Raffaello Sutera

Budd-Chiari Syndrome: Spectrum of Imaging Findings

OBJECTIVE The objective of our study was to illustrate the imaging findings of Budd-Chiari syndrome, including CT, MRI, sonographic, and angiographic findings. CONCLUSION The key imaging findings in Budd-Chiari syndrome are occlusion of the hepatic veins, inferior vena cava, or both; caudate lobe enlargement; inhomogeneous liver enhancement; and the presence of intrahepatic collateral vessels and hypervascular nodules. Awareness of these findings is important for early diagnosis and appropriate treatment.

Plantar fascia evaluation with a dedicated magnetic resonance scanner in weight-bearing position: our experience in patients with plantar fasciitis and in healthy volunteers

PurposeThis study assessed the usefulness of upright weight-bearing examination of the ankle/hind foot performed with a dedicated magnetic resonance (MR) imaging scanner in the evaluation of the plantar fascia in healthy volunteers and in patients with clinical evidence of plantar fasciitis.Materials and methodsBetween January and March 2009, 20 patients with clinical evidence of plantar fasciitis (group A) and a similar number of healthy volunteers (group B) underwent MR imaging of the ankle/hind foot in the upright weight-bearing and conventional supine position. A 0.25-Tesla MR scanner (G-Scan, Esaote SpA, Genoa, Italy) was used with a dedicated receiving coil for the ankle/hind foot. Three radiologists, blinded to patients’ history and clinical findings, assessed in consensus morphological and dimensional changes and signal intensity alterations on images acquired in both positions, in different sequences and in different planes.ResultsIn group A, MR imaging confirmed the diagnosis in 15/20 cases; in 4/15 cases, a partial tear of the plantar fascia was identified in the upright weight-bearing position alone. In the remaining 5/20 cases in group A and in all cases in group B, the plantar fascia showed no abnormal signal intensity. Because of the increased stretching of the plantar fascia, in all cases in group A and B, thickness in the proximal third was significantly reduced (p<0.0001) under upright weight-bearing compared with the supine position.ConclusionsImaging the ankle/hind foot in the upright weight-bearing position with a dedicated MR scanner and a dedicated coil might enable the identification of partial tears of the plantar fascia, which could be overlooked in the supine position.RiassuntoObiettivoScopo del nostro lavoro è stato dimostrare l’utilità dell’esame sotto carico del retropiede/caviglia eseguito con apparecchiatura di risonanza magnetica (RM) dedicata finalizzato alla valutazione della fascia plantare in volontari sani ed in pazienti con evidenza clinica di fascite plantare.Materiali e metodiNel periodo compreso tra gennaio e marzo 2009, 20 pazienti con diagnosi clinica di fascite plantare (gruppo A) ed altrettanti volontari sani (gruppo B), sono stati sottoposti ad esame RM del retropiede/caviglia sia in ortostatismo che in clinostatismo. Per le indagini è stata utilizzata una apparecchiatura RM dedicata da 0,25 Tesla (G-Scan, Esaote SpA, Genova, Italia) con bobina di ricezione dedicata per retropiede/caviglia. Tre radiologi in consenso e in cieco sull’anamnesi e l’obiettività clinica dei soggetti hanno valutato le alterazioni morfo-dimensionali e dell’intensità di segnale nelle immagini acquisite nelle due posizioni, nelle diverse sequenze e nei differenti piani di scansione.RisultatiNel gruppo A, la RM ha confermato la diagnosi in 15/20 casi; in 4/15 casi è stata evidenziata una rottura parziale della fascia plantare visualizzata solo nella posizione ortostatica. Nei restanti 5/20 casi del gruppo A ed in quelli del gruppo B la fascia plantare non presentava alterazioni dell’intensità di segnale. A causa della maggiore tensione della fascia plantare in tutti i casi, gruppo A e B, lo spessore del tratto peri-inserzionale sotto carico si riduceva significativamente (p<0,0001) rispetto al clinostatismo.ConclusioniL’imaging del retropiede/caviglia nella posizione ortostatica con RM dedicata e bobina dedicata potrebbe consentire di dimostrare le rotture parziali della fascia plantare che possono rimanere misconosciute in clinostatismo.

Presacral Myelolipoma A Case Report and Literature Review

Many reports have described adrenal myelolipomas but there have been only a few reports of extra-adrenal myelolipomas. We describe a 74-year-old woman who came to our observation for MRI of the lumbar spine for typical lumbar back pain. In addition to signs of mild scoliosis and spondylo disc arthrosis, MR imaging revealed a presacral mass showing a heterogeneously high signal in all pulse sequences and almost completely suppressed on inversion recovery sequences for fat tissue. CT imaging confirmed the fatty nature of the lesion and no signs of bone involvement. These findings were most consistent with a diagnosis of a rare presacral myelolipoma as confirmed at histopathologic analysis. This work reports a case of one of the rarest presacral masses, emphasizing the role of imaging in the differential diagnosis of other presacral masses.

Study of neurinomas with ultrasound contrast media: review of a case series to identify characteristic imaging patterns

PurposeThe aim of this study was to evaluate whether there exists a characteristic distribution pattern of vessels within neurinomas that may be used to characterise this type of lesion by employing a contrast-specific ultrasound technique.Materials and methodsBetween January 2003 and May 2010, 66 suspected neurinomas were evaluated according to their sonographic features (solid fusiform mass with well-defined margins located in direct continuity with the nerve that was not always discernible and heterogeneous as a result of the presence of small cystic areas or calcifications). The lesions were examined using a sonographic contrast medium consisting of sulphur hexafluoride microbubbles and equipment with dedicated contrast-specific software [contrast tuned imaging (CnTI)]. Of these lesions, five were excluded from the analysis because the definitive diagnosis was not available (in two cases, the follow-up was still in progress, whereas in the remaining three, there was no follow-up). Our study, therefore, is based on 61 surgically excised lesions that were confirmed to be neurinomas by histology, which is regarded as the gold standard.ResultsIn 41/61 cases (67.2%), we identified an enhancement pattern that we termed reticular owing to the interweaving of blood vessels, of which two subtypes were identified depending on whether the interwoven vessels were densely or sparsely packed: loose-knit reticular in 18/41, and tight-knit reticular in 23/41. In 20/61 (32.8%) cases, we observed a vascular pattern of diffuse heterogeneous enhancement, which was divided into two subtypes based on the presence of one (7/20) or more (13/20) avascular areas.ConclusionsResults showed that all neurinomas studied could be divided into two groups according to the type of enhancement pattern observed: reticular or diffuse heterogeneous.RiassuntoObiettivoScopo dello studio è valutare, mediante l’impiego di una tecnica ecografica contrasto-specifica, se esiste una distribuzione caratteristica dei vasi all’interno dei neurinomi che possa essere usata per una caratterizzazione del tipo di lesione.Materiali e metodiNel periodo compreso tra gennaio 2003 e maggio 2010 sono state valutate nel nostro dipartimento 66 lesioni sospette per neurinoma in base alle loro caratteristiche ecografiche (formazioni solide, fusiformi, a margini netti, in diretta continuità con la fibra nervosa, non sempre riconoscibile, disomogenee per l’eventuale presenza di piccole aree similcistiche o calcificazioni), ed esaminate con mezzo di contrasto (MdC) ecografico, costituito da microbolle a base di esafluoruro di zolfo e apparecchiatura dotata di software dedicato Contrast Tuned Imaging (CnTI) contrasto specifico. Di queste lesioni, 5 sono state escluse dall’analisi in quanto non era disponibile una diagnosi definitiva (n=2 follow-up in corso; n=3 assenza di follow-up). Pertanto il nostro studio si basa unicamente sulle 61 lesioni asportate chirurgicamente e confermate come neurinomi all’esame istologico, considerato come gold standard.RisultatiIn 41/61 (67,2%) casi abbiamo identificato una distribuzione del mezzo di contrasto definita “a reticolo” in base all’intreccio formato dalle strutture vascolari, in cui si riconoscono due sottotipi: “reticolo a maglie larghe” in 18/41 e “reticolo a maglie strette” in 23/41, distinti in base all’aspetto dell’incrocio dei vasi, se più rado o più fitto. In 20/61 (32,8%) casi abbiamo osservato un diverso pattern di vascolarizzazione, denominato “impregnazione diffusa disomogenea”, a sua volta suddiviso in due sottotipi in base alla presenza di una (7/20) o più aree avascolari (13/20).ConclusioniI risultati ottenuti in questo studio hanno dimostrato che tutti i neurinomi analizzati possono essere distinti in due gruppi, in base al tipo di pattern vascolare riscontrato: di tipo reticolare o ad impregnazione diffusa disomogenea.

A rare case of Enchondromatosis of the knees and hands with involvement of Hoffa's fat pad and peri-articular soft-tissues

We report a case of a 56-year old man with chronic pain in both knees for several years. This patient had already undergone surgery on his left knee in 2002 after an x-ray showed multiple lytic and well margined lesions in the distal femur and proximal tibia with ground-glass matrix, involving Hoffas fat pad and the patellar ligament. Histology was consistent with an enchondroma. The most recent MRI examination showed enchondromatosis involving both knees with bilateral extension into Hoffas fat pad and the patellar ligament. Subsequently, we performed an additional radiographic examination of the hands and feet, as well as an MRI of both hands to identify other possible enchondromas in the most common sites for this disease. Enchondromatosis with soft tissue involvement is extremely rare, and involvement of Hoffas fat pad has not been reported in the scientific literature. The clinical presentation of this case and the general aspects of Enchondromatosis are discussed.

Femoro-acetabular impingement. Classification, diagnosis and treatment.

The success of a total hip arthoplasty is linked to a long survival, and this one is obtained reducing the surfaces wearing. Polyethylene material was introduced by Sir John Charnley in the 60’s and has been until now the cartilage most similar material regarding the Young modulus, despite metal and ceramic ones. It has been also characterized by a good wear, especially nowadays the highly cross-linked polyethylene technology has been developed. In the last years, research has been oriented to already used materials improvement such as metals and metal alloys (steel, titanium, CrCo, tantalum), to study and product dense and bioactive ceramics (alumina), to study and product polymeric and composite materials. The physical properties of some polymers have shown to be very similar to those of the normal cartilage. Considering that the most relevant impairment in an arthritic hip regard the articular cartilage, it’s easy to figure out the importance of regaining the cartilage function in anatomical THA surgery. Years of study and laboratory tests have led to the production of a new acetabulum module made of PCU (polycarbonate urethane), which would play a buffer/plug role, as the normal cartilage of a healthy hip does. The emerging buffer characteristics consist of the mentioned optimum modulus of elasticity which results moreover as a shock absorber, and the optimum microelastodynamic lubrication which reduce the friction coefficient. The buffer is presented as an acetabular cup to be inserted in a metal back (titanium coated CrCoMo) press-fit implanted. It can also be implanted directly in contact with the acetabular bone, previous the thin residual cartilage layer removal, allowing a more anatomical surgery and a bone stock sparing. PCU buffer is intended to be a new way of thinking total hip arthroplasty, nevertheless the acquired experience is actually confined among few Centers and further laboratory tests are going to be concluded. The path has drawn, it has just to be covered!