Value of blood flow velocity on color Doppler ultrasonography for optimization of delay in scanning time on computed tomography venography in patients with Budd–Chiari syndrome and inferior vena cava obstruction

Purpose

To prospectively determine the value of blood flow velocity in the inferior vena cava (IVC) on color Doppler ultrasonography for the optimization of the delay in scanning time after contrast injection during computed tomography (CT) venography in patients with Budd–Chiari syndrome (BCS) with IVC obstruction.

Methods

We enrolled 122 consecutive BCS patients with IVC obstruction. All patients underwent color Doppler ultrasonography, CT venography, and digital subtraction angiography (DSA) in that order prior to treatment. The delay in scanning time during CT venography was set at 120, 180, 240, and 300 s after contrast injection. The correlation between delay in CT scanning and IVC blood flow velocity on color Doppler ultrasonography was explored. Image quality was classified as good, moderate, or poor. Patients with good CT image quality were considered to have an optimal delay in scanning time.

Results

Delays in scanning time of 120, 180, 240, and 300 s yielded good-quality images in 2, 7, 49, and 64 patients, respectively. The corresponding IVC blood flow velocities in these patients were 16.10 ± 0.42 cm/s (range 15.8–16.4 cm/s), 12.90 ± 1.58 cm/s (range, 11–15 cm/s), 7.53 ± 1.35 cm/s (range 5–10 cm/s), and 1.95 ± 1.75 cm/s (range 0–5.5 cm/s).

Conclusion

IVC blood flow velocity on color Doppler ultrasonography could serve as a useful tool for the optimization of the delay in scanning time during CT venography to ensure good-quality images for the diagnosis of BCS with IVC obstruction.

     

Exclusion of brain lesions: is MR contrast medium required after a negative fluid-attenuated inversion recovery sequence?

We hypothesized that in patients with negative fluid-attenuated inversion recovery (FLAIR) images T(2) weighted fast spin-echo (FSE) images and T(1) weighted spin-echo (SE) images before and after intravenous administration of gadolinium-based contrast medium display no pathology either. Thus, we assessed the negative predictive value of FLAIR images to rule out MR-detectable brain lesions. 1026 consecutive cranial MR examinations were reviewed. Routine MRI of the brain included T(1) weighted coronal imaging before and after administration of gadopentetate dimeglumine, axial T(2) weighted FSE and fast-FLAIR imaging. The FLAIR images were rated by two radiologists into categories of 0 (without pathologic changes) and 1 (with pathologic changes). Two other radiologists analysed the complete examination. In 284 MR examinations of the brain no abnormalities were found (28%). FLAIR-ratings were false-negative in four cases and false-positive in 30 cases. Sensitivity and specificity of the FLAIR sequence for MR-detectable brain lesions were 99.5% and 89.4%. The unselective application of gadolinium avoided one false-negative MR-reading and improved the sensitivity of the MR-examination from 99.5% to 99.6%. Positive and negative predictive values were 96.1% and 98.4%, respectively. The interobserver reliability was kappa=0.93 for the FLAIR-readers and 0.89 for the readers who rated the complete examination. In conclusion, negative FLAIR images provide a high negative predictive value for MR-detectable brain lesions. Thus, in patients with negative FLAIR images the unselective application of gadolinium seems to be unnecessary.     

Vessel-selective, non-contrast enhanced, time-resolved MR angiography with vessel-selective arterial spin labeling technique (CINEMA–SELECT) in intracranial arteries

We demonstrate the feasibility of the vessel-selective, non-contrast, time-resolved magnetic resonance angiography (MRA) technique, “contrast inherent inflow enhanced multi-phase angiography combining vessel-selective arterial spin labeling technique (CINEMA–SELECT)”. This sequence consists of two major techniques: pulsed star labeling of arterial regions (PULSAR) and Look–Locker sampling. We hypothesize that this technique allows selective labeling of single intracranial arteries, consisting of high-resolution four-dimensional data with a wide coverage of the brain. In this study, a new vessel-selective, time-resolved angiographic technique is demonstrated that can produce individual angiograms non-invasively by labeling the principal arterial vessels proximal to the circle of Willis. Clear vessel delineation is achieved, and the separation of the three vessels is evident in healthy volunteers. This technique could play an important role in the assessment of the structure and hemodynamics of intracranial arteries without the use of contrast agents.     

Diagnostic accuracy of short-time inversion recovery sequence in Graves’ ophthalmopathy before and after prednisone treatment

Introduction

In Graves’ Ophthalmopathy, it is important to distinguish active inflammatory phase, responsive to immunosuppressive treatment, from fibrotic unresponsive inactive one. The purpose of this study is, first, to identify the relevant orbital magnetic resonance imaging signal intensities before treatment, so to classify patients according to their clinical activity score (CAS), discriminating inactive (CAS?<?3) from active Graves’ Ophthalmopathy (GO) (CAS?>?3) subjects and, second, to follow post-steroid treatment disease.

Methods

An observational study was executed on 32 GO consecutive patients in different phases of disease, based on clinical and orbital Magnetic Resonance Imaging parameters, compared to 32 healthy volunteers. Orbital Magnetic Resonance Imaging was performed on a 1.5 tesla Magnetic Resonance Unit by an experienced neuroradiologist blinded to the clinical examinations.

Results

In pre-therapy patients, compared to controls, a medial rectus muscle statistically significant signal intensity ratio (SIR) in short-time inversion recovery (STIR) (long TR/TE) sequence was found, as well as when comparing patients before and after treatment, both medial and inferior rectus muscle SIR resulted significantly statistically different in STIR. These increased outcomes explain the inflammation oedematous phase of disease, moreover after steroid administration, compared to controls; patients presented lack of that statistically significant difference, thus suggesting treatment effectiveness.

Conclusion

In our study, we proved STIR signal intensities increase in inflammation oedematous phase, confirming STIR sequence to define active phase of disease with more sensibility and reproducibility than CAS alone and to evaluate post-therapy involvement.     

Changes in Liver Congestion in Patients with Budd–Chiari Syndrome following Endovascular Interventions: Assessment with Transient Elastography

Purpose

Transient elastography (TE) is routinely used for noninvasive staging of hepatic fibrosis. The objective of the present study was to investigate the role of TE (FibroScan) in determining changes in liver congestion in patients with Budd–Chiari syndrome (BCS) treated by endovascular interventions and determine the effects of pretreatment Meta-analysis of Histological Data in Viral Hepatitis (METAVIR) fibrosis score on posttreatment liver stiffness (LS).

Transjugular intrahepatic portocaval shunt placed through the strut of an inferior vena cava stent in a patient with Budd–Chiari syndrome: a technical modification

Transjugular intrahepatic portocaval shunt (TIPS) is performed in patients with symptomatic Budd–Chiari syndrome (BCS) who do not have repairable hepatic veins. We report the case of a patient who had an inferior vena cava (IVC) stent placed previously as part of the management for BCS, and who subsequently required TIPS. The TIPS tract was created through the strut of the previously placed IVC stent; the TIPS stent was placed after dilatation of the liver parenchyma as well as the strut of the IVC stent. This novel technique of “strutplasty” of a previously placed stent as part of TIPS has not been reported in the literature.The transjugular intrahepatic portocaval shunt (TIPS) procedure, as well as stent technology, is continually being improved [1–5]. Direct intrahepatic portocaval shunt (DIPS) – a modification of the TIPS procedure – is especially useful when there are occluded hepatic veins or an unfavourable angle between the inferior vena cava (IVC) and the hepatic vein resulting from hydrothorax and hypertrophy of the caudate lobe of the liver [1]. Herein, we report a technical modification of the TIPS procedure in Budd–Chiari syndrome (BCS).     

Role of semi–quantitative dynamic contrast–enhanced MR imaging in characterization and grading of prostate cancer

ObjectiveThe study retrospectively assessed the diagnostic value of semi-quantitative dynamic contrast-enhanced (DCE) magnetic resonance imaging (MRI) in characterization and grading of prostate cancer, with correlation to histopathological analysis.Materials and methods161 consecutive patients with prostate cancer underwent DCE MRI. 430 lesions, including 200 cancers with Gleason grade (GG) of 6 (n = 25), 7 (n = 112) and 8 or higher (n = 63); 80 benign hyperplasia; and 150 healthy tissues were assessed using a histology–MRI correlation. Time–intensity curve types between two radiologists and kinetic parameters (C_peak, time to peak, wash-in and wash-out) were compared in the different tissue types and GGs. Receiver operating characteristic curve analysis was performed to assess for each parameter to differentiate cancer from benign hyperplasia or healthy tissue, and GG 8 or higher from GG 6 or 7.ResultsType 2 was the prevalent assigned curve type. Inter-radiologist agreement for the curve types was excellent. Cancer and GG 8 or higher significantly showed a higher C_peak and faster wash-in compared to healthy tissue and GG 6. Only wash-in significantly differentiated cancer from healthy tissue, and GG 8 or higher from GG 6, having an area under the curve (AUC) of 0.755 and 0.815 respectively. Wash-in for the combined parameters revealed AUCs of 0.791 and 0.839 in two (C_peak) parameters, and AUCs of 0.862 and 0.891 in three (C_peak and wash-out) parameters.ConclusionSemi-quantitative parameters can differentiate cancer from benign hyperplasia and healthy tissue. Wash-in is the most accurate differentiation parameter of cancer foci and GG 8 or higher.     

Percutaneous Endovascular Creation of an Inferior Vena Cava in a Patient with Caval Agenesis,Budd–Chiari Syndrome,and Iliofemorocaval Thrombosis

A 29-year-old woman with acute iliofemorocaval thrombosis was discovered to have suprarenal caval agenesis with azygous continuation, hepatic congestion, and fibrosis as a result of chronic Budd–Chiari syndrome. Three staged procedures were performed: pharmacomechanical thrombolysis of acute thromboses, transfemoral liver biopsy and hemodynamic assessment, and percutaneous endovascular creation of a “neocava” lined with endografts. Symptomatic improvement and patency were maintained at 12-week follow-up.     

MR findings of the orbit in patients with Vogt–Koyanagi–Harada disease

Purpose

We aimed to evaluate the MR findings of the orbit in patients with Vogt–Koyanagi–Harada disease (VKHD).

Methods

We included 14 patients with clinically diagnosed VKHD, who underwent orbital MR imaging before treatment between May 2011 and August 2017. The mean duration from initial symptom onset to MR imaging was 16 days (range, 2–36 days). Fat-suppressed gadolinium-enhanced T1-weighted images were obtained in six patients. We retrospectively assessed the choroids and Tenon’s capsules for the presence of thickening on unenhanced images and abnormal enhancement on contrast-enhanced images.

Results

Bilateral choroidal thickening was observed in 14 patients (100%) on T1-weighted images and in 12 patients (85.7%) on T2-weighted images. Choroidal thickening showed posterior pole predominance in 11 patients (78.6%) and diffusely distributed in the remaining three patients (21.4%). Bilateral Tenon’s capsule thickening was observed in five patients (35.7%) on T1-weighted images and in 14 patients (100%) on T2-weighted images. On contrast-enhanced images, the choroids and Tenon’s capsules were abnormally enhanced in six patients (100%).

Conclusion

MR imaging sensitively detected abnormalities of the choroids and Tenon’s capsules in patients with VKHD. Bilaterality and predominant posterior pole distribution were characteristic of choroidal VKHD.

     

MR imaging of the salivary glands in sicca syndrome: comparison of lipid profiles and imaging in patients with hyperlipidemia and patients with Sjögren's syndrome

OBJECTIVE: We correlated abnormalities on MR imaging with the plasma lipid profiles of patients with hyperlipidemia and symptoms of sicca syndrome. SUBJECTS AND METHODS: MR imaging features of the salivary glands, salivary function, immunologic abnormalities, and plasma lipid profiles were analyzed in 24 patients with hyperlipidemia and symptoms of sicca syndrome and compared with those of 50 patients with Sj?gren's syndrome. RESULTS: Swelling of the parotid gland, impaired salivary flow, or both were observed in 20 (83%) of 24 patients with hyperlipidemia and symptoms of sicca syndrome. MR imaging findings included an enlarged parotid gland replaced with extensive lipid infiltration, whereas sialography of the parotid gland revealed normal findings. Immunologic studies and analyses of the labial glands of the mouth revealed distinctive features in patients with Sj?gren's syndrome. Importantly, elevated levels of plasma triglyceride correlated with parotid gland swelling, and increased cholesterol levels significantly affected salivary flow. CONCLUSION: Our findings suggest a distinct entity of sicca syndrome in patients with hyperlipidemia compared with patients with Sj?gren's syndrome. Characteristic MR imaging findings of salivary glands in patients with hyperlipidemia included extensive lipid infiltration and gland enlargement.     

Budd–Chiari Syndrome in Young Chinese: Clinical Characteristics,Etiology and Outcome of Recanalization from a Single Center

Purpose

We aimed to characterize the clinical profile, etiology, and outcomes of young Chinese patients with Budd–Chiari syndrome treated with recanalization.

Methods

A total of 35 consecutive young patients (≤25 years of age) with primary Budd–Chiari syndrome treated with recanalization at our center were enrolled in this study between March 2011 and December 2014. Data on baseline information, etiology tests, therapeutic recanalization strategies, and follow-up were collected.

Results

The most common clinical feature was ascites, present in 33 cases (94 %). Hepatic vein obstruction was present in 60 % (21/35) of patients, inferior vena cava obstruction in 3 % (1/35), and combined obstruction in 37 % (13/35). The most common risk factor for thrombosis was hyperhomocysteinemia (14/35, 40 %). Recanalization was technically successful in 32 of 35 patients (91 %), and clinically successful in 28 of these 32 patients (88 %). The cumulative 1- and 3-year primary patency rates were 75.2 and 54.3 %, respectively. The cumulative 1- and 3-year secondary patency rates were 89.3 and 89.3 %, respectively. The cumulative 1- and 3-year survival rates were 96.9 and 93.8 %, respectively.

Conclusion

In this study, the most common type of lesion was hepatic vein obstruction, the most common thrombotic risk factor was hyperhomocysteinemia, and recanalization resulted in good mid-term outcomes in young Chinese patients with Budd–Chiari syndrome.

     

Management of patellar problems in skeletally mature patients with nail–patella syndrome

Purpose

Nail–patella syndrome (NPS) or hereditary onychoosteodysplasia is a rare autosomal dominant disease, characterized by a tetrad of findings, which include fingernail abnormalities, hypoplasia of the patellae, radial head dislocation and prominent iliac horns. Most of the literature on the treatment of patellar problems in NPS concerns paediatric patients, and there is no standard treatment algorithm for adult patients.

Methods

We reviewed the charts of skeletally mature patients with NPS who presented to our clinic. We reviewed the presenting complaints, the physical examination findings and the radiographic imaging.

Results

We identified seven skeletally mature patients with NPS who presented with patellofemoral complaints. Their symptoms were instability, pain, or a combination of the two. Examination and imaging revealed a wide range of severity but included patellar instability and patellar arthritis. In our series, milder forms of the disease were treated with non-operative measures, but the majority of our patients required surgery including medial patellofemoral ligament reconstruction, tibial tuberosity transposition, patellofemoral and total knee arthroplasty. At midterm follow-up, most patients had good results.

Conclusion

Nail–patella syndrome has a wide range of presentations and severity in skeletally mature patients. Knee surgeons should be familiar with the spectrum of clinical presentation and the range of treatment options available in order to provide optimum treatment for patients with this disorder.

Level of evidence

IV.