Comparison of MR imaging with PET and ictal SPECT in 118 patients with intractable epilepsy.

BACKGROUND AND PURPOSE: MR imaging, PET, and ictal SPECT have been studied extensively as individual techniques in the localization of epileptogenic foci, but only a few comparative studies have been done. We evaluated the concordance rates of ictal video/EEG, MR imaging, PET, and ictal SPECT to compare the sensitivities of these imaging methods in the lateralization of epileptogenic foci. METHODS: The study included 118 consecutive patients who underwent surgery for medically intractable epilepsy and who were followed up for 12 months or more. MR imaging was compared retrospectively with ictal video/EEG, FDG-PET, ictal 99mTc-HMPAO SPECT, and invasive EEG as to their ability to localize the epileptogenic focus; the pathologic findings served as the standard of reference. RESULTS: MR imaging was concordant with video/EEG, PET, and ictal SPECT in 58%, 68%, and 58% of patients, respectively. With the pathologic diagnosis as the standard of reference, MR imaging, PET, and ictal SPECT correctly lateralized the lesion in 72%, 85%, and 73% of patients, respectively. Of the patients with good outcomes, MR imaging, PET, and ictal SPECT were correct in 77%, 86%, and 78%, respectively. In the good outcome group, MR imaging was concordant with PET and ictal SPECT in 73% and 62% of patients, respectively. Of 45 patients who underwent invasive EEG, MR imaging was concordant with the invasive study in 47%; PET in 58%; and ictal SPECT in 56%. Of 26 patients with normal MR findings, PET and ictal SPECT correctly lateralized the lesion in 80% and 55%, respectively. CONCLUSION: Overall concordance among the techniques is approximately two thirds or less in lateralizing epileptogenic foci. PET is the most sensitive, even though it provides a broad approximate nature of the epileptogenic zone, which is not adequate for precise surgical localization of epilepsy. PET and/or ictal SPECT may be used as complementary tools in cases of inconclusive lateralization with ictal video/EEG and MR imaging.     

Bone marrow edema and associated pain in early stage osteonecrosis of the femoral head: prospective study with serial MR images

PURPOSE: To determine the accuracy of magnetic resonance (MR) cholangiography for demonstration of the biliary tract and detection of biliary complications in patients who have undergone orthotopic liver transplantation. MATERIALS AND METHODS: Breath-hold half-Fourier rapid acquisition with relaxation enhancement MR cholangiography was performed in 25 patients who had undergone orthotopic liver transplantation. MR cholangiograms were prospectively and independently interpreted by two radiologists for depiction of the biliary tract and ductal anastomosis and for complications (eg, biliary dilatation, stricture, stones). MR cholangiographic findings were correlated with findings from direct cholangiography (n = 24) and surgery (n = 1). RESULTS: MR cholangiography completely demonstrated first-order intrahepatic bile ducts in 23 (92%) patients, the donor extrahepatic bile duct in 25 (100%), the recipient extrahepatic bile duct in 17 of 18 (94%), and the anastomosis in 24 (96%). The sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of MR cholangiography for detection of biliary dilatation and stricture were each 100%. Complete interobserver agreement occurred in the detection of biliary dilatation and stricture. The sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of MR cholangiography for detection of stones were 100% for one radiologist and 86%, 100%, 96%, 100%, and 95%, respectively, for the other. Both radiologists agreed on the diagnosis of bile duct stones in six of seven cases (kappa = 0.90). CONCLUSION: MR cholangiography enables accurate depiction of the biliary tract and detection of biliary complications in patients with an orthotopic liver transplant.     

Diffusion-weighted single-shot echoplanar MR imaging for liver disease.

OBJECTIVE: The aims of this study were to determine apparent diffusion coefficients (ADCs) of the abdominal organs and liver lesions, to determine the effect of the magnitude of b values on the ADCs, and to determine whether measured ADCs of liver tumors help differentiate benign from malignant lesions. SUBJECTS AND METHODS: Six healthy volunteers and 126 patients were examined with diffusion-weighted single-shot echo-planar imaging using multiple b values (maximum, 846 sec/mm2). The ADCs of the liver, spleen, kidney, 49 malignant liver lesions (33 hepatocellular carcinomas, 15 metastatic liver tumors, and one cholangiocellular carcinoma), and 30 benign lesions (17 cysts, 12 hemangiomas, and one angiomyolipoma) were calculated. RESULTS: The ADCs of the abdominal organs and liver lesions showed smaller values when calculated with the greater maximum b values. The ADCs of the benign lesions calculated with all the b values of less than 850 sec/mm2 (2.49+/-1.39 x 10(-3) mm2/sec) were significantly (p = .0024) greater than those of the malignant lesions (1.01+/-0.38 x 10(-3) mm2/sec). When the maximum b value is 846 sec/mm2, use of a threshold ADC of 1.6 x 10(-3) mm2/sec would result in a sensitivity of 98% and a specificity of 80% for differentiation of malignant liver lesions from benign lesions. CONCLUSION. Measurement of ADC has good potential for characterizing liver lesions, but the calculated ADCs could be affected by the magnitude of the maximum b value.     

Takayasu arteritis: diagnosis with MR imaging and MR angiography in acute and chronic active stages.

Early diagnosis and treatment of Takayasu arteritis is important in prevention of serious complications. Spin-echo magnetic resonance imaging (MRI) can depict early wall thickening of the aorta and cine MRI can evaluate aortic valve function. Significant enhancement in and around the aorta and carotid arteries is observed on postcontrast MR images in acute phase Takayasu arteritis. In the chronic phase, contrast enhancement in the aortic wall stronger than in the myocardium suggests activity of the disease. Breath-hold contrast-enhanced three-dimensional MR angiography is very effective in noninvasive evaluation of luminal change of aortitis. Contrast-enhanced MRI and MR angiography have an important role in early diagnosis, activity determination, and follow-up of Takayasu arteritis. MRI and MR angiography can be utilized for initial diagnosis of Takayasu arteritis and replace catheterization angiography. J. Magn. Reson. Imaging 1999;10:751-757.     

Unusual gastric tumors: radiologic-pathologic correlation.

The overlap of radiologic findings in many gastric tumors makes differentiation difficult. However, some unusual gastric tumors have characteristic radiologic features that may suggest a specific diagnosis. At barium study, lipomas typically manifest as a smooth submucosal mass or an ulcerated lesion with a "bull's-eye" appearance that is indistinguishable from other mesenchymal tumors. At computed tomography (CT), lipomas usually manifest as well-circumscribed submucosal masses with fat attenuation. At radiology, glomus tumors appear as smooth submucosal masses with or without ulceration and may contain tiny flecks of calcification. These tumors frequently demonstrate strong enhancement on early-phase contrast material-enhanced images. At barium study, lymphangiomas may appear as smooth intramural masses that are indistinguishable from other mesenchymal tumors. At CT, they manifest as non-enhancing extramucosal masses with homogeneous low attenuation. Diffuse lesions in Brunner gland hamartoma manifest as multiple small nodules, producing a characteristic "cobblestone" appearance. Lymphomas may have typical imaging features (eg, more pronounced and homogeneous mural thickening) that can help differentiate them from adenocarcinoma. In addition, adenocarcinomas may demonstrate unusual findings such as transpyloric spread, unusually large polyps, or intratumoral calcifications. Familiarity with these radiologic features of gastric tumors can help ensure correct diagnosis and proper management.     

Colorectal mucinous carcinoma: findings on MRI

PURPOSE: The purpose of this work was to define the characteristic MR features of colorectal mucinous carcinomas and to correlate the mucin pool with the signal intensity of this tumor. METHOD: MRI of 12 cases of pathologically proven colorectal carcinoma containing mucin was evaluated. We analyzed the signal intensity of tumor on T1- and T2-weighted MR images and correlated the area of intratumoral high signal intensity on T2-weighted images with the mucinous pool on the pathologic specimens. Two radiologists independently estimated the area of high signal intensity in the tumor on T2-weighted images and one pathologist estimated the amount of mucinous pool in the pathologic specimen. RESULTS: In 9 (75%) of 12 cases, focal or diffuse high signal intensity areas were detected on T2-weighted fast spin echo images. In seven cases in which mucin pools were seen macroscopically, partial (n = 3) or diffuse high signal intensity areas were noted on the T2-weighted images. Among the five cases in which microscopic mucinous pools were detected on the pathologic slides, three cases showed no high signal foci on MR images, and in the remaining two cases, high signal intensity areas were noted as small foci. CONCLUSION: Intratumoral high signal intensity on T2-weighted fast spin echo MR images occurs in mucinous carcinomas and correlates with the mucin pools on pathologic specimens.     

CT features of systemic lupus erythematosus in patients with acute abdominal pain: emphasis on ischemic bowel disease

PURPOSE: To evaluate the computed tomographic (CT) features of systemic lupus erythematosus (SLE) in patients with acute abdominal pain. Special emphasis was placed on the analysis of ischemic bowel disease. MATERIALS AND METHODS: The authors retrospectively reviewed the images from 39 abdominal CT examinations performed in 33 patients with SLE and acute abdominal pain. Images were evaluated for bowel wall changes, mesenteric changes, fluid collection, retroperitoneal lymphadenopathy, peritoneal enhancement, and hepatomegaly as well as for changes in other abdominal organs. Ischemic bowel disease was diagnosed if at least three of the following signs were seen: bowel wall thickening, target sign, dilatation of intestinal segments, engorgement of mesenteric vessels, and increased attenuation of mesenteric fat. RESULTS: Thirty-one (79%) of the 39 examinations had CT findings diagnostic of ischemic bowel disease, including symmetric bowel wall thickening (n = 29), target sign (n = 26), and mesenteric vascular engorgement and haziness (n = 31). In 24 cases, bowel wall thickening was multifocal, with variable length, and did not appear to be confined to a single vascular territory. CONCLUSION: The most common CT finding in patients with SLE and acute abdominal pain is ischemic bowel disease. CT is useful for detecting the primary cause of gastrointestinal symptoms, planning treatment, and monitoring for infarction or perforation.     

Laparoscopic resection of retroperitoneal benign schwannoma

Schwannomas are particularly rare neoplasms among tumors of the retroperitoneal space. Only 0.3-3.2% of benign schwannomas are found in retroperitoneal locations. As these tumors are usually asymptomatic and discovered by chance or in the course of the evaluation of an unrelated health problem, they may cause the delay of early diagnosis and treatment. With recent advances in the field of minimally invasive surgery, several laparoscopic approaches to retroperitoneal schwannomas have been reported. In this paper, we present the case of a 59-year-old female patient with an asymptomatic retroperitoneal mass that was found during a regular medical checkup. The mass was located between the inferior vena cava (IVC) and aorta under the pancreaticoduodenal unit (site of lymph node 16b1), compressing the IVC. She underwent successful laparoscopic surgery for retroperitoneal schwannoma. In addition, we summarized the literature on cases regarding the laparoscopic management of the retroperitoneal schwannoma.     

Analysis of anatomical variations of bone and vascular structures around the posterior atlantal arch using three-dimensional computed tomography angiography

OBJECT: The current study evaluates the incidence of anatomical variations of the V(3) segment of the vertebral artery (VA) and the posterior arch of the atlas (C-1). Failure to appreciate these types of anatomical variations can cause catastrophic injury to the VA during posterior approaches to the upper cervical spine. METHODS: In the present study, the authors analyzed the records of 1013 Korean patients who underwent computed tomography (CT) angiography to evaluate the incidence of anomalous variations in the third segment of the VA and to determine the incidence and morphometric characteristics of any detected posterior ponticuli. The authors also hoped to determine any specific imaging features that might indicate a VA anomaly around the craniovertebral junction. RESULTS: The mean age of the patients was approximately 55.7 years and the prevalence of a posterior ponticulus was 15.6%. The incidence rate of a posterior ponticulus in the male population was 19.3%, whereas in the female population it was 12.8%. The incomplete type of posterior ponticulus was more common than the complete type. The mean age of the patients with an incomplete posterior ponticulus (55.7 years) was significantly younger (p = 0.018) than the mean age of patients with a complete posterior ponticulus (57.6 years). The incidence rate of a persistent first inter-segmental artery was 4.7% and the incidence rate of a fenestrated VA was 0.6%. The area of the C-1 transverse foramen on the abnormal side was significantly smaller than that of the contralateral normal side. CONCLUSIONS: The shape of the C-1 posterior arch and the third segment of the VA are heterogeneous. Therefore, preoperative radiological studies should be performed to identify any anatomical variations. Using preoperative 3D CT angiography, we can precisely identify an anomalous VA and significantly reduce the risk of VA injury.     

Tear size and location impacts false lumen pressure in an ex vivo model of chronic type B aortic dissection

BACKGROUND: Follow-up mortality is high in patients with type B aortic dissection (TB-AD) approaching one in four patients at 3 years. A predictor of increased mortality is partial thrombosis of the false lumen which may occlude distal tears. The hemodynamic consequences of differing tear size, location, and patency within the false lumen is largely unknown. We examined the impact of intimal tear size, tear number, and location on false lumen pressure. METHODS: In an ex-vivo model of chronic type B aortic dissection connected to a pulsatile pump, simultaneous pressures were measured within the true and false lumen. Experiments were performed in different dissection models with tear sizes of 6.4 mm and 3.2 mm in the following configurations; model A: proximal and distal tear simulating the most common hemodynamic state in patients with TB-AD; model B: proximal tear only simulating patients with partial thrombosis and occlusion of distal tear; and model C: distal tear only simulating patients sealed proximally via a stent graft with persistent distal communication. To compare false lumen diastolic pressure between models, a false lumen pressure index (FPI%) was calculated for all simulations as FPI% = (false lumen diastolic pressure/true lumen diastolic pressure) x 100. RESULTS: In model A, the systolic pressure was slightly lower in the false lumen compared with the true lumen while the diastolic pressure (DP) was slightly higher in the false lumen (DP 66.45 +/- 0.16 mm Hg vs 66.20 +/- 0.12 mm Hg, P < .001, FPI% = 100.4%). In the absence of a distal tear (model B), diastolic pressure was elevated within the false lumen compared with the true lumen (58.95 +/- 0.10 vs 54.66 +/- 0.17, P < .001, FPI% = 107.9%). The absence of a proximal tear in the presence of a distal tear (model C) diastolic pressure was also elevated within the false lumen versus the true lumen (58.72 +/- 0.24 vs 56.15 +/- 0.16, P < .001, FPI% 104.6%). The difference in diastolic pressure was greatest with a smaller tear (3.2 mm) in model B. In model B, DBP increased by 13.9% (P < .001, R(2) 0.69) per 10 beat per minute increase in heart rate (P < .001) independent of systolic pressure. CONCLUSIONS: In this model of chronic type B aortic dissection, diastolic false lumen pressure was the highest in the setting of smaller proximal tear size and the lack of a distal tear. These determinants of inflow and outflow may impact false lumen expansion and rupture during the follow-up period.