Tommaso Bartalena

Prevalence of thoracolumbar vertebral fractures on multidetector CT: Underreporting by radiologists

OBJECTIVE To evaluate the prevalence of osteoporotic vertebral fractures in patients undergoing multidetector computed tomography (MDCT) of the chest and/or abdomen. MATERIALS AND METHODS 323 consecutive patients (196 males, 127 females) with a mean age of 62.6 years (range 20-88) who had undergone chest and/or abdominal MDCT were evaluated. Sagittal reformats of the spine obtained from thin section datasets were reviewed by two radiologists and assessed for vertebral fractures. Morphometric analysis using electronic calipers was performed on vertebral bodies which appeared abnormal upon visual inspection. A vertebral body height loss of 15% or more was considered a fracture and graded as mild (15-24%), moderate (25-49%) or severe (more than 50%). Official radiology reports were reviewed and whether the vertebral fractures had been reported or not was noted. RESULTS 31 out of 323 patients (9.5%) had at least 1 vertebral fracture and 7 of those patients had multiple fractures for a total of 41 fractures. Morphometric grading revealed 10 mild, 16 moderate and 15 severe fractures. Prevalence was higher in women (14.1%) than men (6.6%) and increased with patients age with a 17.1% prevalence in post-menopausal women. Only 6 out 41 vertebral fractures (14.6%) had been noted in the radiology final report while the remaining 35 (85.45) had not. CONCLUSION although vertebral fractures represent frequent incidental findings on multidetector CT studies and may be easily identified on sagittal reformats, they are often underreported by radiologists, most likely because of unawareness of their clinical importance.

Airway malacia in chronic obstructive pulmonary disease: prevalence, morphology and relationship with emphysema, bronchiectasis and bronchial wall thickening

The aim of this study was to determine the prevalence of airway malacia and its relationship with ancillary morphologic features in patients with chronic obstructive pulmonary disease (COPD). A retrospective review was performed of a consecutive series of patients with COPD who were imaged with inspiratory and dynamic expiratory multidetector computed tomography (MDCT). Airway malacia was defined as ≥50% expiratory reduction of the airway lumen. Both distribution and morphology of airway malacia were assessed. The extent of emphysema, extent of bronchiectasis and severity of bronchial wall thickness were quantified. The final study cohort was comprised of 71 patients. Airway malacia was seen in 38 of 71 patients (53%), and such proportion was roughly maintained in each stage of COPD severity. Almost all tracheomalacia cases (23/25, 92%) were characterised by an expiratory anterior bowing of the posterior membranous wall. Both emphysema and bronchiectasis extent did not differ between patients with and without airway malacia (p > 0.05). Bronchial wall thickness severity was significantly higher in patients with airway malacia and correlated with the degree of maximal bronchial collapse (p < 0.05). In conclusion, we demonstrated a strong association between airway malacia and COPD, disclosing a significant relationship with bronchial wall thickening.

Lung perfusion in patients with pulmonary hypertension: comparison between MDCT pulmonary angiography with minIP reconstructions and 99mTc-MAA perfusion scan.

Objectives:Alterations in lung perfusion are a well-known feature of pulmonary hypertension (PH) seen on nuclear medicine studies. Abnormal radiotracer distribution in patients with PH may be caused by arterial thromboembolic occlusion, like in chronic thromboembolic pulmonary hypertension, by parenchymal destruction as in interstitial lung disease and pulmonary emphysema or by distal arteriopathy, like in idiopathic pulmonary arterial hypertension and other nonembolic forms. The different imaging pattern on radionuclide perfusion studies represents an important element for differential diagnosis. The aim of this study was to evaluate minimum intensity projection (minIP) images as an alternative to perfusion scintigraphy. We compared lung parenchyma attenuation patterns as depicted in minIP reconstructions with scintigraphic findings of lung perfusion in patients affected by pulmonary hypertension from various etiologies. Methods:One hundred and seven consecutive patients affected by PH of different etiology (37 of those had chronic thromboembolic pulmonary hypertension) who had undergone both multidetector computed tomography pulmonary angiography and 99mTc-MAA perfusion scan were included. Five-millimeter thickness contiguous axial, coronal, and sagittal minIP images were reconstructed from the contrast enhanced computed tomography datasets. Two radiologists evaluated the images and qualitatively graded pulmonary attenuation as homogeneous, inhomogeneous with nonsegmental patchy defects, or inhomogeneous with segmental defects. The presence of parenchymal and pleural alterations was recorded. MinIP perfusion grading results were then compared with those of perfusion scintigraphy. Results:In 87 of 107 patients (81.3%), the attenuation pattern seen on minIP images (39 homogeneous patterns, 13 with nonsegmental patchy defects, and 39 with segmental defects) correlated with the nuclear medicine scans. In the remaining 20 patients (18.7%), the imaging pattern was discordant because of 7 false-positive and 2 false-negative thromboembolic patterns at minIP and 11 false-positive thromboembolic patterns at perfusion scan. Air-trapping and parenchymal disease caused false-positive findings at minIP and perfusion scans, respectively. The sensitivity and specificity of minIP in detection of a chronic thromboembolic perfusion pattern were 94.5% and 90%, whereas perfusion scan had 100% sensitivity and 84% specificity. Conclusion:MinIP reconstructions can identify different patterns of pulmonary parenchymal attenuation, which show high concordance with perfusion patterns seen on radionuclide studies in patients with pulmonary hypertension. MinIP is a promising technique to evaluate lung perfusion in PH and may be used as an alternative to scintigraphy in the diagnostic work-up of these patients.

Selective arterial embolisation for bone tumours: experience of 454 cases

PurposeThe authors present the experience of a single institution with selective arterial embolisation for primary and metastatic bone tumours.Materials and methodsA total of 365 patients were treated with 454 embolisation procedures from December 2002 to April 2010. Embolisation was the primary treatment for benign bone tumours, adjuvant treatment to surgery for benign and malignant bone tumours and palliative treatment for bone sarcomas and metastases. Indications for repeat embolisation included pain or imaging evidence of progressive disease: 105 patients had repeat embolisation at the same location at an interval of 1–3 months; 260 patients had one embolisation, 78 had two and 29 had three or more. In all patients, N-2-butyl cyanoacrylate (NBCA) in 33% lipiodol was the embolic agent used.ResultsA total of 419 of the 454 embolisations (93%) were technically successful. In 35 cases, embolisation was not feasible because of poor lesion vascularisation (21 patients with bone metastases and two with aneurysmal bone cysts), origin of the Adamkiewicz artery in the embolisation field (four patients with bone metastases and one with aneurysmal bone cyst), atheromatosis and arteriosclerosis (five patients with bone metastases) and anatomical and technical problems such as small-calibre vessels, many branches and acute vessel angles (two patients with bone metastases). A clinical response was achieved in 406 of the 419 procedures (97%), and no response in 13 procedures in patients with pelvis and sacrum tumours. Complications included postembolisation syndrome in 81 patients (22%), transient paraesthesias in 41 (11%), skin breakdown and subcutaneous necrosis at the shoulder and pelvis in five (1.4%) and paresis of the sciatic nerve in one (0.3%).ConclusionsWe recommend embolisation as primary or palliative treatment or an adjunct to surgery for tumours of variable histology. Strict adherence to the principles of transcatheter embolisation is important. Arteries feeding the tumour and collaterals must be evaluated carefully and catheterised superselectively to protect the normal tissues. NBCA is considered the most appropriate embolic agent for small-vessel occlusion without major complications.RiassuntoObiettivoScopo del nostro lavoro è presentare l’esperienza di una singola istituzione nell’embolizzazione arteriosa selettiva dei tumori primitivi e delle metastasi dell’apparato muscolo-scheletrico.Materiali e metodiTrecentosessantacinque pazienti sono stati sottoposti a 454 embolizzazioni da dicembre 2002 a aprile 2010. L’embolizzazione è stata usata come trattamento primario per pseudo-tumori e tumori benigni, con significato adiuvante nel trattamento dei tumori maligni e nelle forme benigne e con significato palliativo nel trattamento dei sarcomi dell’osso e delle lesioni metastatiche. Il dolore e l’evidenza all’imaging di una progressione di malattia era l’indicazione per la ripetizione dell’embolizzazione; 105 hanno ripetuto l’embolizzazione nella stessa sede, ad intervallo di 1–3 mesi; 260 pazienti sono stati sottoposti ad una sola embolizzazione, 78 pazienti a due embolizzazioni e 29 pazienti a tre o più embolizzazioni. In tutti è stato usato come unico agente embolizzante l’N-2-butil-Cianoacrilato (NBCA) diluito con lipiodol al 33%.RisultatiQuattrocentodiccianove embolizzazioni (93%) sono state portate a termine con successo. Si è ottenuta risposta clinica in 406 procedure (97%) e nessuna risposta in 13 procedure in pazienti con tumori del bacino e del sacro. In 35 pazienti non è stata eseguita alcuna embolizzazione: in 21 pazienti con metastasi e in 2 con cisti aneurismatiche per scarsa vascolarizzazione; in 4 con metastasi ossea ed in 1 con cisti aneurismatica per la presenza di arteria di Adamkiewicz nella vascolarizzazione della lesione; in 5 pazienti con metastasi ossee per problemi steno-ostruttivi su base ateromasica; in 2 pazienti con metastasi per problemi tecnici legati al calibro dei vasi. Per quanto riguarda le complicazioni, in 81 pazienti (22%) è stata osservata una sindrome post-embolica, in 41 pazienti (11%) paresi transitoria, in cinque pazienti (1,4%) necrosi cutanea e sottocutanea di spala e pelvi, e in un paziente (0,3%) è stata riscontrata una paresi transitoria del nervo sciatico.ConclusioniRaccomandiamo l’embolizzazione per tumori ossei di varia istologia come trattamento primario, adiuvante o palliativo. È fondamentale un rigorosa adesione ai principi delle tecniche di embolizzazione. I vasi afferenti alla lesione vanno attentamente valutati e cateterizzati in maniera altamente selettiva al fine di proteggere i tessuti non lesionali. L’NBCA è, a nostro avviso, l’agente embolizzante più adatto per l’occlusione di piccoli vasi in assenza di complicanze maggiori, ma richiede buona esperienza da parte degli operatori.

Incidental vertebral compression fractures in imaging studies: Lessons not learned by radiologists

AIM To assess radiologists reporting rates of incidental vertebral compression fractures in imaging studies. METHODS We performed a review of the current literature on the prevalence and reporting rates of incidental vertebral compression fractures in radiologic examinations. RESULTS The bibliographic search revealed 12 studies: 7 studies using conventional radiology and 5 using multidetector computed tomography (MDCT). The loss of height cut-off to define a vertebral fracture varied from 15% to 25%. Fracture prevalence was high (mean 21.1%; range 9.5%-35%) in both radiographic and MDCT studies (mean 21.6% and 20.2%, respectively). Reporting rates were low with a mean value of 27.4% (range 0%-66.3%) and were significantly lower in MDCT than in radiographic studies (mean 8.1% vs 41.1%). Notably, recent studies showed lower reporting rates than older studies. CONCLUSION Many scientific studies have confirmed a high prevalence of vertebral compression fractures as incidental findings on imaging studies. However, the underreporting of these fractures, as determined in our study, may negatively affect patient care.

Incidental lung nodules on CT examinations of the abdomen: prevalence and reporting rates in the PACS era.

OBJECTIVES To retrospectively evaluate prevalence, reporting rates and clinical implications of incidental pulmonary nodules detected in multidetector computed tomography (MDCT) abdominal studies. MATERIALS AND METHODS Abdominal MDCT studies of 243 consecutive patients, 94 of whom had a history of cancer, were evaluated. Lung bases included in the scan were reviewed on a PACS workstation with different window settings and post-processing techniques. Nodules were classified according to their density (calcified, solid noncalcified, non-solid, part-solid) and size (<4mm; 4-6mm; 6-8mm; >8mm). The study findings were compared with the corresponding radiologic reports. Previous of following CT studies, when available from the PACS, were also reviewed to evaluate changes in number and size of the detected nodules. RESULTS An average of 8.2 cm of lung parenchyma was imaged in each patient. 213 noncalcified nodules (NCNs) were identified in 95 patients (39.1%) but only 8 patients (8.4%) had it mentioned in the final report. Comparison CT studies were available for 44 out of the 95 positive patients showing disappearance of the nodules in 2 cases, no interval change in 26 and progression in size and/or number in 16 patients, in whom a final diagnosis of metastasis or primary lung cancers was achieved. CONCLUSION Radiologists tend to overlook lung portions on abdominal CT studies. Underreporting may affect patient care and have medico-legal implications since images are permanently stored in digital format on PACS and CD-ROMs. Management of the discovered nodules should be tailored to the clinical situation of the patient, and particular care should be reserved to patients with oncologic history.

Vertebral morphometry by X-ray absorptiometry: Which reference data for vertebral heights?

INTRODUCTION The recent improvement in the resolution of dual-energy X-ray absorptiometry (DXA) images enables most vertebral levels to be seen adequately and thus DXA may be a worthwhile alternative to radiologic morphometry for the identification of vertebral fractures (VF). In this multicenter study, we have derived reference data for vertebral heights and their ratios in Italian women using morphometric X-ray absorptiometry (MXA). METHODS DXA scans were acquired in 1254 consecutive pre- and postmenopausal women, (mean age 63.7 ± 11.3, range 26-88 yrs), referred to six osteoporosis centers. MXA analysis of these images was performed by the same operator measuring vertebral heights and height ratios from L4 to T4. We calculated measures of central tendency and dispersion of vertebral heights and vertebral ratios using different approaches (mean and standard deviation as well as median and interquartile range of raw data, mean and standard deviation of trimmed data using an iterative algorithm, and mean and standard deviation of not fractured vertebrae). RESULTS Independently of the approach that we used, all the measures of central tendency were similar, while significant differences were found when compared with reference ranges in other populations. The vertebral heights of our sample at every vertebral level were significantly smaller than both Rea population and the Lunar reference values, even after normalization. Splitting data according to age groups, there was a decrease in the vertebral heights and ratios between the younger and older women. CONCLUSIONS This study demonstrates that reference data for MXA should be population specific and age matched.

High-resolution computed tomography in the diagnosis and follow-up of idiopathic pulmonary fibrosis

Idiopathic pulmonary fibrosis (IPF) is the most common interstitial lung disease and is associated with a fatal prognosis. Familiarity with the typical appearances of IPF on high-resolution computed tomography (HRCT) is important, as in the appropriate clinical setting, it is often sufficient for establishing a confident diagnosis of IPF without the need for surgical biopsy. Moreover, HRCT can provide important prognostic information in IPF. This is noteworthy, as the course of IPF is variable, and many patients develop complications leading to respiratory failure and death. The purpose of this paper is to review the progress made towards a better understanding of the HRCT patterns of IPF.RiassuntoLa fibrosi polmonare idiopatica (idiopathic pulmonary fibrosis, IPF) è la più comune interstiziopatia ed è associata ad una prognosi infausta. È importante avere famigliarità con le tipiche alterazioni della IPF alla tomografia computerizzata ad alta risoluzione (highresolution computer tomography, HRCT), poiché queste, in combinazione con un profilo clinico compatibile, sono spesso sufficienti per ottenere la diagnosi di IPF senza il bisogno di ricorrere alla biopsia chirurgica. Inoltre, la HRCT può fornire importanti informazioni prognostiche per i pazienti con IPF. Questo è importante in considerazione del comportamento variabile della malattia, con molti pazienti in cui si osserva l’insorgenza di complicanze che conducono all’insufficienza respiratoria e alla morte. L’obiettivo di questo articolo è quello di riassumere i recenti progressi fatti verso una migliore comprensione degli aspetti sopra-riportati della IPF.

Three-dimensional analysis of pulmonary nodules: variability of semiautomated volume measurements between different versions of the same software

PurposeThis study was done to evaluate the variability of semiautomated volume measurements of solid pulmonary nodules between two different versions of the same volumetric software.Materials and methodsThe volumes of 100 solid intraparenchymal nodules (mean volume 88.10 mm3; range 7.36–595.25 mm3) studied with the same multidetector computed tomography (MDCT) protocol were determined using two different versions of the same volumetric software (LungCARE 2006G and LungCARE 2007S). The 2006G version is based on a single-segmentation algorithm, whereas the newer version features two algorithms: SmallSizeNodule and AllSizeNodule. The results obtained with the 2006G version were compared with those of the 2007S version with the SmallSizeNodule algorithm, as recommended by the user manual. In addition, we compared the volumetric measurements obtained by the two different algorithms of the 2007S version.ResultsThe 2006G version and the 2007S version with the SmallSizeNodule algorithm agreed in only two of 100 cases and showed a mean variability of 1.66% (range 0%–8.78%). A more significant volumetric discrepancy was observed between the two different algorithms of the 2007S version, with the AllSizeNodule algorithm providing on average larger volumes (mean variability 71.08%; range 6.02%–218.80%) than SmallSizeNodule. Volume discrepancies were more pronounced in the subgroups of smaller nodules in all comparisons.ConclusionsThere is variability also in the results provided by different versions of the same volumetric software, and this may affect the calculation of the nodule-doubling time. Computer-aided assessment of the growth of lung nodules should always be performed using the same version of volumetric software and the same segmentation algorithm.RiassuntoObiettivoScopo del nostro studio è stato valutare la variabilità delle misurazioni volumetriche di noduli polmonari solidi dovuta all’utilizzo di diverse versioni dello stesso software di volumetria.Materiali e metodiI volumi di 100 noduli polmonari solidi intraparenchimali (volume medio di 88,10 mm3; range 7,36–595,25 mm3) sottoposti a tomografia computerizzata (TC) multidetettore con lo stesso protocollo d’esame sono stati misurati con 2 versioni diverse dello stesso software di volumetria (LungCARE 2006G e LungCARE 2007S). La versione 2006G presenta un unico algoritmo di segmentazione mentre la versione 2007S è dotata di 2 algoritmi chiamati SmallSizeNodule e AllSizeNodule. I risultati della versione 2006G sono stati confrontati con quelli della versione 2007S ottenuti con l’algoritmo SmallSizeNodule come consigliato dal manuale del software. Sono stati inoltre confrontati tra loro i risultati delle volumetrie ottenute con i diversi algoritmi della versione 2007S.RisultatiLa versione 2006G e la versione 2007S con algoritmo SmallSizeNodule hanno dato un risultato sovrapponibile solo in 2 casi su 100 ed hanno esibito una variabilità volumetrica media dell’1.66% (range 0%–8,78%). Una discrepanza volumetrica assai maggiore è stata osservata tra i 2 diversi algoritmi di segmentazione della versione 2007S in cui l’algoritmo AllSizeNodule ha fornito volumi mediamente superiori del 71,08% (range 6,02%–218,80%) rispetto all’algoritmo SmallSizeNodule. L’entità delle discrepanze volumetriche è risultata maggiore nei sottogruppi di noduli di minori dimensioni in tutte le comparazioni eseguite.ConclusioniAnche tra diverse versioni dello stesso software di analisi volumetrica esiste una variabilità di risultati che può influenzare il calcolo del tempo di raddoppiamento dei noduli. La valutazione computerizzata del tasso di crescita di un nodulo polmonare andrebbe eseguita utilizzando nei vari controlli sempre la stessa versione del software di volumetria ed il medesimo algoritmo di segmentazione.

DISH of the cervical spine causing epiglottis impingement

Diffuse idiopathic skeletal hyperostosis (DISH) is a condition characterized by calcification and ossification of ligaments and entheses; it mainly affects the vertebral column. We report the case of a patient with pharyngeal dysphagia and episodic aspiration secondary to DISH involvement of the cervical spine, which had caused alteration in the epiglottic tilt mechanism during deglutition.