Spontaneous intramural haematoma of the oesophagus: Radiologic recognition

Spontaneous intramural haematoma of the oesophagus (SIHO) is an uncommon disorder. It presents usually with acute chest pain followed by dysphagia. This condition may mimic spontaneous rupture of the oesophagus (Boerhaave Syndrome), dissection of the thoracic aorta or acute myocardial infarction. Hence early accurate confirmation of the diagnosis by radiology is vital for the appropriate acute management. The condition is frequently mistaken for acute myocardial infarction which may prompt inappropriate thrombolytic therapy. The appearances on contrast studies of oesophagus and on CT scanning are characteristic. Despite this, the diagnosis may easily be missed, if appropriate careful radiological technique is not used. This paper reports three consecutive cases of SIHO managed in one institution. These cases illustrate that early gastrografin contrast radiology followed by barium contrast radiology and if necessary by thoracic CT is diagnostic in all cases of this condition.     

Imaging of thoracic aortic dissection

Acute thoracic aortic dissection has a high mortality if untreated, so the diagnosis must be rapidly made if mortality is to be lowered significantly. Multiple imaging techniques are often used. This retrospective study from 1988 to 1993 assesses the usefulness in diagnosis of chest X-rays, computed tomography (CT) scanning, aortography, magnetic resonance imaging (MRI), trans-thoracic (TTE) and trans-oesophageal (TOE) echocardiography. Forty-two patients with a final clinical diagnosis of dissection were studied. The diagnosis was confirmed in 16 (13 at surgery and three at autopsy). Three died with dissection given as the only cause for death. Chest X-ray abnormalities were seen in all 19 patients with surgery or death from dissection, with a widened mediastinum and/or dilated aorta being present in 17. In the group of 16 patients with surgery or autopsy proof, CT scans found dissections in 9 of 12 patients studied and correctly classified the type in only five. Aortography was performed in five, with accurate depiction of dissection and type in all. TTE found dissections in three of eight patients imaged by this method. MRI and TOE were performed each on two patients, with accurate depiction of dissection and type in each. Because of the relatively low sensitivity of CT scanning in defining aortic dissections Westmead Hospital is currently assessing the use of TOE as the prime imaging modality prior to surgical intervention.     

Dural sinus thrombosis presenting as unilateral lobar haematomas with mass effect: An easily misdiagnosed cause of cerebral haemorrhage

Dural sinus thrombosis has protean clinical and radiological manifestations ranging from minimal effacement of sulci with no symptoms to severe haemorrhagic infarcts associated with focal deficits, coma and even death. An uncommon form of presentation is characterized by unilateral lobar haemorrhage associated with extensive oedema and parenchymal distortion. In an acute presentation, this might resemble haemorrhage into a tumour. In delayed presentations, the haematoma, being iso‐ or hypodense and showing peripheral ring‐like enhancement, can mimic aggressive tumours or infective processes. As this is an uncommon condition, misdiagnosis is common with the potential for mismanagement and adverse outcomes. We present five such consecutive cases that were initially misdiagnosed as other entities. Each of these cases on closer inspection show features observed on CT and MRI that should have suggested a diagnosis of dural venous sinus thrombosis. One of these cases progressed to not only extensively involve the superficial sinuses but also the deep veins, with a significant adverse outcome. The imaging features of this interesting variant of dural sinus thrombosis are reviewed. The haemodynamic basis for haemorrhage and anatomical basis for the lateralization of the lesions are discussed.     

The value of narrow CT window settings in the recognition of subtle acute aortic intramural haematoma

Four patients with acute aortic intramural haematoma are presented. In all patients the typical crescentic hyperdense rim within the aortic wall was not obvious on unenhanced CT when reviewed on standard mediastinal windows, but the hyperdense crescentic rim was well seen on narrow window settings. The findings suggest that all patients with a typical clinical presentation of acute thoracic aortic dissection who do not have a classical dissection on contrast-enhanced CT or a hyperdense intramural haematoma on standard mediastinal settings, should have the non-contrast scans reviewed on narrow window settings.     

Case report on the radiographic features of epipericardial fat necrosis in a patient presenting with acute chest pain

Epipericardial fat necrosis (EFN) is a rare and benign condition. The three cardinal features of EFN are acute pleuritic chest pain, radiological features of an encapsulated fatty lesion within the epipericardial fat and the presence of inflammation within the surrounding pericardium. The exact aetiology is still unknown, and there are no known risk factors. The condition appears to be a transient process with no associated long-term complications. In this case study, we demonstrate the multitude of radiological features associated with this condition. A 29-year-old Caucasian female presented with acute pleuritic chest pain. There were no acute changes on her blood work, electrocardiogram (ECG) or echocardiogram. The chest radiograph showed an opacity projected within the anterior mediastinum. Further imaging, with computed tomography (CT) chest with contrast, was performed to define the characteristics of the opacity. This confirmed an encapsulated, mixed fat, soft tissue density in the left pericardiac region deemed to represent EFN. Follow-up magnetic resonance (MR) cardiac imaging at 1, 4 and 12 months demonstrated the self-resolving characteristics of this condition. EFN is a rare differential diagnosis to consider in patients presenting with acute pleuritic chest pain when laboratory tests are normal and there are no acute ECG findings. EFN should be excluded by imaging with CT or MRI of the heart. We have demonstrated through follow-up MR imaging the progression and resolution of EFN over 12 months.     

M.R.I. Spectrum of Intrinsic Spinal Cord Lesions

We report our experience of 42 patients undergoing magnetic resonance imaging (MRI) studies demonstrating intrinsic lesions of the spinal cord, excluding those secondary to spondylosis, trauma or congenital malformations. Histological confirmation of the radiological diagnosis was obtained in 15 (36%). MRI is more sensitive than either myelography or CT. MRI identified a previously non-visualised lesion in 17 of 30 cases. In a further 13 cases, MRI contributed by identifying associated features such as cysts and haemorrhage which have aided in the diagnosis and management of the patients. The last 12 cases, which were patients with multiple sclerosis, had MRI as the only neuroradiological examination. These illustrate a range of appearances. The overlap of imaging appearances of the various pathologies implies that a useful diagnosis and differential can only be offered by considering the MRI appearances of a lesion, with its associated features, with the clinical presentation, and with other imaging modalities where appropriate.     

Performance of magnetic resonance imaging in pulmonary fungal disease compared to high‐resolution computed tomography

To evaluate the performance of magnetic resonance imaging (MRI) compared to computed tomography (CT) in patients diagnosed with pulmonary mycosis. We prospectively included 21 patients diagnosed with pulmonary mycosis between January 2013 and October 2014. Inclusion criteria were presence of respiratory symptoms, histopathological diagnosis of mycosis and absence of mycosis treatment. Reviewers identified one predominant imaging pattern per patient: nodular, reticular or airspace pattern. Afterwards, all CT findings were analysed separately per lobe and compared to MRI. Nodular pattern was the most common found (CT: 76.20%; MRI: 80.96%), followed by airspace pattern (CT and MRI: 9.52%) and reticular (CT: 9.52%; MRI: 4.76%). Compared to CT, MRI performance varied according to radiological finding and pulmonary region. For nodules, MRI presented high sensitivity (100% [95% CI: 93.52‐100]) and specificity (100% [95% CI: 92.00‐100]). For bronchiectasis and septal thickening, there were poorer positive predictive values (33.33% [95% CI: 1.77‐87.47]; and 83.33% [95% CI: 50.88‐97.06] respectively). As specificity and negative predictive value had superior results than sensitivity and positive predictive value, rather than for diagnosis of this condition, MRI might be more considered for the follow‐up of patients with pulmonary mycosis, an alternative to multiple radiation exposures with CT follow‐up.     

Magnetic Resonance Imaging in Carotid Dissection

Magnetic Resonance Imaging was performed in two cases of suspected internal carotid artery dissection. In both cases it was possible to demonstrate the dissection. It is suggested that magnetic resonance imaging (MRI) could replace more invasive techniques in the diagnosis of this condition.     

Can post-RT neck dissection be omitted for patients with head-and-neck cancer who have a negative PET scan after definitive radiation therapy?

PURPOSE: A prospective, single institution study was conducted to evaluate the role of positron emission tomography with fluoro-deoxyglucose (FDG) before and after definitive radiation therapy for patients with head-and-neck cancer. Correlation with CT or MRI imaging and pathologic findings at the time of planned neck dissection was made. METHODS AND MATERIALS: Twelve patients with AJCC Stages III-IV cancer of the head and neck received CT or MRI and PET imaging before treatment with definitive radiation therapy. One month after completion of treatment, repeat CT or MRI and PET imaging was obtained. All images were reviewed independently by radiologists who were blind to the results of the other modality. Patients then underwent planned neck dissection. Pathologic correlation with posttreatment scans allowed calculation of the sensitivity, specificity, negative predictive value, and the positive predictive value for both CT/MRI and PET. RESULTS: Comparison of CT/MRI to PET obtained before definitive RT revealed both primary tumor and nodal disease were detected by both modalities in all cases where primary tumor was known. After RT, comparison of CT/MRI imaging to findings of neck dissection revealed a sensitivity of 90%, specificity of 100%, positive predictive value of 100%, and negative predictive value of 50%. Comparison of PET imaging with pathologic findings demonstrated sensitivity of 45%, specificity of 100%, positive predictive value of 100%, and a negative predictive value of 14%. CONCLUSIONS: In this small series of patients, the presence of a positive PET 1 month after RT accurately indicated the presence of residual disease in all cases; however, a negative PET indicated absence of disease in only 14%. Further investigation is warranted before FDG-PET should be used to determine whether post-RT neck dissection should be omitted.     

Investigations of fatal causes of chest pain: Case report and literature review

A case of fatal ascending aortic dissection (AAD) misdiagnosed as pulmonary embolism (PE) despite strong radiological evidence is described. The occurrence of this serious pathology is uncommon. Its prompt diagnosis and treatment are crucial. Anticoagulant therapy for pulmonary embolism should be withheld until acute aortic dissection is excluded definitively. A management approach to optimise the outcome of patients with chest pain in which ascending aortic dissection and/or pulmonary embolism are suspected is presented.     

透明血管型Castleman 病的CT及MRI表现

目的:探讨透明血管型Castleman 病的CT 及MRI 影像表现,旨在提高对该病的诊断水平。方法:回顾性分析4例经手术病理证实的透明血管型Castleman 病的CT 及MRI 资料,总结其特征。结果:左锁骨上窝1 例,纵隔1例,肠系膜1 例,肝胃间隙1例,4例临床类型均为局限型,4例病理分型均为透明血管型。 CT表现为椭圆形软组织肿块,平扫与肌肉相比呈等密度,动态增强4例肿块动脉期明显强化,静脉期及延时期均表现为持续强化。MRI 检查T1WI 病灶呈等信号,T2WI 呈高信号,增强表现与CT 近似。结论: 透明血管型Castleman 病有一定的CT和MRI影像学特征,具有较高的诊断价值,但需病理性确诊。     

Emphysematous gastritis: Case report and literature review

Emphysematous gastritis is a rare form of gastritis that results from infection of the stomach wall by gas‐forming organisms. Diagnosis of this commonly fatal condition rests on radiological demonstration of gas within the stomach wall. This can be observed on plain radiographs or CT scans of the abdomen. Only by prompt diagnosis and treatment can mortality be avoided. A new case of empysematous gastritis, diagnosed on CT scan by the demonstration of both intramural and portal venous gas, is presented and the literature is reviewed.     

Neoplastic involvement of the sacroiliac joint: MR and CT features

The radiological findings in five patients with pelvic sort tissue neo plasms directly involving the sacroiliac joint, are described. All patients had Computed Tomography (CT) examinations, two of the patients also having Magnetic Resonance Imaging (MRI). The role of imaging in this uncommon entity is discussed as well as the importance of making this diagnosis, thereby excluding unilateral sacroiliitis. The therapeutic implications of this diagnosis relate to local neural involvement, especially the sciatic nerve, and the fact that involvement of the sacroiliac joint by tumors significantly compromises chances of a successful surgical outcome. The role of MR in this condition is not yet certain, but it may prove to be the method of choice in view of its excellent depiction of skeletal neo plasms.     

Imaging of Primitive Neuroectodermal Tumor (PNET) by Technetium-99m Tetrofosmin

Purpose. Tc-99m tetrofosmin launched for myocardial studies has recently also shown a good detectability for several tumors. Data on PNET imaging by Tc-99m tetrofosmin are not yet available.Patient and method. In the case of a 21-year-old man suffering from pelvis PNET, Tc-99m tetrofosmin scintigraphy was performed additionally to CT and MRI.Results. The gluteal and iliac tumor masses were visualized by Tc-99m tetrofosmin according to the CT and MRI results.Discussion. Imaging with Tc-99m tetrofosmin could provide additional information to the available conventional radiological imaging modalities for diagnosis of PNET, and could be a useful tool for the restaging of the primary tumor.     

18F-FDG PET显像在鼻咽癌诊断治疗中的价值

目的:探讨18F-FDG PET显像在鼻咽癌诊断治疗中的价值.方法:35例鼻咽癌PET与同期CT、MRI、骨ECT诊断结果比较分析,全部经病理组织学证实.结果:35例鼻咽癌PET与临床和CT、MRI、骨ECT诊断相符31例(88.6%),诊断不符4例(11.4%),其中真阴性2例和假阴性2例,1例ECT疑为多处骨转移,PET未发现核素浓聚改变,随访排除了骨转移;1例MRI疑为复发,PET未发现核素浓聚改变,病理及随访排除了复发;1例CT诊断肝转移,1例MRI诊断桥脑转移,PET均未发现核素浓聚改变.PET检测出CT、MRI和ECT未发现的转移灶6例(17.1%).结论:18F-FDG PET对鼻咽癌定性诊断具有较高的准确性和特异性,在诊断淋巴结和远处转移方面优于CT和MRI;诊断肝、脑转移有假阴性表现,提示PET应结合CT、MRI进行综合分析,才能作出正确的诊断.     

腺泡状软组织肉瘤的影像学特征及临床病理表现

背景与目的:腺泡状软组织肉瘤罕见,其影像学表现至今尚未见系统研究,本文旨在探讨腺泡状软组织肉瘤(alveolar soft part sarcomas,ASPS)的临床特征和影像学表现,以提高诊断的准确率。方法:回顾性分析10例经病理证实的腺泡状软组织肉瘤的临床特征和影像学表现,所有患者(术前或活检前)均行X线、CT或MR检查。其中,9例行X线平片检查,9例行CT检查,6例行MRI检查。所有切除或活检组织均行HE染色,5例患者有比较完整的免疫组化结果。结果:ASPS发病年龄较轻,80%(8/10)为30岁以下。多表现为无痛性肿块。3例就诊时已有肺转移。70%(7/10)发生于下肢深部软组织以及臀部。另3例分别位于胸壁、颈部及眼眶内。ASPS的CT表现为软组织肿块影,增强后呈明显不均匀强化。MRI表现为T1WI等或略高信号,T2WI高信号,肿瘤内外可见血管流空信号,增强后肿瘤呈不均匀明显强化。镜下ASPS是由嗜伊红色的大多边形上皮样细胞组成,呈特征性的器官样或腺泡状排列,腺泡之间为衬覆单层扁平内皮细胞的裂隙状或血窦样毛细血管网。免疫组化显示3例神经元特异性烯醇化酶(NSE)阳性,两例抗淀粉酶消化染色(PAS)阳性,1例MyoD1横纹肌特异肌调节蛋白阳性(胞质染色),1例Desmin结蛋白阳性。结论:ASPS虽然是少见软组织肉瘤,但影像学很有特点,结合临床、影像和病理表现是诊断的关键。     

Imaging of axillary lymph nodes

There is increasing interest in the radiological diagnosis of axillary lymph nodes in patients with breast cancer, especially in the preoperative diagnosis of metastatic nodes. Both CT (computed tomography) and MRI (magnetic resonance imaging) are cross-sectional imaging methods that produce high-quality images of the axilla. MRI also uses contrast enhancement profile, for example in imaging of breast lesions. Few studies have been published on this subject, but the latest have shown high sensitivity and specificity (CT 93.8 and 82.1%, respectively; MRI 90 and 82%, respectively), although, both CT and MRI are restricted to imaging only. US (ultrasound) is widely spread and is fast and accurate with high resolution. Sensitivity and specificity vary (68.2-92% and 90-100%, respectively). Most importantly, there is the possibility of US-guided FNAB (fine-needle aspiration biopsy) of pathological nodes, which increases the specificity. Initial results with colour Doppler are promising, but a recent study has shown that the presence of colour Doppler flow signal is highly non-specific. Other parameters such as flow pattern and distribution may prove to be of value in this method. Today, the method of choice for the daily routine is US in conjunction with FNAB.     

Current possibilities of radiodiagnosis in liver tumors

The report deals with potential of present-day techniques for radiological imaging, differential diagnosis and working out of modalities of treatment for primary and metastatic hepatic tumors. Results of complex examination (ultrasound, CT, MRI, PET using fluorine -18 FDG) of patients with benign and malignant tumors are discussed. Sensitivity and specificity of each procedure have been identified to be used in diagnosis of large-size tumors.     

Papillary endothelial hyperplasia presenting as recurrent malignant glioma

The initial management of patients with malignant gliomas depends on accurate histologic diagnosis which, in turn, directs appropriate treatment planning. However, the diagnosis of recurrent disease is often based solely on radiological data which can occassionally be misinterpreted as showing recurrent tumor. Lack of awareness of conditions that mimic recurrent tumor and potentially confound radiological diagnosis can lead to inappropriate therapeutic decisions. We report the case of a patient whose imaging studies suggested recurrence of malignant glioma; however, surgical resection of the lesion guided by MRI scans resulted in the correct diagnosis of papillary endothelial hyperplasia and led to appropriate management of this condition that mimicked tumor recurrence. In this report, we provide a comprehensive review of this rare entity and emphasize the importance of adequately pursuing appropriate diagnostic considerations prior to making definitive treatment decisions.     

A review of the radiological features of intracranial meningiomas

To evaluate the role of radiological imaging of meningiomas in confirming the diagnosis and as a neuroanatomical aid to surgical planning, 115 patients with surgically excised meningiomas between 1990 and 1993 were studied. Computed tomography (CT), magnetic resonance imaging (MRI) (on a 0.5T unit) and angiography were reviewed, and compared with histopathology (when available). Seventy-eight CT, 89 MRI and 85 angiographic studies were reviewed, and correlated with histopathology in 67 cases. In 48 cases, the surgical specimens could not be pathologically classified. The most common lesion sites were the cerebral convexities, falx and sphenoidal ridges. True demarcation of cleavage planes was seen on 73% of MRI and 10% of CT studies. Computed tomography showed hyperostosis in 27% and MRI in 7% of studies. Tumours enhanced strongly with contrast in 98% of CT scans. On MRI there were variable signal intensities on different sequences, and no correlation between signal intensities and histological subtype was found. Oedema was present in 59% of CT and 66% of MRI studies, and was most pronounced in lesions > 3 cm in diameter. Tumour calcification was seen in 62% of CT and 8% of MRI studies. Vascular abnormalities were seen on 65% of MRI, 21% of CT and 84% of angiogram studies. Angiographic tumour vascularity did not correlate with histologic subtype. All three imaging modalities have management roles: CT for bony changes and calcification, MRI for multiplanar and vessel anatomy imaging, and angiography for vessel delineation and embolization if required.