Nuri Tasali

Correlation between breast density in mammography and background enhancement in MR mammography

PurposeWe aimed to analyse the influence of mammographic breast density on background enhancement (BE) at magnetic resonance (MR) mammography in preand postmenopausal women. In addition, we questioned predictability of contrast-enhancement dynamics of normal fibroglandular tissue (NFT) at MR mammography according to mammographic breast density.Materials and methodsTwenty-six patients (mean age 51.54±11.5 years; range 37–79 years) who underwent both MR mammography and conventional mammography were included in this retrospective study. Fourteen patients were premenopausal and 12 were postmenopausal. The ethics committee of our institution approved the study. The mammograms were retrospectively reviewed for overall breast density according to the four-point scale (I–IV) of the Breast Imaging Reporting and Data System (BI-RADS) classification. Two radiologists, who were unaware of the clinical data, separately assessed the MR mammography images. Images were assessed for enhancement kinetic features (enhancement kinetic curve and the early-phase enhancement rate) and BE. MR mammography and conventional mammography findings were compared according to BI-RADS breast density category and menopausal status.ResultsPercentage of increased signal intensity values during the first minute did not change according to mammographic breast density, and the mean early-phase enhancement rate scores were similar among breast density groups (p=0.942). There was no significant difference between pre- and postmenopausal groups. Enhancement kinetic features of the different groups based on BI-RADS breast density category and menopausal status were similar. There was no correlation between breast density and BE in either premenopausal (p=0.211) or in postmenopausal (p=0.735) groups.ConclusionsWe determined no correlation between mammographic breast density and so-called BE in MR mammography in either premenopausal or postmenopausal women. NFT at MR mammography cannot be predicted on the basis of mammographic breast density.RiassuntoObiettivoScopo del nostro studio è analizzare l’influenza della densità mammografica del seno sul background enhancement in risonanza magnetica, considerando donne in pre e post-menopausa. È stata inoltre valutata la prevedibilità delle dinamiche di contrast-enhancement del tessuto fibroghiandolare normale (NFT) in RM, in rapporto alla densità mammografica del seno.Materiali e metodiIn questo studio retrospettivo sono state incluse 26 pazienti (media di età 51,54±11,5; range 37–79 anni), sottoposte sia a RM sia a mammografia convenzionale. Quattordici pazienti erano in premenopausa e dodici in post-menopausa. Lo studio è stato approvato dal comitato etico del nostro istituto. Gli esami sono stati analizzati retospettivamente per valutare la densità complessiva del seno, in accordo con la scala di quattro punti (I–IV) basata sulla classificazione BI-RADS (Breast Imaging Repotring and Data System). Due radiologi, senza conoscere i dati clinici, separatamente, hanno valutato le immagini RM. Sono state analizzate le caratteristiche cinetiche di enhancement (curva della cinetica di enhancement e velocità della fase precoce di enhancement) e il background enhancement. I rilievi ottenuti in RM e in mammografia convenzionale sono poi stati comparati con la classificazione BI-RADS, e lo stato menopausale.RisultatiLa percentuale di valori con intensità del segnale aumentato durante i primi minuti non è risultata variare in rapporto alla densità mammografica del seno, e i valori medi di velocità di enhancement in fase precoce sono risultati simili tra i gruppi di densità del seno (p=0,942). Non sono emerse differenze significative tra gruppi pre e post-menopausa. Le cinetiche di enhancement dei differenti gruppi basati sulla classificazione di densità del seno (BI-RADS) e sullo stato menopausale, sono risultati simili. Non è stata evidenziata correlazione tra densità mammaria e background enhancement nei gruppi premenopausa (p=0,211),o postmenopausa (p=0,735).ConclusioniNon abbiamo rilevato correlazione tra la densità del seno in mammografia e il cosiddetto background enhancement in risonanza magnetica, né per quanto riguarda donne in pre-menopausa, né in postmenopausa. Il tessuto fibroghiandolare in RM non può essere correlato alla densità mammaria mammografica.

Dynamic MR dacryocystography in patients with epiphora

OBJECTIVE The purpose of this study was to investigate the diagnostic value of dynamic MRI dacryocystography (dMR-DCG) for the assessment of nasolacrimal drainage system (NLDS). METHODS The study population consisted of 35 patients with a history of epiphora. Each patient underwent bilateral dMR-DCG and conventional dacryocystography (DCG) to assess the NLDS. Two radiologists, who were unaware of the clinical data, evaluated the images separately for the level of obstruction at the nasolacrimal passage and the presence or absence of lacrimal sac dilatation. The findings from the dMRI-DCG and DCG images were compared. DCG was considered to be the gold standard imaging technique. RESULTS dMRI-DCG had a sensitivity of 90.5% and a specificity of 89.3% to detect nasolacrimal passage. In 24 out of 70 NLDS that were assessed, there was 100% agreement between the dMRI-DCG and DCG images in the detection of the obstructed level in the nasolacrimal pathway. The lacrimal sac dilatation finding detected by DCG was not observed by dMRI-DCG in only two patients, in whom there was a prior history of dacryocystorhinostomy (DCR) operation. These findings suggest that dMRI-DCG has 94.3% sensitivity and 100% specificity for the diagnosis of lacrimal sac dilatation. CONCLUSION dMRI-DCG is an easily performed, minimally invasive imaging technique to identify the presence or absence of obstruction and its level, and lacrimal sac dilatation in the evaluation of NLDS. dMRI-DCG does not require the use of contrast material and ionizing radiation and provides functional information by depicting dynamic behaviour. Thus, dMRI-DCG could be useful as a reliable diagnostic imaging technique in many patients prior to surgery.

Temporomandibular joint (TMJ) pain revisited with dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI)

PURPOSE We aimed to assess the contrast enhancement patterns of the retrodiscal tissue with dynamic contrast-enhanced MR imaging (DCE-MRI) with respect to different temporomandibular joint disc pathologies. Additionally, we questioned the relationship between the temporomandibular joint (TMJ) pain and the contrast enhancement pattern of the retrodiscal tissue regardless of the TMJ disc position. MATERIALS AND METHODS 52 joints of 26 patients (4 males and 22 females) who have pain in at least at one of their TMJ were included in this study. For the qualitative analysis, the joints were divided into four groups in terms of their disc positions: normal (1), partially displaced with or without reduction (2), totally dislocated with reduction (3) and totally dislocated without reduction (4). Besides, two different joint groups were constituted, namely the painful group and painless group according to the clinical findings without taking the TMJ disc positions into account. Quantitative analyses were made by means of measuring signal intensity ratios (SI) ratio at the retrodiscal tissue (from internal side and external side of the each joint) using DCE-MRI and these measurements were analyzed with paired samples t test to define the difference between the measurements. At the second stage, the time-dependent arithmetical mean values of the SI ratios were calculated for each joint group and significant differences between the groups were questioned using analysis of variance (ANOVA) test. Besides, painful and painless groups which were classified on the basis of the clinical data were compared according to the mean SI ratios found for each joint and the significant differences between these two groups were assessed by means of Students T test. The results were assessed in 95% confidence interval where the significance level was p<0.05. RESULTS A significant difference was observed between the internal and external contrast enhancement of the joints with partial displacement. Another significant difference was found between the average time versus SI ratio curves of the four groups. In consequence of the comparison made between the joints classified as painful and painless on the basis of the clinical data, one more significant difference was observed according to the mean SI ratios of the groups without taking the TMJ disc position into account. CONCLUSION The contrast enhancement patterns in the retrodiscal tissues of the painful joints showed significant differences in comparison with the painless joints. This result supports the hypothesis defending that inflammation and increased vascularity are responsible from the TMJ pain. Besides, the measurements from the retrodiscal tissues of the joints with partial displacement show significant difference between the signals of the displaced and non-displaced parts of the joints. Dynamic contrast-enhanced imaging revealed that different disc malpositions create different contrast enhancement patterns. On this basis, it is assessed that the types of the disc malpositions, which are believed to be acquired pathologies, are correlated with the retrodiscal inflammation degrees.

Do Nuss bars compromise the blood flow of the internal mammary arteries

OBJECTIVES Minimally invasive repair of pectus excavatum, the so-called Nuss procedure, has become a popular technique in recent years. The internal mammary arteries (IMAs) lie on the posterolateral surface of the sternum, and the Nuss bar is likely to obstruct the blood flow in these arteries. This obstruction could become important in the later stages of the lives of these young people if they were to require coronary artery bypass grafting. The goal of this study is to investigate the extent of obstruction of the IMAs caused by Nuss bars. METHODS Data were collected prospectively on all patients who underwent the Nuss procedure between October 2011 and May 2012. Patients with a history of pectus excavatum repair by open surgery and those who were younger than 16 years of age were excluded. Computed tomography-angiography (CTA) was performed for the detection of IMA blood flow preoperatively and on the 10th postoperative day. Blood flow in the IMAs was evaluated blindly by two radiologists and classified as blood flow unaffected (group I) or affected (group II) by comparing the assessment of preoperative and postoperative CTAs. The patients in group II were also categorized as having blood flow obstructed bilaterally, blood flow obstructed unilaterally and others (diminished unilaterally/diminished on one side or obstructed on the other side). RESULTS Thirty-four patients (31 male and three female; mean age 20.7 ± 4.2 years) underwent surgery. Blood flow was affected in 15 patients (44%), with bilateral obstruction in five, unilateral obstruction in seven, and unilateral diminished flow in two patients. In one patient, blood flow was diminished on one side and obstructed on the other. There was no significant difference between unaffected group I patients and affected group II patients in terms of sex, age, type of deformity, Haller index and the number of bars placed. CONCLUSIONS Nuss bars cause pressure on the IMAs, but a risk factor for this effect could not be identified. This is a relatively common clinical consequence of minimally invasive repair of pectus excavatum, and the long-term effects will be apparent following bar removal.

Degeneration of the lumbar spine and dual-energy X-ray absorptiometry measurements in patients without osteoporosis

AIM The aim of this study was to evaluate the effects of degenerative findings on the accuracy of readings obtained by dual-energy X-ray absorptiometry (DXA) in patients without osteoporosis. METHODS Twenty-four female patients who had undergone both DXA and lumbar magnetic resonance imaging were included in the study. CONCLUSION This study has demonstrated that degenerative radiologic changes, especially in the osteophyte area, affect bone mineral density measurements, so degeneration should be considered in the evaluation of this measurement.

Non-invasive evaluation of the coronary venous system in patients with chronic systolic heart failure by 64-detector computed tomography

Background Imaging coronary venous systems to guide transcatheter cardiac interventions are becoming increasingly important, particularly in heart failure patients who are selected for cardiac resynchronization therapy (CRT). Failure of left ventricular (LV) lead placement during the procedure has been attributed to the inability to insert catheters into the coronary sinus and the lack of suitable side branches. Purpose To comparatively assess the value of a 64-detector MDCT examination in visualizing the cardiac veins and evaluating the morphological characteristics of the coronary venous system in patients with and without chronic systolic heart failure (SHF). Material and Methods A 64-detector MDCT examination of the heart was performed in 26 consecutive patients (five women, 21 men; mean age 57.80 ± 12.05 years; range 27–81 years) with chronic SHF. The morphological characteristics of the coronary venous system, such as the diameter, the distances between the venous tributaries, the angle and the tortuosity, were evaluated. The group was compared with a subgroup of 52 subjects without SHF (LV ejection fraction >40%) matched for age, sex, and the risk factors for coronary artery disease. Results The coronary sinus (CS), great cardiac vein (GCV), anterior interventricular vein (AIV), and posterior interventricular vein (PIV) were visualized in all 78 individuals. The posterior vein of the left ventricle (PVLV) (63/78), left marginal vein (LMV) (72/78), and the small cardiac vein (SCV) (50/78) were visualized in SHF and control patients (p = NS). The lengths between venous tributaries were higher (p > 0.05) and more dilated (P < 0.001 for CS, GCV, AIV, PVLV, LMV; p = 0.001 for PIV) in the cases with SHF compared with the control population. The angle between the CS-GCV axis and the venous branches was wider (p = 0.02 for LMV and PIV, p = 0.001 for PVLV) and did not have any correlation with the LV diameter in cases with SHF. There was no difference between the SHF and control groups in terms of the tortuosity of PVLV and LMV (p = NS). Conclusion The study demonstrated an increase in the diameters, lengths, and angulations with the CS-GCV axis of the coronary veins in cases with SHF. A 64-detector MDCT is a feasible tool for non-invasive evaluation of the coronary venous system and may provide considerable information regarding numbers and morphology of coronary veins before percutaneous transcatheter cardiac therapy.

Effect of an oral anxiolytic medication and heart rate variability on image quality of 64-slice MDCT coronary angiography.

PurposeThe aim of the study was to investigate the relationship between image quality in 64-slice multidetector computed tomography (MDCT) and patients’ preimaging anxiety status and heart rate variability (HRV), and to evaluate the efficacy of an orally administered anxiolytic medication on HRV and image quality.Materials and methodsSixty patients [14 women, 46 men; mean age 52.53±10.55 (SD), range 33–78 years] were studied. Anxiety levels were assessed with the State-Trait Anxiety Inventory 60 min before the procedure. The participating patients were randomly assigned to one of the two study groups: a control group (no medication administered for anxiety reduction) and an anxiolytic medication group, with 30 patients in each group. The presence of motion artefacts and image quality for each coronary artery segment were evaluated using a four-point grading system. To estimate HRV, the duration of each heartbeat during MDCT data acquisition was measured in each patient.ResultsA moderate correlation was found between HRV during MDCT scanning and the mean image quality for all coronary segments (r=0.47, p<0.01). There was an association between HRV and state anxiety scores in all cases (r=0.370, p<0.01). HRV in the patients who received alprazolam was statistically significantly lower than in controls (p<0.05). The average image quality in patients who used alprazolam was also statistically significantly higher than in controls (p<0.05).ConclusionsThe most important finding in our study is that oral premedication to reduce anxiety is also effective in decreasing HRV and improves image quality. Therefore, we suggest that using alprazolam in addition to a β-blocker may improve image quality in patients undergoing MDCT coronary angiography (MDCT-CA). Anxiolytic usage may improve image quality by lowering the HRV in selected cases where administration of a β-blocker is contraindicated. We also suggest that further studies in larger series are required to validate this finding.RiassuntoObiettivoValutare la relazione tra la qualità delle immagini in TC multidetettore a 64 strati (MDCT), lo stato d’ansia dei pazienti prima dell’esame TC e la variabilità della frequenza cardiaca (HRV); valutare l’efficacia della somministrazione per via orale di ansiolitici sulla variabilità della frequenza cardiaca (HRV) e sulla qualità delle immagini.Materiali e metodiSono stati studiati 60 pazienti [14 donne, 46 uomini;età media 52,53±10,55 (DS), intervallo 33–78 anni]. Il livello d’ansia è stato stimato a monte della procedura con l’ausilio della forma Y dello State-Trait Anxiety Inventory 60 (STAI-Y). I pazienti che hanno partecipato allo studio sono stati casualmente assegnati ad uno dei due gruppi di studio: il gruppo di controllo (ai quali non veniva somministrato ansiolitico per ridurre lo stato d’ansia) ed il gruppo dei pazienti trattati con ansiolitici, quest’ultimo composto da 30 pazienti. La presenza di artefatti da movimento e la qualità delle immagini per ciascun segmento coronarico studiato, sono state valutate utilizzando un sistema di classificazione a 4 punti. La stima della variabilità della frequenza cardiaca (HRV) e la durata di ciascun battito cardiaco durante l’acquisizione dei dati in MDCT sono stati misurati in ogni paziente.RisultatiÈ stata riscontrata una moderata correlazione tra la variabilità della frequenza cardiaca (HRV) durante l’acquisizione delle immagini MDCT e la media della qualità dell’immagine per tutti i segmenti coronarici studiati (r=0,47, p<0,01). Vi era una concordanza tra la variabilità della frequenza cardiaca (HRV) ed il livello d’ansia in tutti i casi (r=0,370, p<0,01). La variabilità della frequenza cardiaca (HRV) nei pazienti trattati con alprazolam era significativamente più bassa che nei controlli (p<0,05). Anche la qualità delle immagini nei pazienti trattati con alprazolam era significativamente più elevata che nei controlli (p<0,05).ConclusioniIl riscontro del nostro studio è che la premedicazione con ansiolitici per via orale riduce lo stato d’ansia ed è efficace anche nel ridurre la variabilità della frequenza cardiaca (HRV) e nel migliorare la qualità delle immagini. Pertanto, suggeriamo che l’utilizzo dell’alprazolam in combinazione con gli β-litici potrebbe migliorare la qualità delle immagini nei pazienti sottoposti ad angiografia coronarica mediante TC multidetettore (MDCT-CA). L’utilizzo degli ansiolitici potrebbe migliorare la qualità delle immagini diminuendo la variabilità della frequenza cardiaca (HRV) in casi selezionati dove è controindicata la somministrazione degli β-litici. Per poter validare questi risultati sono necessari ulteriori studi su casistiche più ampie.

Comparison of Power Doppler Ultrasound with Gray Scale Transrectal Ultrasound in Predicting Cancer Positive Prostate Biopsy Cores

OBJECTIVE The aim of this study is to compare the effect of transrectal power Doppler ultrasound (PDUS) and gray scale transrectal ultrasound (TRUS) for the diagnosis of prostate cancer. MATERIALS AND METHODS Seventy-six patients evaluated with transrectal PDUS and TRUS underwent eight systematic TRUS guided core-needle biopsies, with additional cores from abnormal areas. Histologic diagnoses were classified as benign prostatic hyperplasia, chronic prostatitis, intraepithelial neoplasia and adenocarcinoma. TRUS and PDUS findings of the cases were recorded. RESULTS PDUS sensitivity, specificity, positive predictive value (PPV) and negative predictive values were 81%, 81%, 54% and 94%, respectively. PDUS had a greater sensitivity and specificity than TRUS (43% and 60%, respectively) and identified cancer cases more accurately (Table 2). CONCLUSION Hypervascular foci in PDUS signify suitable zones for biopsy. When combined with systematic TRUS guided biopsy, PDUS increases the cancer detection rate with additional biopsies from suspicious hypervascular foci. Transrectal PDUS guided biopsy should be combined with gray scale TRUS guided biopsy to increase accuracy in the diagnosis of prostate cancer.

Vacuum-assisted stereotactic biopsy for isolated BI-RADS 4 microcalcifications: evaluation with histopathology and midterm follow-up results

PURPOSE The aim of this study was to evaluate the 10-gauge vacuum-assisted stereotactic biopsy (VASB) of isolated Breast Imaging Reporting and Data System (BI-RADS) 4 microcalcifications, using histology and follow-up results. METHODS From January 2011 to June 2013, VASB was performed on 132 lesions, and 66 microcalcification-only lesions of BI-RADS 4 were included into our study. VASB was performed using lateral decubitis stereotaxy for all patients. Pathologic results of VASB and further surgical biopsies were reviewed retrospectively. Patients who were diagnosed to have benign lesions by VASB were referred for follow-up. VASB and surgical histopathology results were compared to determine the underestimation ratios. RESULTS Fifteen out of 66 lesions from 63 patients (median age, 47 years; range, 34-88 years) were identified as malignant by VASB. Pathological results after surgery revealed three cases of invasive ductal carcinoma among the 12 VASB-diagnosed ductal carcinoma in situ (DCIS) lesions, for a DCIS underestimation rate of 25%. The atypical ductal hyperplasia underestimation rate was 0% for the three lesions. The follow-up period was at least 10 months, with an average of 22.7 months for all patients and 21.2 months for patients with VASB-diagnosed benign lesions. None of the patients had malignancy during the follow-ups. The false-negative rate was 0% in the follow-up of 48 patients. CONCLUSION VASB should be the standard method of choice for BI-RADS 4 microcalcifications. This method obviates the need for a surgical procedure in 73% of BI-RADS 4 microcalcification-only patients.

Arterial Compression in a Young Adult due to the Presence of a Cervical Rib: CT and CT Angiographic Findings.

A cervical rib generally arises from the seventh cervical vertebra and is known as an anomalous accessory rib or “Eve’s rib” [1]. A recent literature survey reported that cervical ribs are present in less than 1% of the normal population and are asymptomatic in about 90% of cases [2]. Complete cervical ribs are fused with the tubercle on the upper aspect of the first thoracic rib, very close to the insertion site of the anterior scalene muscle. The supraclavicular part of the subclavian artery is usually substantially displaced in the anterior direction. Cervical ribs that are termed “incomplete” are smaller and do not articulate directly with a thoracic rib. Incomplete ribs generally have an associated fibrous band, which inserts into the first thoracic rib and may lead to compression of the adjacent neurovascular structures. An 18-year-old woman suffering from weakness and pain in her left arm and swelling of her left hand was referred to the Radiology Department. Computed tomography (CT) angiography was ordered after the physical examination, which raised suspicion of an arterial occlusion in her left upper extremity. CT angiography demonstrated a typical complete cervical rib originating from the seventh rib and extending into the supraclavicular region (Figure 1). The cervical rib was fused with the upper contour of the first thoracic rib and caused obstruction of the subclavian arterial lumen by compressing it (Figures 1 and ​and2).2). A thrombus was identified adjacent to the proximal side of the external compression. Figure 1 Figure 2 It is easier to identify cervical ribs on spinal images rather than on chest X-rays. The rib and the articulating vertebra are better defined on spinal film. Cervical ribs often articulate with the anterior part of the first rib. They sometimes occur bilaterally, and their sizes vary. Cervical ribs must also be distinguished from elongated transverse processes of the seventh cervical vertebra. Deformation in cervical ribs may cause compression of the underlying major vessels and severe thoracic outlet syndrome. CT with multiplanar reconstruction capability is a valuable tool to illustrate the relationship between bone deformity and major arterial vessels. Arteriography, which is an intraluminal imaging method, can also be useful for diagnosis and preoperative evaluation [2]. Resection of the cervical rib may resolve the symptoms in selected cases.