC del torace in 30 mesi in pazienti compresi tra 1 giorno e 16 anni con un apparecchio a 64 strati.

Ultrasound findings in dual kidney transplantation.

PurposeThis study was done to analyse colour Doppler ultrasound (CDUS) findings in patients with dual kidney transplantation (DKT) and to compare renal volume and resistive index (RI) values between DKT and single kidney transplantation (SKT).Materials and methodsWe reviewed the clinical and imaging findings [30 CDUS, five magnetic resonance (MR) and one computed tomography (CT) examination] in 30 patients with DKT (23 men and seven women; median age 65 years; range 55–82). Three patients had clinical signs of graft malfunction. Renal volumes and RI were compared with those of 14 SKT patients and comparable levels of renal function.ResultsThree patients had graft dysfunction: one had chronic rejection and two had pathologies involving one kidney only (one encrusted pyeloureteritis of a left graft and one occluded main artery of a left graft). Asymptomatic unilateral pathologies were seen in six cases. In asymptomatic DKT patients, no significant differences in length, volume, cortical echogenicity and RI between the two kidneys were observed; DKTs were smaller (median volume 116.7 vs. 171.6 cc) and had higher RIs (0.76 vs. 0.68) (p<0.01) than SKTs.ConclusionsCDUS provides useful information in patients with DKT, allowing detection of clinically unsuspected unilateral diseases. At comparable levels of renal function, DKT patients had higher RI and lower volumes than SKT patients.RiassuntoObiettivoScopo del presente lavoro è stato analizzare gli aspetti eco-color Doppler (USD) in pazienti con trapianto di doppio rene (DKT) e paragonare volume renale e indice di resistenza (RI) nei pazienti con DKT e con trapianto di rene singolo da donatore ideale (SKT).Materiali e metodiAbbiamo valutato i dati clinici e di imaging [30 USD, 5 risonanze magnetiche (RM) e 1 tomografia computerizzata (TC)] in 30 pazienti con DKT (23 maschi e 7 femmine, età media 65 anni; range 55–82) paragonando volume renale e RI con quelli di 14 pazienti con SKT e livelli simili di funzione renale.RisultatiTre pazienti avevano disfunzione del trapianto: uno con rigetto cronico e due con patologie coinvolgenti un solo rene (1 pielonefrite incrostata rene sinistro e 1 occlusione dell’arteria renale sinistra). Alterazioni asintomatiche unilaterali sono state riscontrate in 6 ulteriori pazienti. Nei DKT asintomatici non sono state riscontrate differenze significative di lunghezza, volume, ecogenicità corticale e RI tra i due reni; nei DKT i reni erano più piccoli (volume 116,7 vs. 171,6 cc) e con RI più alto (0,76 vs. 0,68) (p<0,01) rispetto ai SKT.ConclusioniL’USD fornisce utili informazioni nei pazienti con DKT, permettendo il riscontro di anomalie asintomatiche unilaterali non clinicamente sospette; a livelli comparabili di funzione renale, i pazienti con DKT hanno valori di RI più alti e volume renale inferiore rispetto ai pazienti con SKT.

Multimodality imaging of pediatric airways disease: indication and technique

Congenital and acquired airway anomalies represent a relatively common albeit diagnostic and therapeutic challenge, even for the most skilled operators in dedicated centers. Airway malformations encompass a wide spectrum of pathologies involving the larynx, trachea and bronchi, esophagus, mediastinal vessels. These developmental lesions are often isolated but the association of two or more anomalies is not infrequent. From the traditional chest X-ray to the newest applications of Optical Coherence Tomography, non- or mini-invasive diagnostic techniques represent useful tools to integrate invasive procedures. Comprehensive knowledge of the characteristics of each diagnostic test is mandatory for its useful application. The aim of our paper is to analyze the clinical indications for Imaging the Airway disease in pediatric population, and describe the diagnostic techniques. Only by a close interaction between all the operators involved in diagnosis and treatment of pediatric airway, as it happens in Multidisciplinary Airway Team, the non- or mini-invasive imaging is effective.

Complications After Stent Placement for Aortic Coarctation: A Pictorial Essay of Computed Tomographic Angiography

Stent placement is commonly used to treat aortic coarctation. Although invasive angiography remains the gold standard, follow-up is often performed using computed tomography, which allows rapid, noninvasive assessment of the aorta and surrounding tissues. The goal of this pictorial essay is to provide a guide to the interpretation of these examinations. Normal and abnormal computed tomographic appearance of different stent types is shown along with reconstructions that can help assess stent integrity and the stent position in relation to the aortic wall and branches. Furthermore, imaging findings of complications including aortic wall injuries, restenosis, and intimal hyperplasia are depicted.

Uterine rupture with placental extrusion during the third stage of labour after an apparently uneventful delivery

A 39-year-old woman, gravida 4, para 2 was admitted at 34weeks of gestation in threatened preterm labour. She had a voluntary abortion in 2005 with dilatation and curettage, a normal delivery at term in 2011 and a caesarean section for preterm labour with a breech foetus at 32weeks in 2012. The type of the uterine incision was unknown. Transabdominal ultrasound did not show any abnormality; the placenta was anterograde-fundal and the lower segment thickness was 2.5 cm. Tocolysis and steroid therapy, for lung maturation, were implemented. Nevertheless, 6 days later, after a preterm premature rupture of membranes (pPROM), the labour started. The patient opted for a vaginal birth after caesarean section (VBAC) and, after 2 h, gave birth to a healthy male. An epidural analgesia was not requested. Neither external intervention nor pharmacological augmentation was performed. The continuous cardiotocography was reassuring throughout the labour. After delivery, uterotonics were administered (synthetic Oxytocin, 5 UI i.v.) as postpartum haemorrhage prophylaxis. The third stage, however, was prolonged. Since the patient felt well, she requested to be submitted to as few as possible interventions; her vital signs were stable, and as the bleeding was minimal it was decided to wait. During this time, a controlled cord traction and moderate fundal pressure were administered intermittently. However, after an hour, the placenta was still retained. Before attempting a manual placental removal, an ultrasound was performed and revealed an empty uterus and placental extrusion thought a dehiscence of the uterine scar (see Figure 1(A)). A pelvic MR confirmed the diagnosis and showed that the placenta was completely detached, excluding a morbid adherence to the uterine wall (see Figure 1(B)). The placenta was removed through a laparotomic access. The uterus was contracted around the rupture. No clinically significant hemoperitoneum was found. The uterine scar dehiscence was sutured in double layers. The woman subsequently developed an infection and sepsis, was treated with antibiotics and this was completely solved at her discharge, 5 days after her delivery. Discussion

Computed tomography image quality of aortic stents in patients with aortic coarctation: a multicentre evaluation

BackgroundStents are commonly used to treat aortic coarctation. The objective of this study was to evaluate the post-implantation computed tomography (CT) image quality of different stent types used to treat aortic coarctation.MethodsAdult and paediatric patients with stent-treated aortic coarctation who underwent contrast-enhanced CT were retrospectively included from three tertiary care centres. CT scans were subjectively scored for image quality using a 4-point scale (1 = unacceptable; 2 = poor; 3 = good; 4 = excellent). Furthermore, the amount of stent-induced blooming artefacts was measured as the percentage of the difference between outer and inner stent diameters over the outer stent diameter.ResultsA total of 35 children and 34 adults implanted with 71 stents of six different types were included. The most commonly used stent type was the Cheatham Platinum stent (52 stents, 73%). The subjective image quality of the Cheatham Platinum stents was moderate with a score of 2.0±0.8 (mean ± standard deviation) in children and 2.3±0.6 in adults. The image quality in patients with Formula stents was 2.3±1.2. The Cheatham Platinum stents induced 34–48% blooming, the Formula stents 44–55%. The image quality in patients with the less commonly used Atrium Advanta V12, IntraStent, AndraStent and Palmaz stents was scored 3 (good) to 4 (excellent) with less blooming. The electrocardiographic gating and tube voltage (kVp) did not affect image quality.ConclusionsThere is a substantial variation in CT image quality and blooming artefacts for different stent types used to treat aortic coarctation.

The right atrium value in patients operated for tetralogy of Fallot

Background Left atrium enlargement is directly proportional to the severity of underlying clinical (or subclinical) cardiovascular disease. Right atrium (RA) measurements are not routinely performed despite their prognostic value has been demonstrated in chronic heart failure, atrial and pulmonary arterial hypertension. The aim of the study was to evaluate RA dimensions and volumes by cardiac Magnetic Resonance (CMR) in a large cohort of operated Fallot (opTF) compared to a control group, and correlate the RA size to traditional prognostic parameters and clinical events.

Valutazione eco-color Doppler nel doppio trapianto di rene

PurposeThis study was done to analyse colour Doppler ultrasound (CDUS) findings in patients with dual kidney transplantation (DKT) and to compare renal volume and resistive index (RI) values between DKT and single kidney transplantation (SKT).Materials and methodsWe reviewed the clinical and imaging findings [30 CDUS, five magnetic resonance (MR) and one computed tomography (CT) examination] in 30 patients with DKT (23 men and seven women; median age 65 years; range 55–82). Three patients had clinical signs of graft malfunction. Renal volumes and RI were compared with those of 14 SKT patients and comparable levels of renal function.ResultsThree patients had graft dysfunction: one had chronic rejection and two had pathologies involving one kidney only (one encrusted pyeloureteritis of a left graft and one occluded main artery of a left graft). Asymptomatic unilateral pathologies were seen in six cases. In asymptomatic DKT patients, no significant differences in length, volume, cortical echogenicity and RI between the two kidneys were observed; DKTs were smaller (median volume 116.7 vs. 171.6 cc) and had higher RIs (0.76 vs. 0.68) (p<0.01) than SKTs.ConclusionsCDUS provides useful information in patients with DKT, allowing detection of clinically unsuspected unilateral diseases. At comparable levels of renal function, DKT patients had higher RI and lower volumes than SKT patients.RiassuntoObiettivoScopo del presente lavoro è stato analizzare gli aspetti eco-color Doppler (USD) in pazienti con trapianto di doppio rene (DKT) e paragonare volume renale e indice di resistenza (RI) nei pazienti con DKT e con trapianto di rene singolo da donatore ideale (SKT).Materiali e metodiAbbiamo valutato i dati clinici e di imaging [30 USD, 5 risonanze magnetiche (RM) e 1 tomografia computerizzata (TC)] in 30 pazienti con DKT (23 maschi e 7 femmine, età media 65 anni; range 55–82) paragonando volume renale e RI con quelli di 14 pazienti con SKT e livelli simili di funzione renale.RisultatiTre pazienti avevano disfunzione del trapianto: uno con rigetto cronico e due con patologie coinvolgenti un solo rene (1 pielonefrite incrostata rene sinistro e 1 occlusione dell’arteria renale sinistra). Alterazioni asintomatiche unilaterali sono state riscontrate in 6 ulteriori pazienti. Nei DKT asintomatici non sono state riscontrate differenze significative di lunghezza, volume, ecogenicità corticale e RI tra i due reni; nei DKT i reni erano più piccoli (volume 116,7 vs. 171,6 cc) e con RI più alto (0,76 vs. 0,68) (p<0,01) rispetto ai SKT.ConclusioniL’USD fornisce utili informazioni nei pazienti con DKT, permettendo il riscontro di anomalie asintomatiche unilaterali non clinicamente sospette; a livelli comparabili di funzione renale, i pazienti con DKT hanno valori di RI più alti e volume renale inferiore rispetto ai pazienti con SKT.

Ultrasound findings in dual kidney transplantation@@@Valutazione eco-color Doppler nel doppio trapianto di rene

PurposeThis study was done to analyse colour Doppler ultrasound (CDUS) findings in patients with dual kidney transplantation (DKT) and to compare renal volume and resistive index (RI) values between DKT and single kidney transplantation (SKT).Materials and methodsWe reviewed the clinical and imaging findings [30 CDUS, five magnetic resonance (MR) and one computed tomography (CT) examination] in 30 patients with DKT (23 men and seven women; median age 65 years; range 55–82). Three patients had clinical signs of graft malfunction. Renal volumes and RI were compared with those of 14 SKT patients and comparable levels of renal function.ResultsThree patients had graft dysfunction: one had chronic rejection and two had pathologies involving one kidney only (one encrusted pyeloureteritis of a left graft and one occluded main artery of a left graft). Asymptomatic unilateral pathologies were seen in six cases. In asymptomatic DKT patients, no significant differences in length, volume, cortical echogenicity and RI between the two kidneys were observed; DKTs were smaller (median volume 116.7 vs. 171.6 cc) and had higher RIs (0.76 vs. 0.68) (p<0.01) than SKTs.ConclusionsCDUS provides useful information in patients with DKT, allowing detection of clinically unsuspected unilateral diseases. At comparable levels of renal function, DKT patients had higher RI and lower volumes than SKT patients.RiassuntoObiettivoScopo del presente lavoro è stato analizzare gli aspetti eco-color Doppler (USD) in pazienti con trapianto di doppio rene (DKT) e paragonare volume renale e indice di resistenza (RI) nei pazienti con DKT e con trapianto di rene singolo da donatore ideale (SKT).Materiali e metodiAbbiamo valutato i dati clinici e di imaging [30 USD, 5 risonanze magnetiche (RM) e 1 tomografia computerizzata (TC)] in 30 pazienti con DKT (23 maschi e 7 femmine, età media 65 anni; range 55–82) paragonando volume renale e RI con quelli di 14 pazienti con SKT e livelli simili di funzione renale.RisultatiTre pazienti avevano disfunzione del trapianto: uno con rigetto cronico e due con patologie coinvolgenti un solo rene (1 pielonefrite incrostata rene sinistro e 1 occlusione dell’arteria renale sinistra). Alterazioni asintomatiche unilaterali sono state riscontrate in 6 ulteriori pazienti. Nei DKT asintomatici non sono state riscontrate differenze significative di lunghezza, volume, ecogenicità corticale e RI tra i due reni; nei DKT i reni erano più piccoli (volume 116,7 vs. 171,6 cc) e con RI più alto (0,76 vs. 0,68) (p<0,01) rispetto ai SKT.ConclusioniL’USD fornisce utili informazioni nei pazienti con DKT, permettendo il riscontro di anomalie asintomatiche unilaterali non clinicamente sospette; a livelli comparabili di funzione renale, i pazienti con DKT hanno valori di RI più alti e volume renale inferiore rispetto ai pazienti con SKT.

Multislice CT in congenital bronchopulmonary malformations in children@@@La TC multistrato nello studio delle malformazioni congenite broncopolmonari in età pediatrica

Congenital bronchopulmonary malformations encompass a wide spectrum of pathologies involving the lungs, trachea and bronchi, pulmonary vessels, and oesophagus. These developmental lesions are often isolated, but the association of two or more anomalies is not infrequent. Contrast-enhanced multidetector computed tomography (MDCT), thanks to multiplanar and 3D reconstructions, allows for detailed studies of these malformations, achieving better accuracy compared with conventional techniques such as chest X-ray, fluoroscopy, ventilation and perfusion scintigraphy and ultrasonography. MDCT is characterised by fast data acquisition and does not require sedation in the majority of cases. The main drawbacks of MDCT are the use of ionising radiation and — in many cases —contrast media. Recently, improved CT scanners and optimised CT protocols have made available to children all the benefits of MDCT, thanks to a significant reduction in radiation dose and an improved risk-benefit ratio. The aim of our paper was to evaluate MDCT in children with bronchopulmonary malformations by reporting our experience (about 2,400 studies in 30 months with a 64-slice MDCT scanner) and comparing it with the available literature.RiassuntoLe malformazioni congenite broncopolmonari rappresentano un ampio spettro di patologie che interessano il parenchima polmonare, il sistema vascolare, le vie aeree centrali e l’esofago. I pazienti affetti presentano quadri malformativi semplici o complessi, rispettivamente caratterizzati da una o più anomalie associate. La tomografia computerizzata (TC) volumetrica multidettetore (MDCT) con mezzo di contrasto permette di analizzare dettagliatamente le strutture toraciche coinvolte nelle malformazioni, con ricostruzioni multiplanari e 3D, con un’accuratezza superiore ad altre indagini tradizionalmente utilizzate tra cui il radiogramma toracico, gli studi fluoroscopici, l’ecografia e la scintigrafia ventilatoria perfusionale. Inoltre la rapidità di acquisizione dei dati consente di evitare nella maggior parte dei casi la sedazione del bambino. Lo svantaggio è rappresentato dall’utilizzo di radiazioni ionizzanti e dalla necessità di somministrare mezzo di contrasto per via endovenosa. Recentemente l’evoluzione tecnologica degli scanner TC e la definizione di protocolli pediatrici dedicati ha permesso una significativa riduzione della dose assorbita, pertanto oggi è possibile usufruire delle potenzialità della MDCT nello studio del torace del bambino con un rapporto rischio-beneficio ragionevolmente vantaggioso. Il nostro articolo si propone di valutare i differenti aspetti dell’impiego della TC sul bambino analizzando la letteratura e confrontandola con l’esperienza personale, unica in Italia: circa 2400 TC del torace in 30 mesi in pazienti compresi tra 1 giorno e 16 anni con un apparecchio a 64 strati.