The natural history of familial cerebral cavernomas: a retrospective MRI study of 40 patients

Our objective was to determine the natural history and prognostic factors of familial forms of cerebral cavernous malformations (CCM). Cavernomas are one of the most common central nervous system vascular malformations. Familial CCM is increasingly diagnosed, but little is known about its natural history. In a national survey, we analysed clinical and MRI features of 173 patients from 57 unrelated French families. Of these 40 had undergone at least two clinical and MRI examinations. Occurrence of haemorrhage, new lesions, change in signal intensity and size of lesions have been studied by comparison between first and last MRI studies. The CCM were classified according to Zabramski et al. Mean follow-up was 3.2 years (range 0.5–6.5 years). We followed 232 cavernomas (mean 5.9 per patient, range 1–17). Serial MRI demonstrated changes in 28 patients (70 %). Bleeding occurred in 21 lesions (9.1 %) in 14 patients (35 %). The haemorrhagic risk was 2.5 % per lesion-year, higher in type I and brain-stem CCM. We saw 23 new lesions appear in 11 patients (27.5 %), with an incidence of 0.2 lesions per patient year. Signal change was observed in 11 patients (27.5 %), in 14 lesions (6 %), while 9 lesions (3.9 %) in 9 patients (22.5 %) changed significantly in size. Received: 20 May 1999/Accepted: 1 September 1999     

Spontaneous Dissection of the Superior Mesenteric Artery

Spontaneous dissection of the superior mesenteric artery (SMA) is a rare occurrence, especially when not associated with aortic dissection [1]. Currently, only 28 cases appear to have been reported. Due to the scarcity of cases in the literature, the natural history of isolated, spontaneous SMA dissection is unclear. CT has been reported to be useful for the initial diagnosis of SMA dissection [2–5]. We present two recent cases of spontaneous SMA dissection in which enhanced spiral CT was instrumental in following the disease process and guiding clinical decision making.     

Posterior atlantoaxial dislocation without odontoid fracture

We report a case of posterior atlantoaxial dislocation without a fracture of the odontoid in a 35-year-old woman. There have been nine reported cases of similar injury in the English literature. The integrity of the transverse ligament following posterior atlantoaxial dislocations has not been well documented in these reports. In the present case, MRI revealed an intact transverse ligament, which probably contributed to the stability of the C1–C2 complex following closed reduction.     

Aspects of atypical degenerative lesions of vertebrae

Over the last 20 years, several authors have reported aspects of degenerative disease of the vertebral column with irregularity and sclerosis of the margins of the vertebral bodies [2, 4, 7–9, 13, 15, 17]. Twenty cases of such atypical degenerative vertebral lesions have been studied over a two year period and their radiological characteristics have been compared with vertebral lesions of infective origin and in the rheumatoid disorders.     

The predictive value of angiographic results for the outcome of percutaneous transluminal angioplasty in stenosed femoral bypass grafts

Purpose To assess the predictive value of immediate angiographic results after percutaneous transluminal angioplasty (PTA) for stenoses in femoral bypass grafts using duplex ultrasound (DUS) criteria. Methods A 1-year follow-up with DUS was performed in 38 patients with 50 stenoses in 41 grafts, treated with PTA for a graft stenosis. The indication for PTA according to DUS criteria was a severe stenosis in 43 lesions, and a moderate stenosis in 7 lesions. In the moderate stenosis group 3 patients showed claudication and 1 patient had a nonhealing ulcer. For the purposes of statistical evaluation, primary patency was considered present if the graft was not occluded. The graft was considered to have failed when it was found to be occluded on DUS, or when secondary interventions (surgery, repeat PTA) were performed. Results After 1 year the cumulative primary patency rate was 44$ [95% confidence interval (CI) 27.8–59.8]. Stenoses with initially good angiographic results after PTA (<30% residual stenosis) were 2.9 times more likely to be patent at 1 year than stenoses with initially poor or moderate angiographic results (hazard ratio 2.9, 95% CI 1.3–6.4,p=0.007). Conclusion A poor or moderate angiographic result immediately following PTA was prognostic for poor long-term results and may indicate a requirement for earlier surgical intervention.     

Percutaneous radiofrequency ablation of lung tumors with expandable needle electrodes: current status

Percutaneous radiofrequency thermal ablation (RFA) has been used to treat primary and secondary liver tumors under ultrasound, computed tomography (CT), or magnetic resonance imaging (MRI) guidance for the past decade [Park et al., Radiol Clin North Am 38:545–561, 2000; Siperstein and Gotomirski, Cancer J 6:S293–S301, 2000; Kelekis et al., Eur Radiol 13:1100–1105, 2003]. RFA is a low-cost, minimally invasive treatment that has recently attracted attention for treating tumors in different solid organs with promising results [Dupuy and Goldberg, J Vasc Interv Radiol 12:1135–1148, 2001; Friedman et al., Cardiovasc Intervent Radiol 27:427–434, 2004]. It can be provided with minimal hospitalization, and experienced practitioners have reported low complication rates [Dupuy and Goldberg, J Vasc Interv Radiol 12:1135–1148, 2001; Livraghi et al., Radiology 226:441–451, 2003]. Patients with lung malignancies (primary lung cancer or pulmonary metastases), who cannot be operated, might be candidates for RFA treatment. It can also be used in association with other treatments (i.e., chemotherapy, radiotherapy) for better disease control. Combination of the above with RFA may help reduce morbidity and mortality. Many ways to apply energy to the tumor exist (monopolar and bipolar RFA, microwave, laser, brachytherapy). In this review we will focus on expandable monopolar systems, which despite their deficiencies are the most popular in the interventional radiology sector.     

Acetabular pneumatocyst containing air–fluid level

The presence of intraosseous gas most commonly occurs in osteomyelitis, vacuum phenomenon, and postsurgery or posttraumatic states. Several cases of subchondral gas-filled lesions, called pneumatocysts, have also been described in the sacroiliac joint and clavicle, none of them with intralesional air–fluid level. These pneumatocysts are innocuous lesions of uncertain origin. We describe one case of acetabular pneumatocyst containing air–fluid level in a 62-year-old man with long-standing ankylosing spondylitis involving hip joint. To our knowledge, this is the first reported case of a pneumatocyst in an acetabular location containing air–fluid level. Received: 15 June 1998; Revision received: 4 November 1998; Accepted: 11 December 1998     

Multiple intracerebral cavernous angiomas

Eight patients (seven women and one man) with multiple intracerebral cavernous angiomas (cavernomas), also known as angiomatosis cerebri, were examined with high-field magnetic resonance imaging (MRI). Although previous articles have referred to such cases, a series similar to the one reported here has apparently not been described in the radiology literature. The patients presented with seizures, progressive neurologic deficit or cerebral hemorrhage. In all eight cases the multiplicity of the lesions was an incidental finding in the magnetic resonance images. The MRI appearance of the cavernomas, although characteristic, is similar to that of other angiographically occult intracranial vascular malformations, in particular thrombosed arteriovenous malformations and mixed vascular malformations, as well as that of hemorrhagic metastases. Additional criteria, such as the absence of edema, the presence of calcifications and the temporal evolution of the cavernomas on serial scans, should allow cavernomas to be differentiated from hemorrhagic metastases. The exquisite sensitivity in detecting angiomatosis cerebri and the ability to show the evolution of internal hemorrhage in individual lesions make MRI the method of choice for diagnosing and following this condition.     

Percutaneous transluminal angioplasty of peripheral bypass stenoses

Purpose: To assess the success of percutaneous transluminal angioplasty (PTA) in treating peripheral bypass stenoses. Methods: Patients who received a femoropopliteal or femorocrural bypass graft for limb ischemia were included in a duplex surveillance program. If duplex ultrasound revealed a short (<2 cm) severe (peak systolic velocity ratio ≥ 4.5) stenosis, patients were scheduled for arteriography and PTA. Fifty-eight peripheral bypass stenoses in 39 grafts in 37 patients were treated with PTA. The cumulative primary patency of treated stenoses was calculated. Results: During the first year after PTA 31 (53%) treated lesions remained patent, 15 (26%) lesions restenosed at a median interval of 5.0 (range 1–12) months and 4 (7%) bypasses occluded. The cumulative primary patency of 58 treated graft stenoses at 1 year was 60% [95% confidence interval (CI) 46%–74%] and 55% (95% CI 41%–70%) at 2 years. Graft body stenoses showed a better 2-year cumulative primary patency (86%; 95% CI 68%–100%) compared with juxta-anastomotic lesions (45%; 95% CI 29%–62%; p < 0.05). Conclusion: PTA is justifiable as the initial treatment of peripheral bypass stenoses. Nevertheless, the restenosis rate is rather high, especially in juxta-anastomotic lesions. Continuation of duplex surveillance after PTA and timely reintervention is recommended.     

Histological and ultrastructural evaluation of Leeds-Keio ligament 20 years after implant: a case report

We were capable of undertaking a histological and ultrastructural evaluation of an intact Leeds-Keio ligament implanted 20 years ago to assess the neoligamentization process inside this artificial ligament. The histological evaluation disclosed a collagen fibrils orientation very close to the structure of a normal anterior cruciate ligament (ACL) where the collagen fibres are multidirectional [Strocchi et al. in J Anat 180(3):515–519, 1992]. On the other hand we found an unimodal distribution of collagen fibrils in the reconstructed ACL. This suggests that even at long-term follow-up stress exerts a variable influence. The multidirectional arrangement of collagen fibres resembles a normal ACL, but the unimodal distribution of fibrils is quite different from those seen in normal tendon and ligaments which tend to have a bimodal peak [Decker et al. in J Submicrosc Cytol Pathol 23:9–21, 1991; Strocchi et al. in J Anat 180(3):515–519, 1992]. Studies based on biopsy suffer from the potential weakness that the specimen may not have been representative of the entire prosthesis. Further long-term studies, possibly with the entire prosthesis and not only a biopsy, would highlight the behaviour and remodelling of this artificial ligament in greater detail and could be important for the development of future generations of artificial ligaments or tissue engineering ACL reconstruction.     

Improved preoperative evaluation of cerebral cavernomas by high-field, high-resolution susceptibility-weighted magnetic resonance imaging at 3 Tesla: comparison with standard (1.5 T) magnetic resonance imaging and correlation with histopathological findings--preliminary results

OBJECTIVES: To compare high-field, high-resolution, susceptibility-weighted magnetic resonance imaging (3 Tesla [T] HR-SW-MRI) and standard (1.5 Tesla [T]) MRI for the detection of cerebral cavernomas. To evaluate the ability of 3 T HR-SW-MRI to visualize intralesional structures compared with standard (1.5 T) MRI, in correlation with histopathologic findings. MATERIALS AND METHODS: Seventeen patients with cerebral cavernomas underwent both standard (1.5 T) MRI (T1-SE, T2-TSE, T2*-GRE) and 3 T HR-SW-MRI (TR/TE 43.3/9.1 millisecond; 512 x 384 x 48 matrix; FOV 250 mm; SI 72 mm) at our institution. All MR images were evaluated by 3 radiologists in consensus for detectability, size (1 cm), and conspicuity (good, acceptable, poor) of the lesions at both field strengths, and for the presence of hypointense intralesional tubular structures. In 7 patients, MR findings were correlated with histopathologic findings. RESULTS: Both 3 T HR-SW-MRI and standard (1.5 T) MRI detected 22 lesions in 17 patients; 3 T HR-SW-MRI detected an additional 7 lesions in 6 patients. On average, 3 T HR-SW-MRI detected 1.706 +/- 0.92 (median = 1) lesions per patient, whereas standard (1.5 T) MRI detected 1.235 +/- 0.664 lesions per patient (P = 0.016). Lesion conspicuity was good in all 3 T HR-SW-MR images and good in 68.2% and acceptable in 31.8% of standard (1.5 T) MR images (P = 0.016). In 22 lesions detected at both field strengths, 3 T HR-SW-MRI demonstrated intralesional tubular structures in 72.7% and standard (1.5 T) MRI demonstrated these structures in 31.8% (P = 0.001). Intralesional tubular structure correlated to conglomerates of cavernous vessel, as verified by histopathology. CONCLUSION: Compared with standard (1.5 T) MRI, 3 T HR-SW-MRI allows superior detection and characterization of cerebral cavernomas. Despite increased susceptibility effects, ie, signal loss at higher magnetic field strengths, the visualization of intralesional tubular structures is feasible. This may be helpful in the diagnosis, presurgical planning, and noninvasive follow-up after gamma-knife radiosurgery.     

Comparison of the diagnostic performance of high-frequency ultrasound as a first- or second-line diagnostic tool in non-palpable lesions of the breast

To compare the diagnostic performance of high-frequency ultrasound (HFU) as a first- or second-line diagnostic tool in non-palpable lesions (NPL) of the breast and to define the place of HFU in the diagnostic process, 89 women with this kind of lesion, previously detected by mammography, underwent HFU with 7.5–13 MHz transducers. The examinations were performed by two equally experienced operators of which only one (operator I) was aware of the mammographic findings. The mammographic examinations revealed the following non-palpable lesions: asymmetry-hyperdensity (17 cases), nodule (44 cases), stellate lesion (5 cases), microcalcifications (23 cases). Total sensitivity of HFU in the examinations performed by operator I was 83 %, while in the examinations performed by operator II (unaware of the mammographic findings) it was only 35 %. In all cases HFU allowed the operators to determine the basic features of the lesions. Our experience confirms that ultrasonography, even if performed with high frequency, cannot be proposed as a screening examination but may profitably be employed as a second-step technique to characterize NPL previously identified by mammography. This ’second-step' role can do the following: rule out true pathology (cases of false-positive mammography findings); furnish some basic features in the case of focal lesions; show other findings in the case of microcalcifications, such as microcysts, ’filled duct' appearance, parenchymal inhomogeneities and nodules; guide interventional procedures; and localize lesions preoperatively. Received: 15 April 1996; Accepted: 2 January 1997     

Traumatic complications from placement of thoracic catheters and tubes

The volume of critically ill patients requiring stabilization in emergency departments (EDs) throughout the USA has increased from 42 million per year in 1960 to over 92 million in 1990, as reported by Goldstein [Crit Care Clinics 21(1):81–89, 2005] and Rivers et al. [Curr Opin Crit Care 8(6):600–606, 2002]. With the increase in this patient population, the number of procedures, both invasive and noninvasive, performed in the ED to improve clinical outcomes has also increased. Therefore, emergency medicine physicians must add to their repertoire the ability to recognize potentially fatal traumatic complications. This review will provide readers with imaging findings of traumatic complications from placement of thoracic catheters and tubes and briefly discuss pitfalls of performing these procedures. In particular, complications arising from placement of hemodialysis catheters, central venous catheters, Swan–Ganz catheters, chest tubes, nasogastric and feeding tubes, and endotracheal tubes will be reviewed.     

Adenomatous-Dominant Benign Prostatic Hyperplasia (AdBPH) as a Predictor for Clinical Success Following Prostate Artery Embolization: An Age-Matched Case–Control Study

To investigate the clinical impact of performing prostate artery embolization (PAE) on patients with adenomatous-dominant benign prostatic hyperplasia (AdBPH). Twelve patients from the ongoing proSTatic aRtery EmbolizAtion for the treatMent of benign prostatic hyperplasia (STREAM) trial were identified as having AdBPH; defined as two or more adenomas within the central gland of ≥1 cm diameter on multi-parametric MRI (MP-MRI). These patients were age-matched with patients from the STREAM cohort, without AdBPH. Patients were followed up with repeat MP-MRI at 3 months and 1 year. International prostate symptom score (IPSS), international index for erectile function (IIEF), and quality of life assessment from the IPSS and EQ-5D-5S questionnaires were recorded pre-PAE and at 6 weeks, 3 months, and 1 year. The mean age of patients was 68 (61–76). All patients had PAE as a day-case procedure. The technical success in the cohort was 23/24 (96%). There was a significant reduction in prostate volume following embolization with a median reduction of 34% (30–55) in the AdBPH group, compared to a mean volume reduction of 22% (9–44) in the non-AdBPH group (p = 0.04). There was a significant reduction in IPSS in the AdBPH group following PAE when compared with the control group [AdBPH median IPSS 8 (3–15) vs. non-AdBPH median IPSS 13 (8–18), p = 0.01]. IPSS QOL scores significantly improved in the AdBPH group (p = 0.007). There was no deterioration in sexual function in either group post-PAE. This is the first time that AdBPH has been identified as being a predictor of clinical success following PAE.     

High-resolution endovaginal MR imaging in stress urinary incontinence

The causes of stress urinary incontinence are not completely known. Recent papers have stressed the importance of more anatomical information, which may help to elucidate the mechanism of stress urinary incontinence. The purpose of this study was to evaluate the prevalence of lesions of the urethral support mechanism and lesions (defects and scars, thinning) of levator ani muscle with endovaginal MRI in a case-control study. Forty women (median age 52 years, age range 40–65 years)—20 patients with stress urinary incontinence (cases) and 20 age-matched healthy volunteers (controls)—underwent endovaginal MRI: axial, coronal, and sagittal T2-weighted turbo spin echo. The examinations were evaluated for the presence of lesions of urethral supporting structures and levator ani and scar tissue of the levator ani. The thickness of the levator ani muscle was measured. Lesions of the urethral support system and levator ani were significantly more prevalent in cases than in controls (p<0.01). Median levator ani thickness in patients was significantly lower than in healthy controls [2.5 mm (range 0.9–4.1 mm) vs 3.9 mm (range 1.4–7 mm)] (p<0.01). This study indicates a relationship between stress urine incontinence and the presence of lesions of the urethral support and levator ani and levator ani thinning.     

The injury profile of Karate World Championships: new rules, less injuries

The aim of this paper is to document the injury rate in high-level modern competitive karate after a change of competition rules was implemented in the year 2000, and to compare it with the injury rate found before the rules were changed. A prospective recording of the injuries resulting from 2,762 matches in three consecutive World Karate Championships (representing 7,425 min of active fighting) was performed, and compared with the results from 2,837 matches from the three last World Karate Championships (representing 7,631 min of active fighting) held before the change of competition rules. In total, 497 injuries were recorded, with an incidence of 0.180 injuries per match or 6.7 per 100 min of active fighting. There were 1,901 male category fights (in which 383 injuries were recorded), and 861 female category fights (in which 114 injuries were recorded). The global injury incidence was almost double with the old rules compared to the one with the new rules [OR 1.99, 95% CI (1.76–2.26); p < 0.00001]. In male category, the risk of injury was higher before the rules were changed [OR 1.81, 95% CI (1.56–2.09); p < 0.00001], and also in female category [OR 2.71; 95% CI (2.64–2.80); p < 0.00001]. The rate of severe injuries was not different before and after the change of rules. The implementation of the new competition rules in competitive karate has been associated with a significant reduction in injury rate, making competition safer for athletes.     

CT-guided vertebroplasty: analysis of technical results, extraosseous cement leakages, and complications in 500 procedures

The aim of this study was to analyze the technical results, the extraosseous cement leakages, and the complications in our first 500 vertebroplasty procedures. Patients with osteoporotic vertebral compression fractures or osteolytic lesions caused by malignant tumors were treated with CT-guided vertebroplasty. The technical results were documented with CT, and the extraosseous cement leakages and periinterventional clinical complications were analyzed as well as secondary fractures during follow-up. Since 2002, 500 vertebroplasty procedures have been performed on 251 patients (82 male, 169 female, age 71.5 ± 9.8 years) suffering from osteoporotic compression fractures (n = 217) and/or malignant tumour infiltration (n = 34). The number of vertebrae treated per patient was 1.96 ± 1.29 (range 1–10); the numbers of interventions per patient and interventions per vertebra were 1.33 ± 0.75 (range 1–6) and 1.01 ± 0.10, respectively. The amount of PMMA cement was 4.5 ± 1.9 ml and decreased during the 5-year period of investigation. The procedure-related 30-day mortality was 0.4% (1 of 251 patients) due to pulmonary embolism in this case. The procedure-related morbidity was 2.8% (7/251), including one acute coronary syndrome beginning 12 h after the procedure and one missing patellar reflex in a patients with a cement leak near the neuroformen because of osteolytic destruction of the respective pedicle. Additionally, one patient developed a medullary conus syndrome after a fall during the night after vertebroplasty, two patients reached an inadequate depth of conscious sedation, and two cases had additional fractures (one pedicle fracture, one rib fracture). The overall CT-based cement leak rate was 55.4% and included leakages predominantly into intervertebral disc spaces (25.2%), epidural vein plexus (16.0%), through the posterior wall (2.6%), into the neuroforamen (1.6%), into paravertebral vessels (7.2%), and combinations of these and others. During follow-up (15.2 ± 13.4 months) the secondary fracture rate was 17.1%, including comparable numbers for vertebrae at adjacent and distant levels. The presence of intradiscal cement leaks was not associated with increased adjacent fracture rates. CT-guided vertebroplasty is safe and effective for treatment of vertebral compression fractures. CT-fluoroscopy provides an excellent control of the posterior vertebral wall. The number of cement leakages alone is not directly associated with clinical complications. However, even small volumes of pulmonary PMMA embolism might be responsible for the fatal outcome in cases with underlying cardiopulmonary insufficiency.     

Major prognostic impact of persistent microvascular obstruction as assessed by contrast-enhanced cardiac magnetic resonance in reperfused acute myocardial infarction

The aim of this study was to compare the prognostic significance of microvascular obstruction (MO) and persistent microvascular obstruction (PMO) as assessed by cardiac magnetic resonance (CMR) in patients with acute myocardial infarction (AMI). CMR was performed in 184 patients within the week following successfully reperfused first AMI. First-pass images were performed to evaluate extent of MO and late gadolinium-enhanced images to assess PMO and infarct size (IS). Major adverse cardiac events (MACE) were collected at 1-year follow-up. MO and PMO were found in 127 (69%) and 87 (47%) patients, respectively. By using univariate logistic regression analysis, high Global Registry of Acute Coronary Events (GRACE) risk score (odds ratio [OR] 95% confidence interval [CI]: 3.6 [1.8–7.4], p < 0.001), IS greater than 10% (OR [95% CI]: 2.7 [1.1–6.9], p = 0.036), left ventricular ejection fraction less than 40% (OR [95% CI]: 2.4 [1.1–5.2], p = 0.027), presence of MO (OR [95% CI]: 3.1 [1.3–7.3], p = 0.004) and presence of PMO (OR [95% CI]:10 [4.1–23.9], p < 0.001) were shown to be significantly associated with the outcome. By using multivariate analysis, presence of MO (OR [95% CI]: 2.5 [1.0–6.2], p = 0.045) or of PMO (OR [95% CI]: 8.7 [3.6–21.1], p < 0.001), associated with GRACE score, were predictors of MACE. Presence of microvascular obstruction and persistent microvascular obstruction is very common in AMI patients even after successful reperfusion and is associated with a dramatically higher risk of subsequent cardiovascular events, beyond established prognostic markers. Moreover, our data suggest that the prognostic impact of PMO might be superior to MO.     

Clinical and radiological outcomes of acute ischemic stroke patients without angiographic occlusion on digital subtraction angiogram. A pooled analysis of case series

Introduction  Approximately 20–30% of the patients with acute ischemic stroke do not have any occlusion demonstrated on initial digital subtraction angiography (DSA). We sought to determine the risk and rates of cerebral infarction and favorable neurological outcome in this group of acute ischemic stroke patients. Materials and methods  Patients were identified from a prospectively maintained stroke database and from literature search of MEDLINE, PubMed, and Cochrane databases. All patients had initial neurological assessment on National Institutes of Health Stroke Scale (NIHSS). Patients then underwent DSA after initial head computed tomography (CT) scans. Follow-up radiological assessment at 24–72 h was performed with CT and magnetic resonance imaging scans. Association of stroke risk factors with clinical and radiological outcomes was estimated. Results  A total of 81 patients was analyzed (mean age 63 years; 28 were women). The median NIHSS score was 8 (range 2–25). None of the patients received either intravenous or intra-arterial thrombolytic. Cerebral infarction was detected in 62 (76%) of the 81 patients. Twenty-four to 48-h NIHSS was available for 51 patients only. Neurological improvement was observed in 22 (43%) of the 51 patients. Favorable outcome ascertained at 3-month follow-up was seen in 48 (59%) of the 81 patients. After adjusting for age, sex, and baseline NIHSS, male patients [odds ratio (OR) 4.5 (1.4–14.3), p value = 0.01] and patients with age ≥65 [OR 4.3 (1.2–16.2), p value = 0.03] have a higher risk of cerebral infarcts on the follow-up imaging. Similarly, patients who presented with <10 NIHSS had a better 3-month outcome than those with >10 NIHSS [OR 0.21 (0.08–0.61), p value = 0.004]. Conclusion  Ischemic stroke patients without arterial occlusion on DSA have a higher risk of cerebral infarction and disability particularly in men, patients over 65 years of age and with NIHSS ≥10. The cause of infarction may have been arterial obstruction with spontaneous recanalization or small vessel occlusion not visible on DSA.     

Accuracy of whole-body low-dose multidetector CT (WBLDCT) versus skeletal survey in the detection of myelomatous lesions,and correlation of disease distribution with whole-body MRI (WBMRI)

Aim  The aim of the study is to assess the feasibility of whole-body low-dose computed tomography (WBLDCT) in the diagnosis and staging of multiple myeloma and compare to skeletal survey (SS), using bone marrow biopsy and whole-body magnetic resonance imaging (WBMRI; where available) as gold standard. Materials and methods  Patients referred over an 18-month period for investigation of suspected multiple myeloma or restaging of myeloma were randomized to undergo one of two WBLDCT protocols using high kVp, low mAs technique (140 kVp, 14 mAs; or 140 kVp, 25 mAs). Recent WBMRI scans were reviewed in 23 cases. Each imaging modality was assessed by two radiologists in consensus and scored from 0–3 (0 = normal, 1 = 1–4 lesions, 2 = 5–20 lesions, 3 ≥ 20 lesions/diffuse disease) in ten anatomical areas. Overall stage of disease, image quality score, and the degree of confidence of diagnosis were recorded. Diagnostic accuracy of skeletal survey and WBLDCT were determined using a gold standard of bone marrow biopsy and distribution of disease was compared to WBMRI. Results  Thirty-nine patients were evaluated. WBLDCT identified more osteolytic lesions than skeletal survey with a greater degree of diagnostic confidence and led to restaging in 18 instances (16 upstaged, two downstaged). In those with recent WBMRI, distribution of disease on WBLDCT showed superior correlation with WBMRI when compared with SS. Overall reader impression of stage on WBLDCT showed significant correlation with WBMRI (κ = 0.454, p < 0.05). WBLDCT provided complementary information to WBMRI in nine patients with normal marrow signal following treatment response, but which were shown to have diffuse residual cortical abnormalities on CT. Conclusion  WBLDCT at effective doses lower than previously reported, is superior to SS at detecting osteolytic lesions and at determining overall stage of multiple myeloma, and provides complementary information to WBMRI.