Roberta Vinci

Poly-L-lactic acid — hydroxyapatite (PLLA-HA) bioabsorbable interference screws for tibial graft fixation in anterior cruciate ligament (ACL) reconstruction surgery: MR evaluation of osteointegration and degradation features

PurposeWe evaluated with magnetic resonance imaging (MRI) the degradation and osteointegration features of a new type of bioabsorbable interference (BioRCI) screw composed of poly-L-lactic acid and hydroxyapatite (PLLA-HA) used for tibial graft fixation in anterior cruciate ligament (ACL) reconstruction.Materials and methodsThirty-one patients underwent arthroscopic surgery for ACL reconstruction using doubled gracilis and semitendinosus tendons fixed to the tibial tunnel with PLLA-HA (BioRCI-HA) screws. Two groups of patients were evaluated, one group 10–13 months after surgery and the other after 30–40 months. The standard knee ligament evaluation form of the International Knee Documentation Committee (IKDC) was used for clinical assessment and MRI for the radiological assessment.ResultsMRI after 10–13 months revealed findings referable to healing and integration of the bone-graft-screw system, findings that disappeared at later follow-up examinations. The BioRCI-HA screw remained constantly visible in all patients, although with changes in signal intensity over time.ConclusionsBioRCI-HA screws allow adequate primary stability and superior osteoconduction and biocompatibility in comparison with plain PLLA screws. The absence of ferromagnetic artefacts allows accurate MRI follow-up and adequate evaluation of ligament synovialisation, screw degradation and graft osteointegration.RiassuntoObiettivoValutare con imaging RM gli aspetti dei processi di degradazione ed osteointegrazione di una nuova classe di viti ad interferenza bioriassorbibili in acidi L-polilattici ed idrossiapatite (PLLA-HA), utilizzate per la fissazione di innesti tendinei nelle plastiche Pro-LCA.Materiali e metodiTrentuno pazienti sono stati sottoposti ad intervento chirurgico di ricostruzione di LCA con tendini di muscoli gracile e semitendinoso duplicati, fissati a livello del tunnel tibiale con viti PLLA-HA. Due gruppi di pazienti sono stati valutati dopo l’intervento chirurgico rispettivamente a distanza, uno di 10–13 mesi, l’altro di 30–40 mesi, utilizzando la scheda dell’International Knee Documentation Committee (IKDC) per la valutazione clinica; la valutazione radiologica è stata effettuata mediante RM.RisultatiDall’analisi dei risultati RM è emerso che nei controlli più ravvicinati erano presenti reperti legati ai processi di guarigione ed integrazione osso-innesto-vite, non più evidenti nel follow-up effettuato tardivamente. La vite BioRCI-HA è stata sempre visibile in tutti i controlli con modificazioni dell’intensità di segnale nel tempo.ConclusioniLe viti BioRCI-HA garantiscono una adeguata stabilità primaria, una superiore osteoconducibilità ed una maggiore biocompatibilità rispetto alle viti semplici di PLLA. L’assenza di artefatti ferromagnetici delle viti ha consentito un’efficace valutazione con RM dei processi di sinovializzazione del neo-legamento, di quelli di degradazione delle viti bioriassorbibili e di osteointegrazione dell’innesto.

Double-contrast MRI (DC-MRI) in the study of the cirrhotic liver: utility of administering Gd-DTPA as a complement to examinations in which SPIO liver uptake and distribution alterations (SPIO-LUDA) are present and in the identification and characterisation of focal lesions.

Purpose.The aim of this study was to compare the performance of double-contrast magnetic resonance imaging (DC-MRI) with the sequential use of superparamagnetic iron oxide (SPIO) and gadolinium-diethylenetriaminepentaacetic acid (Gd-DTPA) contrast agents compared with unenhanced MRI and SPIOenhanced MRI (SPIO-MRI) in the study of the cirrhotic liver. Special attention was paid to cases in which alterations of liver uptake and distribution of the SPIO contrast medium [SPIO-liver uptake and distribution alterations (SPIO-LUDA)] could lead to diagnostic errors at SPIO-MRI.Materials and methods.We used DC-MRI to study 67 patients suffering from hepatic cirrhosis and on a waiting list for liver transplant. The study was performed with a 1.5-Tesla device and characterised by three phases: the first phase without contrast material (unenhanced MRI), the second after the administration of ferumoxides (SPIO-MRI), and the third, a double-contrast study following the injection of a bolus of paramagnetic contrast material (DC-MRI). The sensitivity of unenhanced MRI, SPIOMRI and DC-MRI in identifying and characterising hepatic focal lesions was assessed, together with the diagnostic increment of one technique with respect to the others. The gold standard was histological confirmation in 38 cases and clinical–radiological follow-up in all cases. Liver function, kidney function, blood tests and urinalysis were performed in all patients 24–48 h before and after the MRI examination.Results.In 14/67 cases (20.8%), SPIO-LUDA were present, which posed a limitation to the SPIO-MRI examination. Focal lesions were absent in 44 patients, and the action of the ferumoxides was reduced by the presence of SPIO-LUDA in nine cases. There were five cases of confluent fibrosis, two of decompensated cirrhosis, one of vascular thrombosis, and one of scarring in a patient who had undergone hepatic resection for hepatocellular carcinoma (HCC). In all these cases, completion of the MR examination with the DC technique clarified the MR picture, confirming the absence of focal lesions. Twenty-three patients had a total of 68 lesions, which consisted of 37 dysplastic nodules (DN), 19 HCC nodules, two relapses of HCC following chemoembolisation, two HCC associated with portal thrombosis, one cancer-cirrhosis, two angiomas and five small cysts. SPIO-LUDA were present in five patients, thus limiting the identification, characterisation or assessment of the real size of the lesions. SPIO-LUDA were the result of vascular thrombosis in one case and fibrosis in four cases. In all of these cases, DC-MRI proved useful for diagnosis. The sensitivity of unenhanced MRI, SPIO-MRI and DC-MRI for lesion detection was 57.3%, 67.6% and 75%, respectively. The results obtained in the characterisation of the lesions were 20.5%, 63.2% and 73.5% for unenhanced MRI, SPIO-MRI and DC-MRI, respectively. The diagnostic increment of SPIO-MRI over unenhanced MRI for lesion identification and characterisation was 9% and 42.7%, respectively, whereas the diagnostic increment of DC-MRI over SPIO-MRI was 7.4% and 10.3%, respectively.Conclusions.In our study, the combined use of two contrast agents, negative and positive, provided greater diagnostic confidence and caused no side effects in the patients.

Rotator cable at MR imaging: considerations on morphological aspects and biomechanical role.

PurposeThe rotator cable (RC) is a thickening of the coracohumeral ligament. It extends from the coracohumeral ligament to the inferior border of the infraspinatus tendon, with fibres running perpendicularly to the rotator cuff fibres. According to some authors, the RC tends to thicken with age, thus allowing some individuals with a cuff lesion to preserve normal shoulder function. We evaluated the RC with magnetic resonance (MR) imaging and investigated its possible role in the biomechanics of the shoulder affected by cuff lesions.Materials and methodsBetween November 2007 and May 2008, we performed shoulder MR examinations for shoulder pain or disability on 94 patients (46 males, 48 females; age range 16–79 years; mean age 54.09±15.09 years) for a total of 104 shoulders (62 right, 42 left).ResultsRC was more easily detectable in oblique coronal scans where it appeared as a crescent-shaped, regularly marginated structure adjacent to the articular surface of the supraspinatus tendon and medial to the insertion point of this tendon on the greater tuberosity. Its thickness was 2.8±0.3 mm. The structure was identified in 62% of cases (mean patient age 55.3±14.9 years). No statistically significant difference in age was found between patients with and without evidence of RC (Student’s t test=0.05; p=0.82). Among patients with partial- or full-thickness supraspinatus tendon lesions at MR imaging, no statistically significant difference was found between the presence or absence of RC and disability on Jobe’s test (χ2=1.17; p>0.05).ConclusionsRC can be observed at MR imaging in >60% cases. In our sample it did not seem to influence shoulder function in patients with cuff lesions.RiassuntoObiettivoIl rotator cable (RC) è un ispessimento del legamento coraco-omerale. Esso si estende dal legamento coraco-omerale fino al margine inferiore del tendine dell’infraspinato con fibre che decorrono perpendicolarmente a quelle dei tendini della cuffia dei rotatori. Secondo alcuni autori, il RC tenderebbe ad ispessirsi con l’età consentendo ad alcuni pazienti con lesioni di cuffia di conservare la normale funzionalità della spalla. Scopo del nostro lavoro è stato valutare il RC attraverso la risonanza magnetica (RM) e definire il suo possibile ruolo nella biomeccanica della spalla in soggetti con lesione di cuffia.Materiali e metodiDa novembre 2007 a maggio 2008 abbiamo reclutato 94 pazienti (46 maschi e 48 femmine), per un totale di 104 spalle (62 destre e 42 sinistre), di età compresa tra i 16 ed i 79 anni (età media 54,09±15,09 anni), che effettuavano l’esame di RM della spalla per dolore o limitazione funzionale.RisultatiIl RC è più agevolmente individuabile nelle scansioni coronali-oblique ove appare come una struttura a forma di semiluna, con margini regolari, adiacente alla superficie articolare del tendine sopraspinato, medialmente al punto d’inserzione di questo tendine sulla grande tuberosità. Il suo spessore è 2,8±0,3 mm. La struttura è stata identificata nel 62% dei casi (età media dei pazienti 55,3±14,9 anni). Non è stata riscontrata alcuna differenza statisticamente significativa per quanto riguardava l’età tra pazienti con o senza evidenza di RC (test t di Student=0,05; p=0,82). Nel gruppo di pazienti che presentavano lesioni parziali o complete del tendine sovraspinoso non è stata osservata alcuna differenza statisticamente significativa tra presenza o assenza del RC e limitazione funzionale al test di Jobe (χ2=1,17; p>0,05).ConclusioniIl RC può essere osservato in RM in più del 60% dei casi. Nel nostro campione di studio esso non sembra influenzare la funzionalità della spalla in pazienti con lesioni di cuffia.

Diffusion-weighted MRI with parallel imaging technique: apparent diffusion coefficient determination in normal kidneys and in nonmalignant renal diseases

The purpose of the study was to assess the capability and the reliability of apparent diffusion coefficient (ADC) measurements in the evaluation of different benign renal abnormalities. Twenty-five healthy volunteers and 31 patients, divided into seven different groups (A-G) according to pathology, underwent diffusion-weighted magnetic resonance imaging (DW MRI) of the kidneys using 1.5-T system. DW images were obtained in the axial plane with a spin-echo echo planar imaging single-shot sequence with three b values (0, 300, and 600 s/mm²). Before acquisition of DW sequences, we performed in each patient a morphological study of the kidneys. ADC was 2.40±0.20×10⁻³ mm² s⁻¹ in volunteers. A significant difference was found between Groups A (cysts=3.39±0.51×10⁻³ mm² s⁻¹) and B (acute/chronic renal failure=1.38±0.40×10⁻³ mm² s⁻¹) and between Groups A and C (chronic pyelonephritis=1.53±0.21×10⁻³ mm² s⁻¹) (P<.05). An important difference was also observed among Group D (hydronephrosis=4.82±0.35×10⁻³ mm² s⁻¹) and Groups A, B, and C (P<.05), whereas no differences were found between Groups B and C (P>.05). A considerable correlation between glomerular filtration rate and ADC was found (P=.04). In conclusion, significant differences were detected among different patient groups, and this suggests that ADC measurements can be useful in differentiating normal renal parenchyma from most commonly encountered nonmalignant renal lesions.

MR characterisation of dysplastic nodules and hepatocarcinoma in the cirrhotic liver with hepatospecific superparamagnetic contrast agents: pathological correlation in explanted livers

PurposeThe authors sought to evaluate the potential of magnetic resonance (MR) imaging with superparamagnetic iron oxide (SPIO) contrast material for identifying, characterising and differentiating dysplastic nodules (DN) and hepatocellular carcinoma (HCC) in the cirrhotic liver by correlating the results with pathological findings on the explanted liver.Material and methodsMR imaging was used to study the liver of 400 cirrhotic patients awaiting liver transplantation, 31 of whom were selected to receive a liver. Of these 31 patients, we included in the study 22 patients (mean age 53 years; range 46–57 years) who underwent liver transplantation within 12–24 h after MR examination. Patients were studied with a 1.5-T device, and scans were acquired before and after the administration of paramagnetic contrast material. For every lesion, we recorded signal intensity on unenhanced baseline T1- and T2-weighted images and enhancement pattern after SPIO administration. Histological examination of the entire liver provided the definitive diagnosis of the lesions.ResultsHistological examination identified 59 lesions: 14 HCC, 4 HCC-DN, 39 DN, and 2 cystoadenomas. Among the 14 HCC, three were well differentiated, eight were moderately differentiated and three were poorly differentiated. Of the 39 DN, 28 were low-grade and 11 high-grade lesions. Unenhanced baseline MR imaging correctly identified and characterised 20 lesions, equal to 33.90% of all lesions: 6 HCC, 12 DN and 2 DN with a subfocus of HCC. SPIO-enhanced MR imaging showed greater sensitivity detecting and characterising 45 lesions, equal to 76.27% of all lesions identified at histology: 14 HCC, 27 DN and 4 DN with subfocus of HCC. SPIO administration improved the sensitivity of MR imaging in lesion detection and characterisation by 42.37%. False negative results with SPIO-enhanced MR imaging occurred in 12 DN (31%), which histological examination revealed to be low-grade DN with a diameter <1 cm.ConclusionsSPIO-enhanced MR imaging proved to be of value in detecting and characterising lesions in the cirrhotic liver, allowing differentiation of DN from HCC and providing an early diagnosis of neoplastic degeneration of DN.RiassuntoObiettivoObiettivo di questo studio è stato valutare le potenzialità della risonanza magnetica (RM) eseguita con mezzo di contrasto (MdC) superparamagnetico (superparamagnetic iron oxide particles, SPIO) nell’identificazione, caratterizzazione e diagnosi differenziale tra noduli displasici (ND) ed epatocarcinoma (HCC) nel fegato cirrotico, confrontando i risultati della RM con quelli dell’esame anatomo-patologico eseguito su fegato espiantato.Materiali e metodiAbbiamo studiato con RM il fegato di 400 pazienti cirrotici in attesa di trapianto, 31 dei quali selezionati per reperimento d’organo da trapiantare. Dei 31 pazienti selezionati per il trapianto d’organo, sono stati inclusi nello studio 22 pazienti, di età media di 53 anni (range 46–57 anni), sottoposti a trapianto di fegato a distanza di circa 12–24 ore dall’esecuzione dell’esame RM. I pazienti inclusi nello studio sono stati sottoposti ad esame RM con un apparecchio da 1,5 T. Sono state eseguite scansioni prima e dopo somministrazione endovenosa di MdC SPIO. Per ogni lesione identificata è stata indicata l’intensità di segnale nelle sequenze di base pesate in T1 e in T2 ed il comportamento dopo iniezione di MdC SPIO. La diagnosi definitiva delle lesioni è stata effettuata con l’esame istologico di tutto il fegato espiantato.RisultatiCon l’esame istologico sono state identificate 59 lesioni: 14 HCC, 4 HCC-ND, 39 ND, 2 cistoadenomi. Dei 14 HCC, 3 sono risultati ben differenziati, 8 moderatamente differenziati, 3 scarsamente differenziati. Dei 39 ND, 28 erano a basso grado di malignità e 11 ad alto grado di malignità. Con l’esame RM di base abbiamo identificato e caratterizzato correttamente 20 lesioni, pari al 33,90% delle lesioni complessivamente individuate, di cui 6 HCC, 12 ND e 2 ND con foci di HCC. L’esame RM, eseguito dopo somministrazione di MdC SPIO, ha mostrato una maggiore sensibilità identificando e caratterizzando complessivamente 45 lesioni, pari al 76,27% delle lesioni totali individuate con l’esame istologico: 14 HCC, 27 ND e 4 ND con foci di HCC. Dopo la somministrazione di MdC SPIO la sensibilità della RM nella identificazione e caratterizzazione delle lesioni è aumentata rispetto alle immagini di base del 42,37%. I falsi negativi con la RM-SPIO sono stati 12 noduli displasici, pari al 31%, che all’esame istologico sono risultati essere ND a basso grado di malignità e con diametro inferiore al cm.ConclusioniLa RM con utilizzo di MdC SPIO, nella nostra esperienza è risultata utile nella identificazione e caratterizzazione delle lesioni epatiche nel fegato cirrotico mostrandosi in grado di differenziare i noduli displasici dagli HCC e ha consentito una diagnosi precoce della trasformazione carcinomatosa dei noduli displasici.

Mechanism of traumatic knee injuries and MRI findings

Bone bruises are focal abnormalities in subchondral bone marrow due to trabecular microfractures as a result of traumatic force. These trauma-induced lesions are better detected with magnetic resonance (MR) imaging using water-sensitive sequences. Moreover, the pattern of bone bruise is distinctive and allows us to understand the dynamics of trauma and to predict associated soft injuries. This article discusses the mechanism of traumatic injury and MR findings.

Case report: Multimodality imaging of van Neck-Odelberg disease.

Synchondrosis ischiopubic syndrome (SIS), also known as van Neck–Odelberg disease, is a syndrome characterized by an atypical ossification pattern of the ischiopubic synchondrosis. Its radiological features may mimic stress fracture, neoplasm, osteomyelitis, or posttraumatic osteolysis, causing problems in diagnosis, sometimes leading to unnecessary workup. We report two cases in which the correlation between the clinical and multimodality imaging data enabled the correct diagnosis of SIS.

Right ventricular assessment by cardiac magnetic resonance in Takotsubo cardiomyopathy

We would thank the colleagues for their kind interest in our work. We actually do agree that cardiac magnetic resonance (CMR) can be a useful tool for the assessment of the right ventricular (RV) function, in particular, of regional wall motion abnormalities and ejection fraction (EF), where echocardiography often fails. Different patterns of contraction may be found during the acute phase of Takotsubo cardiomyopathy (TTC), including apical, midventricular, basal, and biventricular ballooning. Eitel et al. [1] observed in their study that RV involvement may be present in one third of patients with TTC and reported an association with longer hospitalization, increased levels of heart failure markers, and older age. Consequently, biventricular ballooning may portend a more severe prognosis [2], when compared with isolated left ventricular (LV) involvement. Such findings have been confirmed also in other studies [3,4]. Cardiac magnetic resonance may improve our ability in assessing RV function and identifying the pattern of biventricular ballooning. The case 1 described in our paper [5] is a complex clinical case, where CMR shows its potential in the diagnostic workup of acute cardiac syndromes. The pattern of edema distribution and late gadolinium enhancementmay be useful in the differential diagnosis in acute cardiac setting. In this case, we found RV involvement, with anteroapical segment akinesis. The RVEF was normal (58%) with normal indexed volumes (indexed end-diastolic volume, 61 mL/m; indexed end-systolic volume, 25 mL/m). Our hypothesis is that the LV apical akinesis with hypokinesis of the remaining segments was because of myocardial stunning, probably secondary to microvascular dysfunction in the left anterior descending (LAD) coronary territory. In this case, the LAD was long, extending over the apex and supplying the apical region (so-called wrap around LAD), probably also the anteroapical RV segment. This may explain the regional and localized akinesis of the RV with normal EF. In case 2, instead, the clinical and instrumental data were suggestive for a TTC, further confirmed at CMR on the basis of typical localized edema to midapical LV segments, in the absence of late enhancement. The RV function was normal, without regional wall motion abnormalities (EF, 60%; indexed end-diastolic volume, 47 mL/m; indexed endsystolic volume, 19 mL/m). The assessment of RV abnormalities, when present, could therefore allow an early diagnosis of TTC [6]. We thus believe that a systematic evaluation of RV function by echocardiogram is recommended for an optimal management of patients with TTC [3].

An unusual sigmoid phytobezoar in a patient with a transplanted kidney: A case report

Bezoars are masses formed by the concretion of stomach contents or debris within the gastrointestinal tract. Bezoars are rare and account for only 0.4–4% of all cases of gastrointestinal obstruction and mainly occur in the stomach or small intestine. Intestinal obstruction caused by colonic bezoars is extremely rare. A 39-year-old man with a transplanted kidney came to the hospital because of abdominal pain, constipation, and distension. We performed an abdominal computed tomography scan and found an ovoid intraluminal mass with a mottled gas pattern in the distal sigmoid colon. Subsequently, the patient underwent laparotomic surgery and removal of the bezoar. We report a rare case of large bowel obstruction due to colonic phytobezoar, which was confirmed intraoperatively.

Incidental Extracardiac Findings and Their Characterization on Cardiac MRI

Background Cardiac magnetic resonance imaging (cMRI) has recently emerged as a new noninvasive imaging modality that offers superior structural and functional assessment of the heart. cMRI benefits from a large field of view but, consequently, may capture incidental extracardiac findings (IEFs). We aimed to evaluate the frequency and significance of IEFs reported from clinically indicated cMRI scans. Methods 742 consecutive patients (402 males and 340 females) referred to the Cardiac Magnetic Resonance Center of our University Hospital between January 2015 and December 2016 for clinically indicated cMRI were retrospectively enrolled for the evaluation of IEF prevalence and relevance. The median age of the subjects was 51 years (range: 5–85 years). Results A significant number of patients who underwent cMRI had incidental and clinically significant IEFs (2% of the population, 11.4% of cases). cMRI allowed a correct diagnosis in 116/131 cases with a diagnostic accuracy value of 88.5%. Conclusions IEFs on cMRI are not uncommon and lesions with mild or no clinical significance represent the most frequent findings. cMRI can characterize incidental findings with high accuracy in most cases.