Roberto Passariello

Impact of Primary Coronary Angioplasty Delay on Myocardial Salvage, Infarct Size, and Microvascular Damage in Patients With ST-Segment Elevation Myocardial Infarction : Insight From Cardiovascular Magnetic Resonance

OBJECTIVES We investigated the extent and nature of myocardial damage by using cardiovascular magnetic resonance (CMR) in relation to different time-to-reperfusion intervals. BACKGROUND Previous studies evaluating the influence of time to reperfusion on infarct size (IS) and myocardial salvage in patients with ST-segment elevation myocardial infarction (STEMI) have yielded conflicting results. METHODS Seventy patients with STEMI successfully treated with primary percutaneous coronary intervention within 12 h from symptom onset underwent CMR 3 +/- 2 days after hospital admission. Patients were subcategorized into 4 time-to-reperfusion (symptom onset to balloon) quartiles: < or =90 min (group I, n = 19), >90 to 150 min (group II, n = 17), >150 to 360 min (group III, n = 17), and >360 min (group IV, n = 17). T2-weighted short tau inversion recovery and late gadolinium enhancement CMR were used to characterize reversible and irreversible myocardial injury (area at risk and IS, respectively); salvaged myocardium was defined as the normalized difference between extent of T2-weighted short tau inversion recovery and late gadolinium enhancement. RESULTS Shorter time-to-reperfusion (group I) was associated with smaller IS and microvascular obstruction and larger salvaged myocardium. Mean IS progressively increased overtime: 8% (group I), 11.7% (group II), 12.7% (group III), and 17.9% (group IV), p = 0.017; similarly, MVO was larger in patients reperfused later (0.5%, 1.5%, 3.7%, and 6.6%, respectively, p = 0.047). Accordingly, salvaged myocardium markedly decreased when reperfusion occurred >90 min of coronary occlusion (8.5%, 3.2%, 2.4%, and 2.1%, respectively, p = 0.004). CONCLUSIONS In patients with STEMI treated with primary percutaneous coronary intervention, time to reperfusion determines the extent of reversible and irreversible myocardial injury assessed by CMR. In particular, salvaged myocardium is markedly reduced when reperfusion occurs >90 min of coronary occlusion.

Contrast enhanced magnetic resonance imaging of the terminal ileum in children with Crohn’s disease

Background and aims: Recently, magnetic resonance imaging (MRI) has been introduced in the diagnosis of patients with inflammatory bowel disease (IBD). However, it is still rarely reported in paediatric IBD. We studied the diagnostic value of gadolinium enhanced MRI in revealing inflammation of the distal ileum in children with Crohn’s disease (CD) and in differentiating them from patients with other inflammatory diseases of the gut. MRI was performed using a polyethylene glycol (PEG) solution as oral contrast agent to distend the small bowel (CE-PEG-MRI). Subjects and methods: Seventy five consecutive patients (median age 13.6 years, range 8–17) with suspected CD underwent ileocolonoscopy with biopsy and CE-PEG-MRI. CD activity was measured by the paediatric Crohn’s disease activity index (PCDAI). CE-PEG-MRI was evaluated with an overall score calculated, taking into account both wall thickness and contrast enhancement. Results: Active CD with distal ileitis was diagnosed in 26 cases, active ulcerative colitis (UC) in 18, and spondyloarthropathy and indeterminate ileocolitis in 11; 20 children served as controls. In all CD patients, CE-PEG-MRI revealed a marked ileal involvement with increased wall thickness and parietal contrast enhancement and showed a high concordance with endoscopy and histology, whereas the test was negative in all controls. Of the 18 UC patients, CE-PEG-MRI was negative in 15 and showed a mild parietal contrast enhancement of the terminal ileum in only three of seven patients with backwash ileitis. Among the group of spondyloarthropathy patients, six had mucosal erosions and five mild superficial ileitis: CE-PEG-MRI was negative in four and revealed only mild parietal contrast enhancement of the ileal wall in seven. CE-PEG-MRI did not show an increase in wall thickness of the distal ileum in any of the UC or spondyloarthropathy patients. The sensitivity and specificity of CE-PEG-MRI related to the presence of erosive ileitis, as documented by endoscopy, were 84% and 100%, respectively. In addition, the test correlated markedly with endoscopy and histology in the entire population (r=0.94; r=0.95, respectively) as well as with the PCDAI in CD patients (r=0.91). Conclusions: In children with active CD, CE-PEG-MRI is a very sensitive and specific test for the detection of distal ileitis and for differentiation from other inflammatory diseases of the gut. The test could also be useful for the firstline diagnostic approach in children with suspected CD. The high correlation of CE-PEG-MRI with ileal endoscopy and histology as well as with PCDAI makes this test of great interest for future studies as a tool for monitoring the clinical course and the effect of therapy in CD patients.

Intraindividual Comparison of Gadoxetate Disodium–enhanced MR Imaging and 64-Section Multidetector CT in the Detection of Hepatocellular Carcinoma in Patients with Cirrhosis

PURPOSE To prospectively compare gadoxetate disodium-enhanced magnetic resonance (MR) imaging with multiphasic 64-section multidetector computed tomography (CT) in the detection of hepatocellular carcinoma (HCC) in patients with cirrhosis. MATERIALS AND METHODS Institutional review board approval and informed patient consent were obtained for this prospective study. Fifty-eight patients (39 men, 19 women; mean age, 63 years; age range, 35-84 years) underwent gadoxetate disodium-enhanced MR imaging and multiphasic 64-section multidetector CT. The imaging examinations were performed within 30 days of each other. The two sets of images were qualitatively analyzed in random order by three independent readers in a blinded and retrospective fashion. Using strict diagnostic criteria for HCC, readers classified all detected lesions with use of a four-point confidence scale. The reference standard was a combination of pathologic proof, conclusive imaging findings, and substantial tumor growth at follow-up CT or MR imaging (range of follow-up, 90-370 days). The diagnostic accuracy, sensitivity, and positive predictive value were compared between the two image sets. Interreader variability was assessed. The accuracy of each imaging method was determined by using an adjusted modified chi(2) test. RESULTS Eighty-seven HCCs (mean size +/- standard deviation, 1.8 cm +/- 1.5; range, 0.3-7.0 cm) were confirmed in 42 of the 58 patients. Regardless of lesion size, the average diagnostic accuracy and sensitivity for all readers were significantly greater with gadoxetate disodium-enhanced MR imaging (average diagnostic accuracy: 0.88, 95% confidence interval [CI]: 0.80, 0.97; average sensitivity: 0.85, 95% CI: 0.74, 0.96) than with multidetector CT (average diagnostic accuracy: 0.74, 95% CI: 0.65, 0.82; average sensitivity: 0.69, 95% CI: 0.59, 0.79) (P < .001 for each). No significant difference in positive predictive value was observed between the two image sets for each reader. Interreader agreement was good to excellent. CONCLUSION Compared with multiphasic 64-section multidetector CT, gadoxetate disodium-enhanced MR imaging yields significantly higher diagnostic accuracy and sensitivity in the detection of HCC in patients with cirrhosis.

Role of Dynamic Contrast-Enhanced Magnetic Resonance (MR) Imaging and Proton MR Spectroscopic Imaging in the Detection of Local Recurrence after Radical Prostatectomy for Prostate Cancer

OBJECTIVES To assess the accuracy of magnetic resonance (MR) spectroscopic imaging (1H-MRSI) and dynamic contrast-enhanced MR (DCEMR) in the depiction of local prostate cancer recurrence in patients with biochemical progression after radical prostatectomy (RP). MATERIALS AND METHODS 1H-MRSI and DCEMR were performed in 70 patients at high risk of local recurrence after RP. The population was divided on the basis of the clinical validation of MR results with the use of a transrectal ultrasound biopsy examination in a group of 50 patients (group A) and the prostate-specific antigen (PSA) serum level restitution after external beam radiotherapy, in a group of 20 patients (group B). RESULTS In group A, 1H-MRSI analysis alone showed a sensitivity of 84% and a specificity of 88%; the DCEMR analysis alone, a sensitivity of 71% and a specificity of 94%; combined 1HMRSI-DCEMR, a sensitivity of 87% and specificity of 94%. Areas under the receiver operating characteristic (ROC) curve for 1HMRSI, DCEMR, and combined 1HMRSI /DCEMR were 0.942, 0.93,1 and 0.964, respectively. In group B, 1HMRSI alone showed a sensitivity of 71% and a specificity of 83%; DCEMR, a sensitivity of 79% and a specificity of 100%; combined 1HMRSI and DCEMR, a sensitivity of 86% and a specificity of 100%. Areas under the ROC curve for each of these groups were 0.81, 0.923, and 0.94, respectively. CONCLUSION Our results show that combined 1H-MRSI and DCMRE is an accurate method to identify local prostate cancer recurrence in patients with biochemical progression after RP.

Value of magnetic resonance spectroscopy imaging and dynamic contrast-enhanced imaging for detecting prostate cancer foci in men with prior negative biopsy

Purpose: This study aimed to prospectively analyze the role of magnetic resonance spectroscopy imaging (MRSI) and dynamic-contrast enhancement magnetic resonance (DCEMR) in the detection of prostate tumor foci in patients with persistently elevated prostate-specific antigen levels (in the range of ≥4 ng/mL to <10 ng/mL) and prior negative random trans-rectal ultrasound (TRUS)-guided biopsy. Experimental Design: This was a prospective randomized single-center study. One hundred and eighty eligible cases were included in the study. Patients in group A were submitted to a second random prostate biopsy, whereas patients in group B were submitted to a 1H-MRSI-DCEMR examination and samples targeted on suspicious areas were associated to the random biopsy. Results: At the second biopsy, a prostate adenocarcinoma histologic diagnosis was found in 22 of 90 cases (24.4%) in group A and in 41 of 90 cases (45.5%) in group B (P = 0.01). On a patient-by-patient basis, MRSI had 92.3% sensitivity, 88.2% specificity, 85.7% positive predictive value (PPV), 93.7% negative predictive value (NPV), and 90% accuracy; DCEMR had 84.6 % sensitivity, 82.3% specificity, 78.5% PPV, 87.5% NPV, and 83.3% accuracy; and the association MRSI plus DCEMR had 92.6% sensitivity, 88.8% specificity, 88.7% PPV, 92.7% NPV, and 90.7% accuracy, for predicting prostate cancer detection. Conclusions: The combination of MRSI and DCEMR showed the potential to guide biopsy to cancer foci in patients with previously negative TRUS biopsy. To avoid a potential bias, represented from having taken more samples in group B (mean of cores, 12.17) than in group A (10 cores), in the future a MRSI/DCEMR directed biopsy could be prospectively compared with a saturation biopsy procedure. Clin Cancer Res; 16(6); 1875–83

Fat in the liver: diagnosis and characterization

The purpose of this article is to provide an update on imaging techniques useful for detection and characterization of fat in the liver. Imaging findings of liver steatosis, both diffuse steatosis and focal fatty change, as well as focal fatty sparing, are presented. In addition, we will review computed tomography (CT) and magnetic resonance (MR) findings of focal liver lesions with fatty metamorphosis, including hepatocellular carcinoma, hepatocellular adenoma, focal nodular hyperplasia, angiomyolipoma, lipoma, and metastases.

Detection of colorectal lesions with virtual computed tomographic colonography

BACKGROUND The aim of our study was to compare the performance of virtual computed tomographic colonography with that of conventional colonoscopy in a blinded, prospective study in 165 patients with suspected colorectal lesions. METHODS There were 165 patients, all referred for conventional colonoscopy, who underwent preliminary virtual computed tomographic colonography. Computed tomograhic images of all suspected lesions were analyzed and subsequently compared with conventional colonoscopy findings. RESULTS There were 30 colorectal cancers and 37 polyps identified at conventional colonoscopy. Virtual computed tomographic colonography correctly detected all cancers, as well as 11 of 12 polyps of 10 mm in diameter or larger (sensitivity, 92%); 14 of 17 polyps between 6 and 9 mm (sensitivity, 82%); and 4 of 8 polyps of 5 mm or smaller (sensitivity, 50%). The per-patient sensitivity and specificity were 92% and 97%, respectively. CONCLUSIONS Virtual computed tomographic colonography has a diagnostic sensitivity similar to that of conventional colonoscopy for the detection of colorectal lesions larger than 6 mm in diameter.

Prostate cancer: 1HMRS-DCEMR at 3 T versus [(18)F]choline PET/CT in the detection of local prostate cancer recurrence in men with biochemical progression after radical retropubic prostatectomy (RRP)

OBJECTIVES This study compares proton magnetic resonancespectroscopic imaging (1H-MRSI) and dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) combined techniques at 3T magnet versus [(18)F]choline PET/computed tomography (CT) in the detection of local prostate cancer recurrence in patients with biochemical progression after radical retropubic prostatectomy (RRP). MATERIALS AND METHODS 84 consecutive patients at high risk of local recurrence underwent combined 1HMRSI-DCEMR and 18-Fcholine- PET/CT. MR scan protocol included turbo spin echo (TSE) T2-weighted sequences in the axial, sagittal and coronal planes; three-dimensional (3D) chemical shift imaging (CSI) sequences with spectral/spatial pulses optimized for quantitative detection of choline and citrate; dynamic contrast enhanced gradient-echo (GRE) T1-weighted sequence. The population was divided into two groups. Group A included 28 patients with a lesion size ranging between 5.00mm and 7.2mm and PSA reduction following radiation therapy. Group B included 56 patients with a lesion size between 7.6mm and 19.4mm. Sensitivity, specificity, positive predictive value (PPV) and accuracy were evaluated and receiver operating characteristic (ROC) curves were performed. RESULTS In Group A combined 1H-MRSI and DCE-MRI showed a sensitivity of 92%, a specificity of 75% (PPV 96%) while PET-CT examination showed a sensitivity of 62% and a specificity of 50% (PPV 88%) in identifying local recurrence. The accuracy of MRI was 89% while PET-CT showed an accuracy of 60%. Areas under the ROC curve (AUC) values for MR and PET-CT were 0.833 and 0.562, respectively. In Group B combined 1H-MRSI and DCEMR showed a sensitivity of 94% and a specificity of 100% (PPV 100%) with accuracy of 94%. PET-CT had a sensitivity of 92% and a specificity of 33% (PPV 98%) with accuracy of 91%. The AUCs for MR and PET-CT values were 0.971 and 0.837, respectively. CONCLUSION The diagnostic accuracy of combined 1HMRSI-DCEMR was higher than PET/CT to identify local prostate cancer recurrence, mostly in patients with low biochemical progression after RRP (0.2-2ng/mL).

Peliosis Hepatis: Spectrum of Imaging Findings

OBJECTIVE It is important to recognize the imaging characteristics of peliosis hepatis because peliotic lesions may mimic several different types of focal hepatic lesions CONCLUSION We illustrate the spectrum of imaging findings of peliosis hepatis, including sonography, CT, MR, and angiography.

Magnetic resonance-cholangiopancreatography in the diagnosis of biliopancreatic diseases

BACKGROUND Magnetic resonance cholangiopancreatography (MRCP) is a new, noninvasive imaging technique for the visualization of the biliary ducts with cholangiographic images similar to those obtained with endoscopic retrograde cholangiopancreatography and percutaneous transhepatic cholangiography. No contrast medium injection is used. The aim of this study was to assess the feasibility of MRCP versus ERCP in the diagnosis of biliary tract and pancreatic diseases. PATIENTS AND METHODS One hundred and thirty-six patients were submitted to MRCP. They were referred to MR study according to four inclusion criteria: (1) evidence or suspicion of choledocholithiasis, (2) benign or malignant bile ducts stenosis, (3) follow-up of patients submitted to biliary-enteric anastomosis, and (4) chronic pancreatitis with Wirsung duct dilatation. The MRCP was performed with a 0.5T superconducting magnet (Philips Gyroscan T5). When neoplastic disease was detected, additional images on axial planes were acquired. MRCP allowed images of diagnostic value to be obtained in all the cases. RESULTS In choledocholithiasis, MRCP showed 91.6% sensitivity, 100% specificity, and overall diagnostic accuracy 96.8%. Of 48 patients with stenotic lesions, 16 were correctly characterized as benign and 30 as malignant. Two cases of focal chronic pancreatitis were misdiagnosed as pancreatic head carcinoma. In the patients submitted to biliary-enteric anastomosis, MCRP was able to detect the dilatation of the intrahepatic ducts, the stenosis, and associated stones in all 8 positive cases. In the remaining 7 patients with mild signs of cholangitis, MCRP showed irregular aspects of the biliary tree in the main ducts. In the 11 patients with chronic pancreatitis, MCRP was able to depict the dilated Wirsung duct and the stenotic tract, although the fine details of the secondary ducts were not evaluated due to the low spatial resolution as compared with conventional films. CONCLUSIONS MRCP can be considered a technique able to completely replace diagnostic ERCP. Further studies are necessary for a better evaluation of the potential advantages and disadvantages of this technique.