Nicolas Sans

CT-guided percutaneous treatment of inoperable pulmonary aspergillomas: a study of 40 cases

OBJECTIVE To treat symptomatic pulmonary aspergilloma in patients who were not considered to be operable. MATERIAL AND METHODS Forty patients were treated by CT-guided percutaneous injection of amphotericin paste, the aim being to fill the cavity completely and create an anaerobic environment for the aspergillus. The aspergillomas had developed after bacillary infection and pulmonary fibrosis. Surgery was contra-indicated in these patients because of severe respiratory failure. The authors detail the method of preparation of the paste and the technique of percutaneous injection. RESULTS Hemoptysis ceased in all 40 patients, with a follow-up ranging from 6 to 28 months; six patients were also treated with bronchial embolization. In 26 patients, the aspergilloma disappeared and serum tests for aspergillus became negative. Complete disappearance of both the aspergilloma and the cavity was obtained in three patients. CONCLUSION This technique appears to be a valuable contribution to non-surgical treatment of inoperable patients with pulmonary aspergilloma, but study should be continued in a larger series to define the exact indications and the interaction with other treatments which have recently been introduced.

Ultrasonography of the brachial plexus, normal appearance and practical applications

Ultrasound examination of the brachial plexus, although at first sight difficult, is perfectly feasible with fairly rapid practical and theoretical training. The roots are accurately identified due to the shape (a single tubercle) of the transverse process of C7 in the paravertebral space, and the superficial position of C5 in the interscalene groove. The téléphérique technique allows the roots, trunks and cords to be followed easily into the supraclavicular fossa. In just a few years, ultrasound imaging of the plexus has become a routine anesthesia examination for guiding nerve blocks. In trained hands, it also provides information in thoracic outlet syndromes, traumatic conditions (particularly for postganglionic lesions) and tumoral diseases. Even if MRI remains the standard examination in these indications, ultrasound, with its higher definition and dynamic character, is an excellent additional method which is still under-exploited.

3-T MRI with diffusion tensor imaging and tractography of the median nerve

AbstractObjectiveTo apply diffusion tensor imaging (DTI) and tractography to the median nerve by use of a 3-T MRI device in order to demonstrate potential differences in diffusion parameters between healthy subjects and patients with carpal tunnel syndrome (CTS).MethodsThe median nerve of 15 patients and 20 healthy volunteers was examined in two sequences: DTI and a high-resolution T1-weighted sequence. Mean fractional anisotropy (FA) and mean apparent diffusion coefficient (ADC) were measured based on tractography findings. Mean FA was significantly lower in CTS patients (P = 0.01) whereas no significant difference was found in mean ADC. Focal measurements of FA and ADC were also obtained at three locations along the course of the median nerve.ResultsWe observed a highly significant difference (P < 0.0001) between FA measured at the proximal carpus and FA measured at the distal carpus in healthy subjects and CTS patients. Focal FA values along the median nerve showed an opposite trend in the two groups: in healthy subjects FA tended to increase (P < 0.05) whereas in subjects with CTS it tended to decrease (P = 0.0001). We defined a threshold value of −0.058 (FA3-FA1) that was sensitive and specific for nerve compression.ConclusionDTI and tractography can detect chronic nerve compression.Key Points• Diffusion tensor magnetic resonance imaging offers new information about carpal tunnel syndrome. • Diffusion tensor MRI of the median nerve provides some functional data. • Mean fractional anisotropy (FA) was lower in patients with CTS than volunteers. • There was no significant difference in ADC values between patients and volunteers. • Fractional anisotropy seems a sensitive and specific predictor of chronic nerve compression.

Low-dose biplanar radiography can be used in children and adolescents to accurately assess femoral and tibial torsion and greatly reduce irradiation.

PurposeTo evaluate in children the agreement between femoral and tibial torsion measurements obtained with low-dose biplanar radiography (LDBR) and CT, and to study dose reduction ratio between these two techniques both in vitro and in vivo.Materials and methodsThirty children with lower limb torsion abnormalities were included in a prospective study. Biplanar radiographs and CTs were performed for measurements of lower limb torsion on each patient. Values were compared using Bland-Altman plots. Interreader and intrareader agreements were evaluated by intraclass correlation coefficients. Comparative dosimetric study was performed using an ionization chamber in a tissue-equivalent phantom, and with thermoluminescent dosimeters in 5 patients.ResultsAverage differences between CT and LDBR measurements were –0.1° ±1.1 for femoral torsion and –0.7° ±1.4 for tibial torsion. Interreader agreement for LDBR measurements was very good for both femoral torsion (FT) (0.81) and tibial torsion (TT) (0.87). Intrareader agreement was excellent for FT (0.97) and TT (0.89). The ratio between CT scan dose and LDBR dose was 22 in vitro (absorbed dose) and 32 in vivo (skin dose).ConclusionLower limb torsion measurements obtained with LDBR are comparable to CT measurements in children and adolescents, with a considerably reduced radiation dose.Key points• LDBR and CT lower-limb torsion measurements are comparable in children and adolescents.• LDBR considerably reduced radiation dose necessary for lower-limb torsion measurements.• LDBR can be used for evaluation of lower limb-torsion in orthopaediatric patients.

Prognosis value of early diffusion MRI in Legg Perthes Calvé disease

PURPOSE To evaluate diffusion MRI of the proximal femoral epiphysis and metaphysis as a prognosis factor in Legg Calvé Perthes (LCP) disease. METHODS Thirty-one children (mean age 5.5 years, range 2.5-10.5) with unilateral LCP were included in a prospective, consecutive series. Radiographs were analysed and classified as per Herring criteriae. Mean follow-up was 19 months (range 6-30). Forty-nine MRI scans were performed at either the condensation or fragmentation stage. Apparent Diffusion Coefficient (ADC) of both the femoral epiphysis and metaphysis were measured bilaterally and ADC ratio were calculated, then compared to the Herring group. RESULTS Sixteen hips were rated Herring A or B, 3 Herring B-C and 12 Herring C. ADC was increased in affected hips compared to unaffected sides, both at the femoral epiphysis (P<0.001) and metaphysis (P<0.0001). ADC ratio of the femoral metaphysis was positively correlated to Herring classification: if superior to 1.63, it was associated with a bad prognosis (Herring B-C or C) (P=0.0017, sensitivity=89%, specificity=58%). Interobserver reliability of ADC measurement was excellent. The 1.63 threshold could be determined as early as the condensation stage. CONCLUSIONS Diffusion presents several advantages including being non radiating and non invasive. It does not need contrast medium administration and it can be performed without anaesthesia. The origin of the increased ADC remains unknown. Basically, it reflects molecular changes (true diffusion) but it is also influenced by the vascular supply (pseudo-diffusion). ADC ratio could provide an early prognosis before Herring classification is applicable. LEVEL OF EVIDENCE Level III. Prospective uncontrolled study.

Diffusion MRI of the neck of the femur in Legg-Calve-Perthes disease: a preliminary study.

PURPOSE To evaluate diffusion MR imaging of the neck of the femur in Legg-Calve-Perthes disease (LCPD). MATERIAL AND METHODS This is a prospective study in 27 children followed for unilateral LCPD. Forty-six MRIs were carried out with bilateral quantification of the apparent diffusion coefficient (ADC) of the neck of the femur. The intra- and inter-observer variability of the ADC measurements was evaluated. The association between the ADC and age as well as the healthy or pathological status of the neck of the femur and the Catterall classification were looked for. RESULTS Intra- and inter-observer reproducibility of the ADC measurements was excellent. A statistically significant negative correlation between the ADC of the healthy neck of the femur and age was found. There was a significant increase in the ADC of the pathological neck of the femur compared to the healthy neck. The ratio of the pathological neck ADC and the healthy neck ADC was significantly associated with the Catterall classification. CONCLUSION The quantification of the ADC of the neck of the femur is reproducible. This could be useful in the treatment of LCPD, where there is an early and significant increase in the ADC on the pathological side. This increase could have a prognostic value, as it is correlated with the Catterall classification.

Métastase osseuse d’un cancer viscéral sur hanche prothésée: À propos de trois cas

Three cases of metastasis on a previous total hip arthroplasty are reported. The hips had been operated a few years earlier for osteoarthritis. The patients then developed a carcinoma (kidney, prostate, breast) which disseminated producing bony metastases around the prosthesis which caused loosening. All three patients underwent a revision procedure for prosthesis replacement with a metaphysodyaphyseal implant. Carcinological resection was performed in one patient because the metastasis appeared to be unique. At last follow-up two years later, this patient was doing well.

DIV14 Scanner multicoupe : 100 cas radio-cliniques aux urgences

Objectifs A travers une centaine de cas radio-cliniques didactiques nous montrons l’interet d’un scanner multicoupe dedie dans un site d’accueil des urgences. Materiels et methodes Ce travail prospectif collige « 100 cas radio-cliniques » traumatiques ou non traumatiques. Chaque patient a ete pris en charge dans un service d’urgence de CHU et a ete explore sur un scanner multicoupe (16 canaux). L’ensemble des cas est presente dans un CD-Rom pedagogique (interface navigateur Web) qui permet un acces facile et convivial aux differents dossiers radio-cliniques. Chaque cas contient les renseignements cliniques, les elements iconographiques les plus representatifs et une discussion basee sur les donnees recentes de la litterature et particulierement sur l’apport du scanner multicoupe pour chaque pathologie. Resultats II s’agit de cas de polytraumatises, d’urgences osteoarticulaires, abdomino-pelviennes, thoraciques, nephro-urologiques, vasculaires et de quelques pathologies diverses, pour lesquels le scanner a contribue a etablir le diagnostic et a constitue un element decisionnel dans la prise en charge du patient. Conclusion Ce CD-Rom est evolutif et peut constituer une base de donnees pour la prise en charge des urgences et leur exploration a l’aide d’un scanner multicoupe.

Interventional chest radiology.

The authors review the various interventional radiology techniques currently used in 1996 by a Medico-Radio-Surgical team. CT guided needle biopsy has an important place in the diagnostic approach to parenchymal as well as mediastinal tumours. But CT guidance allows also routine drainage of thoracic collections and sometimes thoracic sympatholysis. Superior vena cava and tracheobronchial stenting are palliative treatments as the percutaneous aspergilloma treatment. Embolization of bronchial and thoracic systemic arteries are also palliative but effective therapeutic procedures as well as vasoocclusion for arterio-venous fistulae.

Anterolateral ligament injuries in knees with an anterior cruciate ligament tear: Contribution of ultrasonography and MRI

AbstractObjectivesTo describe the pathological appearance of the anterolateral ligament (ALL) on US and MRI in knees with an anterior cruciate ligament (ACL) tear.MethodsThis prospective study included 30 patients who had a suspected acute ACL tear. Their injured and contralateral knees were evaluated with radiography, US and MRI. Two radiologists evaluated the ALL on the MRI and US examinations. Agreement between these examiners’ findings was evaluated with Cohen’s kappa.ResultsOn US examination, the ALL was found to be injured in 63% of cases (19/30; k = 0.93). The enthesis was found to be torn in 50% of cases (15/30; k = 1), with the tear located at the tibial attachment in all instances. On the MRI exam, the ALL was found to be injured in 53% of cases (16/30; k = 0.93). The enthesis was found to be torn in 13% of cases (4/30; k = 0.76), with the tear located at the tibial attachment in all instances (k = 0.93).ConclusionALL injuries that occur with ACL tears are located at the tibial enthesis. They are often associated with bone avulsion at the enthesis and are better viewed on US.Key Points• ALL injuries often occur in combination with ACL tears. • ALL injuries can be assessed with ultrasonography and MRI. • ALL injuries associated with ACL tears are located at the tibial enthesis.