Roberta Zappetti

Value of contrast-enhanced ultrasonography for detecting renal infarcts proven by contrast enhanced CT. A feasibility study

The effectiveness of contrast-enhanced ultrasonography (CEUS) in the evaluation of patients with acute renal infarcts was investigated, using contrast-enhanced helical computed tomography (CT) as the reference imaging procedure. Twenty-seven consecutive patients with acute renal infarcts detected with contrast-enhanced helical CT underwent CEUS. Digital cine-clips of CEUS were evaluated by two independent readers blinded to CT findings. Image quality was rated subjectively on a four-point scale. Then, readers were asked to assign a confidence level in diagnosis of renal infarct at the upper pole, medium portion, and lower pole of each kidney according to a five-degree scale, ranging from definitely absent to definitely present. ROC curve analysis was employed to assess the overall confidence of diagnosis of infarct, and weighted kappa values were calculated to assess inter-reader agreement. The subjective image quality of CEUS was lower than the image quality of CT at the upper poles. However, the diagnostic performance of CEUS was excellent (area under receiver-operator characteristic curve 0.992 ± 0.006 for reader 1; 0.991 ± 0.007 for reader 2), with very good inter-reader agreement (weighted kappa value = 0.83). CEUS is a reproducible tool to detect acute renal infarcts in men, with a diagnostic performance approaching that of CT.

Effect of Tadalafil on prostate haemodynamics: preliminary evaluation with contrast-enhanced US.

PurposePhosphodiesterase-5 (PDE-5) inhibitors have an established role in the treatment of erectile dysfunction, but there is increasing evidence that these drugs are effective also for the treatment of lower urinary tract symptoms and benign prostatic hyperplasia (BPH). The mechanism of action of PDE-5 inhibitors in the prostate, however, is poorly understood. It is conceivable that these drugs act by reducing the smooth muscle tone of the organ, but this effect could produce vascular changes as well. The aim of this study was to investigate whether administration of Tadalafil, a PDE-5 inhibitor, in patients with BPH produces haemodynamic changes in the prostate that can be assessed using contrast-enhanced US (CEUS).Materials and methodsTwelve consecutive patients with BPH underwent transrectal CEUS before and 90 min after administration of 20 mg Tadalafil. CEUS was performed during bolus injection of SonoVue (4.8 ml) using a nondestructive US mode. The same scan plane, imaging parameters and technique were used before and after Tadalafil administration. Digital clips were recorded and processed using dedicated software (QontraXt v.3.60. Signal intensity (SI) changes in a region of interest (ROI) encompassing the entire prostate were fitted to a gammavariate curve. Changes in enhancement peak, time to peak (TTP), sharpness of the bolus transit and area under the curve (AUC) were considered for further analysis.ResultsAfter Tadalafil administration, the enhancement peak and AUC increased significantly (p<0.01), reflecting changes in prostate vascularity. TTP and sharpness did not change significantly.ConclusionsIn patients with BPH, vascular changes are observed in the prostate after Tadalafil administration, which can be detected with CEUS.RiassuntoObiettivoGli inibitori della 5-fosfodiesterasi (PDE-5) hanno un ruolo ben definito nella terapia della disfunzione erettile, ma vi è una crescente evidenza che questi farmaci siano efficaci anche per il trattamento dei disturbi delle basse vie urinarie e dell’iperplasia prostatica benigna (IPB). Il meccanismo d’azione a livello prostatico degli inibitori delle PDE-5 è tuttavia scarsamente compreso. È verosimile che questi farmaci agiscano riducendo il tono della muscolatura liscia dell’organo, ma questo effetto può produrre anche variazioni della vascolarizzazione. Scopo di questo lavoro è valutare se nei pazienti con IPB la somministrazione di Tadalafil, un inibitore delle PDE-5, produce variazioni emodinamiche nella prostata valutabili con ecocontrastografia.Materiali e metodiDodici pazienti consecutivi con IPB sono stati studiati con ecocontrastografia prima e dopo la somministrazione di 20 mg di Tadalafil. L’ecocontrastografia è stata eseguita con un software contrastospecifico non distruttivo dopo somministrazione in bolo di SonoVue (4,8 ml). Prima e dopo la somministrazione di Tadalafil è stata utilizzata la stessa tecnica d’esame, sullo stesso piano di scansione e con gli stessi parametri. Gli esami sono stati registrati in forma digitale e analizzati con un software dedicato (QontraXt v.3.60, AMID, Roma, Italia). Le variazioni dell’intensità di segnale misurate in una regione di interesse (ROI) comprendente tutta la prostata sono state adattate ad una curva gamma-variata. Le variazioni del picco di enhancement, del tempo di picco (TTP), della ripidezza del transito del bolo e dell’area sotto la curva (AUC) sono state valutate statisticamente. Risultati. Dopo la somministrazione di Tadalafil si apprezza un aumento statisticamente significativo del picco di enhancement e dell’AUC, indice di una variazione nella vascolarizzazione della prostata. Non si sono apprezzate variazioni significative del TTP e della ripidezza del transito del bolo.ConclusioniNei pazienti con IPB dopo somministrazione di Tadalafil si osservano variazioni della vascolarizzazione prostatica rilevabili con l’ecocontrastografia.

Painful Penile Induration: Imaging Findings and Management

A number of benign and malignant diseases with different causes, clinical features, management, and outcome can manifest as painful penile induration. The most common such conditions are active Peyronie disease, inflammation, trauma, venous or corporal thrombosis, acute ischemic disorders, and primary or secondary tumors. In patients with painful penile induration, a preliminary differential diagnosis is based on the patients history and results of laboratory studies, penile inspection, and palpation. Imaging is often required to confirm the clinical diagnosis, assess the extent of disease, and determine patient treatment. A basic clinical investigation comprising penile inspection and palpation should be performed by the radiologist before imaging; such an evaluation is a great help in selecting the best imaging modality and examination technique. Moreover, acquisition of preliminary clinical information eases interpretation of the imaging features and facilitates identification of clinically relevant information that may result in a change in patient treatment. In standard clinical practice, color Doppler ultrasonography is often the first imaging modality used to evaluate patients with painful penile induration. This technique clearly demonstrates normal penile anatomy and its corresponding changes in most of the clinically relevant situations. Magnetic resonance imaging is the optimal imaging modality for tumor staging. Other imaging modalities are required less frequently.

Characterization of Atypical Cystic Renal Masses With MDCT: Comparison of 5-mm Axial Images and Thin Multiplanar Reconstructed Images

OBJECTIVE The purpose of this study was to investigate whether cystic renal masses are better characterized on thin axial and multiplanar reconstructed MDCT images than on 5-mm images. MATERIALS AND METHODS The records of 70 complex cystic renal masses in 59 patients (45 men, 14 women; mean age, 68 +/- 13 years) who underwent 64-MDCT at two medical centers were studied. Twenty-three of the masses were confirmed on the basis of the histologic findings and 47 in 2-4 years of follow-up. Images were reviewed in two sessions by two radiologists with 12 and 2 years of experience. In the first session, 5-mm axial images were analyzed, and in the second, thin axial images and multiplanar reconstructions. To assess intraobserver variability, analysis was repeated after 1 month. Statistical analysis was performed with Wilcoxons signed rank test, receiver operating characteristic analysis, and weighted kappa statistics. RESULTS Radiologists 1 and 2 detected thicker cystic walls (p < 0.001, p < 0.005) and septa (p < 0.03, p < 0.05) and fewer septa (p < 0.005, p < 0.002) on 5-mm axial images and assigned significantly different Bosniak categories than they did in analysis of the volume data (p < 0.04, p < 0.05). Variability was reduced in thin axial and multiplanar views. No significant differences were found in characterization of lesions as benign or malignant in review of 5-mm axial images and volume data sets. The areas under the receiver operating characteristic curve were 0.89 for 5-mm images and 0.96 for volume data sets for radiologist 1 and 0.87 and 0.90 for radiologist 2. CONCLUSION Analysis of volume data sets is associated with less intraobserver and interobserver variability than review of 5-mm axial images. Wall thickness and the number and thickness of septa may differ, resulting in assignment of different Bosniak categories. Diagnostic performance in characterizing lesions as benign or malignant, however, is not statistically different for the thick and thin images.

Differential diagnosis between splenic nodules and peritoneal metastases with contrast-enhanced ultrasound based on signal-intensity characteristics during the late phase

PurposeThis study was done to assess the enhancement characteristics of splenic implants and to evaluate whether contrast-enhanced ultrasound (CEUS) after SonoVue injection allows the differential diagnosis with peritoneal metastases.Material and MethodsThirteen consecutive patients with splenosis and 13 consecutive patients with peritoneal metastases were investigated with CEUS after injection of 2.4 ml of SonoVue. Lesion enhancement was evaluated in real time for 240 s. All examinations were recorded digitally and analysed retrospectively. Frames were selected at different time intervals ranging from 0 to 4 min after injection. Average signal intensity was evaluated by measuring the average grey level in a region of interest encompassing the entire nodule. Results were evaluated using the Mann-Whitney test and interobserver variability using the Bland and Altmann method.ResultsSplenic grafts presented with intense enhancement and without significant washout. Metastases presented with variable enhancement and progressive washout. Signal intensity values were significantly higher for splenic grafts, starting from 40 s after microbubble administration. Starting from 90 s after injection, there was no overlapping between enhancement of splenic grafts and peritoneal metastases, and only splenic grafts showed a percent of enhancement higher than 60% of the maximum enhancement.ConclusionsCEUS after SonoVue injection may be considered a valuable alternative to scintigraphy for characterising peritoneal splenic grafts without radiation.RiassuntoObiettivoDescrivere il comportamento perfusionale delle isole di splenosi e valutare se l’ecocontrastografia dopo iniezione di SonoVue ne consente la diagnosi differenziale rispetto alle metastasi peritoneali.Materiali e metodiSono stati valutati con ecocontrastografia 13 pazienti consecutivi con splenosi peritoneale e 13 con metastasi peritoneali iniettando 2,4 ml di SonoVue ed osservando l’enhancement delle lesioni in tempo reale per 240 s. Gli esami sono stati registrati in forma digitale e analizzati retrospettivamente selezionando immagini a intervalli di tempo compresi tra 0 e 4 minuti dopo l’iniezione. L’intensità di segnale è stata valutata misurando il livello di grigio medio in una regione di interesse comprendente l’intero nodulo. I risultati sono stati analizzati utilizzando il test di Mann-Whitney. La variabilità interosservatore è stata valutata con il metodo di Bland e Altmann.RisultatiGli impianti splenici hanno presentato intenso enhancement senza significativo wash-out. Le metastasi hanno presentato enhancement variabile e progressivo wash-out. A partire da 40 secondi dopo l’iniezione delle microbolle i valori di intensità del segnale sono risultati significativamente più elevati per gli impianti splenici. A partire da 90 secondi dopo l’iniezione non vi era sovrapposizione tra i valori di enhancement degli impianti e delle metastasi, e solo i noduli splenici presentavano un enhancement maggiore del 60% del massimo enhancementConclusioniL’ecocontrastografia dopo iniezione di SonoVue consente la diagnosi differenziale tra isole di splenosi e metastasi peritoneali.

Color Doppler Appearance of Penile Cavernosal-Spongiosal Communications in Patients with High-Flow Priapism

Background: Superselective embolization of the torn artery is currently considered the treatment of choice for patients with high-flow priapism. After embolization, however, the arterial-sinusoidal fistula is still patent in a significant percentage of patients, despite arteriographic evidence of occlusion. Purpose: To investigate the prevalence and flow characteristics of penile cavernosal-spongiosal communications (CSCs) in patients with high-flow priapism, and to establish whether the recognition of these vessels before and after angiographic embolization has a role in predicting the outcome of therapy. Material and Methods: Twelve consecutive patients with high-flow priapism underwent penile color Doppler ultrasound before and after angiographic embolization of the arterial-sinusoidal fistula. The prevalence of CSCs feeding the fistula was evaluated before and after embolization. Results: Before angiographic embolization, color Doppler ultrasound identified five CSCs in 3/12 patients. One CSC was proximal to the fistula, and 4/5 were distal. After angiographic embolization, the fistula was not completely closed in these patients, fed by the distal CSCs. However, spontaneous closure occurred within 1 month. The fistula was also fed by CSCs in another two patients in whom these vessels were not evident before embolization. In one case, the fistula closed spontaneously within 1 week, while in the other case the fistula remained patent, fed by other collateral vessels. Conclusion: The type of vessels that are involved in refilling the fistula after embolization is of concern for the outcome of the patients. In our series, the fistulas supplied only by CSCs closed spontaneously within 1 month. Watchful waiting should be preferred to repeated embolization to avoid the risk of unnecessary procedures.

Comparison of conventional ultrasound and real-time spatial compound imaging in evaluation of patients with severe Peyronie's disease.

Background: Real-time spatial compound imaging (C-US) is an ultrasound (US) method which effectively reduces image artifacts and noise. In contrast to conventional techniques, multiple frames are acquired from different viewing angles and combined to form a single compound image. Purpose: To evaluate whether C-US improves ultrasound evaluation of patients with severe Peyronies disease. Material and Methods: 60 consecutive patients with severe Peyronies disease underwent conventional US and C-US after intracavernous prostaglandin E1 injection. Corresponding images of the same scan plane were obtained with both methods, and subjective image quality was scored retrospectively using a four-point scale by two blinded readers with different experience in penile imaging. Readers focused on evaluation of the tunica albuginea, plaques, involvement of the penile septum, and overall image quality. Also, presence of large albugineal calcifications or microcalcifications was considered. To assess intrareader agreement, both readers repeated evaluation after a 1-month interval. Statistical analysis was performed using the Wilcoxon signed-rank test and McNemar test. Weighted κ values were calculated to assess intra- and inter-reader agreement. Results: Average scores were significantly higher for reader 1 (P<0.001). Both readers rated C-US better (P<0.001) than conventional US. Despite higher image quality scores, C-US was as effective as conventional grayscale US in assessing involvement of the penile septum. No differences were found between the two methods for visualization of large calcifications, while microcalcifications were better visible with compound imaging. Intrareader agreement was higher for the more experienced reader 1. Conclusion: C-US is subjectively superior to conventional US in evaluating patients with severe Peyronies disease.

The radiologist and the cytologist in diagnosing thyroid nodules: results of cooperation.

PurposeThis study was done to evaluate the effectiveness of cooperation between the radiologist and the cytopathologist in ultrasound-guided fine-needle aspiration biopsy (FNAB) of thyroid nodules.Materials and methodsSince 1995, FNAB of thyroid nodules at our department has been performed under ultrasound guidance by the radiologist with a cytopathologist present on-site. The results of ultrasound-guided FNAB procedures performed at our department in 1995, 1999, and 2005 were retrospectively evaluated and compared with those of other departments in the Trieste Province where thyroid nodules are sampled by palpation-guided FNAB performed by a clinician.ResultsFrom 1995 to 2005, the number of ultrasound-guided FNAB procedures performed at our department rose steadily, whereas the number of inadequate samples fell progressively. In patients who underwent surgery, the number of discrepancies between the cytological findings and the final histological diagnoses decreased progressively.ConclusionsUltrasound-guided FNAB performed by the radiologist with a cytopathologist present on-site is superior to palpation-guided FNAB. The results are optimised by cooperation between the radiologist and cytologist.RiassuntoObiettivoValutare i risultati della collaborazione tra radiologo e citologo nella agoaspirazione ecoguidata dei noduli tiroidei.Materiali e metodiNella nostra unità operativa dal 1995 l’agoaspirazione tiroidea viene eseguita sotto guida ecografica dal radiologo in collaborazione con il citologo. Sono stati rivalutati i risultati delle agoaspirazioni tiroidee ecoguidate eseguite presso la nostra unità operativa negli anni 1995, 1999, 2005. I risultati sono stati confrontati con quelli dei prelievi eseguiti in altre strutture della nostra Provincia nelle quali l’agoaspirazione viene effettuata dal clinico sotto guida palpatoria.RisultatiIl numero di agoaspirazioni tiroidee sotto guida ecografica nella nostra unità operativa è aumentato progressivamente dal 1995 al 2005. Il numero di prelievi inadeguati si è ridotto progressivamente. Nei pazienti sottoposti a intervento chirurgico le discrepanze tra la citologia e la diagnosi istologica definitiva si sono progressivamente ridotte.ConclusioniL’agoaspirazione sotto guida ecografica eseguita congiuntamente dal radiologo e dal citologo è superiore alla agoaspirazione sotto guida palpatoria. La stretta collaborazione tra radiologo e citologo consente di ottimizzare i risultati.

Color Doppler sonography of intrahepatic vascular shunts

To illustrate the sonographic and Doppler features of the different types of intrahepatic vascular shunts.

Prevalence of extravascular collateral findings during 64-slice CT angiography of the abdominal aorta and lower limbs

PurposeThe aim of this study was to assess the prevalence of extravascular collateral findings during 64-slice CT angiography of the abdominal aorta (AA-CTA) and lower limbs (LL-CTA).Materials and methodsThe images of 536 AA-CTA and LL-CTA examinations performed for suspected aortic and peripheral vascular disease in 500 patients were retrospectively reviewed. Two radiologists evaluated the 5-mm axial images independently using appropriate window settings for the area under investigation. Collateral findings were divided according to their clinical significance into significant, nonsignificant and meriting further investigation.ResultsNo collateral findings were identified in 97/500 patients (19.4%). In the remaining patients, 821 collateral findings were detected, of which 43 (5.24%) were classified as significant, 135 (16.44%) as meriting further investigation and 643 (78.32%) as nonsignificant. The findings indicative of the presence of a malignant lesion totalled 36 (4.5%).ConclusionsAA-CTA and LL-CTA demonstrate a nonnegligible prevalence of collateral findings, many of them major. It therefore appears that the evaluation should focus not only on the image reconstructions to identify vascular disease, but also on the native axial images to detect incidental findings.RiassuntoObiettivoScopo di questo studio è quello di valutare la prevalenza dei reperti collaterali extravascolari in corso di indagini di angio-TC dell’aorta addominale (AA-CTA) e degli arti inferiori (AI-CTA).Materiali e metodiSono state valutate retrospettivamente le immagini di 500 pazienti sottoposti ad AA-CTA e AI-CTA, per un totale di 536 esami, mediante apparecchiatura a 64 strati per sospetta patologia vascolare aortica e periferica. Due radiologi hanno valutato separatamente le immagini assiali a 5 mm utilizzando finestre di vista adeguate al distretto valutato. I reperti collaterali sono stati divisi a seconda della loro rilevanza clinica in significativi, non significativi e meritevoli di approfondimento.RisultatiSu 500 pazienti, solo in 97 non sono stati riscontrati reperti collaterali (19,4%); sono stati identificati 821 reperti accessori, dei quali 43 (5,24%) sono stati reputati significativi; 135 (16,44%) meritevoli di approfondimento e 643 (78,32%) non significativi. I reperti suggestivi per la presenza di una lesione neoplastica sono stati 36 (4,5%).ConclusioniGli esami di angio-TC addominali e degli arti inferiori presentano una prevalenza di reperti collaterali anche maggiori non trascurabile. Appare quindi necessario effettuare una valutazione dei reperti accessori sulle immagini assiali native, senza limitarsi alla sola valutazione delle ricostruzioni focalizzate alla valutazione vascolare.