Inaccurate preoperative imaging assessment on biliary anatomy not increases biliary complications after living donor liver transplantation

Backgrounds and aims

Accurate assessment of graft bile duct is important to plan surgical procedure. Magnetic resonance cholangiopancreatography (MRCP) has become an important diagnostic procedure in evaluation of pancreaticobiliary ductal abnormalities and has been reported as highly accurate. We aim to estimate the efficacy of preoperative MRCP on depicting biliary anatomy in living donor liver transplantation (LDLT), and to determine whether inaccurate preoperative imaging assessment would increase the biliary complications after LDLT.

Methods

The data of 118 cases LDLT were recorded. Information from preoperative MRCP was assessed using intraoperative cholangiography (IOC) as the gold standard. The possible risk factors of recipient biliary complications were analyzed.

Results

Of 118 donors, 84 had normal anatomy (type A) and 34 had anatomic variants (19 cases of type B, 9 cases of type C, 1 case of type E, 2 cases of type F and 3 cases of type I) confirmed by IOC. MRCP correctly predicted all 84 normal cases and 17 of 34 variant cases, and showed an accuracy of 85.6% (101/118). The incidence of biliary complications was comparable between cases with accurate and inaccurate classification of biliary tree from MRCP, and between cases with normal and variant anatomy of bile duct. While cases with graft duct opening ≤5 mm showed a significant higher incidence of total biliary complications (21.1% vs. 6.6%, P = 0.028) and biliary stricture (10.5% vs. 1.6%, P = 0.041) compared with cases with large duct opening >5 mm.

Conclusion

MRCP could correctly predict normal but not variant biliary anatomy. Inaccurate assessment of biliary anatomy from MRCP not increases the rate of biliary complications, while small-sized graft duct may cause an increase in biliary complications particularly biliary stricture after LDLT.     

The role of ultrasound and magnetic resonance cholangiopancreatography for the diagnosis of biliary stricture after liver transplantation

Purpose

To identify the diagnostic value of ultrasound (US) and magnetic resonance cholangiopancreatography (MRCP) in diagnosing biliary strictures after liver transplantation.

Materials and methods

Sixty patients with clinically suspected biliary strictures after liver transplantation were retrospectively evaluated. All patients underwent US and MRCP before the standard of reference (SOR) procedure: endoscopic retrograde cholangiopancreatography or percutaneous transhepatic cholangiography. Radiological images were analyzed for biliary dilatation and strictures.

Results

By SOR, biliary dilatation was present in 55 patients, stricture in 53 (44 anastomotic, 4 intrahepatic, 5 both), and dilatation and/or stricture in 58. Dilatation was diagnosed by US and MRCP in 39 and 45, respectively (sensitivity 71% vs. 82%, p = 0.18). Stricture was diagnosed by US and MRCP in 0 and 42, respectively (sensitivity 0% vs. 79%, p < 0.0001). False positive stricture was diagnosed by MRCP in 2. Dilatation and/or stricture was diagnosed by US in 39 and MRCP in 50 (sensitivity 67% vs. 86%, p = 0.01); however, using both techniques, sensitivity increased to 95%.

Conclusions

MRCP is superior to US for diagnosing biliary strictures after liver transplantation primarily because MRCP can detect stricture. The combination of US and MRCP seems superior to either method alone. Our data suggest that in patients with normal US and MRCP, direct cholangiography could be avoided.     

Comparison of three-dimensional negative-contrast CT cholangiopancreatography with three-dimensional MR cholangiopancreatography for the diagnosis of obstructive biliary diseases

Purpose

The purpose of our study was to compare three-dimensional (3D) negative-contrast CT cholangiopancreatography (3D-nCTCP) with 3D MR cholangiopancreatography (3D-MRCP) for the diagnosis of obstructive biliary diseases.

Materials and methods

3D-nCTCP and 3D-MRCP were performed on seventy clinically documented obstructive biliary diseases patients. The accuracy of each technique in determining the location and cause of biliary obstruction was evaluated compared with the final clinical diagnoses.

Results

Both methods achieved 100% of accuracy in the diagnosis of the presence and location of biliary obstruction, and had a similar sensitivity, specificity, accuracy in differentiating benign from malignant biliary obstruction or calculous from noncalculous biliary obstruction (p > 0.05). At 3D-nCTCP, six patients with stones were misinterpreted as cholangitis (N = 2), papillitis (N = 3), or bile duct adenocarcinoma (N = 1); two metastases were mistaken as acute pancreatitis or pancreatic head carcinomas, and one intrahepatic cholangiocarcinoma was misled as bile duct adenoma. At 3D-MRCP, one small stone, one ampullary adenoma, and one intrahepatic cholangiocarcinoma were mistaken as cholangitis, ampullary stone, and intrahepatic bile duct stone, respectively, and three gallbladder carcinomas and another intrahepatic cholangiocarcinoma were misdiagnosed as hilar cholangiocarcinoma (N = 3) or common hepatic duct stone (N = 1); four metastases were mistaken as pancreatic head carcinomas (N = 3) or distal cholangiocarcinoma (N = 1). The overall accuracy in making specific diagnosis of the cause of biliary obstruction was 87.1% for 3D-nCTCP and 84.3% for 3D-MRCP, respectively, (p > 0.05).

Conclusion

3D-nCTCP has the similar effects as 3D-MRCP for the diagnosis of biliary obstruction and, the location and the cause of biliary obstruction. In view of selected cases contraindications for MRI, 3D-nCTCP is a potential substitute.     

Clinical usefulness of free-breathing navigator-triggered 3D MRCP in non-cooperative patients: comparison with conventional breath-hold 2D MRCP

Purpose

To assess the clinical usefulness of free-breathing 3D MRCP in non-cooperative patients compared conventional breath-hold 2D MRCP.

Materials and methods

We performed FB navigator-triggered 3D MRCP using prospective acquisition correction and BH 2D MRCP in 48 consecutive, non-cooperative patients among 772 patients. Thirteen patients had malignant obstruction. Two radiologists independently graded the likelihood of a malignant obstruction, the overall image quality, and the visibility of ten, individual anatomic segments of both the biliary and pancreatic duct in each sequence. The area under the ROC curve and the repeated measures analyses of variance with multiple comparisons were used for the comparison. The κ statistics were used for interobserver agreement.

Result

The diagnostic performance for detecting malignancy was significantly higher on FB MRCP (A_z = 0.962) than on either BH SS-RARE (A_z = 0.820, P < 0.0185) or MS-HASTE MRCP (A_z = 0.816, P < 0.0067). Interobserver agreement was excellent for FB MRCP (κ = 0.889) and fair for both BH SS-RARE (κ = 0.578) and MS-HASTE MRCP (κ = 0.49). FB MRCP had a significantly higher technical quality than BH MRCP (P < 0.001). FB MRCP was seen to have statistically better visibility of peripheral IHD, right main IHD, CHD, cystic duct, and CBD than BH MRCP (P < 0.001). FB MRCP and BH SS-RARE MRCP had statistically better visibility of both the left main IHD and pancreatic duct than did BH MS-HASTE MRCP (P < 0.001).

Conclusion

FB 3D MRCP is useful for non-cooperative patients in whom conventional BH 2D methods cannot be used successfully.     

Primary biliary cirrhosis: evaluation with T2-weighted MR imaging and MR cholangiopancreatography

Purpose

The aim of this retrospective study is to evaluate the role of T2-weighted MR imaging (MRI) and MR cholangiopancreatography (MRCP) findings in the diagnosis of primary biliary cirrhosis (PBC).

Materials and methods

The following T2-weighted MRI and MRCP findings: segmental hepatic atrophy/hypertrophy, irregular liver surface, parenchymal lace-like fibrosis, rounded low signal intensity lesions centering portal vein branches (periportal halo sign), periportal hyperintensity (cuffing), splenomegaly, ascites, lymphadenopathy, venous collaterals, and the configuration of intrahepatic biliary ducts were reviewed for their diagnostic significance by two observers in 13 female patients (mean age: 49 years) with PBC. Discordant readings of the observers were resolved at consensus.

Results

When parenchymal lace-like fibrosis and periportal halo sign were seen together the sensitivity of T2-weighted MR images was 69%. In six cases periportal hyperintensity (cuffing) and periportal halo sign were seen together. Segmental hypertrophy was present in nine patients and hepatic surface irregularity due to regenerative nodules were present in 10 patients. Lymphadenopathy was seen in 10, splenomegaly was seen in 5, collateral vascular structures were seen in 2 and minimal perihepatic free fluid was seen in 2 patients. MRCP images revealed various mild irregularity in the intrahepatic bile ducts in 8 patients and focal narrowing at the common bile duct level in 1 patient.

Conclusion

MRI and MRCP may support the clinical and laboratory findings of PBC even in the early stages of the disease. MRI can also be a choice of method for the recommended prolonged follow up.     

Anatomic Variation in Intrahepatic Bile Ducts: an Analysis of Intraoperative Cholangiograms in 300 Consecutive Donors for Living Donor Liver Transplantation

Objective

To describe the anatomical variation occurring in intrahepatic bile ducts (IHDs) in terms of their branching patterns, and to determine the frequency of each variation.

Materials and Methods

The study group consisted of 300 consecutive donors for liver transplantation who underwent intraoperative cholangiography. Anatomical variation in IHDs was classified according to the branching pattern of the right anterior and right posterior segmental duct (RASD and RPSD, respectively), and the presence or absence of the first-order branch of the left hepatic duct (LHD), and of an accessory hepatic duct.

Results

The anatomy of the intrahepatic bile ducts was typical in 63% of cases (n=188), showed triple confluence in 10% (n=29), anomalous drainage of the RPSD into the LHD in 11% (n=34), anomalous drainage of the RPSD into the common hepatic duct (CHD) in 6% (n=19), anomalous drainage of the RPSD into the cystic duct in 2% (n=6), drainage of the right hepatic duct (RHD) into the cystic duct (n=1), the presence of an accessory duct leading to the CHD or RHD in 5% (n=16), individual drainage of the LHD into the RHD or CHD in 1% (n=4), and unclassified or complex variation in 1% (n=3).

Conclusion

The branching pattern of IHDs was atypical in 37% of cases. The two most common variations were drainage of the RPSD into the LHD (11%) and triple confluence of the RASD, RPSD and LHD (10%).     

Impact of butylscopolamine on image quality of magnetic resonance cholangiopancreatography

Purpose

To assess the effect of parenteral butylscopolamine on magnetic resonance cholangiopancreatography (MRCP) image quality.

Materials and methods

The 3D free-breathing respiratory-compensated MRCP images (mean acquisition time 7 min) of 94 consecutive non-paired patients (47 with and 47 without 20 mg intramuscular butylscopolamine) were analysed retrospectively. Two experienced abdominal radiologists scored the image quality of five predefined pancreaticobiliary ductal segments on the MRCP images in a blinded fashion in both cohorts using a 5 point validated scale, ranging from perfect visualization of the entire ductal structure to the ductal structure being not visible. Interobserver agreement was determined.

Results

Parenteral butylscopolamine injection significantly reduced bowel peristalsis-related artefacts of the inferior common bile duct (CBD; p = 0.031) and the pancreatic duct (PD; p = 0.034) for reader 1 and the inferior CBD (p = 0.041) for reader 2. The difference in visualization of all remaining ductal segments, and of the overall pancreaticobiliary tree, was not statistically significant between the two cohorts. Interobserver agreement between the two readers was substantial for the superior CBD, common hepatic duct (CHD) and PD, was moderate for the inferior CBD, and was fair for the peripheral intrahepatic ducts.

Conclusion

On free-breathing 3D MRCP images, parenteral butylscopolamine improves only the visualization of the inferior CBD and the PD. However, no significant improvement in visualization of other ductal segments was demonstrated.     

Paediatric MRCP: 10 year experience with 195 patients

Purpose

Magnetic resonance cholangiopancreatography (MRCP) has now largely substituted endoscopic retrograde cholangiopancreatography (ERCP) in evaluating the biliary tree in adults giving its high sensitivity and specificity. Whilst smaller series published to date suggests this may be extrapolated to the paediatric population, its routine use in children is still debatable. The aim of our study is therefore to review the utility of MRCP in a large series of paediatric patients.

Methods and materials

All MRCPs performed in our institution were examined for diagnostic quality, spectrum of diagnoses and correlation with direct cholangiography (DC) were available. Correlation with histopathology results and final clinical diagnosis was made in the subset of patients in whom a MRCP had been performed to evaluate the presence of primary sclerosing cholangitis (PSC).

Results

There were 245 MRCP examinations performed on 195 patients and 219 were diagnostic. There was 100% MRCP and DC concordance in the 16 cases where both had been performed. MRCP yielded a sensitivity of 89% in the subset of patients with PSC.

Conclusion

MRCP was a valuable diagnostic tool in our paediatric population. Image quality is sufficiently diagnostic and shows good correlation with clinical diagnosis in conditions encountered in our population, including primary sclerosing cholangitis, post liver transplant biliary strictures, post surgical complications, dilated common bile ducts, choledochal cysts, cholelithiasis and choledocholithaisis.     

Dual-energy CT-cholangiography in potential donors for living-related liver transplantation: improved biliary visualization by intravenous morphine co-medication

Purpose

To prospectively evaluate whether intravenous morphine co-medication improves bile duct visualization of dual-energy CT-cholangiography.

Materials and methods

Forty potential donors for living-related liver transplantation underwent CT-cholangiography with infusion of a hepatobiliary contrast agent over 40 min. Twenty minutes after the beginning of the contrast agent infusion, either normal saline (n = 20 patients; control group [CG]) or morphine sulfate (n = 20 patients; morphine group [MG]) was injected. Forty-five minutes after initiation of the contrast agent, a dual-energy CT acquisition of the liver was performed. Applying dual-energy post-processing, pure iodine images were generated. Primary study goals were determination of bile duct diameters and visualization scores (on a scale of 0 to 3: 0—not visualized; 3—excellent visualization).

Results

Bile duct visualization scores for second-order and third-order branch ducts were significantly higher in the MG compared to the CG (2.9 ± 0.1 versus 2.6 ± 0.2 [P < 0.001] and 2.7 ± 0.3 versus 2.1 ± 0.6 [P < 0.01], respectively). Bile duct diameters for the common duct and main ducts were significantly higher in the MG compared to the CG (5.9 ± 1.3 mm versus 4.9 ± 1.3 mm [P < 0.05] and 3.7 ± 1.3 mm versus 2.6 ± 0.5 mm [P < 0.01], respectively).

Conclusion

Intravenous morphine co-medication significantly improved biliary visualization on dual-energy CT-cholangiography in potential donors for living-related liver transplantation.     

Preoperative assessment of longitudinal extent of bile duct cancers using MDCT with multiplanar reconstruction and minimum intensity projections: comparison with MR cholangiography

Objective

To compare the performance of MDCT, including multiplanar reformation (MPR) and minimum intensity projection (MinIP) images, with that of transaxial MDCT with MR cholangiography (MRC) in the preoperative evaluation of the longitudinal extent of bile duct cancer.

Methods

Twenty-seven patients with surgically proven bile duct cancer, who had undergone preoperative multiphasic MDCT and MRC, were included. Two radiologists evaluated the MDCT set with MPR and MinIP images and the image set of transaxial MDCT with MRC, regarding the longitudinal extent of bile duct cancer. The results were compared with the surgical and pathology findings.

Results

The area under the receiver operating characteristic curves of the MDCT set with MPR and MinIP images and the image set of transaxial MDCT with MRC for predicting the longitudinal extent of bile duct cancer, were 0.938, 0.923 and 0.839, 0.836 for both reviewers. The differences were not statistically significant for either image set or either reviewer. The sensitivity and specificity of the MDCT image set for detecting tumor involvement of the biliary second confluences or intrapancreatic segment were similar for both reviewers to those of transaxial MDCT with MRC.

Conclusions

MDCT with MPR and MinIP images showed comparable diagnostic performance to that of transaxial MDCT with MRC for predicting the longitudinal extent of bile duct cancer.     

An increased flip angle in late phase Gd-EOB-DTPA MRI shows improved performance in bile duct visualization compared to T2w-MRCP

Objectives

To estimate the additional value of an increased flip angle of 35° in late phase Gd-EOB-DTPA-enhanced magnetic resonance cholangiography, as compared to T2w-MRCP.

Methods

40 adult patients underwent Gd-EOB-DTPA enhanced MRI of the liver including a T2-weighted 3D TSE MRCP (T2w-MRCP) as well as a late phase T1-weighted THRIVE sequences applying a flip angle of 35° (fa35). Two experienced observers evaluated the images regarding the delineation of the different biliary regions using a three-point grading system. A five-point scale was applied to determine the readers’ confidence in identifying anatomical variations of the biliary tree. ROI analysis was performed to compare the signal-to-noise (SNR) and contrast-to-noise (CNR) ratios.

Results

The quality for visualizing the biliary tree differed between T2w-MRCP and fa35 (p = <0.001). Late phase EOB-MRC was rated as good for delineating the entire biliary system, whereas T2w-MRCP received an overall poor rating. Especially the depiction of the intrahepatic bile ducts was estimated as problematic in T2w-MRCP. T2w-MRCP and fa35 revealed a discordant assessment of anatomical variations in 12.5% of the cases, comprising a generally higher confidence level for fa35 (4.0 ± 1.1 vs. 2.2 ± 1.2, p = <0.001). SNR proofed to be significantly higher in fa35 (p = <0.001), whereas T2w-MRCP revealed a significantly higher CNR (<0.001).

Conclusions

Gd-EOB-DTPA enhanced magnetic resonance cholangiography acquired with a flip angle of 35° revealed a better diagnostic performance compared to T2w-MRCP and might be a valuable adjunct in assessing functional bile duct abnormalities.     

Intra-biliary contrast-enhanced ultrasound for evaluating biliary obstruction during percutaneous transhepatic biliary drainage: A preliminary study

Objectives

The aimed of this study was to investigate the value of intra-biliary contrast-enhanced ultrasound (IB-CEUS) for evaluating biliary obstruction during percutaneous transhepatic biliary drainage (PTBD).

Materials and methods

80 patients with obstructive jaundice who underwent IB-CEUS during PTBD were enrolled. The diluted ultrasound contrast agent was injected via the drainage catheter to perform IB-CEUS. Both conventional ultrasound and IB-CEUS were used to detect the tips of the drainage catheters and to compare the detection rates of the tips. The obstructive level and degree of biliary tract were evaluated by IB-CEUS. Fluoroscopic cholangiography (FC) and computer tomography cholangiography (CTC) were taken as standard reference for comparison.

Results

Conventional ultrasound displayed only 43 tips (43/80, 53.8%) of the drainage catheters within the bile ducts while IB-CEUS identified all 80 tips (80/80, 100%) of the drainage catheters including 4 of them out of the bile duct (P < 0.001). IB-CEUS made correct diagnosis in 44 patients with intrahepatic and 36 patients with extrahepatic biliary obstructions. IB-CEUS accurately demonstrated complete obstruction in 56 patients and incomplete obstruction in 21 patients. There were 3 patients with incomplete obstruction misdiagnosed to be complete obstruction by IB-CEUS. The diagnostic accuracy of biliary obstruction degree was 96.3% (77/80).

Conclusion

IB-CEUS could improve the visualization of the drainage catheters and evaluate the biliary obstructive level and degree during PTBD. IB-CEUS may be the potential substitute to FC in the PTBD procedure.     

MR Imaging Findings of Clonorchiasis

Objective

The purpose of this study was to evaluate the MR spectrum and MR cholangiographic imaging findings of clonorchiasis.

Materials and Methods

We reviewed 26 patients with confirmed clonorchiasis by either stool tests (n=24) or surgery (n=2). MR imaging was performed on a 1.5 T system (GE Medical Systems, Milwaukee, WI) with a torso coil. Axial T1- and T2-weighted, gadolinium-enhanced dynamic images and MR cholangiography were obtained. Image analyses were used to identify abnormalities of the intrahepatic and extrahepatic bile ducts and the presence of hepatobiliary malignancy. All MR examinations were reviewed by the consensus of two abdominal radiologists.

Results

Intrahepatic bile duct abnormalities were seen in 23 (89%) of the 26 patients. The most common finding was mild dilatation of the intrahepatic bile duct which was found in 21 (81%). "Too many intrahepatic ducts" were found in 16(62%), wall enhancement and thickening in 21 (81%) and filling defects and ductal stricture in the intrahepatic bile duct in 6 (24%) and 3 (12%) patients, respectively. Extrahepatic ductal dilation was found in 5 (19%) and 9 (35%) revealed hepatobiliary malignancy.

Conclusion

MR imaging revealed various findings of clonorchiasis, including dilatation, wall enhancement, stricture of the intrahepatic ducts and filling defect within the intrahepatic bile duct.     

Anatomic variations of intrahepatic bile ducts in the general adult Egyptian population: 3.0-T MR cholangiography and clinical importance

Objective

To describe the anatomical variations occurring in intrahepatic bile ducts (IHDs) and their frequencies in general adult Egyptian population using 3.0-T MR cholangiography (MRC) as well as its clinical importance to reduce the biliary complications of hepatobiliary surgery.

Materials and methods

MRC was applied to a study group of 106 subjects (26 potential liver donors and 80 volunteers). Anatomical variations in IHDs were classified based on the variable insertion of right posterior hepatic bile duct (RPHD) using Huang classification.

Results

According to this classification, the frequencies of each type were as follows: Huang A1 (typical pattern): 63.2% (n = 67), Huang A2: 10.4% (n = 11), Huang A3: 17% (n = 18), Huang A4, 7.5% (n = 8), and Huang A5: 1.9% (n = 2). Total frequency for atypical types (i.e. A2, A3, A4 and A5) was 36.8%. No significant difference was detected in the distance between RPHD insertion to the junction of right and left hepatic duct in-between these Huang types. This distance was short (<1 cm) in 21 of subjects under Huang A classification. Twenty-one donors underwent intraoperative cholangiograms, of which twenty (95.2%) had similar classification in both intraoperative and MRC findings.

Conclusion

The incidence of variant biliary anatomy in general Egyptian population (36.8%) as well as the presence of Huang type A with short distance (<1 cm) between RPHD insertion and junction of right and left hepatic duct (19.8%) enhance the importance of MRC as a pre-operative tool before hepato-biliary surgical procedures to reduce post-operative biliary complications.     

Autoimmune pancreatitis: Assessment of the enhanced duct sign on multiphase contrast-enhanced computed tomography

Purpose

To assess the usefulness of the computed tomography (CT) finding of main pancreatic duct (MPD) wall enhancement, termed the “enhanced duct sign”, for diagnosis of autoimmune pancreatitis (AIP) in comparison with diagnosis of pancreatic carcinoma and chronic pancreatitis.

Materials and methods

Two radiologists independently evaluated the presence or absence of the enhanced duct sign on multiphase contrast-enhanced CT in patients with AIP (n = 55), pancreatic carcinoma (n = 50), and chronic pancreatitis (n = 50). The sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of AIP were calculated. In patients demonstrating the enhanced duct sign, additional findings were evaluated by consensus.

Results

The enhanced duct sign was more frequently observed in patients with AIP (37/55, 67%) than in patients with pancreatic carcinoma (5/50, 10%) or chronic pancreatitis (0/50, 0%) (P < 0.05). The sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of the finding were 0.67, 0.95, 0.85, 0.88, and 0.84, respectively. In AIP, the lumen within the enhanced duct was completely or partially invisible in 29 of 37 (78%) patients, and the enhanced duct was observed within the affected pancreatic parenchyma in 35 of 37 (95%) patients. In pancreatic carcinoma, the lumen within the enhanced duct was visible in all patients (5/5, 100%), and the enhanced duct was observed downstream of the tumor (5/5, 100%).

Conclusion

The enhanced duct sign is highly specific of AIP.     

CT cholangiography: assessment of feasibility and diagnostic reliability

Objective

To assess the reliability of computed tomography (CT) cholangiography in evaluating the anatomy of the intrahepatic biliary ducts.

Materials and methods

Twenty-eight patients underwent CT cholangiography at the National Cancer Institute of Milan, Italy. Twenty-one patients were candidates for liver surgery and seven had suspected postoperative biliary complications. The patients had not dilatation of the intrahepatic biliary ducts at US examination and bilirubin levels were not higher than 2 mg/dl. To define the reability of the CT cholangiography, a scoring system (from 0 to 3) was used for each order of biliary branches.

Results

In all cases, it was technically possible to carry out the CT cholangiography according to the protocol. There were no adverse reactions to the contrast agent. Two radiologists gave the maximum score of 3 for visualisation of the first- and second-order biliary branches in all cases. For visualisation of third- and fourth-order biliary branches the maximum score of 3 was given in 18 patients, a score of 2 in 8 patients and a score of 1 in 2 patients. Three anatomical variants of biliary ducts were detected. CT cholangiography was diagnostic in all seven cases of suspected postoperative biliary complications.

Conclusion

Our work confirms the high spatial resolution and reability of CT cholangiography in evaluating the intrahepatic biliary anatomy of patients who are candidates for liver surgery, with non-dilated biliary ducts and with bilirubin levels no higher than 2 mg/dl.     

Clinical usefulness of the visibility of the transcerebral veins at 3T on T2*-weighted sequence in acute stroke patients

Objectives

The objective of this work was to investigate the clinical usefulness of the visibility of the transcerebral veins (VTV) in acute ischemic stroke patients at 3 T.

Methods

Sixty consecutive carotid artery territory stroke patients were included retrospectively. Two readers categorized the VTV on T2*-weighted sequence at 3 T for each hemisphere, and asymmetry of this sign was assessed between each hemisphere by an asymmetry index (AI) using a three-item scale. The VTV and AI were correlated with clinical and radiological covariates. Particular interest was focused on patients for whom initial diffusion-weighted imaging alone was inconclusive.

Results

VTV were detected in the stroke hemisphere in 58.3% (n = 35) and in the contralateral side in 10% (n = 6, p < 0.0001). Asymmetry of the VTV between ischemic and contralateral hemispheres was present in 53.3% (n = 32). Intracranial artery occlusion, final infarct volume and symptomatic hemorrhagic transformation were correlated with a higher AI at baseline (ρ = 0.563, ρ = 0.291, and ρ = 0.285, p < 0.05, respectively). Three hyperacute stroke patients with subtle DWI high signal intensity at admission demonstrated VTV.

Conclusions

The pathological value of the VTV seems to reside in its asymmetry between hemispheres, as it was correlated with important clinical parameters. This study also suggests that the VTV could be a supportive finding in stroke diagnosis, especially when DWI is unreliable.     

Role of MRCP in assessment of biliary variants in living donor liver transplantation

Introduction

Liver transplantation can be done by three different methods: Cadaveric, heterotopic and living donor liver transplantation (LDLT). In LDLT usually the right lobe of a donor liver is transplanted into the patient after proper volumetric studies. The native patient bile ducts are connected to the biliary tree of the transplanted liver segment.

Patients and methods

From January 2010 to August 2011, 50 potential LDLT donors were evaluated with preoperative MRCP.

Results

The radiologist evaluated the visualization of the common duct, right and left intra-hepatic ducts, and insertion of the right posterior lobe duct. The data were classified according to Huang and Hakki classifications. According to the more detailed classification of Hakki 13 patients (26%) were Type K1; 15 patients (30%) were Type K2a; three patients (6%) were Type K2b; 11 patients (22%) Type K3a; four patients (8%) were Type K3b; two patients (4%) were Type K4 and no patients were Type K5. Two patients with unclassified anatomical biliary pattern were encountered. In conclusion, this study has shown an extremely high accuracy of MRCP in preoperative assessment of live hepatic donors, which aided in the style and procedure of the operation and ultimately to a high success rate of the transplantation procedures.     

Diagnostic performance of MRI and EUS in the differentiation of benign from malignant pancreatic cyst and cyst communication with the main duct

Purpose

To assess the diagnostic ability of MRI and EUS for differentiating benign from malignant pancreatic cyst focusing on cyst communication with pancreatic duct.

Materials and methods

During 44 months, we performed MRI on 65 pancreatic cysts. Among them, 36 patients had confirmed cyst communication with duct by ERCP or surgery and 39 patients underwent EUS. Fifty-one had proven by surgery or aspiration. Among them, 36 had confirmed malignant cysts. Two radiologists independently graded cyst communication with duct and the likelihood of malignancy. When the readers’ interpretations differed, third opinion was obtained. They also measured the size of cyst and main duct. The diagnostic performance was analyzed using the ROC curve. The Mann–Whitney U test and κ statistics were used to determine interobserver agreement.

Results

The Az of MRI and EUS for determining diagnostic performance regarding the cyst communication with duct, were 0.931 and 0.930, without statistically difference (p = 0.6). Interobserver agreement was excellent (κ = 0.81) on MRI and substantial (κ = 0.69) on EUS. The Az of MRI and EUS for assessing diagnostic performance to differentiate malignant from benign cyst, was 0.902 and 0.923, without statistically difference (p = 0.587). Interobserver agreement was excellent (κ = 0.81) on MRI and moderate (κ = 0.47) on EUS. The mean cyst size (3.98 cm + 2.74: 3.17 cm + 1.26, p = 0.327) and the duct size (5.20 mm + 3.22: 4.39 mm + 4.12, p = 0.227) showed no statistically difference between malignant and benign cysts.

Conclusion

MRI and EUS can accurately assess pancreatic cyst communication with duct and are very useful for obtaining a differential diagnosis of malignant cyst versus benign pancreatic cyst.     

Comparison of qualitative and quantitative approach to prostate MR spectroscopy in peripheral zone cancer detection

Objective

To compare the diagnostic performance of a qualitative (pattern recognition) and a quantitative (numerical assessment) approach to magnetic resonance spectroscopy (MRS) in the diagnosis of peripheral zone prostate cancer.

Methods

185 patients (131 with histopathologically proven cancer, 54 normal/benign after at least 12 months follow-up) were prospectively evaluated with qualitative MRS using a 4-point scale between 3/2004 and 1/2008, and retrospectively reassessed using a prototype quantitative postprocessing software in April 2008. Based on pathology and follow-up data, diagnostic performance parameters were calculated.

Results

The qualitative and quantitative approaches were concordant in 78.9% (146/185) of cases. The difference between the areas under the ROC curve (0.791 versus 0.772, respectively) was not statistically significant. The sensitivity, specificity and accuracy were 55.7%, 94.4% and 67.0% for the qualitative approach, and 55.0%, 83.3% and 63.2% for the quantitative approach. The sensitivity for high grade tumours (Gleason 4 + 3 or higher) was 85.2% (23/27) for both approaches. All cancers missed on either one approach separately (31/31) and 91% of cancers missed on both approaches together (23/27) were of lower grade (Gleason 3 + 4 or lower).

Conclusions

Qualitative and quantitative approaches to MRS yield similar diagnostic results. Discordances in tumour detection only occurred in lower grade cancers.