Olivier Vignaux

Detection of myocardial involvement in patients with sarcoidosis applying T2-weighted, contrast-enhanced, and cine magnetic resonance imaging: initial results of a prospective study.

Purpose To assess myocardial magnetic resonance imaging (MRI) findings in sarcoidosis. Methods Cardiac assessment was prospectively performed in patients with sarcoidosis and included physical examination, electrocardiogram, echocardiography, thallium-201 myocardial scintigraphy, and coronary angiography if coronary disease was suspected. T2-weighted black-blood single-shot and inversion recovery fast spin echo, functional gradient echo, and T1-weighted gadolinium-DTPA-enhanced cardiac MRI examinations were performed in 40 patients while other cardiac disease was excluded. Results Results of the MRI images were normal in cardiac-asymptomatic stage I or Lofgren syndrome patients (n = 4). Among the patients with cardiac-asymptomatic multiple organ sarcoidosis, 17 of 31 patients (54%) had MRI myocardial abnormalities similar to those observed in five patients with cardiac symptoms: nodular peripheral increased intramyocardial signal intensity on both T2-weighted and contrast-enhanced images (n = 5), focal or patchy increased signal on contrast-enhanced images with or without myocardial thickening (n = 10), and focal increased signal only on T2-weighted images with or without myocardial thinning (n = 2). Focal contractility abnormalities were noticed in nine patients. Conclusions These preliminary results emphasize the occurrence of subclinical myocardial MRI abnormalities in patients with ongoing systemic sarcoidosis.

Effects of corticosteroids and immunosuppressors on idiopathic inflammatory myopathy related myocarditis evaluated by magnetic resonance imaging

Background: Cardiac involvement in idiopathic inflammatory myopathy has been recognised as an important prognostic factor, but treatment remains empirical. Objective: To investigate the effects of corticosteroids and immunosuppressors on myocarditis in patients with inflammatory myopathies. Methods: Patients with inflammatory myositis of recent onset who had not received treatment were evaluated for associated myocarditis by magnetic resonance imaging (MRI) and reinvestigated after treatment with high dose corticosteroids and immunosuppressors. Results: Four patients with histologically proven myositis were included. Two patients with polymyositis had cardiac clinical symptoms. Two other patients with dermatomyositis and diffuse cutaneous systemic sclerosis-polymyositis overlap syndrome were asymptomatic. In three cases the usual conventional screening tests were normal. For all patients an area of contrast enhancement and hypokinesia detected by cardiac MRI was markedly reduced after treatment with corticosteroids and immunosuppressors for 6 months. Conclusion: Treatment with intravenous methylprednisolone followed by prednisone and immunosuppressive therapy seems to be effective for treating myocardial involvement in patients with idiopathic inflammatory myopathies, either alone or presenting as overlap syndromes. Cardiovascular MRI is a non-invasive technique that may be a powerful tool for diagnosis and monitoring of myocardial inflammation in this setting.

Benefit of an early and systematic imaging procedure after cardiac arrest: Insights from the PROCAT (Parisian Region Out of Hospital Cardiac Arrest) registry ☆

AIMS Identification of the cause of out-of-hospital cardiac arrest (OHCA) is of paramount importance. We investigated the ability of our imaging strategy to provide an early etiological diagnosis of OHCA and the influence of this strategy on ICU survival. METHODS Retrospective review of a prospectively acquired ICU database (01/2000-12/2010) including all OHCA patients without obvious extracardiac cause, for which an early diagnosis research was conducted (coronary angiography and/or brain and chest CT scan) within 24h after resuscitation. These procedures could be performed separately or be combined, according to a decision algorithm. RESULTS Of the 1274 patients admitted after OHCA during this 10-year period, the imaging strategy was applied in 896 patients. Patients who benefited from coronary angiography and/or CT scan were admitted to our ICU after a median delay of 180 [130-220]min after resuscitation. Seven hundred and forty-five coronary angiographies were performed, of which 452 (61%) identified at least one significant coronary lesion deemed responsible for the OHCA. CT-scan was performed in 355 patients and provided a diagnosis in 72 patients (20%), mainly stroke (n=38) and pulmonary embolism (n=19). Overall, this strategy allowed early diagnosis in 524 patients (59%). ICU survival was significantly higher for patients with a diagnosis identified by coronary angiography as compared with CT-scan (43% vs 10%, p<0.001). CONCLUSION The use of an early diagnosis protocol with immediate coronary angiography and/or CT scan provided the etiology of nearly two thirds of OHCA cases. In this large retrospective database, coronary angiography yielded a better diagnostic value than brain and/or chest CT-scan.

Hemorrhagic necrosis due to peliosis hepatis: imaging findings and pathological correlation.

Abstract. Peliosis hepatis is an uncommon liver condition characterized by blood-filled cavities. We report the CT, angiographic and MR features of a case of peliosis hepatis with no obvious etiology and spontaneously regressing hemorrhagic necrosis. Helical CT showed multiple peripheral low-density regions with foci of spontaneous high density suggesting the presence of blood component. On MR imaging, the multiple peripheral lesions were hypointense on T1-weighted and hyperdense on T2-weighted images, with bright foci on all sequences suggesting subacute blood. Angiography showed no evidence of tumor or vascular malformation; multiple nodular vascular lesions filling in the parenchymal phase and persisting in the venous phase suggested blood-filled cavities. Pathological examination showed blood-filled spaces with no endothelial lining, characteristic of the parenchymal type of peliosis. Knowledge of the imaging features of hemorrhagic necrosis due to peliosis hepatis is important since it can be responsive to antibiotic therapy. Furthermore, differentiating hemorrhagic necrosis from hepatic abscess avoids dangerous and sometimes fatal percutaneous drainage.

Churg–Strauss syndrome cardiac involvement evaluated by cardiac magnetic resonance imaging and positron-emission tomography: a prospective study on 20 patients

OBJECTIVE Churg-Strauss syndrome (CSS) cardiac involvement is associated with a poor prognosis. Recently cardiac MRI (CMRI) has emerged as a promising technique to detect early CSS cardiac involvement. However, CMRI-detected myocardial delayed enhancement (MDE) could correspond to fibrosis or inflammation. Fluoro-2-deoxyglucose PET (FDG-PET) was previously used in other systemic diseases to distinguish between them. To determine whether the CMRI-MDE detected in CSS patients reflected fibrosis or myocardial inflammation, patients in CSS remission underwent FDG-PET. METHODS Twenty consecutive CSS patients in remission (BVAS = 0) were recruited. Fourteen patients [eight men, six women; mean (S.D.) age 49 (9) years; mean disease duration 3.5 (2.9) years] with CMRI-detected MDE, and six patients [four men, two women; mean (S.D.) age 44 (15) years; mean disease duration 3.5 (5.3) years] with normal CMRI underwent FDG-PET. Segments with MDE on CMRI were analysed on FDG-PET images, with myocardial FDG hypofixation defining fibrosis and hyperfixation corresponding inflammation. RESULTS Among the 14 patients with MDE on CMRI, FDG-PET showed 10 had hypofixation, 2 had hyperfixation and 2 had normal scans. CSS duration at the time of CMRI was shorter for patients with myocardial inflammation than in those with fibrosis. The six patients with normal CMRI had normal FDG-PET images. CONCLUSION For CSS patients in remission, CMRI detected subclinical active myocardial lesions and could be recommended to assess cardiac involvement. However, because CMRI-detected MDE can reflect fibrosis or inflammation, FDG-PET might help to distinguish between the two.

Reversible decrease of portal venous flow in cirrhotic patients: a positive side effect of sorafenib.

Portal hypertension, the most important complication with cirrhosis of the liver, is a serious disease. Sorafenib, a tyrosine kinase inhibitor is validated in advanced hepatocellular carcinoma. Because angiogenesis is a pathological hallmark of portal hypertension, the goal of our study was to determine the effect of sorafenib on portal venous flow and portosystemic collateral circulation in patients receiving sorafenib therapy for advanced hepatocellular carcinoma. Porto-collateral circulations were evaluated using a magnetic resonance technique prior sorafenib therapy, and at day 30. All patients under sorafenib therapy had a decrease in portal venous flow of at least 36%. In contrast, no specific change was observed in the azygos vein or the abdominal aorta. No portal venous flow modification was observed in the control group. Sorafenib is the first anti-angiogenic therapy to demonstrate a beneficial and reversible decrease of portal venous flow among cirrhotic patients.

Rapidly reversible myocardial edema in patients with acromegaly: assessment with ultrafast T2 mapping in a single-breath-hold MRI sequence.

OBJECTIVE The purpose of this study was to use a single-breath-hold T2-mapping MRI sequence to evaluate the reversibility of myocardial edema in patients treated for acromegaly. SUBJECTS AND METHODS Before and after treatment, 15 patients with acromegaly underwent myocardial T2 mapping with an experimental single-breath-hold black-blood fast spin-echo sequence. Myocardial T2 mapping with both a multiple-breath-hold fast spinecho sequence and the experimental sequence also was performed on 14 volunteers. T2 relaxation times were calculated with a standard linear least-squares fit applied to myocardial signal intensity. The T2 relaxation times of patients were compared with those of volunteers and correlated with levels of serum growth hormone and insulinlike growth factor 1. Left ventricular function and mass index were determined with cine MRI. RESULTS T2 values before treatment were higher in patients (71 +/- 12 milliseconds) than in volunteers (55.9 +/- 3.6 milliseconds) (p = 0.0003). These T2 values in patients decreased soon after treatment (57.6 +/- 6.6 milliseconds, p = 0.0007). This reduction correlates with successful reduction of levels of serum growth hormone and insulinlike growth factor 1. In volunteers, myocardial T2 values did not vary significantly between the single-breath-hold sequence and the multiple-breath-hold fast spin-echo sequence. In patients, myocardial mass and left ventricular function did not differ significantly before and after treatment. CONCLUSION Patients with acromegaly have increased myocardial T2 values, which decrease soon after treatment, reflecting reversible myocardial edema. T2 value is more sensitive than left ventricular mass index in the detection of early reversal of acromegalic cardiomyopathy. These results highlight the potential role of MRI in direct assessment of the tissular effects of growth hormone and insulinlike growth factor 1 and in evaluation of the efficacy of treatment.

Lung and heart-lung transplantation for systemic sclerosis patients. A monocentric experience of 13 patients, review of the literature and position paper of a multidisciplinary Working Group

Systemic sclerosis per se should not be considered as an a priori contraindication for a pre-transplantation assessment in patients with advanced interstitial lung disease and/or pulmonary hypertension. For lung or heart-lung transplantation, a multidisciplinary approach, adapting the pre-transplant assessment to systemic sclerosis and optimizing systemic sclerosis patient management before, during and after surgery should improved the short- and long-term prognosis. Indications and contraindications for transplantation have to be adapted to the specificities of systemic sclerosis. A special focus on the digestive tract involvement and its thorough evaluation are mandatory before transplantation in systemic sclerosis. As the esophagus is almost always involved, isolated gastro-oesophageal reflux disease, pH metry and/or manometry abnormalities should not be a systematic per se contraindication for pre-transplantation assessment. Corticosteroids may be harmful in systemic sclerosis as they are associated with acute renal crisis. A low dose corticosteroids protocol for immunosuppression is therefore advisable in systemic sclerosis.

Pancreatic Atrophy — A New Late Toxic Effect of Sorafenib

Pancreatic exocrine insufficiency and a reduction in the volume of the pancreas on computed tomography developed in two patients after more than 24 months of sorafenib therapy.

Coronary artery stenosis in high-risk patients: 64-section CT and coronary angiography--prospective study and analysis of discordance.

PURPOSE To assess the diagnostic accuracy of multisection (64-section) computed tomography (CT) versus coronary angiography in detection of and assignment of grades for coronary artery stenoses in a high-risk population and to investigate causes for discordance between the two. MATERIALS AND METHODS The protocol was approved by the local ethics committee. Patients gave informed consent. The study included 114 patients (103 men, 11 women; mean age, 63 years +/- 8.2 [standard deviation]) with potential myocardial ischemia. Multisection CT images were interpreted independently by two radiologists with unequal experience in reading coronary CT angiograms. Diagnostic performance of 64-section CT in detection of stenoses of 50% or more was assessed per patient, per artery, and per segment. Interrater agreement was assessed by using the Cohen kappa coefficient. Agreement between 64-section CT and coronary angiography for assigning grades to stenoses was assessed by using Bland-Altman analysis. RESULTS Sixty-eight percent of patients had stenoses of 50% or more. Good interrater agreement was found, with kappa values of 0.77-0.85. For the most experienced radiologist, the sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio were 73.4%, 95.0%, 14.7, and 0.28 per segment, 95.2%, 94.7%, 18.0, and 0.05 per artery, and 100%, 89.2%, 9.26, and zero per patient, respectively. Discordance between 64-section CT and coronary angiography was related to either under- or overestimation of the degree of stenosis, anatomic misclassification, and coronary artery segments that were not assessable at 64-section CT. Bland-Altman analysis showed poor agreement, especially for intermediate stenosis (mean bias, 1.3%; 95% limits of agreement: -27.3%, 29.9%). CONCLUSION Despite excellent sensitivity and negative likelihood ratios in a per-patient or per-vessel analysis, some coronary artery stenosis remained misdiagnosed with 64-section CT, resulting in limited sensitivity on a per-segment basis owing to anatomic discordance and failure to accurately quantify intermediate stenosis.