Musculoskeletal manifestations of sickle cell disease,diagnosis with whole body MRI

Purpose

The aim of work is to define the musculoskeletal abnormalities in patients with sickle-cell disease using whole body MRI.

Patients and methods

Twenty-seven patients with known sickle cell disease were included in this study complaining of acute painful vaso-occlusive crisis. All the patients complaining of bony pain in different body regions. Some patients complaining of bony swellings and joint pain. Whole body (W.B) MRI studies were performed for all the patients .Three coronal (T1, T2, and STIR) sequences were performed for whole-body MR imaging. In selected cases, dedicated examination of certain body parts was performed.

Results

Persistent red marrow, intramedullary bone hyperplasia and bone infarcts were seen in all patients. Vertebral bone infarcts were found in 23 patients. Bilateral proximal femoral head epiphysis avascular necrosis were found in 9 patients. Osteomylitis was diagnosed in 6 patients and septic arthritis in 2 patients.

Conclusion

Whole body MRI can help identifying muscloskeletal abnormalities in sickle cell disease in a single session. MRI is a useful imaging tool in distinguishing acute osteomylitis and bone infarct. Knowledge of the range of imaging findings is crucial in order to accurately depict the complication and initiate appropriate therapy.     

Different findings in Tc-99m MDP bone scintigraphy of patients with sickle cell disease: report of three cases

Objective Sickle cell anemia is an inherited disorder caused by abnormal hemoglobin, the S hemoglobin. Although vaso-occlusive crises can occur virtually in any organ, they are particularly common in the bony skeleton of affected patients. Bone marrow necrosis, bone infarcts, osteomyelitis, and aseptic necrosis are common complications in patients with sickle cell disease. Beside these abnormalities of the skeletal system, diffuse micro or macro calcification resulting from both splenic infarction and repeated vaso-occlusive episodes in the kidneys can be shown by technetium-99m methylenediphosphonate (Tc-99m MDP) bone scintigraphy. We present here the different osseous and extraosseous abnormalities noted on bone scintigraphies of three patients with sickle cell anemia. Methods Whole-body bone scan was performed after injecting 740 MBq of Tc-99m MDP in three patients with sickle cell disease. Results Tc-99m MDP whole-body image of the first patient showed non-uniform uptake in the anterior and posterior aspects of multiple ribs and bilateral femurs and tibias that was attributed to repetitive infarcts. Additionally, increased activity in shoulders, right elbow, and right knee was consistent with arthritis. Tc-99m MDP image of the second patient demonstrated avascular necrosis of the left femoral head and diffuse activity in the enlarged kidneys. Increased activity in the spleen that was attributed to repetitive infarcts was visualized in bone scan of the third patient. Conclusions In light of the findings in these cases, bone scintigraphy is a reliable imaging method in detecting both osseous and extraosseous abnormalities of sickle cell disease and may be used initially.     

MRI findings of septic arthritis and associated osteomyelitis in adults

OBJECTIVE: The purpose of this study was to describe the soft-tissue, synovial, and osseous MRI findings of septic arthritis. MATERIALS AND METHODS: At 1.5 T (T1-weighted, T2-weighted or STIR, and contrast-enhanced images), 50 consecutive cases of septic arthritis were evaluated by two observers for synovial enhancement, perisynovial edema, joint effusion, fluid outpouching, fluid enhancement, and synovial thickening. The marrow was assessed for abnormal signal on T1- and T2-weighted images or after contrast enhancement. We noted whether the marrow signal was diffuse or abnormal in bare areas. MRI findings were compared with microbiologic, clinical, and surgical data and diagnoses. RESULTS: The frequency of MRI findings in septic joints was as follows: synovial enhancement (98%), perisynovial edema (84%), joint effusions (70%), fluid outpouching (53%), fluid enhancement (30%), and synovial thickening (22%). The marrow showed bare area changes (86%), abnormal T2 signal (84%), abnormal gadolinium enhancement (81%), and abnormal T1 signal (66%). Associated osteomyelitis more often showed T1 signal abnormalities and was diffuse. CONCLUSION: Synovial enhancement, perisynovial edema, and joint effusion had the highest correlation with the clinical diagnosis of a septic joint. However, almost a third of patients with septic arthritis lacked an effusion. Abnormal marrow signal-particularly if it was diffuse and seen on T1-weighted images-had the highest association with concomitant osteomyelitis.     

骨瘤的MRI表现及其与病理对照分析

目的探讨骨瘤的MRI影像特征及其与病理间的关系,提高对骨瘤MRI特征的认识。资料与方法14例经病理证实的骨瘤,均行MRI平扫及增强扫描,着重分析其MRI强化特征并与病理结果对照。结果(1)骨瘤多呈类圆形,边缘清晰,无软组织肿块和骨膜反应;(2)9例骨瘤T1WI、T2WI均呈低信号,Gd-DTPA增强扫描轻度强化6例,无强化3例,病理上9例均为成熟骨板和纤维组织,其中6例有大量骨母细胞,包括1例位于大腿根部肌间隙内的骨外骨瘤,呈轻度强化,病理上含有成熟的哈氏系统;(3)5例呈均匀或不均匀长T1、长T2信号,Gd-DTPA增强扫描呈不均匀轻度强化4例,明显强化1例,病理上除成熟骨板和纤维组织外,均有多少不一的骨髓成分,明显强化的1例含有较多的扩张毛细血管。结论对于典型骨瘤病例,MRI具特征性表现;对于增强扫描强化较明显的病例,尚需依赖病理确诊。     

颅底胆脂瘤的MRI特征

目的探讨颅底胆脂瘤MRI分型的意义及其MRI诊断特征。方法观察15例颅底胆脂瘤的CT、MRI与病理学资料，根据肿瘤T1WI信号的不同，将颅底胆脂瘤分为Ⅰ型和Ⅱ型，分析两型胆脂瘤在CT、MRI征象和颅底骨质侵犯等方面的差异。结果15例颅底胆脂瘤T2WI显著高信号，肿瘤实质无强化。15例中，Ⅰ型，6例，肿瘤位于桥前池和桥小脑角区，CT均匀低密度，T1WI均匀低信号，包膜不强化，颅底骨质改变轻微，肿瘤实质为胆固醇结晶；Ⅱ型，9例，肿瘤位于一侧中、后颅窝底，CT呈混杂密度，T1WI呈混杂信号，其中4例为低信号中夹杂少量高信号，另5例以高信号为主，包膜强化，颅底骨质呈显著外压性改变，肿瘤实质为角化上皮和蛋白。结论颅底胆脂瘤分为Ⅰ型和Ⅱ型是合理的，体现了两型颅底胆脂瘤组织病理和生物学行为的差异，对指导MRI诊断有积极意义。T1WI信号多样性、T1WI显著高信号、肿瘤实质不强化以及与MRI分型相关的颅底骨质侵犯是颅底胆脂瘤的MRI诊断特征。     

Imaging the bone marrow with magnetic resonance during a crisis and in chronic forms of sickle cell disease

Five patients with sickle cell disease have been studied by magnetic resonance imaging (MRI) in three instances during a crisis. Attention was directed to the pelvis and lower extremities. Bone marrow pathology has been classified according to generalised or circumscribed alterations in signal intensity on T1 weighted spin-echo sequences. Both acute and chronic changes were observed.     

Sportsman hindfoot pain: role of magnetic resonance imaging]

PURPOSE: To assess the outcome of Magnetic Resonance Imaging (MRI) in the diagnosis of sportsman hindfoot pain. MATERIALS AND METHODS: Fortythree professional athletes (31 men, 12 women, age range: 17-37 years) affected by hindfoot pain underwent MRI. Spin echo (SE) T1W, Gradient echo (GE) T2*W, and fat suppression (Short Time Inversion Recovery: STIR) images were acquired with a 0.5 T superconductive unit (Vectra, GE Medical System, Milwaukee, WI, USA). A dedicated extremities transmitter/receiver coil was used. The lesion site, the presence of anatomic variants (os trigonum, Haglund's deformity), and signal intensity changes were evaluated. RESULTS: In all cases MRI allowed the identification of the cause of the hindfoot pain, in relation to soft tissue (bursae, synovial or nervous structures), bone and articular diseases. Particularly, as regards soft tissue diseases, tendinous abnormalities and inflammatory bursal involvement were frequently found (77% of cases). Bone diseases (22% of cases with posterior talalgia alone), mostly involved the heel (60%), whereas cartilagineous diseases were present in 9% of cases. In 60% of cases an intra-articular osseous or cartilagineous displaced fragment coexisted, determinating joint locking during foot flexo-extension movements. In 38% of cases contemporary involvement of different articular structures was observed. DISCUSSION: Both MRI high contrast resolution and multiplanar capabilities allow the complete evaluation of hindfoot region. In our experience sagittal and axial planes were particularly well suited for the diagnosis and the assessment of disease extension. Furthermore, T2W (GET2*) and fat suppression (STIR) images allow high sensitivity even in early disease detection, when hyperemia or fluid collection occur. CONCLUSIONS: According to our results, it seems possible to state that nowadays MRI is the most reliable technique for identifying the causes of hindfoot pain, in order to provide a correct and effective pre-therapeutic planning.     

软骨母细胞瘤MRI及X线平片和CT的表现特征

目的 研究软骨母细胞瘤的影像表现,探讨其MRI与X线平片、CT征象的对应关系.方法 分析16例经手术、病理证实的良性软骨母细胞瘤的影像资料,总结其MRI表现与X线平片、CT征象的对应关系.结果 16例软骨母细胞瘤均位于骨骺,大小为0.9 cm×0.8 cm×1.0 cm～4.8 cm×4.3 cm×5.1 cm,呈不同程度的分叶状.在T1WI上以等、低信号为主,T2WI上呈混杂信号,CT上为软组织密度,内见钙化和更低密度区.边缘呈长T1、短T2信号,在CT上表现为硬化边.MRI可见病灶周围有骨髓水肿,在X线和CT上表现为骨质硬化区.病灶邻近软组织肿胀.MRI显示骨膜异常9例,8例与病灶不相邻;X线和(或)CT显示骨膜新生骨6例.MRI显示关节积液12例,CT显示6例.MRI上病灶均呈不均匀强化,骨髓水肿、骨膜反应和软组织肿胀均见强化.软骨母细胞瘤在扩散加权成像(DWI)上呈等、高信号,在MR平扫中的等T1、等T2成分和长T1、长T2成分,以及骨髓水肿、骨膜反应和软组织肿胀在DWI上均呈高信号.结论 MRI和X线平片、CT从不同方面反映软骨母细胞瘤的病理改变,联合应用不同检查手段可更全面显示软骨母细胞瘤的特点.     

副肿瘤边缘叶脑炎的MRI表现

目的:探讨副肿瘤边缘叶脑炎(PLE)的MRI表现。方法:临床诊断副肿瘤边缘叶脑炎8例患者,常规MRI检查(T1WI、T2WI、FLAIR)及常规增强检查。2例患者行MR扩散加权成像(DWI)检查。结果:6例病灶为双侧,2例为单侧,所有患者均不同程度累及边缘叶,有4例同时累及边缘叶以外:桥脑及桥臂2例、岛叶1例、额叶1例。病变均表现为T2WI高信号,在FLAIR图像上更清晰,增强后2例有轻度强化。结论:PLE典型影像学改变表现为边缘叶T2WI高信号,增强后扫描无明显强化,FLAIR是观察PLE异常信号改变的最敏感方法。     

Giant hemorrhagic myelolipoma in a patient with sickle cell disease

Adrenal myelolipoma is a rare, benign tumor consisting of adipose tissue and hematopoetic elements. It is generally diagnosed as an incidental finding due to its nonfunctioning, asymptomatic nature (Meaglia and Schmidt J Urol 147:1089, 1992). With increasing size, however, as seen in this case, myelolipomas can cause flank pain and abdominal distention. This lesion was diagnosed in a young male with sickle cell disease during a vaso-occlusive crisis.     

MRI与CT对颅颈移行区肿瘤的诊断价值评估：附16例分析

本文旨在评价ＭＲＩ与ＣＴ对颅颈移行区病变的诊断价值，共１６例分析，包括斜坡脊索瘤５例，小脑下蚓部肿瘤２１例，延髓肿瘤４例，上颈段脊髓肿瘤５例。患者均作ＭＲＩ平扫，采用ＳＥ系列，Ｔ１Ｗ（ＴＲ５００／ＴＥ３０ｍｓ）、Ｔ２Ｗ（ＴＲ１８００／ＴＥ９０ｍｓ）和质子密度像（ＴＲ１８００／ＴＥ３０ｍｓ），其中２例作了Ｇｄ－ＤＴＰＡ顺磁增强，所有病例均作了ＣＴ平扫，６例同时还作了增强ＣＴ扫描。通过本组病例分析：１     

Sudden death due to sickle cell crisis during law enforcement restraint

We report a case of vaso-occlusive sickle cell crisis in a young schizophrenic man with undiagnosed sickle cell trait who was restrained. Prior to being restrained he had locked himself in his apartment for two days without food or water. He was subsequently restrained, and transferred to hospital while handcuffed to the stretcher. He died suddenly during restraint. At autopsy, there was acute vaso-occlusive sickle cell crisis associated with hypernatremic dehydration. There were no injuries present. We conclude that the death was due to vaso-occlusive sickle cell crisis secondary to dehydration. It is important for the forensic pathologist to remember that death may occur suddenly during restraint from an unexpected mechanism other than excited delirium leading to cardiac arrhythmia or restraint asphyxia.     

AUR memorial Award. Induced alignment of flowing sickle erythrocytes in a magnetic field. A preliminary report

Deoxygenated sickle erythrocytes in static suspension align perpendicular to a magnetic field. To assess the importance of this observation to MRI of sickle-cell disease, an in vitro flow apparatus was devised and the orientation of sickle erythrocytes flowing through a 0.38 T magnetic field was investigated. We showed a significant perpendicular alignment of fully deoxygenated sickle erythrocytes flowing at 3 to 4 mm/minute (P less than .001). These results suggest that deoxygenated erythrocytes in a sickle-cell patient could orient perpendicular to a magnetic field, and therefore that MRI of such patients could possibly result in worsening of vaso-occlusive complications. Further studies are needed to assess the possible hazards of MRI of sickle-cell disease, especially at high field strengths.     

Possibilities of MR tomography of diseases of the hand and wrist

MRI studies of 63 patients with various abnormalities of the hand and wrist were analyzed. Studies were performed on scanners with a field strength of 0.35, 0.5, or 1.5 T. Imaging parameters included T1- and T2-weighted sequences in the coronal and transverse planes and contiguous slices 3-5 mm thick. In 37 patients with post-traumatic disorders, MRI revealed carpal avascular necrosis, tendon abnormalities and, in some cases, abnormalities of interosseous ligaments and the triangular fibrocartilage. In 15 patients with such inflammatory diseases as arthritis, tenosynovitis and carpal tunnel syndrome and in 11 patients with tumors, MRI provided clear delineation of osseous and soft tissue abnormalities. The current role of MRI in the diagnosis of hand and wrist abnormalities is discussed on the basis of these results.     

Usefulness of gadolinium in MRI evaluation of non surgically treated herniated disk

PURPOSE: The rationale for the use of Gadolinium (Gd) in the MRI evaluation of non surgically treated herniated disk is based on the known presence of inflammatory granulation tissue and neoangiogenesis which plays an important role in both pain and the spontaneous resorption of the hernia. The AIM: of this study was to determine the usefulness of Gd in MRI examination for detecting the inflammatory reaction around the discal hernia. MATERIALS AND METHODS: Thirty-eight patients (mean age 45 years; range 20-70 years) with non surgically treated herniated disk were evaluated with MRI between January 2000 and July 2004. T2w-FAST-SE sagittal and T1w-SE transaxial and sagittal images were acquired before and after the administration of Gd. RESULTS: Twenty out of 22 patients with acute sciatic pain (symptoms =/< 40 days) showed significant peri-hernial enhancement which facilitated the differential diagnosis with other extradural lesions, such as synovial cysts (2/22 cases), as well as the correct definition of the extension of discal hernia in the spinal canal. In the remaining 16 with chronic sciatic pain (symptoms > 6 months) the discal hernia did not show peri-hernial enhancement. CONCLUSIONS: In MRI evaluation of the herniated disk, peri-hernial enhancement is correlated with inflammatory reaction around the hernia which is associated with acute symptoms. The absence of peri-hernial enhancement in chronic herniated disk is due to the poorly vascular fibrotic tissue. Therefore, peri-hernial enhancement facilitates the differential diagnosis in uncertain cases and represents a reliable prognostic index of response to non-surgical therapy and of the possible spontaneous resorption of discal hernia.     

Masticator space abnormalities associated with mandibular osteoradionecrosis: MR and CT findings in five patients

BACKGROUND AND PURPOSE: Imaging of patients with a clinical diagnosis of mandibular osteoradionecrosis (ORN) is often performed to support that clinical suspicion, evaluate the extent of the disease, or exclude coexistent tumor recurrence. The purpose of our study was to describe the clinical, MR imaging, and CT features of five patients with mandibular ORN associated with prominent soft-tissue abnormality in the adjacent masticator muscles. METHODS: The MR and CT examinations of five patients with mandibular ORN associated with soft-tissue abnormalities in the adjacent masticator muscles were reviewed. All patients had received external beam radiotherapy for primary head and neck malignancies, with a total radiation dose range of 60 Gy to 69 Gy in 30 to 38 fractions. RESULTS: CT revealed the typical osseous findings of cortical disruption, trabecular disorganization, and fragmentation in all five patients. Abnormal diffuse enhancement of the adjacent masseter and pterygoid muscles was noted in all patients. Four patients had prominent mass-like thickening of these muscles adjacent to the osseous abnormality. Of the three patients who underwent MR imaging, all showed homogeneous abnormal T1 hypointensity, T2 hyperintensity, and intense enhancement of the bone marrow in the involved mandible. The masticator muscles adjacent to the osseous abnormality also showed abnormal T2 hyperintensity and intense diffuse enhancement on MR images. CONCLUSION: Mandibular ORN can be associated with prominent soft-tissue thickening and enhancement in the adjacent musculature. These changes can appear mass-like and are not related to tumor recurrence or metastatic disease.     

The value of ultrasound and aspiration in differentiating vaso-occlusive crisis and osteomyelitis in sickle cell disease patients.

We have studied 50 patients with sickle cell disease who presented with musculoskeletal pain over a 2-year period to assess the use of ultrasound in differentiating infection from infarction. All the patients were evaluated by ultrasound. Five had soft tissue oedema and no fluid collection adjacent to the bone. Forty-five had a subperiosteal fluid collection. Twelve patients whose collections were not aspirated were diagnosed according to clinical evaluation. The remaining 33 patients underwent aspiration under ultrasound guidance to distinguish between an infection and infarction. Twenty-three of these were diagnosed as osteomyelitis and 10 as vaso-occlusive crises. In 21 out of the 23 infected cases, the fluid collection was greater than 10 mm at its thickest point perpendicular to the bone surface and all those with infarction had fluid less than 10 mm thickness. Aspiration under ultrasound guidance is a useful method to differentiate the two clinical entities. In patients suffering from osteomyelitis, identification of the organisms guides antibiotic administration. Needle decompression can help to relieve pain in osteomyelitis and vaso-occlusive crisis.     

骨外周性原始神经外胚层瘤的影像学表现

目的探讨骨外周性原始神经外胚层瘤(pPNETs)的临床和影像学表现。方法分析10例骨pPNETs的临床和X线、CT及MR影像资料。结果pPNETs多以局部疼痛(9例)伴肿块(7例)为主诉。X线示溶骨性骨质破坏8例，伴有不规则硬化和轻度膨胀的溶骨性骨质破坏1例，未见异常1例；7例见软组织肿块；均未见骨膜反应。7例CT扫描中，边界不清的溶骨性骨质破坏6例。伴有不规则硬化和轻度膨胀的溶骨性骨质破坏1例，均有软组织肿块形成，2例伴有细小的点状钙化，均未见骨膜反应；10例MR扫描中，9例在T1WI呈等信号，1例呈中等偏高信号；在T2WI和短时反转恢复(STIR)序列，8例呈不均匀中、高信号，2例呈均匀高信号；均见明显软组织肿块形成；4个疗程化疗以后，肿瘤有明显缩小。结论骨pPNETs以溶骨性骨质破坏伴明显的软组织肿块、无骨膜反应为主要表现，缺乏特征性，但影像学检查有助于了解病变的范围、治疗措施的制定和治疗效果的评价。     

Magnetic resonance imaging features of allografts

Objective. To investigate the magnetic resonance imaging (MRI) features of allografts at various time intervals after surgery in patients with osteoarticular allografts. Design and patients. Sixteen patients who were treated with osteoarticular allografts and who were followed over time with MRI studies as part of their long-term follow-up were retrospectively selected for this study. T1-weighted images were obtained both before and after gadolinium administration along with T2-weighted images. All images were reviewed by an experienced musculoseletal radiologist, with two other experienced radiologists used for consultation. Imaging studies were organized into three groups for ease of discussion: early postoperative period (2 days to 2 months), intermediate postoperative period (3 months to 2 years), and late postoperative period (greater than 2 years). Results. In the early postoperative period, no gadolinium enhancement of the allograft was visible in any of the MR images. A linear, thin layer of periosteal and endosteal tissue enhancement along the margin of the allograft was visible in images obtained at 3–4 months. This enhancement apeared gradually to increase in images from later periods, and appears to have stabilized in the images obtained approximately 2–3 years after allograft placement. The endosteal enhancement diminished after several years, with examinations conducted between 6 and 8 years following surgery showing minimal endosteal enhancement. However, focal enhancement was noted adjacent to areas of pressure erosion or degenerative cysts. All the cases showed inhomogeneity in the marrow signal (scattered low signal foci on T1 with corresponding bright signal on T2), and a diffuse, inhomogeneous marrow enhancement later on. Conclusion. We have characterized the basic MRI features of osteoarticular allografts in 16 patients who underwent imaging studies at various time points as part of routine follow-up. We believe that the endosteal and periosteal enhancement observed on MRI during the first few months to 2 years following surgery represents vascular ingrowth and early skeletal repair. The zone of periosteal enhancement could also include the new bone laid on the surface of the allograft through which the soft tissues bind to the cortex. The exact reason for the inhomogeneity in the marrow signal, and the diffuse, inhomogeneous marrow enhancement is not clear. This may represent saponified and/or necrotic marrow fat interspersed with the fibrovascular tissue. The features noted here should provide radiologists with useful information regarding imaging characteristics they can expect to see in other allograft replacement patients. Received: 14 August 1998 Revision requested: 23 October 1998 Revision received: 2 February 1999 Accepted: 22 February 1999     

Usefulness of selective partial inversion recover (SPIR) sequences in optic nerve diseases]

PURPOSE: To evaluate the yield of SPIR sequences with fat suppression in the diagnosis of optic nerve lesions. MATERIAL AND METHODS: Ten patients with suspected optic nerve involvement on the basis of clinical data and abnormalities of visual evoked potentials were examined. MRI was performed with a 1.5 T unit (Philips NT 15) using T1 weighted conventional spin-echo and T1- and T2 weighted SPIR sequences with fat suppression. Axial images were obtained along the optic nerve course, while coronal images throughout the optic nerve axis; slices were 3 mm thick. Axial T2 weighted SPIR sequences were also performed with the volumetric technique (1.5 mm thickness); coronal and parasagittal reconstructions along the nerve axis were obtained too. After paramagnetic contrast medium injection, conventional T1 weighted and SPIR sequences were performed on axial and coronal planes. RESULTS: Optic nerve lesions consistent with the diagnosis of neuritis were demonstrated with T2 weighted images in 4 of 10 patients. No abnormalities and/or nerve enlargement were found on T1 weighted images. An enhancement area was seen after contrast medium injection in only one case. MRI showed a pilocytic astrocytoma in one patient and selective atrophy of the right optic nerve in another. MRI showed normal findings in 4 patients. CONCLUSIONS: T1 and T2 weighted fat-suppressed SPIR imaging of the optic nerve improves anatomical definition, lesion detection and characterization in optic nerve conditions.