JBR 2011-5 by office

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WETTEREN 1

P 702083

Volume 94 Page 229-308

September-October Bimonthly

–

2011

DIAGNOSTIC AND INTERVENTIONAL IMAGING, RELATED IMAGING SCIENCES, AND CONTINUING EDUCATION

ORGANE DE LA SOCIETE ROYALE BELGE DE RADIOLOGIE (SRBR) ORGAAN VAN DE KONINKLIJKE BELGISCHE VERENIGING VOOR RADIOLOGIE (KBVR)

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Subscribers’ information The JBR-BTR is published 6 times a year. Subscription of members of the Belgian Society of Radiology are included in membership dues and are handled by the Society. Non-members’ subscriptions are available from the ARSMB-KVBMG. The rate is valid to date and can be amended without notice according to fluctuation of printing and material costs. Annual subscriptions or single issue orders should be made promptly. The publishers cannot guarantee supply of back issues. Change of address must be notified 60 days in advance. RATES: Annual Belgium 150 € Other Countries 175 € All amounts are net and include postal and handling charges.

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You are kindly invited to address all your correspondence to Mrs A. Hirsch and execute all payments to ARSMBKVBMG (see below).

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Webaddress: http://www.ulb.ac.be/medecine/loce/amb.htm E-mail: jbr-btr@skynet.be Bank Account: Post Office Account Fortis: 210-0251210-32 Giro: 000-0273502-59 IBAN: BE 90210025121032 IBAN: BE 84000027350259 BIC: GE BABEBB36A BIC: BPOTBEB1

01-JBR-contents-11-5_Opmaak 1 7/10/11 09:05 Pagina 1

JBR-BTR ♦ 94/5 ♦ 2011 Journal Belge de ♦ Belgisch Tijdschrift voor ♦ RADIOLOGIE

Founded in 1907 A bimonthly journal devoted to diagnostic and interventional imaging, related imaging sciences, and continuing education Contents

REVIEW ARTICLES Mesenteric panniculitis. Part 1: MDCT - pictorial review B. Coulier . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 229 Mesenteric panniculitis. Part 2: prevalence and natural course: MDCT prospective study B. Coulier . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 241 MR imaging findings of lesions involving cartilage and bone in the paediatric knee: a pictorial review. L.B.O. Jans, J.L. Jaremko, M. Ditchfield, K.L. Verstraete . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 247 Dental cone beam CT and its justified use in oral health care. R. Jacobs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 254 Dialysis arteriovenous fistulas: the critical role of color doppler ultrasound. N. Verbeeck, F. Prospert, D. McIntyre, S. Lamy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 266

ORIGINAL ARTICLES Comparison of combined oral and IV contrast-enhanced versus single IV contrast-enhanced MDCT for the detection of acute appendicitis. K. Hekimoglu, U.M. Yildirim, E. Karabulut, M. Coskun . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 278 Imaging features of aggressive fibromatosis in psoas muscle W. Ya-Rong, W. Wei, Z. Jia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 283 Duodenal metastasis of alveolar soft part sarcoma I. Willekens, C. Paradisi, L. Sarria, A. Puertas, J. Pac, E. Mayayo . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 287 Tolosa-Hunt syndrome in children. D.E. Benzohra, N. Damry, I. Delpierre, S. Huybrechts, A. Monier, C. Christophe . . . . . . . . . . . . . . . . . . . . . . . . . 290 MRI findings in giant pontine capillary telangiectasis associated with a developmental venous anomaly. H.N. Ozcan, S. Avcu, J. De Bleecker, M. Lemmerling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 293 Ectopic gastric pancreatitis: unusual cause of epigastric pain. T. De Beule, L. Ardies, L. Van Hoe, P. D’Haenens, P. Vanhoenacker . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 295

IMAGES IN CLINICAL RADIOLOGY The Macaroni sign. M. Apaydin, M. Varer, G. Sezgin, U. Yetkin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 297 Prenatal MRI of an esophageal duplication cyst with polyhydramnios and right pleural effusion. L. Yu-Peng, L. Yi-Lan, S. Wen-Ko . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 298 Cesarean scar pregnancy: MRI features. J. Marrannes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 299 Diverticulum of the bladder simulating ovarian cyst: pitfalls in the differential diagnosis. A.J. Kruse, F.C.H. Bakers, R.F.P.M. Kruitwagen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 300 Sinus venosus ASD. K. Boeren, Y. De Bruecker, J. Roosen, D. Perdieus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 301 Melorheostosis of the foot. J. De Cock, K. Mermuys, S. Van Petegem, B. Houthoofd, K. Van De Moortele, K. Vanslambrouck . . . . . . . . . . . 302

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Abstract of papers for full membership at the Royal Belgian Society of Radiology . . . . . . . . . . . . . . . . . . . . . . . . 303 Indications for embolisation with the Amplatzer®Vascular Plug 4. C. Kenis, M. Camerlinck, T. Van der Zijden, J. Maes, O. D’Archambeau Postgraduaat radiologie van de Vlaamse Universiteiten. Programma 2011-2012 . . . . . . . . . . . . . . . . . . . . . . . . . . . 303 PROCARE newsletter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 304 Classified service: Institut Jean-Godinot (Reims) recruits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 304 Forthcoming Courses and Meetings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 305 Grants of the RBRS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 306 Instructions to Authors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Subscribers information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Advertising index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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The terms used for indexation of subjects were developed by the Radiological Society of North America (RSNA) over a period of years. Their use here is by permission of the RSNA. The terms may not be used in any other index, print or electronic, except by specific permission of RSNA. ◆◆ Indexed in Index Medicus and in Zentralblatt Radiologie. Evaluated for Medline User, EMBASE and CANCERNET. Abstracted in Excerpta Medica Journals. ◆

...work together in perfect

distributedÂ by

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Editor: J. Pringot

Royal Belgian Society of Radiology: Http://www.rbrs.org

Managing Editor: P. Seynaeve

President: B. Desprechins Vice-presidents: J.F. De Wispelaere, R. Hermans

Editorial Board: B. Appel, F. Avni, P. Beeckman, L. Breysem,N. Buls, P. Clapuyt, B. Coulier, B. Daenen, E. Danse,H. Degryse, P. Demaerel, B. Ghaye, J. Gielen, P. Habibollahi, N. Hottat, M. Laureys, F. Lecouvet, M. Lemmerling, B. Lubicz, J.F. Monville, T. Mulkens, J.F. Nisolle, B. Op de Beeck, R. Oyen, S. Pans, V.P. Parashar (USA), P. Parizel, P. Peene, H. Rigauts, N. Sadeghi, S. Sintzoff Jr, M. Smet, A. Snoeckx, J. Struyven, H. Thierens, P. Van Dyck, F. Vanhoenacker, Ph. Van Hover, J. Verschakelen, K. Verstraete.

Past-President: M. Lemort General Secretaries: F. Avni, J. Verschakelen Executive Secretaries: D. Henroteaux, M. Spinhoven Treasurers: D. Brisbois, A. Van Steen Coordinators of continuing education: E. Coche, G. Villeirs Coordinators of professional defence: C. Delcour, D. Bielen Webmasters: J. de Mey, J. Struyven

Sections of the Royal Belgian Radiological Society (SRBR-KBVR): Abdominal and digestive imaging

B. Op de Beeck, E. Danse

Bone and joints

P. Van Dyck, J.F. Nisolle

Breast imaging

C. Van der Merckt, A. Van Steen

Cardiac imaging

R. Salgado, O. Ghekière

Cardiovascular and interventional radiology

G. Maleux, M. Laureys

Chest radiology

B. Ghaye, W. De Wever

Head and neck radiology

J. Widelec, R. Hermans

Neuroradiology

P. Demaerel, N. Sadeghi

Pediatric radiology

B. Desprechins, L. Rausin

For addresses and particulars, see website at http://www.rbrs.org

Instructions to authors The purpose of The Belgian Journal of Radio logy is the publication of articles dealing with diagnostic radiology and related imaging techniques, therapeutic radiology, allied sciences and continuing education. All — new and revised — manuscripts and correspondence should be addressed to JBR-BTR Edito rial Office, Avenue W. Churchill 11/30, B-1180 Bruxelles, tel.: 02-374 25 55, fax: 32-2-374 96 28. Please note that the following instructions are based on the “Uniform Requirements for manuscripts Submitted to Biomedical Journals” adopted by the International Committee of Medical Journal Editors (Radiology, 1980,135: 239-243). It should however be noted that presentation modifications may be introduced by the Editorial Office in order to conform with the JBR-BTR personal style. Authors should specify to which of the following headings their manuscript is intended: Original Article, Review Article, Case Report, Pictorial Essay, Continuing Education, Technical Note, Book Review, Opinion, Letter to the Editor, Comment, Meeting News, in Memoriam, News. Authors should consider the following remarks and submit their manuscripts accordingly. All articles must contain substantive and specific scientific material. – Original articles are articles dealing with one specific area of Radiology or allied science related through the personal experience of the author. – Review articles are special articles reporting the experience of the author considered in

–

the general perspective of the literature over the topic. Case reports are short descriptions of a particular case providing a message directly linked to an individuel patient investigated. No more than one case should be described in detail and clinical description should be kept to a minimum. Case reports should invest the usual headings of articles but should focus on the particular radiologic procedure that contributed to the diagnosis. References should be present, though limited in number. Tables and acknowledgements are usually omitted. Pictorial essays are articles presenting information through illustrations and legends. The presentation remarks stated in the paragraph dealing with case reports apply to pictorial essays. Continuing education articles are designed in accordance with the general guidelines for articles published in the JBR-BTR in particular they are divided into introduction, material and methods, results, discussion, references, and are provided with an abstract. However, papers addressing the continuing education may have only additionnally to their contents an introduction (stating the aim of the article and providing any background information useful to understand why the topic is relevant, and describing the subtopics covered by the study), references, and an abstract. Tables should be limited to a maximum of one table per 6 pages of manuscript. Illustrations should also be limited to a maximum of one illustration (1010 cm)

(possibly made up of different parts) per 3 pages of manuscript. All the material should be made available to the JBR- BTR editorial office (2 copies of the manuscript with 2 sets of illustrations) with the corresponding diskette though there will not be peer review. – Images in Clinical Radiology are short (max. 1 typed page) case reports designed to illustrate with max. 3 figures a specific entity. The report should not include abstract nor discussion nor references but consist of a synthetic description of the clinical and radiological features as well as the final diagnosis. Technical notes are short descriptions of a specific technique, procedure or equipment of interest to radiologists. Technical notes may originate from radiologists having experience of the item presented or from commercial firms (these should contact the Editorial Office to obtain specific guidelines for publication). The manuscript length should be inferior to 1 typed page, original language should be English, the manuscript may be accompanied by maximum 1 b/w figure, and include one major reference. – Book reviews should be limited to one typed page, mention full references of the book, including number of pages, of illustrations (when available), and price. The author should specify to whom the book is intended and give a personal appreciation. They will be published with the initial letters of the signature.

(continued on JBR-BTR 2011, 94-4: p. VI)

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• The recommended dose of MultiHance® injection in adult patients is 0.1 mmol/kg body weight. This corresponds to 0.2 mL/kg of the 0.5 M solution.(1)

Reference: 1. Multihance Spc Please consult locally approved information.

1. NAAM VAN HET GENEESMIDDEL: MultiHance, 0.5 M oplossing voor injectie. 2. KWALITATIEVE EN KWANTITATIEVE SAMENSTELLING: 1 ml oplossing voor injectie bevat: 334 mg gadobeenzuur (0,5 M) als het dimeglumine-zout [gadobeendimeglumine 529 mg = gadobeenzuur 334 mg + meglumine 195 mg]. Voor hulpstoffen, zie 6.1. 3. FARMACEUTISCHE VORM: Oplossing voor injectie. Heldere waterige oplossing, afgevuld in kleurloze glazen flacons. Osmolaliteit bij 37 ºC: 1,97 osmol/kg. Viscositeit bij 37 ºC: 5,3 mPa.s. 4. KLINISCHE GEGEVENS: Therapeutische indicaties: Dit geneesmiddel is uitsluitend bestemd voor diagnostisch gebruik. MultiHance is een paramagnetische contrastvloeistof die wordt gebruikt voor de magnetische resonantie tomografie (MRI) geïndiceerd voor: MRI van de lever voor de detectie van focale leverlaesies bij patiënten met bekende of verdachte primaire leverkanker (b.v. hepatocellulair carcinoom) of metastasen. MRI van de hersenen en het ruggenmerg, waar het de detectie van laesies verbetert en aanvullende diagnostische informatie kan geven op de informatie uit de niet contrast-versterkte MRI. Contrastversterkte MR-angiografie (MRA) bij patiënten met verdachte of bekende vasculaire ziekten van de abdominale of perifere arteriën. Dosering en wijze van toediening: MRI van de lever: de aanbevolen dosis MultiHance bij volwassenen bedraagt 0,05 mmol/kg lichaamsgewicht, hetgeen overeenkomt met 0,1 ml/kg van de 0,5 M oplossing. MRI van de hersenen en het ruggenmerg: de aanbevolen dosis MultiHance bij volwassenen is 0,1 mmol/kg lichaamsgewicht hetgeen overeenkomt met 0,2 ml/kg van de 0,5 M oplossing. MRA: de aanbevolen dosis MultiHance bij volwassenen is 0,1 mmol/kg lichaamsgewicht hetgeen overeenkomt met 0,2 ml/kg van de 0,5 M oplossing. MultiHance moet onmiddellijk voor het gebruik in de injectiespuit worden opgezogen en mag niet worden verdund. Eventuele ongebruikte restanten contrastvloeistof moeten worden vernietigd, en mogen niet worden gebruikt voor ander MRI onderzoek. Om de mogelijke risico’s van extravasatie van MultiHance in het spierweefsel te voorkomen dient men erop toe te zien dat de i.v. naald of canule zorgvuldig in de vena wordt aangebracht. Lever en hersenen en ruggenmerg: de oplossing dient intraveneus te worden toegediend als bolus of als langzame injectie (10 ml/min.). MRA: de oplossing dient intraveneus als een bolus injectie te worden toegediend, handmatig of gebruikmakend van een automatisch injecteersysteem. Na de injectie dient een spoeling met fysiologische zoutoplossing plaats te vinden. Post-contrast tomogrammen acquisitie: Lever

Dynamische tomografie:

Onmiddellijk na een bolus injectie.

Vertraagde tomografie:

Tussen de 40 en 120 minuten na de injectie, afhankelijk van de individuele tomografische behoefte.

1. DENOMINATION: MultiHance 0,5 mmol/ml solution injectable. 2. COMPOSITION QUALITATIVE ET QUANTITATIVE: MultiHance 0,5 mmol/ml solution injectable. COMPOSITION QUALITATIVE ET QUANTITATIVE : 1 mL de solution contient : acide gadobénique 334 mg (0,5 M) sous forme de sel de diméglumine. [529 mg de gadobénate de diméglumine = 334 mg d’acide gadobénique + 195 mg de dimglumine]. Pour les excipients, cf. 6.1. 3. FORME PHARMACEUTIQUE: Solution injectable. Solution aqueuse limpide, incolore, remplie dans des flacons de verre incolore. Osmolalité à 37°C : 1,970 Osmol/kg. Viscosité à 37°C : 5,3 mPa.s. 4. DONNEES CLINIQUES: Indications thérapeutiques: Ce médicament est à usage diagnostique uniquement. Produit de contraste paramagnétique utilisé dans l’imagerie par résonance magnétique (IRM) et indiqué dans : IRM du foie pour la détection des lésions hépatiques lorsqu’un cancer hépatique secondaire ou primitif (carcinome hépatocellulaire) est suspecté ou connu. IRM du cerveau et de la moelle épinière où il améliore la détection des lésions et apporte des informations diagnostiques supplémentaires comparativement à une IRM sans produit de contraste. Angiographie par résonance magnétique (ARM) où il améliore l’exactitude diagnostique pour la détection de la maladie vasculaire sténo-occlusive cliniquement significative lorsqu’une pathologie vasculaire des artères abdominales ou périphériques est suspectée ou connue. Posologie et mode d’administration: IRM du foie: La dose recommandée chez l’adulte est de 0,05 mmol/kg de poids corporel, soit 0,1 ml/kg de la solution 0,5 M. IRM du système nerveux central: La dose recommandée chez l’adulte est de 0,1 mmol/kg de poids corporel, soit 0,2 ml/kg de la solution 0,5 M. ARM: La dose recommandée chez l’adulte est de 0,1 mmol/kg de poids corporel, soit 0,2 ml/kg de la solution 0,5 M. MultiHance doit être introduit dans la seringue immédiatement avant l’injection et ne doit pas être dilué. Tout reliquat éventuel doit être jeté et ne doit pas être utilisé pour d'autres examens IRM. Pour diminuer le risque d’extravasation de MultiHance dans les tissus mous environnants, il est conseillé de s’assurer de la bonne disposition de l’aiguille ou de la canule dans la veine. Foie et système nerveux central : le produit doit être administré par voie intraveineuse soit en bolus soit en injection lente (10 mL/min). ARM: le produit doit être administré par voie intraveineuse en bolus, soit manuellement soit à l’aide d’un injecteur automatique. L’injection doit être suivie d’un bolus de chlorure de sodium à 0,9%. Acquisition des images post-contraste: Foie

Imagerie dynamique

Immédiatement après l’injection en bolus

Imagerie retardée

Entre 40 et 120 minutes après l’injection (IRM retardée), en fonction du type d’imagerie nécessaire

Hersenen en ruggenmerg

Tot 60 minuten na toediening.

Système nerveux central

Jusqu’à 60 minutes après administration

MRA

Onmiddellijk na toediening, met scan vertraging die op basis van de testbolus of automatische bolus detectie techniek wordt berekend.Indien een automatische contrastdetectie puls-sequentie niet wordt gebruikt voor bolus timing, dan dient een test bolus injectie <2 ml van de oplossing gebruikt te worden om de geschikte scan vertraging te berekenen.

ARM

Immédiatement après l’administration, avec un délai d’acquisition calculé sur la base du bolus test ou par la technique de détection automatique du bolus. Si la détection automatique du contraste en séquence pulsée n’est pas utilisée, alors l’injection d’un bolus test de 2 mL de produit au maximum devra être réalisée pour calculer le timing d’acquisition adéquat.

De veiligheid en de werkzaamheid van MultiHance zijn niet vastgesteld bij patiënten beneden 18 jaar. Het gebruik van MultiHance bij deze patiëntengroep wordt derhalve niet aanbevolen. Contra-indicaties: MultiHance dient niet te worden toegepast bij patiënten met een overgevoeligheid voor één van de bestanddelen. MultiHance mag eveneens niet worden toegepast bij patiënten die eerder allergische reacties of andere bijwerkingen ondervonden ten gevolge van andere gadoliniumchelaten. 5. HOUDER VAN DE VERGUNNING VOOR HET IN DE HANDEL BRENGEN: Bracco Imaging Deutschland GmbH, Max-Stromeyer-Straße 116, 78467 Konstanz, Duitsland. 6. NUMMER VAN DE VERGUNNING VOOR HET IN DE HANDEL BRENGEN: MultiHance 5 ml: BE199963, MultiHance 10 ml: BE199972, MultiHance 15 ml: BE19998, MultiHance 20 ml: BE199997. 7. DATUM VAN EERSTE VERLENING VAN DE VERGUNNING/HERNIEUWING VAN DE VERGUNNING: Datum eerste verlening van de vergunning: 22 juli 1997. Datum laatste renewal: 21 juli 2007. 8. DATUM VAN HERZIENING VAN DE TEKST: Augustus 2008. Goedkeuringsdatum: 09/2008. 9. AFLEVERINGSWIJZE: Geneesmiddel op medisch voorschrift.

La sécurité d’emploi et l’efficacité de MultiHance n’ont pas été établies chez les sujets de moins de 18 ans. Par conséquent, l’utilisation de MultiHance dans cette population n’est pas recommandée. Contre-indications: MultiHance est contre-indiqué chez les patients présentant une hypersensibilité à l’un de ses constituants. MultiHance ne doit pas être utilisé chez les patients ayant des antécédents d’allergie ou d’effet indésirable liés à d’autres chélates de gadolinium. 5. TITULAIRE DE L’AUTORISATION DE LA MISE SUR LE MARCHE: Bracco Imaging Deutschland GmbH Max-Stromeyer-Straße 116, 78467 Konstanz Allemagne. 6. NUMERO(S) D’AUTORISATION DE MISE SUR LE MARCHE: MultiHance 5 ml: BE199963, MultiHance 10 ml: BE199972, MultiHance 15 ml: BE199981, MultiHance 20 ml: BE199997. 7. DATE DE PREMIERE AUTORISATION/DE RENOUVELLEMENT DE L’AUTORISATION: Date de première autorisation: 22 juillet 1997. Date de dernier renouvellement: 21 juillet 2007. 8. DATE DE MISE A JOUR DU TEXTE: Août 2008. Date d’approbation: 09/2008. 9. STATUT LEGAL DE DELIVRANCE: Médicament soumis à préscription médicale.

www.bracco.com

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Iopromide

Ultravist® 300-370 ULTRAVIST® 240/300/370 Forme pharmaceutique: solution injectable et pour perfusion. Indications: Ultravist 240: Renforcement du contraste dans la tomographie computérisée (TC), angiographie numérisée (DSA), urographie intraveineuse, phlébographie des membres, visualisation des cavités corporelles (ex. arthrographie, hystérosalpingographie, fistulographie), à l’exception de la myélographie, de la ventriculographie et de la cisternographie - Ultravist 300: Renforcement du contraste dans la tomographie computérisée (TC), angiographie numérisée (DSA), urographie intraveineuse, phlébographie des membres, vénographie, artériographie, visualisation des cavités corporelles (ex.: arthrographie, hystérosalpingographie, fistulographie), à l’exception de la myélographie, de la ventriculographie et de la cisternographie.- Ultravist 370: Renforcement du contraste dans la tomographie computérisée (TC), angiographie numérisée (DSA), urographie intraveineuse, artériographie et particulièrement l’angiocardiographie, visualisation des cavités corporelles (p.ex. arthrographie, fistulographie), à l’exception de la myélographie, de la ventriculographie et de la cisternographie. Le flacon de 200 ml d’Ultravist 370 est indiqué dans les examens angiographiques qui requièrent des volumes élevés d’un opacifiant à haute teneur en iode, comme p.ex. l’angiocardiographie (y compris la coronarographie sélective et la ventriculo-coronarographie), de même que l’angiographie des gros vaisseaux et l’angiographie au moyen d’un tube à fin foyer. Contre-indications: Hyperthyréose manifeste. Hypersensibilité à l’iopromide ou à un des autres composants. Au cours d’une grossesse ou en cas de phénomènes inflammatoires aigus dans le bassin, on ne doit pas pratiquer d’hystérosalpingographie. La cholangiopancréatographie rétrograde endoscopique est contre-indiquée en cas de pancréatite aiguë. Réactions anaphylactoïdes/hypersensibilité. On a rapporté souvent: léger angioœdème, conjonctivite, toux, prurit, rhinite, éternuements et urticaire. Ces réactions, qui peuvent apparaître indépendamment de la quantité administrée et du mode d’administration, peuvent être des signes précurseurs d’un état de choc débutant. Des bronchospasmes, des spasmes du larynx ou de l’œdème et de l’hypotension peuvent apparaître dans de rares cas. Des réactions d’hypersensibilité peuvent apparaître jusqu’à plusieurs jours après l’administration d’opacifiants iodés. Ces réactions indésirables se manifestent principalement par une réaction cutanée (érythème, prurit, urticaire) mais quelques cas d’œdème respiratoire, d’œdème de Quincke, de bronchospasmes et d’hypotension ont déjà été rapportés également. Glande thyroïde: en cas de thyroïdite auto-immune accompagnée d’euthyroïdie ou d’hyperthyroïdie, ou de goitre nodulaire, les opacifiants iodés peuvent provoquer une hyper- ou hypothyroïdie. Le corps dans son ensemble: des sensations de chaleur et des maux de tête ont été rapportés comme apparaissant souvent. Des malaises, des frissons ou de la transpiration et des réactions vasovagales apparaissent parfois. Dans de rares cas, des modifications de la température corporelle et un gonflement des glandes salivaires sont possibles. Respiration: des troubles passagers de la fréquence respiratoire, une dyspnée et une détresse respiratoire et de la toux apparaissent souvent. L’arrêt respiratoire et l’œdème pulmonaire sont des réactions rares. Cardio-vasculaire: des troubles passagers, d’une certaine importance clinique, de la fréquence cardiaque, de la tension, des troubles du rythme ou de la fonction cardiaque et un arrêt cardiaque sont rares. Des réactions sévères exigeant un traitement d’urgence sont rares et peuvent se manifester sous forme de réaction cardio-vasculaire s’accompagnant d’une vasodilatation périphérique suivie d’hypotension et de tachycardie de réflexe, de dyspnée, d’agitation, de confusion et de cyanose, pouvant éventuellement entraîner une perte de conscience. Des incidents thromboemboliques sévères provoquant un infarctus du myocarde ont été rapportés dans de rares cas. Gastro-intestinal: des nausées et des vomissements sont des réactions apparaissant souvent. Des troubles du goût apparaissent parfois. Une douleur abdominale a été rapportée rarement. Cérébro-vasculaire: l’angiographie cérébrale et d’autres explorations où l’opacifiant atteint le cerveau dans des concentrations élevées par le sang artériel, peuvent s’accompagner de complications neurologiques passagères telles que des vertiges et maux de têtes (rarement), de l’agitation ou de la confusion, de l’amnésie, des troubles de la parole, de la vue ou de l’ouïe, des convulsions, des tremblements, de la parésie/paralysie, de la photophobie, de la cécité passagère, un coma, de la somnolence (rarement). Des incidents thromboemboliques sévères, fatals dans des cas isolés, entraînant une attaque ont été signalés dans de rares cas. Rénal: dans de rares cas, on a signalé un affaiblissement de la fonction rénale ou une insuffisance rénale aiguë. Peau: un léger angio-œdème, une réaction de bouffée de chaleur accompagnée de vasodilatation, de l’urticaire, du prurit et de l’érythème ont été observés souvent. Des réactions cutanées toxiques telles qu’un syndrome mucocutané (ex.: le syndrome de Stevens-Johnson ou de Lyell) peuvent se développer dans de rares cas. Utilisation intratécale : sur base de l’expérience avec les autres produits de contraste non-ioniques, les effets indésirables suivants peuvent se présenter lors d’un usage intratécal en plus des effets de la liste ci-dessus: nerveux, psychiatriques. Neuralogie, meningisme (commun). Paraplégie, psychose, méningite aseptique, variation de l’EEG (rare) - Irritation locale (au site d’injection): une douleur locale se produit principalement en angiographie périphérique. Une extravasation de l’opacifiant, y inclus l’Ultravist, donne lieu à des douleurs locales et de l’œdème mais disparaît généralement sans séquelles. Une inflammation et même une nécrose de la peau ont cependant été constatées dans de très rares cas. Une thrombophlébite et une thrombose veineuse sont rares. Utilisation dans d’autres cavités corporelles: des réactions à la suite de l’administration dans des cavités corporelles sont rares. La plupart se manifestent quelques heures après l’administration en raison d’une absorption lente à partir du site d’administration et une distribution à travers le corps entier, principalement par des processus de diffusion. Après cholangiopancréatographie endoscopique rétrograde, on constate souvent une certaine augmentation des taux d’amylases. On a démontré qu’une opacification des glandes après cholangiopancréatographie endoscopique rétrograde est accompagnée d’un risque accru de pancréatite cholangiopancréatographique rétrograde post-endoscopique. De rares cas de pancréatite nécrosante ont été décrits. Dans le cadre d’une hystérosalpingographie des réactions vasovagales se manifestent parfois. Après administration orale, une gêne gastro-intestinale apparaît parfois. Réactions anaphylactoïdes/hypersensibilité: une hypersensibilité systémique est rare, habituellement de nature légère et elle se manifeste généralement sous forme de réactions de la peau. La possibilité d’une réaction d’hypersensibilité grave peut toutefois pas être exclue totalement. Pour une information complète concernant les réactions anaphylactoïdes, voir les données ci-dessus concernant l’utilisation intra-vasculaire. Titulaire de l’enregistrement : NV SCHERING SA - B-1831 Diegem – Dernière mise à jour de la notice: juillet 2004 - Approbation de la présente notice: 18 avril 2005. L’enregistrement de Ultravist en Belgique est actuellement transféré chez Bayer Schering Pharma (avenue Louise 143 - 1050 Bruxelles).

BAY-55-B-05-07

d e c n a l a b l l e W

ULTRAVIST 240, flacon 50 ml : iopromid. 24,95 g - natrii calcii edetas - trometamol. - acid. hydrochloric. dilut. - aqua ad iniect. ad 50 ml • ULTRAVIST 240, flacon 200 ml : iopromid. 99,74 g - natrii calcii edetas - trometamol. - acid. hydrochloric. dilut. - aqua ad iniect. ad 200 ml • ULTRAVIST 300, flacon 10 ml : iopromid. 6,23 g - natrii calcii edetas trometamol. - acid. hydrochloric. dilut. - aqua ad iniect. ad 10 ml • ULTRAVIST 300, flacon 20 ml : iopromid. 12,47 g natrii calcii edetas - trometamol. - acid. hydrochloric. dilut. - aqua ad iniect. ad 20 ml • ULTRAVIST 300, flacon 50 ml : iopromid. 31,17 g - natrii calcii edetas - trometamol. - acid. hydrochloric. dilut. - aqua ad iniect. ad 50 ml • ULTRAVIST 300, flacon 100 ml : iopromid. 62,34 g - natrii calcii edetas - trometamol. - acid. hydrochloric. dilut. - aqua ad iniect. ad 100 ml • ULTRAVIST 300, flacon 150 ml : iopromid. 93,51 g - natrii calcii edetas - trometamol. - acid. hydrochloric. dilut. - aqua ad iniect. ad 150 ml • ULTRAVIST 300, flacon 200 ml : iopromid. 124,68 g - natrii calcii edetas - trometamol. - acid. hydrochloric. dilut. - aqua ad iniect. ad 200 ml • ULTRAVIST 370, flacon 50 ml : iopromid. 38,44 g -natrii calcii edetas - trometamol. - acid. hydrochloric. dilut. - aqua ad iniect. ad 50 ml • ULTRAVIST 370, flacon 100 ml : iopromid. 76,88 g - natrii calcii edetas - trometamol. - acid. hydrochloric. dilut. - aqua ad iniect. ad 100 ml • ULTRAVIST 370, flacon 150 ml : iopromid. 115,3 g - natrii calcii edetas - trometamol. - acid. hydrochloric. dilut. - aqua ad iniect. ad 150 ml • ULTRAVIST 370, flacon 200 ml : iopromid. 153,76 g - natrii calcii edetas - trometamol. - acid. hydrochloric. dilut. - aqua ad iniect. ad 200 ml Dit geneesmiddel is een niet-ionisch röntgencontrastmiddel, uitsluitend voor diagnostisch gebruik ·Indicaties: Ultravist 240 Contrastversterking bij de computertomografie (CT), digitale subtractieangiografie (DSA), intraveneuze urografie, extremiteitenflebografie, zichtbaar maken van lichaamsholten (b.v. arthrografie, hysterosalpingografie, fistulografie) met uitzondering van myelografie, ventriculografie, cisternografie. Ultravist 300 Contrastversterking bij de computertomografie (CT), digitale subtractie-angiografie (DSA), intraveneuze urografie, extremiteitenflebografie, venografie, arteriografie, zichtbaar maken van lichaamsholten (b.v. arthrografie, hysterosalpingografie, fistulografie) met uitzondering van myelografie, ventriculografie, cisternografie. Ultravist 370 Contrastversterking bij de computertomografie (CT), digitale subtractie-angiografie (DSA), intraveneuze urografie, arteriografie en in het bijzonder angiocardiografie, zichtbaar maken van lichaamsholten (b.v. arthrografie, fistulografie) met uitzondering van myelografie, ventriculografie, cisternografie. Contra-indicaties: Tijdens een zwangerschap of bij acute ontstekingsprocessen van het bekken mag geen hysterosalpingografie uitgevoerd worden. Endoscopische retrograde cholangiopancreatografie is gecontra-indiceerd bij acute pancreatitis. Aanbevolen Posologie: aortaboogangiografie 50 - 80 ml Ultravist 300, retrograde carotisangiografie 30 - 40 ml Ultravist 300, selectieve angiografie 6 - 15 ml Ultravist 300 * Thoracale aortografie 50 - 80 ml Ultravist 300 * Abdominale aortografie 40 - 60 ml Ultravist 300 * Extremiteitenangiografie bovenste extremiteit:arteriografie 8 - 12 ml Ultravist 300 flebografie 50 - 60 ml Ultravist 240 15 - 30 ml Ultravist 300 onderste extremiteit: arteriografie 20 - 30 ml Ultravist 300flebografie 50 - 80 ml Ultravist 240 30 - 60 ml Ultravist 300 * Angiocardiografie selectief in de afzonderlijk hartcaviteiten 40 - 60 ml Ultravist 370 * Coronarografie 5 - 8 ml Ultravist 370 · Arthrografie 5 - 15 ml Ultravist 300 · Digitale subtractie angiografie (DSA) Voor contrastrijke visualiseringen van grote vaten, pulmonale arteriën en van de slagaders van hals, hoofd, nieren en ledematen, wordt op grond van de ervaringen met ionische contrastmiddelen aanbevolen 30 à 60 ml Ultravist 300 of 370 als bolus intraveneus te injecteren (injectiesnelheid 8 - 12 ml/s in de vena cubitalis; 10 - 20 ml/s in de vena cava). De contacttijd van het contrastmiddel met de venenwand kan verminderd worden door onmiddellijk aansluiten met een bolusinjectie van 20 à 40 ml fysiologische natriumchloride-oplossing. Ongewenste effecten: in samenhang met het gebruik van gejodeerde intravasculaire contrastmiddelen zijn gewoonlijk licht tot middelernstig en voorbijgaand van aard. Men heeft echter ook zware en levensbedreigende zelfs fatale reacties waargenomen. Nausea, braken, een pijngevoel en een algemeen gevoel van warmte zijn de meest frequent genoteerde reacties. Anafylactoïde reacties/overgevoeligheid: Een licht angio-oedeem, conjunctivitis, hoesten, pruritus, rhinitis, niezen en urticaria werden vaak vermeld. Deze reacties, die onafhankelijk van de toegediende hoeveelheid en van de toedieningswijze kunnen optreden, kunnen de eerste tekens van een beginnende shocktoestand zijn. Toedienen van het contrastmiddel moet dan onmiddellijk onderbroken worden en – zonodig – moet er langs een veneuze toegang een geschikte therapie aangevangen worden. Zware reacties die een spoedbehandeling vereisen kunnen onder de vorm van een circulatoire reactie optreden die gepaard gaat met perifere vasodilatatie en daaropvolgende bloeddrukdaling, reflextachycardie, dyspnoe, agitatie, verwardheid en cyanose die eventueel tot bewusteloosheid kan leiden. Bronchospasmen, laryngeaal spasme of oedeem en hypotensie kunnen in zeldzame gevallen optreden. Overgevoeligheidsreacties kunnen optreden tot dagen na toedienen van gejodeerde contrastmiddelen. Dergelijke ongewenste effecten komen hoofdzakelijk tot uiting als een huidreactie (erytheem, pruritus, urticaria), maar enkele gevallen van respiratoir oedeem, Quinckes oedeem, bronchospasmen en hypotensie zijn ook reeds gerapporteerd. Bij auto-immuunthyreoiditis met euthyreoidie of hyperthyreoidie, of struma nodosa kunnen joodhoudende contraststoffen een hyper- of hypothyreoidie uitlokken. Lichaam als geheel: Warmtesensaties en hoofdpijn werden gerapporteerd als vaak optredend. Malaise, rillingen of zweten en vasovagale reacties treden soms op. Ademhaling: Voorbijgaande stoornissen van de ademhalingsfrequentie, dyspnoe en ademhalingsnood en hoesten treden vaak op. Ademhalingsstilstand en pulmonair oedeem zijn zeldzame reacties. Cardiovasculair: Voorbijgaande stoornissen, van enig klinisch belang, van hartfrequentie, bloeddruk, stoornissen van hartritme of hartfunctie en hartstilstand zijn zeldzaam. Ernstige reacties die een spoedbehandeling vereisen zijn zeldzaam en kunnen optreden onder de vorm van een circulatoire reactie die gepaard gaan met perifere vasodilatatie en daaropvolgende hypotensie, reflextachycardie, dyspnoe, agitatie, verwardheid en cyanose die eventueel tot bewusteloosheid kan leiden. Ernstige thrombo-embolische incidenten die een myocardinfarct veroorzaken werden in zeldzame gevallen gerapporteerd. Cerebrovasculair: Cerebrale angiografie en andere procedures waarbij het contrastmiddel de hersenen in hoge concentraties met het arteriële bloed bereikt, kunnen gepaard gaan met voorbijgaande neurologische complicaties zoals vertigo en hoofdpijn (ongewoon), agitatie of verwardheid, amnesie, verstoorde spraak, zicht of gehoor, convulsies, tremor, paresis/paralysis, fotofobie, voorbijgaande blindheid, coma, slaperigheid (zeldzaam). Ernstige, in geïsoleerde gevallen fatale, trombo-embolische incidenten die een beroerte veroorzaken, werden in zeldzame gevallen gemeld. In zeldzame gevallen werd een verzwakking van de nierfunctie of acute nierinsufficiëntie gemeld. Extravasatie van contrastmiddelen met inbegrip van Ultravist geeft aanleiding tot lokale pijn en oedeem maar wijkt gewoonlijk zonder sequellen. Inflammatie en zelfs huidnecrose werden evenwel in zeer zeldzame gevallen gezien. Tromboflebitis en veneuze trombose zijn zeldzaam. Verpakkingen: Ultravist® 240-50 en 200; Ultravist® 300 10, 20, 50, 100, 150 en 200; Ultravist® 370- 50, 100, 150 en 200 Registratiehouder : N.V. SCHERING S.A. B - 1831 MACHELEN Fabrikant: SCHERING AG D - 13342 Berlin Deze bijsluiter is voor het laatst herzien in juli 2004. De datum van de goedkeuring van deze bijsluiter is 18 april 2005. De registratie van Ultravist in België wordt momenteel getransfereerd naar Bayer Schering Pharma (143 Louizalaan - 1050 Brussel).

www.bayer-schering-diagnostics.be Adv_A4_Ultravist_300-370.indd 1 pub well balanced.indd 1

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JBR–BTR, 2011, 94: 229-240.

REVIEW ARTICLES MESENTERIC PANNICULITIS PART 1: MDCT - PICTORIAL REVIEW B. Coulier1 Mesenteric panniculitis is an uncommon benign inflammatory condition of unknown etiology that involves the adipose tissue of the mesentery and for which an extremely varied terminology has been used, causing considerable confusion. It can be evaluated as a single disease with two pathological subgroups: Mesenteric Panniculitis (MP), representing the very large major subgroup where inflammation and fat necrosis predominate and Retractile Mesenteritis (RM), much rarely found, where fibrosis and retraction predominate. In histo-pathological terms the preferred terminology is sclerosing mesenteritis. We hereby extensively illustrate the characteristic MDCT findings of MP through pictures selected among a collection of cases constituted over a 5-year period. All patients were scanned with 64-row MDCT equipment. We also review the literature and discuss the differential diagnosis. The radiological diagnosis of MP was based on classical CT signs described in the literature and comprising: the presence of a well-defined “mass effect” on neighbouring structures (sign 1) constituted by mesenteric fat tissue of inhomogeneous higher attenuation than adjacent retroperitoneal or mesocolonic fat (sign 2) and containing small soft tissue nodes (sign 3). It may typically be surrounded by a hypoattenuated fatty “halo sign” (sign 4) and an hyperattenuating pseudocapsule may also surround the all entity (sign 5). The last two signs are considered inconstant but very specific. The absence of histological verification constitutes the weakness of our study. The differential diagnosis of MP is extensive and includes all disorders that can affect the mesentery. The most common ones are lymphoma, well-differentiated liposarcoma, peritoneal carcinomatosis, carcinoid tumor, retroperitoneal fibrosis, lipoma, mesenteric desmoid tumor, mesenteric inflammatory pseudotumor, mesenteric fibromatosis and mesenteric edema. PET/CT is proved useful to correctly exclude mesenteric tumoral involvement in patients presenting with typical MP. The course of MP is favorable in most cases and progression of MP to retractile mesenteritis not only appears very being rare but finally remains doubtful. Key-words: Mesentery, diseases – Mesentery, CT.

Mesenteric Panniculitis (MP) is an uncommon benign inflammatory condition of unknown etiology that involves the adipose tissue of the mesentery and for which an extremely varied terminology has been used, causing considerable confusion. Now it can be evaluated as a single disease with two pathological subgroups: Mesenteric Panniculitis (MP), representing the very large majoritary subgroup where inflammation and fat necrosis predominate and Retractile Mesenteritis (RM), rarely found, where fibrosis and retraction predominate. In histo-pathological terms the preferred terminology is Sclerosing Mesenteritis. We hereby extensively illustrate the characteristic MDCT findings of MP through pictures selected among a collection of cases constituted over a 5 years period. All patients were scanned with

64-row MDCT machines. We also review the literature and discuss the differential diagnosis. Material The material of this CT pictorial review consists of illustrations chosen among a wide collection of cases constituted over a 5-yearperiod in our department of medical imaging. Most presented images were obtained with two different 64row MDCT machines (Lightspeed Ultra and Lightspeed VCT, General Electric, Wisconsin). The collimation was 64 x 0.65 mm with a pitch comprised between 0.516 and 1.375. The 1.25/0.65 mm or 1.25/1.25 axial series were used for axial cineview analysis and dynamic MPR on a Workstation (Advantage Workstation 4.3 and 4.4, General Electric, Wisconsin).

From: 1. Department of Diagnostic Radiology, Clinique St Luc, Bouge, Belgium. Address for correspondence: Dr B. Coulier, M.D., Department of Diagnostic Radiology, Clinique St Luc, Rue St Luc 8, B-5004 Bouge (Namur) Belgium. E-mail: bcoulier@skynet.be

Discussion Generalities Mesenteric panniculitis is a benign fibrosing and inflammatory condition that involves the adipose tissue of the mesentery (1-4). This uncommon disorder of unknown etiology is likely underdiagnosed (5). It was first described by Jura (6) in 1924 as “Retractile Mesenteritis” and further labeled as “Mesenteric Panniculitis” by Odgen (7) later in the 1960s. Only few large series have been reported and the literature comprises mainly case reports and studies of small series (8-10). Currently, the pathology has several names: sclerosing mesenteritis, mesenteric lipodystrophy, mesenteric panniculitis, mesenteric sclerosis, retractile mesenteritis, mesenteric Weber-Christian disease, liposclerotic mesenteritis, lipomatosis and lipogranuloma of the mesentery (1, 3, 4, 11-14). This varied terminology has caused considerable confusion (3) but the condition can now be evaluated as a single disease with two pathological subgroups: if

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★ C

Fig. 1. — A: axial, B: sagittal and C,D coronal oblique MPR views of a very marked MP found in a 61 year-old man presenting with nonspecific abdominal pain; in this case panniculitis was considered as being idiopathic and unrelated to the spontaneously resolving abdominal pain. All typical signs are found comprising a mass effect, a peripheral pseudocapsule, numerous little hazy and hypodense nodes and a very increased density of fat enlightening the perinodal halo phenomenon. The ileal mesentere typically looks normal (white star).

inflammation and fat necrosis predominate over fibrosis, the condition is known as Mesenteric Panniculitis (MP), and when fibrosis and retraction predominate, the result is Retractile Mesenteritis (RM) (3, 15). MP, the very most frequent and benign situation, could thus represent a sort of “acute” grade of the disease and RM the “chronic” grade but the real kinship between the two entities remains doubtful and speculative (16). In histo-pathological terms, the preferred terminology is sclerosing mesenteritis (2, 10, 12, 17). It represents the more accurate terme because of the presence of some degree of fibrosis as a common denominator (3, 17). With its different forms of expression slerosing mesenteritis is grouped among idiopathic fibrosclerotic disorders and

inflammatory pseudoneoplasms, which include entities such as retroperitoneal fibrosis, sclerosing cholangitis, Riedel's thyroiditis, and orbital pseudotumor. The exact nosologic and pathologic relationships of sclerosing mesenteritis to these disorders are unknown. What unifies these conditions is that they are all masses leading to displacement of surrounding structures or to organ dysfunction caused by compressive growth, and all have histologic findings limited to chronic inflammation and fibrosis (17). Clear statistics based on a real histological proof are unfortunately lacking in the literature. Clinical links may also exist, because many of the conditions coexist in a single patient or have familial trends. Suggested causes are many and varied, with autoimmunity commonly suggested.

The evolution of the disease has been described in three stages (1, 5, 18-19). Stage 1 is mesenteric lipodystrophy, in which mesenteric fat is replaced by sheets of foamy macrophages. Acute inflammatory signs are minimal or non-existent. The disease tends to be clinically asymptomatic and prognosis is good. Stage 2 is mesenteric panniculitis, characterized by inflammatory changes and lymphatic distension with early fibrosis. Histology reveals an infiltrate made up of plasma cells and a few polymorphonuclear leukocytes, foreign-body giant cells, and foamy macrophages. This may be the beginning of symptomatic presentation. Finally, stage 3 is the rare retractile mesenteritis , which shows collagen deposition, fibrosis, and inflammation. Collagen deposition leads to scarring and retraction of the mesentery, which in turn, leads to the formation of abdominal masses and obstructive symptoms. The clear proof of a real kinship between theses three stages is difficult to find in the literature and thus remains doubtful. For this reason, it is our opinion that it is probably better to speak about three types than about three stages of a disease. Most studies have indicated that the disease is more common in men with a male/female ratio of 2-3:1, more frequent between the 6th and 7th decades of life and several reports have indicated it to be more common in Caucasian men (1, 3, 5, 8, 11, 19). Pediatric cases are exceptional, probably because children have less mesenteric fat when compared to adults. Its prevalence in abdominal CT examinations has been estimated at approximately 0.6%, commonly appearing as an incidental finding, mostly in middle or late adulthood (3, 12, 14). The vast majority of cases of Sclerosing Mesenteritis (SM) (comprising the large majority subgroup of MP) are considered as idiopathic and benign (8). The pathogenic mechanism of MP could be a nonspecific response to a wide variety of stimuli (1). Although various causal factors have been identified, the precise etiology remains unknown. The disease is related to many other factors, such as trauma, prior abdominal surgery, mesenteric thrombosis, mesenteric arteriopathy, vasculitis, carcinoid, gardner syndrome, drugs, thermal or chemical injuries, granulomatous disease, avitaminosis, autoimmune disease, rheumatic disease, retained suture material, pan-

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Fig. 2. — A-B and C-D represent two groups of axial views of the mesenteric area obtained within an interval of 14 months in a 50 year-old patient presenting with recurrent colonic diverticulitis. Typical asymptomatic mesenteric panniculitis has developed during the period (black arrows).

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Fig. 3. — A: axial and B: coronal oblique MPR views in a 50-year old male presenting with simultaneous massive duodenal lymphoma (black star) and typical mesenteric panniculitis (white arrow). On follow studies (not illustrated) lymphoma will drastically regress under chemotherapy but panniculitis will remain unchanged. All typical sings are present including the presence of a pseudocapsule.

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Fig. 4. â&#x20AC;&#x201D; A) axial preoperative, B) & C) axial & D) coronal MPR postoperative views of the mesenteric root of a 65-year old man developing typical mesenteric panniculitis (white arrow) with typical pseudocapsule (black arrow) 14 months after Akyama procedure for oesophagal cardia carcinoma. PET/CT evaluation (not illustrated) was normal.

creatitis, bile or urine leakage, hypersensitivity reactions, and even bacterial infection (2, 4, 8, 13-15, 19). Other factors, such as gallstones, coronary disease, cirrhosis, abdominal aortic aneurysm, peptic ulcer, or chylous ascitis, have also been linked to this disease (20). More recent studies have shown a strong relationship between tobacco consumption and MP (14). The actually reported rate of trauma or previous abdominal surgery as an etiologic factor is 4.76% (4) (Fig. 4 and 6). MP has also been associated with a large number of malignant diseases such as lymphoma (Fig. 3 and 7), lung cancer, melanoma, colon cancer, renal cell cancer, myeloma, gastric carcinoma, chronic lymphocytic leukemia, Hodgkinâ&#x20AC;&#x2122;s disease, large cell lymphoma, carcinoid tumor, and thoracic mesothelioma (1, 13-14). In a large but single series MP was related to malignancy in 69% of patients (14). These malignancies

included mostly urogenital or gastrointestinal adenocarcinoma or lymphoma but also breast and lung cancer and melanoma. The pathogenic mechanism linking MP and malignancy remains unknown. It has been then suggested that MP could be an associated and/or causative factor for malignancies. This association with malignancy may also be coincidental or secondary to an autoimmune inflammatory reaction, the mechanism of which has not yet been elucidated. The same study of Daskalogiannaki et al. (14) also noted that an association between MP and lymphoma (Fig. 7) had been suggested in the previous literature. In any experience, the CT scans of patients with non-Hodgkin lymphoma, especially with mesenteric involvement or enlarged nodes at the root of the mesentery may demonstrate a dirty or cloudyappearing mesentery that may

simulate MP (Fig. 3, 9, 12). The abnormality may improve or disappear with successful treatment or worsen with progression of the disease. Perhaps this appearance is secondary to obstruction to lymphatic flow or to actual lymphomatous involvement of the mesentery. Sometimes the appearance persists even after the lymphoma has completely resolved, perhaps reflecting residual fibrosis or scarring. The point is that one should carefully assess the mesentery for the specific features described by Daskalogiannaki et al. (14) and the absence of enlarged mesenteric lymph nodes before ascribing the finding to MP and not lymphoma. PET/CT has been proved useful to correctly exclude mesenteric tumoral involvement in patients presenting with typical MP (12). The reason is that classically no 18F-FDG uptake is seen in MP. In a patient

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Fig. 5. â&#x20AC;&#x201D; A: axial, B: coronal oblique, D: sagittal MPR views and C: coronal oblique MIP view of an extremely marked jejunal mesenteritis panniculitis fortuitously found in a 74 year-old female in a context of inflammatory syndrome of unknown origin. All typical signs are maximally present with a particularly increased density of mesenteric fat enhancing the typical perinodal and perivascular halo phenomenon.

with an oncologic or lymphoma history, the demonstration of 18F-FDG uptake, even in small-sized nodules intermingled within an associated MP, is highly suggestive of neoplastic or lymphomatous involvement of the mesentery (Fig. 6, 8). This increased 18F-FDG uptake may secondarily decrease following a favorable response to treatment. As a consequence if MP is suspected on the CT part of the PET/CT study,

special attention should be paid to the 18F-FDG-avidity of the findings. A negative PET has high diagnostic accuracy in excluding tumoral or lymphomatous mesenteric involvement while increased uptake may suggest the co-existing of metastatic deposits, particularly in patients with lymphoma. Increased 18F-FDG uptake is, however, not tumour-specific as it may be seen in benign inflammatory conditions like sarcoidosis.

Diagnosis MP was rarely diagnosed before the area of ultrasound and CT (12). The main reason is that most cases of MP are asymptomatic and are incidentally detected on abdominal CT performed for unrelated conditions (3, 12, 14) (Fig. 2). In over 90% of cases, MP involves the smallbowel mesentery, although it may sometimes involve the sigmoid

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Fig. 6. — A to C a typical pattern of jejunal panniculitis (white arrow) was found on follow-up abdominal CT after whipple procedure for pancreatic adenocarcinoma in this 60-year-old female. The benign nature of this ambiguous panniculitic process – and especially of nodes – was confirmed by 3 negative PET/CT performed during a 14 months period (D). The typical aspect of MP remains present and stable after 3 years (E).

mesentery (1). On rare occasions, it may involve the mesocolon (especially the mesosigmoid), peripancreatic region, omentum, retroperitoneum or pelvis (2, 13, 21). Rare sites described are the mesoappendix, peripancreatic area, omentum and pelvis. Clinical manifestations of MP are very inconstant and non-specific (2). In as many as half of the cases reported MP has been an incidental finding in asymptomatically presenting patients (2, 8). In “symptomatic” patients, a wide variety of gastrointestinal and systemic manifestations have been associated with this disorder including abdominal pain, abdominal fullnees, nausea, vomiting, pyrexia, diarrhea, constipation, anorexia, weight loss, fatigue, fever of unknown origin, ascites, pleural and pericardial effusion (1-2, 5, 10).

On occasions, the disease may also present with merely a single or multiple palpable masses. Exceptionally, rectal bleeding, jaundice, gastric outlet obstruction, and even acute abdomen have been reported. MP has been best diagnosed radiologically with multidetector CT and MRI (2, 10, 12-13) (Fig. 1, 5, 9). A single abdominal CT scan may point towards the diagnosis in about half the cases (8). On CT (8, 12, 22), MP appears as a mass of increasedattenuation mesenteric fat containing small soft-tissue nodes, with a maximal transverse diameter directed toward the left abdomen consistent with the orientation of the jejunal mesentery. The mesenteric softtissue nodes ranged between immeasurable, numerous small nodules, to discrete nodes measuring up to 0.9 cm in the short axis and

1.9 cm in the long axis. The infiltrated fat typically engulfs the mesenteric vessels and displaces adjacent bowel loops without invading them (3, 13-14). Calcification may be present (13), usually in the central necrotic portion of the mass, and may be related to the fat necrosis. They are a relatively rare finding (3). Cystic components have also been described and may be the result of lymphatic or venous obstruction as well as necrotic change. Two CT findings are considered more specific for the diagnosis of MP as they have not been reported in other mesenteric diseases (3, 5, 23-26): the presence of a tumoral pseudocapsule (found in up to 60% of MP cases) and the "fat ring" sign of hypodense fatty halo surrounding mesenteric nodules and vessels (seen in up to 75% of cases) (5, 8, 12, 27-28) (figures 1, 3,

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Fig. 7. — A-D represent four axial views obtained at four different periods of the evolution of a lymphoma in a 70-year old female. Moderate mesenteric panniculitis coexists and persists uniformly during the period of observation comprising the initial CT with numerous nodes (A), the CT obtained after a first period of remission (B), another CT illustrating recurrence of the disease with recrudescence of lymphadenopathies (C) and the last CT after a second phase of remission (D).

4, 5). Three-dimensional CT and CT angiography may also aid in diagnosis by providing a better perspective of its complex relation to other mesenteric structures. In our experience multiplanar and 3D CT also demonstrated a peculiar and, to our knowledge, never before described characteristic of the soft-tissues nodes associated with MP: in many cases these nodes appeared unusually irregular, ramified and/or connected to each other by linear densities – dilated lymphatics ducts? – a characteristic not classically found with benign or tumoral nodes (Fig. 9 and 10). Nevertheless, even if the CT features of MP are well recognized and

may suggest the correct diagnosis in the vast majority of cases, they are non-specific and can appear in other conditions such as mesenteric oedema, granulomatous diseases, primary or secondary abdominal neoplasms and lymphoma (12). In cases of MP and known intra-abdominal malignancies, differentiating MP from tumoural involvement of mesenteric lymph nodes is of crucial importance and PET/CT evaluation may be performed in ambiguous cases. The definite diagnosis of mesenteric panniculitis is established by biopsy (5) but it is rarely performed because of the high rate of cases presenting as incidental findings in asymptomatic patients.

Differential diagnosis The differential diagnosis of MP is broad and includes all disorders that can affect the mesentery (3, 5, 10, 13). The most common are lymphoma, well-differentiated liposarcoma, peritoneal carcinomatosis, carcinoid tumor, retroperitoneal fibrosis, lipoma, mesenteric desmoid tumor, mesenteric inflammatory pseudotumor, mesenteric fibromatosis and mesenteric edema (13). Unlike MP lymphoma, unless previously treated, will not contain calcification (13). Both conditions can encase mesenteric vasculature, but lymphoma will almost never result in ischemia. If large nodes are

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visualized, lymphoma is the more likely diagnosis (Fig. 11). Treated lymphoma may also produce a misty mesentery and simulate the CT appearance of the MP (Fig. 12). The preservation of a halo of normal fat around the involved vessels and nodes – “fat ring sign“ – also favors a diagnosis of MP. The CT appearances of carcinoid tumor and MP can be identical. Both can appear as an ill-defined, infiltrating soft-tissue mass in the root of the mesentery with associated calcification and desmoplastic reaction and both may result in ischemia and obstruction. Again, the “fat ring sign” favors a diagnosis of MP. In patients with carcinomatosis, mesenteric implants can simulate the CT appearance of MP. Calcification can be present in both conditions, especially if the primary tumor is a mucinous adenocarcinoma (eg, ovarian or colon cancer). However, in patients with carcinomatosis, implants will not be confined to the root of the mesentery but will also be present in the omentum and on the surface of the liver, spleen, or bowel. Ascites is also common in carcinomatosis but is not associated with MP. Primary mesenteric mesothelioma can produce mesenteric soft-tissue implants that may simulate the CT appearance of MP. However, mesothelioma is usually not confined to the mesentery, and tumor implants will also be seen in the omentum and along the bowel surfaces. Ascites may also be present in mesothelioma but calcification are uncommon. Mesenteric edema may result from various conditions such as cirrhosis, hypoalbuminemia, heart failure, portal or mesenteric vein thrombosis, and vasculitis. Trauma can also result in edema and hemorrhage in the mesentery. When fluid or blood infiltrates the mesentery, the attenuation of the mesenteric fat increases. This finding may mimic the CT appearance of MP. Mesenteric edema secondary to systemic disease is often diffuse and coexists

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Fig. 8. — A: coronal CT MPR view, B: transverse ultrasound views – with power Doppler – and C: PET/CT views in a very obese 64 year-old female presenting with abdominal follicular lymphoma. Diffuse and non nodular hazy infiltration of the mesenteric root is found (white arrow) mimicking diffuse panniculitis. This infiltration is associated with numerous retroperitoneal aortocaval lymphadenopathies (not illustrated) evocating lymphoma. The definite diagnosis was obtained through histopathologic study of an inguinal node and confirmed by the hypermetabolic nature of the infiltration on PET/CT (white arrows on C).

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Fig. 9. — A,C: coronal oblique and B: axial MPR views obtained in a 27-yearold patient presenting with ileocolonic Crohn’s disease in association with typical jejunal mesenteric panniculitis. The morphology of mesenteric nodes appears different in the two entities: those associated with Crohn’s disease (black arrows) appear round, sharply demarcated and rather dense whereas those classically associated with panniculitis (white arrows) appear smaller, irregular, ramified and more hypodense with hazy contours.

Fig. 10. — A: coronal, B: sagittal MIP views obtained in a 76 year-old man presenting with prostatic neoplasm. A typical jejunal mesenteric panniculitis is visible. Multiples irregular and ramified nodes are found whose aspect differs from more round and regular related to lymphoma (white arrows).

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Fig. 11. — Coronal MPR (A) and axial view (B) of a typical abdominal lymphoma with mesenteric involvement (white arrow) in a 56-year-old female. This classical aspect drastically differs from mesenteric panniculitis: the typical pseudocapsule is absent, the fat component is not swollen and remains hypoechoic, the nodes are numerous, dense, round and many entities are larger than 10 mm; the typical halo sign is absent. C: complete normalization after healing (black arrows).

with generalized subcutaneous edema and ascites, which will not be present in patients with sclerosing mesenteritis. Also, the clinical history will often be the clue to the correct diagnosis. MP must also be differentiated from inflammatory pseudotumor, Crohn’s disease with fibrofatty proliferation, and lipogenic liposarcoma (3). The “fat ring sign” and the presence of a pseudocapsule are not described in this last entity. Evolution The course of MP is favorable in most cases, because the disease usually progresses slowly and subsides spontaneously. Nevertheless significant morbidity and a chronic debilitating course have been reported in up to 20% of patients (5). Currently, there is no established regimen for the management of MP (5, 8). The treatment is usually empiric and individualized. No thera-

peutic procedures have yet shown an unequivocal efficacy, and treatment of the symptomatic forms is not well established (3). The indolent forms do not usually require specific treatment. Other authors have also reported a beneficial effect of corticosteroid therapy (5, 8). Other empirically proposed therapy options include tamoxifen, azathioprine, cyclophosphamide, oral progesterone and thalidomide in advance or progressive cases. Surgical resection is generally not recommended and has no beneficial effects, except in cases of intestinal obstruction and other complications, such as ischemia. The natural course of MP is as inconsistent as its presentation (3, 8). It may partially or completely regress, may follow a long benign nonprogressive stable course or may rarely have an aggressive course that occasionnaly has a fatal outcome. This variability has been observed in both treated and

untreated cases. Predominant lipodystrophy usually has a favorable prognosis, whereas fibrotic cases are thought to have a more negative outcome; chronic inflammation lies in the middle of the spectrum. Real extensive and longitudinal studies are unfortunately lacking to proof these sporadically reported data. Progression of MP to debilitating retractile mesenteritis is difficult to predict. It seems to remain a very rare event (16) and therefore such a progression may also be considered as doubtful. A real kinship or a complete independence between the two entities remains thus an open question which cannot be unequivocally answered. For this reason the benefit of a systematic follow-up of the many cases that are spontaneously discovered during CT practice is questionable. The major complication are related to a potential but not really proved progressive fibrosis (3): shortening of the mesentere

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Fig. 12. â&#x20AC;&#x201D; 3 groups of axial views (A to C) are obtained at three different stages of the evolution of an abdominal lymphoma under chimiotherapy in a 88-year old female. During treatment a drastic regression the numerous large retroperitoneal lymphadenopathies is observed (white arrows) and the mesentere (black arrow) evolves from diffuse infiltration (A) to complete healing (C) trough a transitory pseudo panniculitic state (B).

and compression of mesenteric vessels with partial or complete intestinal obstruction or ischemia which may require surgery. During a 5 year-period we have not encountered such dramatic evolution of MP to aggressive retractile mesenteritis.

Daskalogiannaki (14) found a great stability of the CT findings of MP in 20/21 patients in which followup abdominal CT examinations were available within an interval of 5 months to 3 years. Only one patient showed a slight increase of the fatty mass.

References 1. Issa I., Baydoun H.: Mesenteric panniculitis: various presentations and treatment regimens. World J Gastroenterol, 2009, 15: 3827-3830. 2. Chawla S., Yalamarthi S., Shaikh I.A., Tagore V., Skaife P.: An unusual presentation of sclerosing mesenteritis as

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JBR–BTR, 2011, 94 (5) pneumoperitoneum: case report with a review of the literature. World J Gastroenterol, 2009, 15: 117-120. Sabaté J.M., Torrubia S., Maideu J., et al.: Sclerosing mesenteritis: imaging findings in 17 patients. AJR., 1999, 172: 625-629. Kara T., Canyigit M.: Relationship between abdominal trauma or surgery and mesenteric panniculitis. World J Gastroenterol, 2009, 15: 6139. Ferrari T.C., Couto C.M., Vilaça T.S., Xavier M.A., Faria L.C.: An unusual presentation of mesenteric panniculitis. Clinics (Sao Paulo), 2008, 63: 843844. Jura V.: Mesenteritis retratille-caso clinico: risultati sperimentali, rilievi patogenici, considerazoni cliniche. Policlinoco, 1927, 34: 535-556, 566599. Ogden W.W., Bradburn D.M., Rives J.D.: Mesenteric Panniculitis: review of 27 cases. Ann Surg, 1965, 161: 864-875. Zafar A.M., Rauf M.A., Chawla T., Khanda G.: Mesenteric panniculitis with pedal edema in a 33-year-old Pakistani man: a case report and literature review. J Med Case Reports, 2008, 2: 365. Akram S., Pardi D.S., Schaffner J.A., Smyrk T.C.: Sclerosing mesenteritis: clinical features, treatment, and outcome in ninety-two patients. Clin Gastroenterol Hepatol., 2007, 5: 589596. Vettoretto N., Diana D.R., Poiatti R., et al.: Occasional finding of mesenteric lipodystrophy during laparoscopy: a difficult diagnosis. World J Gastroenterol, 2007.13: 5394-5396.

11. Levy A.D, Rimola J., Mehrotra A.K., Sobin L.H.: From the archives of the AFIP: benign fibrous tumors and tumorlike lesions of the mesentery: radiologic-pathologic correlation. Radiographics, 2006.26: 245-264. 12. Zissin R., Metser U., Hain D., EvenSapir E.: Mesenteric panniculitis in oncologic patients: PET-CT findings. Br J Radiol, 2006, 79: 37-43. 13. Horton K.M., Lawler L.P., Fishman E.K.: CT findings in sclerosing mesenteritis (panniculitis): spectrum of disease. Radiographics, 2003, 23: 1561-1567. 14. Daskalogiannaki M., Voloudaki A., Prassopoulos P., Magkanas E., Stefanaki K., Apostolaki E., Gourtsoyiannis N. CT evaluation of mesenteric panniculitis: prevalence and associated diseases. AJR, 2000, 174: 427-431. 15. Emory T.S., Monihan J.M., Carr N.J., Sobin L.H.: Sclerosing mesenteritis, mesenteric panniculitis and mesenteric lipodystrophy: a single entity? Am J Surg Pathol, 1997, 21: 392-398. 16. Pickhardt P.J., Bhalla S.: Unusual nonneoplastic peritoneal and subperitoneal conditions: CT findings. Radiographics, 2005, 25: 719-730. 17. Lawler L.P., McCarthy D.M., Fishman E.K., Hruban R.: Sclerosing mesenteritis: depiction by multidetector CT and three-dimensional volume rendering. AJR, 2002, 178: 97-99. 18. Rajendran B., Duerksen D.R.: Retractile mesenteritis presenting as protein-losing gastroenteropathy. Can J Gastroenterol, 2006, 20: 787789. 19. Delgado Plasencia L., Rodríguez Ballester L., López-Tomassetti

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Fernández E.M., et al.: Mesenteric panniculitis: experience in our center. Rev Esp Enferm Dig, 2007, 99: 291-297. Patel N., Saleeb S.F., Teplick S.K.: General case of the day. Mesenteric panniculitis with extensive inflammatory involvement of the peritoneum and intraperitoneal structures. Radiographics, 1999, 19: 1083-1085. Popkharitov A.I., Chomov G.N.: Mesenteric panniculitis of the sigmoid colon: a case report and review of the literature. J Med Case Reports, 2007, 1: 108. Durst A.L., Freund H., Rosenmann E., Birnbaum D.: Mesenteric panniculitis: review of the literature and presentation of cases. Surgery., 1977, 81: 203211. Mindelzun R.E., Jeffrey R.B. Jr., Lane M.J., Silverman P.M.: The misty mesentery on CT: differential diagnosis. AJR, 1996, 167: 61-65 Katz M.E., Heiken J.P., Glazer H.S., Lee J.K.: Intraabdominal panniculitis: clinical, radiographic, and CT features. AJR, 1985, 145: 293-296. Nguyen B.D. F-18 FDG PET demonstration of sclerosing mesenteritis. Clin Nucl Med, 2003, 28: 670-671. Mata J.M., Inaraja L., Martin J., Olazabal A., Castilla M.T.: CT features of mesenteric panniculitis. Comput Assist Tomogr, 1987, 11: 1021-1023. Azzam I., Croitoru S., Naschitz J.E.: Sclerosing mesenteritis: a diagnostic challenge. Isr Med Assoc J, 2004, 9: 567-568. Okino Y., Kiyosue H., Mori H., et al.: Root of the small-bowel mesentery: correlative anatomy and CT features of pathologic conditions. Radiographics, 2001, 21: 1475-1490.

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MESENTERIC PANNICULITIS PART 2: PREVALENCE AND NATURAL COURSE: MDCT PROSPECTIVE STUDY B. Coulier1 Background: Mesenteric panniculitis (MP) is an uncommon benign inflammatory condition of unknown etiology that involves the adipose tissue of the mesentery. I can be evaluated as a single disease with two pathological subgroups: MP, representing the very large majoritary subgroup where inflammation and fat necrosis predominate and Retractile Mesenteritis, rarely found, where fibrosis and retraction predominate. Objective: To re-estimate the prevalence of MP in general population through a large prospective study, to compare the results with those of the literature and to evaluate the natural course of the condition. Methods: A continuous series of 613 consecutive unselected patients (280 females and 333 males) imaged with abdominal MDCT for various neoplastic (27%) or non neoplastic conditions (73%) constitutes the prospective material. A positive CT diagnosis of MP was based on the observation of at least three of five typical CT signs comprising: the presence of a well-defined “mass effect” on neighbouring structures (sign 1) constituted by mesenteric fat tissue of inhomogeneous higher attenuation than adjacent retroperitoneal or mesocolonic fat (sign 2), containing small soft tissue nodes (sign 3) typically surrounded by a hypoattenuated fatty “halo sign” (sign 4). Finally a hyperattenuating pseudocapsule may surround the all entity (sign 5). Results: A positive diagnosis of MP was made in 48 patients (prevalence of 7,83%) on the basis of the presence of at least 3 CT signs. After reconsidering the presence of the “halo sign” (sign 4) and of the “pseudocapsule” (sign 5) as “sine qua non” conditions for a positive diagnosis, a more restricted positive group of 21 cases was constituted (prevalence of 3,42%) comprising 10 males (3%) and 11 females (3,93%). There were 14 “non-neoplastic” patients – 6 males (2,27 %) and 8 females (3,6%) – and 7 “neoplastic” patients – 4 males (3,73%) and 3 females (5,17%) –. Conclusions: The prevalence of MP appears much higher than previously reported and the reason probably resides in the major technological evolution experienced in CT imaging during the last decade. This high prevalence probably explains the spontaneous association with the numerous and probably unrelated clinical situations found in the literature. Finally the vast majority of cases are considered as idiopathic, benign an asymptomatic. Except a discrete higher prevalence found in patients presenting with bladder and/or prostatic neoplasms and with lymphoma in group 1 the general prevalence of MP in our study doesn’t significantly differs in the “neoplastic” and “non neoplasic” groups of patients. We conclude that the value of MP in term of predictivity of an associated neoplasm is probably non relevant. Finally PET/CT is proved useful to correctly exclude mesenteric tumoral involvement in patients presenting with typical MP and follow-up studies show a great stability of the CT findings of MP in about 85% of cases. Key-words: Mesentery, diseases – Mesentery, CT.

Mesenteric panniculitis (MP) is an underdiagnosed uncommon benign inflammatory condition of unknown etiology that involves the adipose tissue of the mesentery and for which an extremely varied terminology has been used, causing considerable confusion. Now it can be evaluated as a single disease with two pathological subgroups: MP, representing the very large major subgroup where inflammation and fat necrosis predominate and retractile mesenteritis, rarely found, where fibrosis and retraction predominate. In histo-pathological terms the preferred terminology is sclerosing mesenteritis.

The goal of this study was to reestimate the prevalence of MP in general population through a large prospective study, to compare the results with those of the literature and to evaluate the natural course of the condition. Material During a 22 weeks period the same experienced radiologist scrupulously searched for signs of mesenteric panniculitis (MP) on all abdominal CT performed during his own CT attendances. A continuous series of 613 unselected patients comprising 280 females (16-95 years,

mean age 65 +/- 15, 25 years) and 333 males (20-89 years, mean age 63,66 +/- 14,65 years) was constituted. The patients were scanned with two different 64-row MDCT machines (Lightspeed Ultra and Lightspeed VCT, General Electric, Wisconsin). The collimation was 64 x 0.65 mm with a pitch comprised between 0.516 and 1.375. The 1.25/0.65 mm or 1.25/1.25 axial series were used for axial cineview analysis and dynamic MPR on a Workstation (Advantage Workstation 4.3 and 4.4, General Electric, Wisconsin). On the basis of their clinical records the patients were classified as “neoplastic” (diagnosis and /or follow-up) (n = 165 or 27%) and “non neoplastic” patients (n = 448 or 73%). The “neoplastic” group was composed of 107 males (32% of males) and 58 females (20,7% of females) and the “non neoplastic” group was composed of 226 males

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Fig. 1. — A: volume rendering view, B: sagittal and coronal oblique MPR views and C: selective volume rendering view of nodes obtained in a 57 year-old patient presenting with a sharp mesenteric panniculitis. The CT was performed to study the renal arteries in a context of hypertension. All typical sings are present and the typical nodes, surrounded by a halo (white arrows) have a ramified and irregular shape.

(68% of males) and 222 females (79,3% of females). A positive CT diagnosis of MP required the presence of at least 3 typical signs comprising: a welldefined “mass effect” on neighbouring structures (sign 1) constituted by mesenteric fat tissue of inhomogeneous higher attenuation than adjacent abdominal fat (sign 2) containing small soft tissue nodes – lymphadenopathies – (sign 3) which may be surrounded, like mesenteric vessels, by an hypoattenuated fatty halo (sign 4). The last sign (sign 5) was constituted by the presence of a hyperattenuating pseudocapsule surrounding the mesenteric fat tissue.

Table I. — Scores of positive cases.

The results are expressed in percentage.

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The signs were scored in four grades: absent (score 0), discrete (score 1), moderate (score 2) and marked (score 3). A case was being considered positive when at least 3 signs were simultaneously present. Thus the minimal positive score was 3 (score 1 for at least 3 signs) and the maximal score was 15 (score 3 for all five signs). Globally MP was arbitrary characterised as minimal (score </= 5), moderate (score 5 to 9) or marked (score 10 to 15). The medical records of the “positive” patients were systematically reviewed and all their previous and subsequent abdominal CT examinations were retrieved from our picture archiving system (PACS) and secondarily reinterpreted by the same radiologist to follow the evolution of MP.

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Results The positive diagnosis of MP was conditioned by the presence of at least 3 positive CT. With this criteria 48 patients (= group 1) (7,83%) were found positive comprising 19 females (6,79%) and 29 males (8,71%) (M/F ratio = 1/1,28). MP was found in 31 “non neoplastic” patients (6,9%) comprising 16 males (7,5%) and 15 females (6,75%). 17 “neoplastic patients” were positive (10,3%) comprising 13 males (12,1%) and 4 females (6,9%) (Table II). The malignancies included colorectal adenocarcinoma (23,5%), vesical and prostatic neoplasms (41,2%), lymphoma (11,8%) and miscellaneous malignancies (23,5%). 14,9% of vesico-prostatic neoplasms and 15,4% of lymphoma were associated with MP. MP was scored as minimal (score </= 5) in 5 cases (10,4%), moderate (score 5 to 9) in 28 cases (58,3%) and marked (score 10 to 15) in 14 cases (29,16%). The mean general score was 8 in “neoplastic” and 7,9 in “non neoplastic” patients (Table I). Signs 1 to 3 were present in all cases but the “halo sign” (sign 4) (figures 1-5) and a “pseudocapsule” (sign 5), which are considered in the literature as the most typical and specific CT signs of MP were absent respectively in 6 (12,5%) and 27 (56%) of the 48 “positive” cases. After reconsidering the presence of the “halo sign” (sign 4) and of a “pseudocapsule” (sign 5) as “sine qua non” conditions for a positive diagnosis, a restricted positive group of 21 cases (group 2) was constituted (prevalence of 3,42%) com-

C Fig. 2. — A, B: axial CT views obtained during abdominal CT performed in a 82 year-old patient presenting with hematuria. B is obtained during abdominal compression (black arrowhead) performed for analysis of the pyelocaliceal tree and illustrates the incompressibility of the panniculitic mesentere. C is obtained 27 months later and panniculitis is still present and appears unchanged. In this patient hematuria was finally attributed to vesical transitional tumor which secondarily extended to the liver.

prising 10 males (3%) and 11 females (3,93%). There were 14 “non-neoplastic” patients – 6 males (2,27 %) and 8 females (3,6%) – and 7 “neoplastic” patients – 4 males (3,73%) and 3 females (5,17%) (Table II). A CT follow-up was available in 25 (52%) of the 48 positive patients of the group 1. The follow-up period was varying from 9 to 104 months

(mean 36 +/- 21 months). A discrete majoration of score was observed in only 2 patients and a subtle regression was observed in 2 patients. The great majority of cases (21/25 = 84%) appeared extremely stable during follow-up studies. The same result was found in the restricted positive group (group 2) in which 85,7% of the 14 patients with follow-up

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Fig. 3. â&#x20AC;&#x201D; A: axial CT views obtained during abdominal CT performed in a 72 year-old female patient suffering from bladder cancer. A marked panniculitis is found and remains extremely stable on similar axial CT views (B) obtained 104 months later.

studies (mean 34 +/- 25 months) remained stable. Discussion Mesenteric Panniculitis (MP) is a benign fibrosing and inflammatory condition that involves the adipose tissue of the mesentery (1-5) and this uncommon disorder of unknown etiology is likely underdiagnosed (6). In histo-pathological terms, the preferred terminology is Sclerosing Mesenteritis (1, 3, 7-9). It represents the more accurate term because of

the presence of some degree of fibrosis as a common denominator (4, 9). Most studies have indicated that the disease is more common in men, more frequent between the 6th and 7th decades of life, with a male/female ratio of 2-3:1, and several reports have indicated it to be more common in Caucasian men (1-2, 4, 6, 10-11). In our series the male predominance appeared less evident with a male/ female ration of 1,28:1. Pediatric cases are exceptional, probably because children have less mesenteric fat when compared to adults.

Classically on CT, MP appears as a mass of increased-attenuation mesenteric fat containing small softtissue nodes, with a maximal transverse diameter directed toward the left abdomen consistent with the orientation of the jejunal mesentery. The mesenteric soft-tissue nodes ranged between immeasurable, numerous small nodules, to discrete nodes measuring up to 0.9 cm in the short axis and 1.9 cm in the long axis. Two CT findings are considered more specific for the diagnosis of MP as they have not been reported in

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Table II. — Prevalence of Mesenteric panniculitis in the different groups of patients for the two positive groups: group 1 characterized by at least 3 “positive” CT signs and group 2 in which all 5 typical CT signs are present including the “halo sign” and the presence of a “pseudocapsule”.

other mesenteric diseases (1, 4, 6, 12-15): the presence of a tumoral pseudocapsule (found in up to 60% of MP reported cases) and the "fat ring" sign of hypodense fatty halo surrounding mesenteric nodules and vessels (seen in up to 75% of reported cases) (1, 6, 8, 16-18) (Fig. 1). The overall prevalence of MP in abdominal CT examinations has previously been estimated at approximately 0.6%, commonly appearing as an incidental finding, mostly in middle or late adulthood (1, 4, 8, 19). It is our opinion that this prevalence has probably been extremely underestimated when compared with the results of our prospective study which shows a mean prevalence of 7,83% when at least 3 CT signs are found (group 1) and still of 3,42% when all five CT signs are considered (group 2) including the “halo sign” and the presence of a “pseudocapsule”. The reason probably resides in the major technological evolution experienced in CT imaging during the last decade. When compared with the CT parameters of the study of Daskalogiannaki (19) (where 10-mmthick continuous axial views are analysed) there is no doubt that the dynamic multiplanar examination of hundreds of millimetric views allows a much higher sensitive diagnosis of sometimes subtle mesenteric abnormalities. In the large but single series of MP of Daskalogiannaki was related to malignancy in 69% of patients (19). These malignancies included mostly urogenital or gastrointestinal adeno-

carcinoma or lymphoma but also breast and lung cancer and melanoma. In our study MP is found heaving not only a much greater prevalence than previously reported but moreover this prevalence doesn’t not significantly differs in the two - “neoplastic” and “non neoplastic” groups. MP thus probably represents an idiopathic phenomenon whose value in term of predictivity of associated neoplasm is probably not relevant. A discrete higher prevalence of MP was only found in patients presenting with vesical and prostatic neoplasms and with lymphoma in group 1. Daskalogiannaki et al. (19) also noted that an association between MP and lymphoma had been suggested in the previous literature. In our series, MP was effectively associated with lymphoma in a higher percentage (15,4% of patients of the group 1) than in the general population. A wide variety of clinical manifestations of MP have been described which are very inconstant and nonspecific (1, 3) but as many as half of the cases reported MP has been an incidental finding in asymptomatically presenting patients (3, 16). It’s also our opinion that this proportion of asymptomatic presentations is extremely much higher. Such a wide variety of potential clinical manifestations would first mean that a large number of illnesses must be considered for differential diagnosis. For us the real unanswered question is: are all these various symptoms really related to MP

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or do they only represents the unrelated features which lead patients to imaging studies? As suggested by our results the relatively high prevalence of MP probably explains a spontaneous association with numerous and probably unrelated clinical situations. The course of MP is favorable in most cases, because the disease usually progresses slowly and subsides spontaneously. In about 20% of patients – but it is not sure that this high percentage is not overestimated – MP is associated with significant morbidity and a chronic debilitating course (6). Nevertheless Daskalogiannaki (19) found a great stability of the CT findings of MP in 20/21 patients in which follow-up abdominal CT examinations were available within an interval of 5 months to 3 years. Only one patient showed a slight increase of the fatty mass. Our results are exactly the same. In the 25 patients in which a follow up was available – within a mean interval of 36 +/21 months – 21 (84%) showed an extremely stable appearance of their MP (Fig. 2-3). A discrete increase in score was observed in only 2 patients and a subtle regression was observed in 2 patients. Conclusions The prevalence of MP was much higher in our study than previously reported in the literature and the reason probably resides in the major technological evolution experienced in CT imaging during the last decade. This high prevalence probably explains the spontaneous association with the numerous and probably unrelated clinical situations found in the literature. Finally the vast majority of cases are considered as idiopathic, benign an asymptomatic. Except a discrete higher prevalence found in patients presenting with bladder and/or prostatic neoplasms and with lymphoma in group 1 the general prevalence of MP in our study doesn’t significantly differs in the “neoplastic” and “non neoplasic” groups of patients. We conclude that the value of MP in term of predictivity of an associated neoplasm is probably not relevant. Finally PET/CT is proved useful to correctly exclude mesenteric tumoral involvement in patients presenting with typical MP and follow-up studies show a great stability of the CT findings of MP in about 85% of cases.

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Bibliography 1. Coulier B. Mesenteric panniculitis (part I): MDCT – pictorial review. JBRBTR, 2011, 94: 229-240. 2. Issa I., Baydoun H.: Mesenteric panniculitis: various presentations and treatment regimens. World J Gastroenterol, 2009, 15: 3827-3830. 3. Chawla S., Yalamarthi S., Shaikh I.A., Tagore V., Skaife P.: An unusual presentation of sclerosing mesenteritis as pneumoperitoneum: case report with a review of the literature. World J Gastroenterol, 2009, 15: 117-120. 4. Sabaté J.M., Torrubia S., Maideu J., et al.: Sclerosing mesenteritis: imaging findings in 17 patients. AJR, 1999, 172: 625-629. 5. Kara T., Canyigit M.: Relationship between abdominal trauma or surgery and mesenteric panniculitis. World J Gastroenterol, 2009, 15: 6139. 6. Ferrari T.C., Couto C.M., Vilaça T.S., Xavier M.A., Faria L.C.: An unusual presentation of mesenteric panniculitis. Clinics (Sao Paulo), 2008, 63: 843844. 7. Vettoretto N., Diana D.R., Poiatti R., et al.: Occasional finding of mesenteric

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MR IMAGING FINDINGS OF LESIONS INVOLVING CARTILAGE AND BONE IN THE PAEDIATRIC KNEE: A PICTORIAL REVIEW L.B.O. Jans, J.L. Jaremko, M. Ditchfield, K.L. Verstraete The knee is the joint which is most commonly imaged by MRI in children and adolescents. With increasing participation in competitive sports, traumatic knee injuries with osteochondral lesions are increasingly common in children. However, it is also important to exclude non traumatic conditions that result in defects of the articular cartilage and/or subchondral bone plate or growth plate of the knee, since timely diagnosis and therapy may help prevent lifelong disability in these patients. Moreover, there are normal variants that occur in the ossifying knee that should not be mistaken for lesions. The aim of this essay is to review the wide range of conditions that may result in MRI signal changes of the ossifying knee in children.

Musculoskeletal injury in children is common and can lead to lifelong disability. The knee joint is often involved in sports-related as well as in non traumatic pathological conditions in the paediatric population. Magnetic resonance imaging (MRI) is the imaging investigation of choice due to the absence of radiation, multiplanar imaging options, high image resolution and superb soft tissue contrast. MRI visualizes the cartilaginous ends of growing bones, bone marrow and supporting soft tissue structures making it ideally suited for evaluation of bone and cartilage injury and the complicating growth disturbance in young patients (1). Although several of the injuries in the paediatric knee occur in adults as well, the paediatric knee is also subject to unique developmental and pathological processes which may be related to the presence of unfused physes (2). Musculoskeletal lesions can be the first manifestation of systemic disease. Also, there are normal findings of the growing and developing femoral condyle such as ossification variants that are not seen in the adult population and should be differentiated from pathology (3). The aim of this pictorial review is to familiarize the reader with the MR imaging features of the wide variety of lesions that may result in damage to the cartilage and bone in the paediatric knee.

Fig. 1. â&#x20AC;&#x201D; Chondral fracture in an 11-year-old boy. A. Coronal T1-weighted image demonstrates a large loose body (arrows) with signal intensity f cartilage in the femorotibial joint space. B. Sagittal T1-weighted image demonstrates the avulsed osteochondral fragment (arrows) anteriorly in the femorotibial joint space. Note the presence of hydrops (asterisk).

patients. These lesions are often subtle but can be significant clinically and may easily remain undetected. It is important to include MRI sequences that are sensitive to articular cartilage injury in the evaluation of internal derangement of the paediatric knee (4). 1.1.1. Chondropathy MRI shows chondropathy as focal cartilaginous thickening, superficial or deep ulceration or fissuring and demonstrates associated bone bruise and osteochondral separated fractures (5). 1.1.2. Chondral fracture With shear stress mechanism of injury, chondral avulsion fracture may occur. A focal defect in the articular cartilage and the presence of a

cartilaginous fragment in the joint space may be demonstrated (Fig. 1ab).

From: Ghent University Hospital, Ghent, Belgium. Address for correspondence: L.B.O. Jans, M.D., Ghent University Hospital, De Pintelaan 185, B-9000 Ghent, Belgium. E-mail: lennartjans@hotmail.com

TPD is often an unexpected finding on MRI of the knee in children. Paediatric manifestations of TPD

1. Traumatic paediatric knee lesions 1.1. Chondral injury Cartilaginous injuries are the most common lesions after acute knee trauma in skeletally immature

1.2. Physeal Fractures Approximately 15% of all paediatric fractures involve the physis (6). MRI demonstrates the cartilaginous path of the fracture, as well as associated findings (7). Nearly 15% of all physeal fractures lead to growth arrest with the formation of a bone bridge across the physis, causing subsequent limb shortening or angular deformity. The distal femur (1.4%) and proximal tibia (0.8%) are infrequent sites of physeal fracture, but have high incidences of post-traumatic premature physeal fusion (35% and 16% respectively) (1). 1.3. Temporary Patellar Dislocation (TPD)/Patellar subluxation

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trauma with stretched ACL may result in avulsion of the tibial spine. The composition of the tibial spine in children renders it weaker than the ACL (11). Non-operative versus surgical management is determined by the degree of displacement of the osseous fragment and is controversial in skeletally immature athletes because the reconstruction technique requires crossing of the growth plate (5). 1.6. Osteochondritis dissecans (OCD)

Fig. 2. â&#x20AC;&#x201D; Temporary patellar dislocation (patellar subluxation) in a 7-year-old girl. Axial T2-weighted image with fat saturation demonstrates bone marrow edema (arrows) in (A) the lateral femoral condyle and (B) in the entire patella.

Fig. 3. â&#x20AC;&#x201D; Patellar sleeve avulsion in a 10-year-old boy. A. Sagittal and (B) coronal T2-weighted images with fat saturation demonstrate a hypointense fracture line with surrounding bone marrow oedema (arrows) in the inferior aspect of the patella.

seen on MRI are similar to those in adults. Bone bruising of the inferomedial patella and the lateral femoral condyle (kissing contusions), cartilage injuries of the inferomedial patella and the lateral femoral condyle, osteochondral fragments and injuries of the medial patellar restraints are the most common findings of TPD on MRI (Fig. 2a-b) (2, 8). 1.4. Patellar sleeve avulsion The composition of the ossifying patella renders it weaker than the patellar tendon. Rapid forceful contraction of the quadriceps against resistance in partial flexion of the knee can result in avulsion fracture of the inferior patellar pole. The typical patient is 9 to 12 years old and presents with acute inferior patellar pain. The cartilaginous injury is always much more extensive than the avulsed fragment of ossified bone (Fig. 3a-b) (9). Patella alta may

be present if the avulsion is complete. In some cases the avulsed fragment may be entirely cartilaginous and therefore occult on radiography. MRI establishes the extent of the cartilaginous injury and delineates joint involvement and the degree of fragment displacement. This information can be useful diagnostically and in guiding therapy. Treatment involves prompt surgical reduction and internal fixation of the disrupted patellar tendon. If a bony fragment is visible on conventional radiography and the displacement is less than 2 mm, closed treatment in a cast in extension is justified (10). Injuries at the superior patellarquadriceps junction also occur but are less frequent (9). 1.5. Tibial spine avulsion fracture Tibial spine avulsion fractures are common before physeal closure (Fig. 4a-b). In paediatric athletes,

Repetitive microtrauma is felt to play a role in the etiology of juvenile OCD. The lesion is thought to be an osteochondral fracture with avascular necrosis of subchondral bone and overlying cartilage (Fig. 5). In the knee, OCD most commonly affects the lateral aspect of the medial femoral condyle (3). MRI confirms the diagnosis and evaluates the stability of the lesion (12). A high T2 signal intensity rim surrounding a juvenile OCD lesion indicates instability if it has the same signal intensity as adjacent joint fluid, if it is surrounded by a second outer rim of low T2 signal intensity, or if it is accompanied by multiple breaks in the subchondral bone plate on T2weighted images. Cysts surrounding the lesion indicate instability only if they are multiple or large in size (> 5 mm) (13, 14). MRI can assess the integrity of the overlying cartilage and identifies the presence of loose bodies in the joint (15). OCD must be differentiated from normal variants of ossification in the paediatric knee, most commonly seen at the posterior aspect of the lateral femoral condyle without associated bone marrow oedema (16, 17). 2. Non-traumatic paediatric knee lesions 2.1. Infection Infection of the musculoskeletal system in children is challenging. In the appropriate clinical context, the main responsability for the radiologist is to raise the possibility of infection when reporting conventional radiography or ultrasound studies and to select the appropriate next imaging modality to confirm diagnosis. Since no single MRI feature can differentiate septic from non septic arthritis, biopsy may be warranted in the work-up of these lesions (18-20). 2.1.1. Septic arthritis A missed diagnosis of septic arthritis of the knee in children may lead to severe long-lasting sequelae

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Fig. 4. — Tibial spine avulsion in a 14-year-old boy. A. Coronal T1-weighted image and (B) sagittal T2-weighted image with fat saturation demonstrate avulsion fracture of the tibial spine (long arrows) with bone marrow oedema of the fracture fragments. There is no tear of the anterior cruciate ligament (short arrows).

Fig. 6. — Bone and cartilage lesions due to septic arthritis of the knee in (a) an 9-year-old boy and (b) in a 7-year-old girl. A. Coronal T1-weighted image demonstrates ill-defined osteochondral defects (arrows) in the medial and lateral femoral epiphysis. B. Coronal T1-weighted image demonstrates a large bony bar of the distal epiphysis of the femur (arrow) following meningococcus septic arthritis of the knee.

and disability. In young patients with an acutely swollen knee joint, the diagnosis of septic arthritis must always be excluded. If sepsis is suspected, urgent joint aspiration is mandatory since early appropriate treatment is curative (18). Numerous investigations including plain radiographs, US, CT and MRI may be needed for diagnosis and to guide therapy. It is important to realize that changes on conventional radiography are only seen in late stage disease, therefore negative radiographs do not exclude septic arthritis. US, CT or MR guided percutaneous biopsy may obtain the causative micro-organism (19). Although no single MRI feature can differentiate septic from non septic arthritis, the presence of several abnormal findings increases the

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probability of infection (20). Bone erosions appear earlier compared with non septic arthritis. Concomitant bone erosions and marrow oedema are highly suggestive of septic arthritis, and the added presence of synovial oedema and thickening, soft tissue oedema or bone marrow enhancement is even more suggestive of infection (Fig. 6a-b) (21). Joint effusion can be present in both septic and non septic joints, up to one third of patients with septic arthritis lacks a joint effusion. Abnormal marrow signal is worrisome for concomitant osteomyelitis, especially if diffuse and visible on T1weighted images (22). 2.1.2. Osteomyelitis MRI is not suitable for screening in paediatric osteomyelitis, but it

Fig. 5. — Osteochondritis dissecans in an 11-year-old boy. Sagittal Pd-weighted image demonstrates a large osteochondral lesion (long arrows) surrounded by a rim of high signal (short arrows) and multiple small perilesional cysts (arrowhead) in keeping with unstable OCD. Note the lesion extends along the middle and posterior third of the femoral condyle.

first choice imaging modality for complementary examination if there is a clinical suspicion but conventional radiography is negative. MRI can also be guided by other imaging studies (eg. Tc bone scan in case of suspected chronic recurrent osteomyelitis). In osteomyelitis, the tubular bones are most of the time affected at the metaphysis level, but epiphyseal involvement may occur as well (19). In early osteomyelitis bone marrow oedema is present, enhancing with IV Gadolinium administration. There is usually a poor delineation between normal and abnormal bone marrow. In chronic osteomyelitis, there is a sharp differentiation between normal and abnormal soft tissues surrounding the bones. Gadolinium enhancement delineates intraosseous and soft tissues abscesses and collections. Infection extending to the growth plates is ideally demonstrated in the coronal or sagittal imaging planes. Underlying preexisting conditions include sickle cell disease, immunodeficient state and chickenpox (19). CRMO (Chronic recurrent multifocal osteomyelitis) is considered part of the SAPHO syndrome (synovitis, acne, pustulosis, hyperostosis, osteitis). In CRMO, multiple foci of osteocondensation and osteolysis with ill-defined bone marrow edema involving metaphysis and diaphyses are seen (19).

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Fig. 7. — Juvenile arthritis of the knee in a 9-year-old girl. A. Coronal T1-weighted image demonstrates a subchondral lesion (arrows) in the medial femoral epiphysis. B. Sagittal T1-weighted image demonstrates a subchondral lesion (arrow) in the weight-bearing aspect of the medial femoral epiphysis. Note the presence of a large joint effusion (asterisk).

condition (24). Moreover, MRI may play a role in therapy monitoring. The early MRI features of JIA in the knee joint are irregularity of the infrapatellar fat pad, lymphadenopathy, ill-defined areas of bone marrow oedema and joint effusion. If these features are present gadolinium can be administered to assess the degree of synovial hypertrophy. Erosions are one of the endpoints of the disease process in JIA and indicate destruction of both bone and cartilage (Fig. 7a-b). Erosions can occur at any point along the articular surface of the bone but are most often seen at the insertion site of the intraosseous ligaments and at the sites of synovial reflection, as these areas have relatively less overlying protective cartilage (25). Erosions are seen as well circumscribed lesions with low T1 and high T2 signal, often showing marked enhancement following gadolinium administration (26). Differential diagnosis with septic arthritis is often challenging and biopsy may be necessary (20). 2.2.2. PVNS (Pigmented villonodular synovitis)

Fig. 8. — Haemophiliac arthropathy of the knee in a 13-year-old boy. A. Sagittal T2-weighted image with fat saturation demonstrates several ill-defined subchondral lesions and a subchondral cyst (arrowheads) in the lateral femoral epiphysis and lateral tibial epiphysis. Hemosiderin staining is demonstrated as a T2 hypointens lining of the synovium (arrow). Moderate to large joint effusion is present (asterisk). B. Sagittal T1-weighted image with fat saturation after IV contrast administration demonstrates ill-defined subchondral lesions (short arrows) in the medial and lateral femoral epiphysis. The synovium enhances and is slightly thickened (long arrows).

2.2. Inflammatory disease A variety of conditions may result in cartilagenous or bony lesions of the knee due to synovial inflammation, including juvenile idiopathic arthritis (JIA), haemophilia, pigmented villonodular synovitis (PVNS) and intraarticular vascular lesions. Clinical presentation may be suggestive. Patients with JIA classically present with persisting articular inflammatory symptoms > 6 weeks, with onset before the age of 16years-old and may present with

chronic uveitis, arthritis of the temporomandibular joint or cervical spine ankylosis. Anemic symptoms in patients with hemophilia also suggest the correct diagnosis (3). 2.2.1. JIA Juvenile idiopathic arthritis (JIA) is the most common chronic rheumatic disease of childhood and is an important cause of short-term and long-term disability (23). The radiologist has an important role in suggesting the diagnosis of JIA as the clinician may not be aware of the

PVNS is a mono-articular process involving the knee in 80% (27). With PVNS, synovial proliferation and signal loss due to chronic hemosiderin deposition is demonstrated. The latter finding is accentuated on gradient echo imaging due to magnetic susceptibility artefact, known as ‘blooming’. Contrast-enhanced imaging is useful in diagnosis and assessment of the lesion extent of PVNS in paediatric patients (28). MRI features are particularly useful for differentiating PVNS from hemophilia. Differential diagnosis includes hemophilia (typical clinical history) and hemangioma (presence of serpentine vascular channels) (27). 2.2.3. Haemophilia Haemophiliac arthropathy due to recurrent haemartrosis is the main clinical feature of severe haemophilia and a major cause of morbidity in this group of patients. The most common findings in haemophiliac arthropathy of the knee are joint effusion, synovial hypertrophy, synovial haemosiderin deposits and osteochondral lesions resulting in joint space narrowing (Fig. 8a-b). The latter finding is accentuated on gradient echo imaging. MRI clearly depicts these changes, which may not be identified by conventional radiography in early stages, even before the presence of symptoms.

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Fig. 9. — Juxtaarticular VM (venous malformation) of the knee in a 17-year-old girl. A. Axial T2-weighted image with fat saturation demonstrates a small VM (arrow) centred along the anterior aspect of the knee joint, extending into the synovium. B. Coronal T2-weighted image with fat saturation demonstrates signal changes of the lateral femoral condyle and tibial plateau representing subchondral cyst formation (arrows) and focal bone marrow oedema (arrows). An osteophyte of the lateral femoral condyle is present (thin arrow).

Fig. 11. — Bone tumour of the knee (a) a 15 year-old boy and (b) a 10-year-old boy. A. Sagittal T1-weighted images demonstrates a large osteosarcoma in the distal femoral diaphysis, metafysis and epiphysis with cortical breach and extraosseous invasion (arrows). B. Sagittal T1-weighted images demonstrates a large tumour (arrows) in the proximal tibial epiphysis with cortical breach and intraarticular invasion. Diagnosis of enchondroma was confirmed after lesion biopsy.

Early diagnosis of joint haemorrhage and synovial hypertrophy alters the therapeutic management and may prevent progressive joint destruction and surgery (29, 30, 31). 2.2.4. Vascular lesions Vascular lesions with intraarticular extension may cause osteochondral lesions due to inflammatory response of the synovium and synovial fluid to hemosiderin deposition. The presence of abnormal juxtasynovial vascular structures will suggest the diagnosis (32).

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2.2.4.1. Venous malformation (VM) VM is the most common vascular malformation of the extremities and is clinically blue and compressible. Ultrasound demonstrates venous flow within the lesion. Typical MR imaging findings of VM include cystic or sinusoidal T2 hyperintense structures, presence of phleboliths and central enhancement pattern (32). There is a high prevalence (nearly 50%) of intra-articular extension of venous malformations (VMs) adjacent to the knee joint, and a

Fig. 10. — Osteonecrosis in a 10-yearold boy. Sagittal T2-weighted image with fat saturation demonstrates well circumscribed lesions with an interface that appears as a thin, winding line in the epiphysis (arrows) and metaphysis (arrowheads) of the femur and tibia.

strong association of these deep lesions with arthropathy (nearly 90%), often with haemosiderin deposition indicating bleeding into the joint (Fig. 9a-b). The frequency of arthropathy increases with increasing extension of the VM into the joint. MRI evaluation of all juxtaarticular VMs identifies possible associated arthropathy, which may be important in determining the timing and aggressiveness of therapy (32). 2.2.4.2. Synovial haemangioma Synovial haemangioma presents as a nodular mass lesion. Ultra sound demonstrates arterial flow within the lesion. Within the mass, signal void due to the presence of abnormal vessels may mimic hemosiderin deposits. Intense enhancement of the mass lesion following gadolinium administration with flow voids suggests the diagnosis (33). 2.3. Osteonecrosis Osteonecrosis of the knee is a frequent complication of high dose steroid treatment of acute leukaemia in children and can lead to joint collapse and may predispose to secondary arthritis (34). MRI findings of osteonecrosis might be present before any symptoms occur, allowing the earliest and most accurate diagnosis of osteo-

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Fig. 12. â&#x20AC;&#x201D; Bipartite patella in a 14-year-old girl. A. Coronal T2-weighted image with fat saturation demonstrates bipartite configuration of the cranial lateral aspect of the patella (arrows). B. Sagittal Pd-weighted image with fat saturation demonstrates a hypointense lesion in the cranial aspect of the patella (arrows). The retropatellar articular cartilage appears normal (long arrow).

and biopsy of the tumour is mandatory. Correlation with age and site of the lesion (eg. epiphyseal, diaphyseal or metaphyseal) may be helpful in the differential diagnosis. Metastasis of neuroblastoma and leukemia have to be included in the differential diagnosis in infants whereas osteosarcoma is the most common malignant primary bone tumour in children and adolescents (36-37). The most important role of MRI is to image the extend of the primary tumour and to look for skip metastasis. Dynamic contrast-enhanced MRI may be helpful in monitoring response to therapy in osteosarcoma since the active tumoral tissues in size with treatment, whereas lesional volume reduction does indicate response to therapy for Ewing sarcoma (37). 3. Developmental ossification variants 3.1. Bipartite patella (BP) and dorsal patellar defect (DPD)

Fig. 13. â&#x20AC;&#x201D; Normal ossification variants of the femoral condyle mimicking osteochondral lesion. A. Sagittal T1-weighted MR image in a 7-year-old girl demonstrates an ill-defined osseous defect (arrow) in the posterior third of the lateral femoral condyle. An ossification completely fills the defect. B. Sagittal T1-weighted MR image in a 10-year-old boy of the knee demonstrates the presence of extra ossification centres (arrows) in the non-ossified cartilage of the posterior third of the lateral femoral condyle.

The patella usually arises from a single ossifying nucleus, but secondary centres of ossification may be located in the supero-lateral quadrant. These usually fuse to form a single bone, but may remain separate to form a bipartite or multipartite patella (Fig. 12a-b). The dorsal patellar defect is also thought to represent a failure in the ossification of the patella (38-40). Skeletal normal variants may become symptomatic after repetitive stress: painful bipartite patella is related to the effects of traction forces in the fibrocartilaginous synchondrosis (37). Most DPD remain asypmtomatic as the cortical defect is usually compensated by overgrowing articular cartilage (40). 3.2. Ossification variants of the femoral condyle

necrosis (35). The lesions typically have a geographical appearance with a characteristic interface between living and dead bone at the periphery of the lesion that appears as a thin, winding line with low T1 signal and high T2 signal that circumscribes and clearly demarcates the zone of necrosis (Fig. 10ab). In case of progression with sub chondral collapse, which is a complication of progressive osteonecrosis near a joint surface, the inner zone of necrosis may show low signal intensity or might be inhomogeneous (36).

2.4. Tumour The diagnosis of a bone tumour in children is often delayed and at time of diagnosis intraarticular extension with osteochondral destruction may be present. Enhancing osseous mass lesions with extensive surrounding bone marrow oedema, breach of the cortex with periosteal reaction and extension into the soft tissues fit every definition of malignant tumour (Fig. 11a). However, benign bone tumours may demonstrate extraosseous extension as well (Fig. 11b). Prompt recognition

Normal variants of ossification are common in rapidly growing children and should not be confused with lesions (16, 17). Ossification defects in the posterior femoral condyles with intact overlying cartilage, accessory ossification centres, spiculation, greater residual physeal cartilage and lack of bone marrow oedema are features of developmental variants (17). Sample images of ossification variant are presented in Fig. 13 a-b. Early ossification centre in the residual cartilage is the most common ossification variant, followed by spiculated configuration of

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the secondary ossification centre, pre-ossification centre, extra ossification centre, puzzle piece and incomplete puzzle piece configuration ossification variant (17).

12.

Conclusion Lesions of the knee become increasingly more common in children. MRI clearly depicts osteochondral lesions of the paediatric knee and can differentiate traumatic from non traumatic knee lesions. Recognition of these conditions is mandatory since timely diagnosis guides therapy and may prevent lifelong disabilties. Normal ossification variants may occur in the ossifying knee and can mimic lesions.

13.

14.

15.

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injury versus tibial spine fracture in the skeletally immature knee: a comparison of skeletal maturation and notch width index. J Pediatr Orthop, 2004, 24: 185-188. Bohndorf K.: Osteochondritis (osteochondrosis) dissecans: A review and new MRI classification. Eur Radiol, 1998, 8: 103-112. De Smet A.A., Fisher D.R., Graf B.K., et al.: Osteochondritis dissecans of the knee: value of MR imaging in determining lesion stability and the presence of articular cartilage defects. AJR, 1990, 155: 549-553. Kijowski R., Blankenbaker D.G., Shinki K., et al.: Juvenile versus adult osteochondritis dissecans of the knee: appropriate MR imaging criteria for instability. Radiology, 2008, 248: 571-578. Hughes J.A., Cook J.V., Churchill M.A., et al.: Juvenile osteochondritis dissecans: a 5-year review of the natural history using clinical and MRI evaluation. Pediatr Radiol, 2003, 33: 410-417. Nawata K., Teshima R., Morio Y., et al.: Anomalies of ossification in the posterolateral femoral condyle: assessment by MRI. Pediatr Radiol, 1999, 29: 781-784. Gebarski K., Hernandez R.J.: Stage-I osteochondritis dissecans versus normal variants of ossification in the knee in children. Pediatr Radiol, 2005, 35: 880-886. Johnson K., Witkop D., Haigh F., Ryder C., Gardner-Medwin J.M.: The early magnetic resonance imaging features of the knee in juvenile idiopathic arthritis. Clinical Radiology, 2002, 57: 466-471. Schmit P., Glorion C.: Osteomyelitis in infants and children. Eur Radiol, 2004, 14: 44-54. Bancroft L.W.: MR imaging of infectious processes of the knee. Radiol Clin N Am, 2007, 45: 931-941. Graif M., Schweitzer M.E., Deely D., Matteucci T.: The septic versus nonseptic inflamed joint: MRI characteristics. Skeletal Radiol, 1999, 28: 61620. Karchevsky M., Schweitzer M.E., Morrison W.B., Parellada J.A.: MRI findings of septic arthritis and associated osteomyelitis in adults. AJR, 2004, 182: 119-122. Damasio M.B., Malattia C., Martini A., Toma P.: Synovial and inflammatory diseases in childhood: role of new imaging modalities in the assessment of patients with juvenile idiopathic arthritis. Pediatr Radiol, 2010, 40: 985-998. Johnson K.: Imaging of juvenile idiopathic arthritis. Pediatr Radiol, 2006, 36: 743-758. Kight A.C., Dardzinski B.J., Laor T., et al.: Magnetic resonance evaluation of the effects of juvenile rheumatoid arthritis on distal femoral weightbearing cartilage. Arthritis Rheum, 2004, 50: 901-905.

253 26. Malattia C., Damasio M.B., Magnaguagno F., et al.: Magnetic resonance imaging, ultrasonography, and conventional radiography in the assessment of bone erosions in juvenile idiopathic arthritis. Arthritis Rheum, 2008, 59: 1764-1772. 27. Murphey M.D., Rhee J.D., Lewis R.B., et al.: Pigmented villonodular synovitis: Radiologic-Pathologic correlation. Radiographics, 2008, 28: 1493-1518. 28. Eckhardt B.P., Hernandez R.J.: Pigmented villonodular synovitis: MR imaging in pediatric patients. Pediatr Radiol, 2004, 34: 943-947. 29. Dobon M., Lucia J., Aguilar C., Mayayo E., Roca M., Solano V., Pena S., Giralt M., Ferrandez A.: Value of magnetic resonance imaging for the diagnosis and follow-up of haemophilic arthropathy. Haemophilia, 2003, 9: 76-85. 30. Nuss R., Kilcoyne R., Rivard G., et al..: Late clinical, plain x-ray and magnetic resonance imaging findings in haemophilic joints treated with radiosynoviorthesis. Haemophilia, 2000, 6: 658-663. 31. Ng W.H., Chu W.C., Shing M.K., et al.: Role of imaging in management in hemophilic patients. Am J Roent genol, 2005, 184: 1619-23. 32. Jans L., Ditchfield M., Jaremko J.L., Stephens N., Verstraete K.: MRI demonstrates the extension of juxtaarticular venous malformation of the knee and correlates with joint changes. Eur Radiol, 2010, 7: 1792-8. 33. Helpert C., Davies A.M., Evans N., Grimer R.J.: Differential diagnosis of tumour-like lesions of the infrapatellar (Hoffa's) fat pad: pictorial review with an emphasis on MR imaging. Eur Radiol, 2004, 14: 2337-2346. 34. Karimova E.J., Kaste S.C.: MR imaging of osteonecrosis of the knee in children with acute lymphocytic leukemia. Pediatr Radiol, 2007, 37: 1140-1146. 35. Karimova E.J., Rai S.N., Ingle D., et al.: MRI of knee osteonecrosis in children with leukemia and lymphoma: part 2, clinical and imaging patterns. AJR, 2006, 186: 477-482. 36. Dorfman H.D., Czerniak B.: Bone cancers. Cancer, 1995, 75: 203-210. 37. Hoffer F.: Primary Skeletal neoplasms: Osteosarcoma and Ewing sarcoma. Topics in Magnetic Resonance Imaging, 2002, 13: 231-240. 38. Mellado J.M., Salvado E., Ramos A., Camins A., Sauri A.: Dorsal defect on a multipartite patella: imaging findings. Eur Radiol, 2001, 11: 11361139. 39. Lawson J.P.: Clinically significant radiologic anatomic variants of the skeleton. AJR, 1994, 163: 249-255. 40. Van Holsbeeck M., Vandamme B., Marchal G., Martens M., Victor J., Baert A.L.: Dorsal defect of the patella: concept of its origin and relationship with bipartite and multipartite patella. Skeletal Radiol, 1987, 16: 304311.

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DENTAL CONE BEAM CT AND ITS JUSTIFIED USE IN ORAL HEALTH CARE R. Jacobs1 While dental 2D radiology is still the most frequent diagnostic tool, the inherent nature of jaws and teeth might surely benefit from 3D diagnosis. Nowadays, dental cone beam computed tomography may offer high quality images at low radiation doses and costs. Yet, effective dose ranges of CBCT machines may easily vary from 10-1200 microsievert, being an equivalent of 2 to 240 dental panoramic radiographs. The same holds true for diagnostic image quality, which exhibits a huge variation amongst machines and parameter settings. For segmentation accuracy, lower limits of accuracy are around 200 micrometer, yet again, larger inaccuracies may apply. For linear accuracies, values below 500 micrometer are feasible, with some machines and CBCT parameter settings allowing linear accuracies of up to 200 micrometer. Apart from the radiodiagnostic possibilities, dental cone beam CT may offer a vast therapeutic potential, including possibilities for surgical guidance and further treatment via CAD/CAM solutions for crown and bridgework on teeth or implants. In conclusion, dental CBCT imaging could be justified when dealing with specific indications including jaw bone and maxillofacial surgery, endodontic retreatment, traumata, jaw bone lesions and TMJ pathology. Yet, guidelines for CBCT optimisation and justification are mandatory, especially when used for pediatric indications. Key-words: Computed tomography (CT), image processing – Jaws, CT – Teeth.

Imaging is the most important and most frequently used diagnostic tool in dentistry. More than one quarter of all medical radiographs in Europe is made by dentists, in some countries this number even approaches 50% (e.g. Sweden). The importance of radiographs for dental diagnosis is illustrated by the fact that hardly two weeks after discovery of the x-ray by WC von Röntgen, German dentist Walkhoff already made a first radiographic image of human teeth. For more than a century this type of dental radiographs has been the dominant source for diagnostic information on the maxillofacial complex, jaws and teeth. Yet, 2D projective techniques cannot fully display complicated 3D anatomical structures and related pathologies such as impacted teeth, root resorption, apical granulomata, periodontal breakdown, cystic lesions or benign tumors (1). In the eighties, a first revolution came with the introduction of digital dental (radiographic) imaging in dentistry. A second shockwave came in the nineties when three-dimensional imaging modalities for typical dentomaxillofacial applications appeared on the market. Yet, in the nillies, there has been a very important and steep upward trend in using 3D information as an aid in dento maxillofacial diagnostics. This 3D acquisition was initially realized by

conventional computed tomography. Nowadays, dental cone beam computed tomography enables volumetric jaw bone imaging at reasonable costs and doses and often with a relative advantage of having this equipment nearby. The latter aspect is very important when considering the fact that the power of a dental 3D dataset is not only situated in the diagnostic field, yet also in a multitude of presurgical and therapeutic applications. Indeed, currently, the rapid advances of digital technology and computer-aided design/ computer-aided manufacturing (CAD/ CAM) systems are creating exciting opportunities for diagnosis, surgical planning and delivery of restorative dentistry. Because dentists are considered prolific users of digital diagnostic software, there is a huge demand for even better interactive software as such to obtain the maximum diagnostic benefit from radiographic, optical and other clinical photographic images. Concomitantly with these evolutions, the public becomes more and more medically demanding and informed, therefore wishing even greater explanation and demonstration of what treatment options are possible. The latter often involves image manipulation to demonstrate therapeutic stages and likely outcomes. The present review will evaluate whether the inherent three-dimen-

From: 1. Oral Imaging Centre, Department of Dentistry, Oral Pathology and Maxillo facial Surgery, Faculty of Medicine, Catholic University of Leuven, Belgium. Address for correspondence: Dr R. Jacobs, D.D.S., Ph.D., Msc. Dental Radiology, Periodontologist, Oral Imaging Centre, Faculty of Medicine, Katholieke Universiteit Leuven, Kapucijnenvoer 33, B-3000 Leuven, Belgium. E-mail: Reinhilde.Jacobs@uzleuven.be

sional nature of the skull and related pathologies of jaws and teeth would benefit from 3D diagnosis. Demonstrating potential benefits and indications might surely apply to preoperative planning of jaw bone surgery, which is a relatively common procedure, yet not without risks. Furthermore other tooth- or jaw bone related pathologies might gain from three-dimensional diagnostics. Such 3D diagnosis might be accomplished via de dental cone beam CT. Up till now, as it is a relatively new technique, there are no consensus guidelines and a wide variety of machines and performances, stressing the need to establish the optimization strategies for CBCT use. By critically reviewing the available evidence, the aim of the present literature study is twofold: 1) to provide some support for the hypothesis on use of 3D information for jaw bone surgery; 2) to attempt formulating some guidelines for justified and optimized use of CBCT during the various implant treatment phases. Is cross-sectional imaging justified for dental indications? Although various dentomaxillofacial imaging options are available for a multitude of dentomaxillofacial indications, cross-sectional imaging seems to be favoured for specific indications. The most important one being the presurgical planning of implant placement, primarily to avoid neurovascular trauma, but also to enable integration of anatomic, functional, biomechanic and esthetic factors (2, 3) (Fig. 1). Although panoramic and intraoral views are the first choice radiographs to assess teeth and periodontal

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Fig. 1. â&#x20AC;&#x201D; The prime indication of dental CBCT is the presurgical planning of implant placement, primarily to avoid neurovascular trauma, but also to enable integration of anatomic and functional factors.

status, an obvious limitation is that these do not provide information on the buccolingual dimensions, jaw bone morphology and irregularities within the alveolar bone. Intraoral periapical images offer a high spatial resolution, making them valuable for detailed diagnosis of tooth-related pathologies. These radiographs might also give a rough idea of the trabecular bone structure, yet the anatomic structure overlap prevents detecting trabecular bone lesions. Furthermore, intra-oral radiographs lack the potential to visualise bone morphology. Finally, these images are limited in size, therefore depicting less anatomic information than sometimes required, meanwhile also preventing a comparison of a local problem with the environment or the contralateral side. This can be the case in the posterior mandible, where localisation of the mandibular canal and mental foramen is essential. Similarly, the maxillary sinus region may not always be sufficiently visualized (2). Usually, the visualization of odontogenic sinusitis problems is much lower with intra-oral radiographs than with CBCT. The latter also applies for panoramic radiographs, which are typically providing information on the gross anatomy of the jaws and related anatomical

structures, allowing a global treatment plan to be made. The twodimensional nature and substantial anatomic structure overlap, the inherent distortion and enlargement, the tomographic effect and limited resolution, make these images less well suited for evaluating details in teeth and bone, particularly in the horizontal planes (2). These drawbacks have a serious impact on assessing the relationship between anatomic structures, and limit detailed diagnosis. Furthermore, there is a true lack of accurately assessing the neurovascular structures, presenting a peroperative risk for neurovascular trauma (3) (Fig. 2). Although the widespread use of both intra-oral and panoramic radiographs for typically dental and periodontal indications; the aforementioned drawbacks of either technique may explain their limited value when there is a need for visualizing anatomical structures in 3 dimensions, such as in preoperative planning of jaw bone and maxillofacial surgery. To overcome these drawbacks, cross-sectional or even true three-dimensional imaging may be advocated, if the radiation burden can be kept at low levels. Nowadays, the most obvious choice to obtain this, is by using the dedicated dental

Fig. 2. â&#x20AC;&#x201D; In this patient, a panoramic radiograph was taken as the basis of the presurgical planning protocol. The presence of the incisive nerve in the anterior jaw bone was ignored and the implant was placed right on top of the nerve, inducing a chronic neuropathia.

cone beam CT (CBCT). Since the introduction of the first dental CBCT in the nineties, the market has been exponentially growing. More than 50 devices are currently available. Unfortunately, this exponential growth has created a gap between scientific literature and available hardware. Indeed, available research evidence for one CBCT machine may not automatically apply to other equipment and research findings cannot simply be generalised. Dental CBCT use beyond radiodiagnostics As indicated above, the prime diagnostic tool for 3D image acquisition in dentistry, has rapidly become dental CBCT imaging. As the prime use of dental CBCT is related to oral implant placement (covering 2/3 of the indications), the exponential growth of the dental CBCT market has gone hand in hand with the

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Fig. 3. — The dental CBCT is a compact and easy-to-operate equipment for use in a dental office.

increasing use of oral implants for tooth replacement. Dental CBCT is a novel technique, capable of capturing three-dimensional dentomaxillofacial radiographs at low radiation dose levels and low cost (1). The

dental CBCT is reasonably affordable, compact and easy-to-operate equipment for in-office use (Fig. 3). The conical x-ray beam allows an entire volume to be scanned in one single rotation, with a reduced x-ray

tube power, while using a flat 2dimensional image receptor (4). The lower power configuration greatly reduces both costs and radiation (5), but is often associated with increased noise and -together with the smaller dynamic range of CBCT detectors- with a lower contrast resolution, making CBCT not suitable for soft-tissue imaging. Yet, due to the isotropic acquisition of CBCT and its image receptor, a high spatial resolution can be accomplished, needed for depicting small tooth or bony structures (6). Its compact size (< 4 m²), the greatly reduced costs and maintenance, the low dose and high spatial resolution have led to an exponential growth of available CBCT systems for dentomaxillofacial applications. Unfortunately, CBCT images are generally hampered by a varying degree of artifact expression. Major artifacts may derive from patient jaw movement and from dense dental restorative materials. Furthermore; altering CBCT geometrical configurations create a variable expression of artifacts including truncation, partial volume and several other artifacts. In addition, varying reconstruction protocols greatly impact image output and artifact expression (such as beam hardening and metal streak artifact). On top of that, the large variations within CBCT units may lead to variable degrees of linear, diagnostic and 3D model accuracy all needed to refine diagnostic tasks, surgical planning and CAD/CAM transfer. Nowadays, studies are typically focused on overcoming inherent drawbacks of the

Fig. 4. — Radiation dose levels vary amongst and within CBCT devices, with the lowest ones approaching the dose of one or two panoramic radiographs (9).

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radiographs; 8, 9) (Fig. 4). It should also be considered that even in the same machine, there can be a huge range of variable options in field-ofview, resolution and exposure parameter setting, with as a consequence an effective dose range of the same order as the variability amongst the machines (9). Cone beam CT as the method of choice for cross-sectional imaging oral health care Fig. 5. — A CBCT could easily replace a diagnostic cast considering an inherent segmentation accuracy of up to 200 µm (17).

technology by exploring modified scanning protocols or by fusion of CBCT image datasets with optical datasets to overcome the drawback of artefacts caused by metallic dental restorations (7). These optical datasets are derived from threedimensional optical cameras, most of them introduced in the nillies, and have a potential to turn the conventional dentistry completely upside down. Such optical camera systems may indeed offer the opportunity to avoid traditional, analog impressiontaking, eliminating not only the necessity of impression materials to be placed in the mouth, yet also reducing time and handling limitations associated with the impressions. The available intraoral 3D scanners may have the potential to offer excellent accuracy (up to 20 µm) with a more comfortable experience for the patient and a far more efficient workflow for the office. Fusions with basic CBCT data would thus allow a digital cast with an accurate surface to be used or transferred for therapeutic applications via CAD/CAM procedures. This semi-automation may eliminate manual steps and inevitable human errors when producing dental restorations. Nowadays, CAD/CAM procedures based on 3D information are used in dental practice, dental laboratories or elaborate production centers. As a result of continuous developments in computer hardware and software, new methods of production and new treatment concepts are to be expected. It may lead to simplification and more automation, resulting in dental restorations that are more precise in fit and more customized to the individual patient. Furthermore, it should also be mentioned that integrated facial scanning has become possible in

several CBCT units. The latter implies a concomitant laser 3D laser acquisition of the soft tissues of the face, during the CBCT acquisition. The latter allows a fully integrated planning with the 3D facial tissue scan on top of the bony skull image. The availability of fully integrated and accurate three-dimensional information of both face and bone, allows a more effective planning and predication of the treatment outcome. It not only enhances the transfer to the surgical field, yet also increases possibilities for radiation free follow-up of such surgical cases. Dosimetric aspects of dental CBCT Radiology is essential to dentists for determining the presence and extent of disease in jaw bone and teeth. It also has roles in treatment planning, monitoring disease progression and in assessing treatment efficacy. However, an integral part of radiology is exposure of patients and clinical staff. Unlike most medical imaging, dentists use radiology often as one of the diagnostic tools available in the dental practice, for intra-oral radiography even available chairside. At the same time, dentists may use such techniques to a relatively greater extent on children and young adults, so the need for thoughtful use is of paramount importance. Effective radiation doses should be typically far below the levels of clinical spiral CT, to be accepted as a true advantage. It should preferably be an equivalent of 2 to maximally 10 panoramic radiographs (20-100 µSv). Unfortunately, many of those systems seem to vary enormously. Reported radiation dose levels vary according to the CBCT device being assessed, from around 10 µSv to 1200 µSv (which is an equivalent of 2-240 panoramic

Cross-sectional imaging in oral health care was initially realized by conventional computed tomography, associated with relatively high radiation dose levels and costs. Nowadays, dental cone beam computed tomography enables volumetric jaw bone imaging at reasonable costs and doses. A potential drawback is that this is often associated with increased noise and a lower contrast resolution, preventing softtissue imaging. Nevertheless, the most important dentomaxillofacial diagnostic requirement is high 3D spatial resolution for depiction of small bony structures (1). Numerous scanners have now been developed for dentomaxillofacial use. Patient scanning is most often standing or seated which makes in-office units resemble compact panoramic machines (see Fig. 3). However, most scanners differ in geometrical configuration. This leads to a wide range of different field-of-views (FOV) with truncation or partial volume artifacts since the entire volumes are often not covered by the detector. In addition, data reconstruction may be very different, leading to variations in image quality and radiation dose. On top of that, exposure parameters further influence image quality within one system. Measurement accuracy has been found to be adequate for CBCT and MSCT, yet large differences between and within units may depend on exposure parameters (10, 11). Thus, despite the excellent properties and growing use of CBCT and even though the excess of studies demonstrating CBCT’s added value over other imaging techniques within almost all areas of dentistry, research is inconsistent in technology, exposure parameters or settings. Therefore, evidence-based guidelines are being established dealing with justification, optimization and referral criteria of CBCT for clinical practice (12, 13). Besides justification of 3D examinations, adequate training is required to ensure responsible

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Fig. 6. — As molar root often protrude in the maxillary sinus, extraction may easily cause a oroantral perforation (A). If the latter is large and the apical tooth region infection, this perforation does sometimes not heal, causing odontogenic sinusitis (B).

use and adequate diagnosis of possible additional findings (12). Indications of Cone Beam CT in oral health care The EADMFR basic principles on the use of Cone Beam CT published by Horner et al. (12) are a useful guidance for the justification and optimization. Typically, CBCT examinations should not be carried out unless a history and clinical examination have been performed. CBCT should add new information to aid the patient’s management. It should not be repeated routinely on a patient without a new risk/benefit assessment. The referring dentists should supply sufficient clinical information (which can include 2D radiographs) to allow performing the justification process and optimize the scanning. The following indications have been identified – preoperative planning of implant placement and autotransplantations of teeth; – dental anomalies; – eruption problems with impaction of permanent, surnumerary or supplementary teeth; – cleft-lip and palate; – maxillofacial surgery; – surgical wisdom tooth removal, with assumed interrelation between mandibular canal and wisdom tooth apices;

– assumed presence and follow-up of dento-alveolar trauma; – diagnosis after endodontic treatment failure to assess the prognoses and potential retreatment strategy; – bone-related TMJ problems; – diagnostic and/or therapeutic approach of benign jaw bone tumors and cysts; Oral implant placement The use of osseointegrated implants has revolutionized oral health care. Up till now there were no international consensus guidelines regarding the use of CBCT for pre-implant imaging. Some have advocated cross-sectional imaging for specific clinical circumstances (14) whereas others have proposed that cross-sectional imaging is the method of choice for most implant patients (15). The introduction of CBCT, offering imaging at low dose and relatively low costs, has increased the applicability and strengthened the justification of cross-sectional presurgical imaging. Apart from the reduction in radiation dose, there an also be a gain in image quality. Nowadays, it is therefore considered by far the most frequent application of dental CBCT. Oral implant treatment can be divided in different phases, with imaging playing a significant role in each of these phases (2).

The initial preoperative diagnostic phase should follow the clinical examination, during which it becomes obvious that implants might be a good alternative for the global treatment of the consulting patient. If it turns out that implants are needed in areas with a potential risk to damage vital structures, one may afterwards opt for adding the third dimension. More provocative, but probably also more efficient is the following reasoning: if a clinical examination reveals several edentulous areas, while pocket probing indicates some severe periodontal breakdown with the presence of crown and bridges weakening the roots, it could be hypothesized that the initial examination becomes a 3D low dose Cone Beam CT scan. The latter would then enable the practitioner to make an individualized reconstructed panoramic image, not suffering from the inherent tomographic effect nor from the cumbersome soft tissue overlap. This panoramic reslice could subsequently be used as an orientational reference to indicate where to place implants and where to inspect remaining teeth. It could even be used as a diagnostic cast considering an inherent segmentation accuracy of up to 200 µm, surely when the CBCT model is fused with a digital impression which then becomes very useful in the subsequent phase (11, 16, 17) (Fig. 5).

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The next phase is the preoperative planning, that should consider bone quality, bone quantity and anatomic limitations while incorporating prosthetic demands. In addition to a thorough clinical evaluation, imaging assessment is crucial in determining the regional morphologic and structural bony characteristics of the proposed implant site and the location of anatomical landmarks (Fig. 6). In addition, implant dimensions and the potential need for additional treatment prior or during implant placement (such as bone augmentation procedures) may be determined (see Fig. 1). The perioperative treatment phase involves all surgical and clinical aspects of implant and prosthesis placement. Cross-sectional imaging, particularly CBCT, may aid the transfer of the preoperative planning data to the surgical field. There are basically 2 methods of perioperative imagebased planning transfer: 1. surgical navigation; 2. surgical template guidance. While this was previously based on spiral CT data, more recently, image guided surgical techniques have been developed to incorporate initial CBCT imaging into computer-assisted operative strategies (18, 19). In this respect, it is also important to mention the intra-operative C-bows, which are derivatives of a CBCT imaging and may find indications for intra-surgical navigation, e.g. in complex maxillofacial surgery, in combination with implant placement (20). Risks for neurovascular trauma during jaw bone surgery With the increasing use of oral implants, the number of reported surgical complications has also been emerging. The latter applies for both maxilla and mandible and may include sensory disturbances as well as severe hemorrhage. Sensory disturbances can be caused by direct trauma to the nerve, indirect trauma (e.g. pressure by haematoma in canal) or chronic stimulation to the mandibular nerve or any of its branches (21). If an implant is situated aside of or on top of the nerve, then the nerve can be stimulated recurrently each time when biting or chewing. It is likely that such chronic stimulation may therefore end up as chronic neuropathy (3). Hypoaesthesia, anaesthesia and paraesthesia may display as a sensory disturbance. In some case, the sense of pain is mainly disturbed, but in others the

tactile and temperature senses are also disturbed. All these changes can be transient or persistent, depending on the degree of damage to the nerve tissue involved. Extensive hemorrhage in the floor of the mouth may occur during or after implant placement in the mental interforaminal region and may cause acute airway obstruction (21). The hemorrhage can not only be induced by instrumentation through a perforation of the lingual cortical plate, but may also be caused by touching and damaging the neurovascular bony canals, such like lingual canals. Vascular supplies from lingual artery, sublingual artery and submental artery are anastomotic for superior, inferior and lateral foramina. The multiple vascular anastomoses may thus lead a profuse bleeding even from a broken small size bony canal. A review of the literature shows 12 references describing 13 cases of hemorrhage in the floor of the mouth and potentially life-threatening upper airway obstruction, after the placement of implants in the anterior mandible (22) (Figs. 2 and 7). Importantly, the vascular size and canal diameter have often been identified as large enough to cause significant damage and bleeding when touching (3). In the maxilla visualization of pertinent anatomic structures, such as the nasoplatine canal, nasal fossa or maxillary sinus has received less attention in the literature. While the presence of these structures may impede and influence implant success, violation of these structures does not usually result in serious side effects (3, 21). Yet, even then, one should be cautious. Orthodontics A correct orthodontic diagnosis needs to be based on accurate images of the craniofacial region and is crucial for the development of a valid orthodontic treatment plan. Up till now, such images typically have a 2D nature, including panoramic radiography and lateral cephalography. Lateral cephalometric analysis has been used and developed for orthodontic treatment planning for decades (23). To suit this purpose, lateral skull radiographs with head fixation are generally used. Recently there has been an introduction of software which eases the orthodontists in indicating the anatomical landmarks, calculating the data and indicating the most suitable treatment plan. This tech-

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Fig. 7. â&#x20AC;&#x201D; Placement of an oral implant in the neighborhood of the mandibular midline lingual canal may cause hemorrhage in the floor of the mouth and potentially life-threatening upper airway obstruction. As the canal has a neurovascular content with a significant size, neural disturbances may also occur.

nique allows orthodontists to analyse teeth alignment, jaw class, soft tissue profile and growth development of the patients. Yet, one should consider the drawbacks including overlap of left and right structures (with a different image enlargement), superimposition of teeth and other structures on the critical anatomical landmarks, and poor soft tissue profiles, all leading to incorrect landmark identification and incorrect calculations for the analysis. In normal cases, these factors may not interfere with the treatment planning but in borderline cases or severe skeletal malformation, they may affect the treatment planning and further therapeutic approach. Indeed, all structures studied (teeth, jaws, skull and their interrelation) and treated have a 3D nature and thus a true volumetric analysis may be assumed to come closer to reality. During the last decade, there has been an upward trend in using 3D information as an aid in dentomaxillofacial diagnosis. Initially, this was realized by conventional computed tomography, associated with relatively high radiation dose levels and costs. Nowadays, dental cone beam computed tomography (CBCT) enables volumetric jaw bone imaging at reasonable costs and doses. This offers numerous diagnostic potentials and may change treatment strategies in oral health care, as long as radiation doses, image quality, diagnostic yield and treatment outcome can be properly balanced. This surely applies for the orthodontic field where justification is needed for volumetric scanning in children in order to increase benefits

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yield all necessary information not only including the 3D volume and its internal bone and tooth structures, yet also including a panoramic reslice, a cephalometric analysis in 2D/3D and a virtual cast. Thus, it may be replacing a cascade of 2-D radiographic images and depending on the machine type and exposure parameters. Up till now, some attempts have been made using the cone beam CT data for orthodontic treatment planning and 3D-cephalometric analysis (25, 26). Furthermore, some researchers have been performed to evaluate the accuracy of the 3D imaging technique (25-27). Yet so far, none has investigated the advantages of 3D over 2D imaging regarding diagnosis, treatment planning and therapeutic outcome for orthodontic applications. Tooth impaction Fig. 8. â&#x20AC;&#x201D; Damage to the inferior alveolar nerve during surgical extraction of deeply impacted third molars is a serious complication. The present case shows a complicated relation between the nerve (red line) and the roots of the impacted wisdom tooth.

Fig. 9. â&#x20AC;&#x201D; CBCT scans are superior to conventional panoramic radiographs in determining the location and orientation of an impacted tooth and its relationship to adjacent vital structures. The information can help to make the surgical exposure / removal minimally invasive.

in diagnosis, treatment planning and outcome (24-26). Yet, one should be aware that proper use of cone beam CT scanning should not necessarily

imply an increased radiation dose to those children. Indeed, if cases are carefully selected, one cone beam CT volumetric scan may be able to

Impaction is defined as a failure of tooth eruption at its appropriate site in the dental arch, within its normal period of growth, or with a delayed eruption time and not expected to erupt completely based on clinical and radiographic assessment. Dental impaction has been reported to affect as much as 25% to 50% of the population (28). The teeth predominantly involved in tooth impaction are third molars (28). Permanent maxillary canines are the second most frequently impacted teeth after the third molars (29). The prevalence of impacted third molars is variable in different populations, while the incidence appears to be increasing (30). Surgical removal of impacted teeth demands precise knowledge of the tooth location in the jaw and its relation to other teeth and surrounding anatomical structures (30). Before planning extraction of an impacted mandibular third molar, the topographic relationship between the mandibular canal and the molar should be clearly inspected as such to avoid damaging the inferior alveolar nerve (31). Damage to the inferior alveolar nerve during surgical extraction of deeply impacted third molars is a well-known complication. Over the years, numerous reports of inferior alveolar nerve injuries after wisdom teeth surgery have been recorded (31) (Fig. 8). Maxillary canine impaction occurs in approximately 1% to 3% of the population with a 2:1 female to male ratio for review (29). The maxillary canines are more commonly impacted than the mandibular canines.

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relationship to adjacent vital structures (Fig. 9). Supplementary and surnumerary teeth Polygenesis, the formation of one or more supernumerary teeth occurs much less frequently than agenesis. Supernumerary teeth can be found anywhere within the jaw, but the anterior midline of the maxilla is the most common site, in which case the supernumerary tooth is known as a mesiodens (32). Their presence may give rise to various clinical problems. Such teeth may have a highly aberrant form, often tucked-in to the lingual of the normal tooth row. Detection of supernumerary teeth is best achieved by thorough clinical and radiographic examination. Reports in prevalence of supernumerary teeth can be as high as 3.6% in the permanent dentition, depending on the population studied (32). An inverted supernumerary tooth is rather uncommon. Eruption of inverted teeth is extremely rare, but has been described for mesiodens and premolars (33). Treatment depends on the type and position of the supernumerary tooth and on its effect on adjacent teeth. By adequate diagnosis in 3 dimensions using CBCT and a further image-based presurgical planning, minimal invasive surgery can be performed, enhancing efficiency while reducing post-operative complaints.

Tooth agenesis

B Fig. 10. â&#x20AC;&#x201D; This patient has agenesis of 12 and 22 (A), and horizontal impaction of 23 (B). In such case, orthodontic treatment planning might benefit from 3D imaging.

Other teeth are less frequently impacted. In the Caucasian population, canines are impacted palatally at least 2 to 3 times more frequently than labially. In Asian subjects, however, it appears that impacted canines are usually bucal in position. To develop a treatment strategy, localisation of impacted canines relative to the incisors and premolars is crucial. Information regarding the palatal orientation of an impacted canine and its proximity to the roots of neighboring teeth is essen-

tial to allow for an effective and timely surgical intervention. Con ventional panoramic radiographs are routinely obtained to evaluate tooth impaction pre-operatively. However, the 2D nature of the image and the superimposition of adjacent anatomical structures impede precise assessment of the tooth relative to adjacent anatomical structures. CBCT scans are superior to conventional panoramic radiographs in determining the location and orientation of an impacted tooth and its

Agenesis of one or more teeth is one of the most common of human developmental anomalies (34). Failure of formation of one or more third molars occurs in a fifth of the population. The reported incidence of other missing teeth varies from 1.6% to 9.6%. Next in frequency of absence are the upper lower second premolars (3%) followed by the maxillary lateral incisors (2%). Absence of just a single premolar happens frequently. The absence of four or more teeth (other than third molars) occurs in 0.25% of the population. When a deciduous tooth is missing, its permanent counterpart is also absent. Occurrence of other anomalies in the deciduous dentition is a good predictor of anomalies in the corresponding teeth in the permanent teeth, although not necessarily of the same type. Although for tooth agenesis, a 3D image is not strictly required, those images can become a necessi-

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ty for the treatment options. When dealing with tooth agenesis, it may be decided to go for orthodontics and as seen in the aforementioned paragraph, the use of 3D imaging may be a valuable treatment option (Fig. 10). Should one however prefer to keep the deciduous tooth in place as long as possible, adult life may be reached as such that the location can then be prepared for oral implant installation. Such surgical strategy demands a presurgical CBCT-based planning. Finally, sometimes it is impossible to wait till adult age for replacing the particular tooth (eg esthetic demand in absence of upper lateral incisor), in that case a protocol for stereolithographic based tooth autotransplantation may be considered a valuable treatment option. Although the use and benefit of rapid prototyping models has already been documented (35), it is often claimed that a major drawback – especially in children – is the radiation burden. Yet when using a lowdose CBCT, with an exposure equivalent to 2 panoramic radiographs, approximating 1 day of background radiation, this drawback could be easily justified. Autotranplantation may thus become a more reliable treatment method for tooth replacement when using 3D CBCT-based

Fig. 11. — A cleft palate patient usually needs a series of revision surgeries with the need of presurgical imaging. Such patient also has a complicated complicated tooth eruption scheme (A), which may surely benefit from a true 3D imaging approach (B). The low dose CBCT may suit well for this task.

pre-surgical planning with transfer by stereolithographic surgical guidance. The final outcome of the autotransplantation may benefit from a significantly reduced extra-oral time, a more accurate recipient site preparation, and a better position of the donor tooth (35). Cleft lip and palate and maxillofacial surgery in general In cleft lip and palate patients, information regarding the number and orientation of teeth, dental and skeletal age and the amount and quality of available bone in the cleft region are considered vital for the clinical management of such cases. Panoramic radiographs are often used to investigate the incidence and number of missing teeth and to determine dental and skeletal age in cleft lip and palate patients. However, the amount and quality of available bone cannot be accurately assessed on a panoramic radiograph. The same applies to the complicated tooth eruption scheme. It is obvious, that diagnosis and management may gain from a true 3D imaging approach. Yet, considering the repeated use in children and the relatively low dose, CBCT is rapidly replacing medical CT for this

task (36) (Fig. 11). 3D CBCT reconstructions of nose and facial skin are also possible. These principles, advantages and drawbacks surely also apply for maxillofacial surgery in general. The possibilities of CBCT to deliver integrated 3D information beyond diagnostics may surely help maxillofacial surgeons in preparing or preoperatively transferring the surgical demands. The availability of digital impressions for a refined occlusal surface and the use of CBCT devices with a concomitant facial scan may surely add to to the possibilities of an optimized transfer of the preoperative planning phase to the surgical theatre. Maxillofacial trauma Although plain radiographs are useful in the initial evaluation of suspected facial fractures, CT is advised for detecting radiographically occult fractures, or fractures suspected on the basis of secondary signs, such as a sinus air–fluid level, and for defining fracture displacements of fractures prior to surgical reduction and fixation. One could assume that CBCT might also suit that purpose, which can be partly confirmed. Yet in complex maxillofacial and head trauma, the suspected presence of

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various studies have indicated a superiority in detection internal and external root resorption lesions in the teeth. It has also been shown that trauma of teeth can be better assessed in three dimensions (Fig. 12). Taken together, CBCT imaging may allow an assessment of tooth prognosis when clinical signs and symptoms indicate an unexplained endodontic treatment failure and with assumed tooth trauma. CBCT findings may modify treatment planning, as well as the techniques employed during both nonsurgical and surgical endodontic treatment (1). Bone-related TMJ problems Bony pathology of the TMJ including cysts, tumors or joint morphology changes as well as TMJ trauma may be diagnosed using CBCT. In temporomandibular joint osteoarthritis, discrete changes in joint morphology may help in early diagnosis or in assessment of disease progression or treatment effects. Else and most often TMJ related pain problems are not found in bony tissue defects, necessitating the use of MRI.

Diagnostic and/or therapeutic approach of benign jaw bone tumors and cysts

B Fig. 12. â&#x20AC;&#x201D; An intra-oral radiograph does not always reveal the true lesion extent (A). The present case indicates a palatal lesion, around an horizontal tooth root trauma.

other than bony defects, might push towards spiral CT imaging. Diagnosis of dental trauma and endodontic treatment failure Root canal treatment of molars and other teeth presenting with complex root canal configurations

can be diagnostically and technically challenging. The use of CBCT imaging in endodontically challenging cases can facilitate a better understanding of the complex root canal anatomy, which ultimately enables the clinician to explore the root canal system and clean, shape, and obturate it more efficiently. Besides,

Most cystic lesions occurring in the jaws are related to teeth (odontogenic); some are non-odontogenic, and others are not true cysts, but are conveniently considered within this category because of cyst-like radiographic appearances. Some neoplasms, notably ameloblastoma, can appear cystic, and must be considered in the differential diagnosis of a cyst. Cone-beam CT has excellent spatial and high contrast resolution and may allow for the production of panoramic, axial and cross-sectional 2D reconstructions (1). The extent of a lesion's relationship to teeth, root resorption, internal structure, cortical expansion and erosion, the boundary of a lesion and the presence of multiple lesions can all be evaluated. This surely aids diagnosis yet also surgical treatment planning, by using the 3D information. Conclusions CBCT offers numerous potentials in both the diagnostic and dental therapeutic field. Yet, it is obvious that the latter should not be done without proper optimisation strate-

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gies. The EADMFR basic principles on the use of Cone Beam CT published by Horner et al. (12) are a useful guidance for the justification and optimization. It is clear that to maintain a proper balance (optimisation) between on one hand costs and radiation dose and on the other hand information required. Also, the scanned area should not exceed the area of interest. This will limit the dose substantially, thus justifying its use for preparing implant surgery. Furthermore, such strategy would also prevent that areas are visualised that cannot be properly scanned and diagnostically interpreted. Considering that dental CBCT enables volumetric imaging of the craniofacial complex at reasonable costs and doses, numerous diagnostic potentials are opened. These challenges may also have an impact on disease management, therapy planning and even aid therapeutic approaches. Development of procedures for surgical template and CAD/CAM procedures as well as surgical navigation go hand in hand with procedures for cone beam CT scanning. These concomitant developments will probably alter the treatment strategies in oral health care. Yet, more clinical research is needed to validate the outcome of various applications in this particular field. References 1. Vandenberghe B., Jacobs R., Bosmans H.: Modern dental imaging: a review of the current technology and clinical applications in dental practice. Eur Radiol, 2010, 20: 2637-2655. 2. Jacobs R., van Steenberghe D.: Radiographic planning and assessment of endosseous oral implants, 1st edn. Berlin: Springer-Verlag, 1998. 3. Jacobs R., Lambrichts I., Liang X., Martens W., Mraiwa N., Adriaensens P., Gelan J.: Neuro vascularization of the anterior jaw bones revisited using high-resolution magnetic resonance imaging. Oral Surg Oral Med Oral Pathol Oral Radiol Endod, 2007, 103: 683-693. 4. Coppenrath E., Draneart F., Lechel U., Veit R., Meindl T., Reiser M., MuellerLisse U.: Cross-sectional imaging in dentomaxillofacial diagnostics: dose comparison of dental MSCT and NewTom9000 DVT. Rofo, 2008, 180: 396-401. 5. Sukovic P.: Cone beam computed tomography in craniofacial imaging. Orthod Craniofacial Res, 2003, 6: 3136. 6. Loubele M., Maes F., Jacobs R., van Steenberghe D., White S.C., Suetens P.: Comparative study of image quality for MSCT and CBCT

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scanners for dentomaxillofacial radiology applications. Radiat Prot Dosimetry, 2008, 129: 222-226. Nkenke E., Vairaktaris E., Neukam F.W., Schlegel A., Stamminger M.: State of the art of fusion of computed tomography data and optical 3D images. Int J Comput Dent, 2007, 10: 11-24. Loubele M., Bogaerts R., Van Dijck E., Pauwels R., Vanheusden S., Suetens P., Marchal G., Sanderink G., Jacobs R.: Comparison between effective radiation dose of CBCT and MSCT scanners for dentomaxillofacial applications. Eur J Radiol, 2009, 71: 461-468. Pauwels R., Beinsberger J., Collaert B., Theodorakou C., Rogers J., Walker A., Cockmartin L., Bosmans H., Jacobs R., Bogaerts R., Horner K. The SEDENTEXCT Project Consortium.: Effective dose range for dental cone beam computed tomography scanners. Eur J Radiol, 2010, Dec 31 [Epub ahead of print]. Liang X., Jacobs R., Hassan B., Li L., Pauwels R., Corpas L., Souza P.C., Martens W., Shahbazian M., Alonso A., Lambrichts I.: A comparative evaluation of Cone Beam Computed Tomography (CBCT) and Multi-Slice CT (MSCT) Part I. On subjective image quality. Eur J Radiol, 2010, 75: 265-269. Liang X., Lambrichts I., Sun Y., Denis K., Hassan B., Li L., Pauwels R., Jacobs R. A comparative evaluation of Cone Beam Computed Tomography (CBCT) and Multi-Slice CT (MSCT). Part II: On 3D model accuracy. Eur J Radiol, 2010, 75: 270-274. Horner K., Islam M., Flygare L., Tsiklakis K., Whaites E. Basic principles for use of dental cone beam computed tomography: consensus guidelines of the European Academy of Dental and Maxillofacial Radiology. Dentomaxillofac Radiol, 2009, 38: 187-195. Sedentexct (http://www.sedentexct. eu). Harris D., Buser D., Dula K., GrĂśndahl K., Jacobs R., Lekholm U., Nakielny R., van Steenberghe D., van der Stelt P.: E.A.O. Guidelines for the use of Diagnostic Imaging in Implant Dentistry. Clin Oral Impl Res, 2002, 13: 566-570. Tyndall AA., Brooks SL.: Selection criteria for dental implant site imaging: a position paper of the American Academy of Oral and Maxillofacial radiology. Oral Surg Oral Med Oral Pathol Oral Radiol Endod, 2000, 89: 630-637. Hassan B., Couto Souza P., Jacobs R., de Azambuja Berti S., van der Stelt P.: Influence of scanning and reconstruction parameters on quality of threedimensional surface models of the dental arches from cone beam computed tomography.Clin Oral Investig, 2010, 14: 303-310. Al-Rawi B., Hassan B., Vandenberge B., Jacobs R.: Accuracy assessment of three-dimensional sur-

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face reconstructions of teeth from Cone Beam Computed Tomography scans. J Oral Rehabil, 2010, 37: 352358. Mraiwa N., Jacobs R., van Steenberghe D., Quirynen M.: Clinical assessment and surgical implications of anatomic challenges in the anterior mandible. Clin Implant Dent Relat Res, 2003, 5: 219-225. Liang X., Lambrichts I., Corpas L., Politis C., Vrielinck L., Ma G.W., Jacobs R.: Neurovascular disturbance associated with implant placement in the anterior mandible and its surgical implications: literature review including report of a case. Chin J Dent Res, 2008, 11: 56-64. Van Assche N., van Steenberghe D., Quirynen M., Jacobs R.: Accuracy assessment of computer-assisted flapless implant placement in partial edentulism. J Clin Periodontol, 2010, 37: 398-403. Van Assche N., van Steenberghe D., Guerrero M.E., Hirsch E., Schutyser F., Quirynen M., Jacobs R.: Accuracy of implant placement based on pre-surgical planning of three-dimensional cone-beam images: a pilot study. J Clin Periodontol, 2007, 34: 816-821. Heiland M., Schmelzle R., Hebecker A., Schulze D.: Intraoperative 3D imaging of the facial skeleton using the SIREMOBIL Iso-C3D. Dentomaxillofac Radiol, 2004, 33: 130-132. Proffit W.R., Fields H.W. Jr.., Sarver D.M.: Contemporary Orthodontics. 4th ed., Mosby Inc., Elsevier Science, Philadelphia, 2006. Olszewski R., Cosnard G., Macq B., Mahy P., Reychler H.: 3D CT-based cephalometric analysis: 3D cephalometric theoretical concept and software. Neuroradiol, 2006, 48: 853-862. Swennen G.R., Schutyser F., Barth E.L., De Groeve P., De Mey A.: A new method of 3-D cephalometry Part I: the anatomic Cartesian 3-D reference system. J Craniofac Surg, 2006, 17: 314-325. Swennen G.R., Schutyser F.: Threedimensional cephalometry: Spiral multi-slice vs cone-beam computed tomography. Am J Orthod Dentofacial Orthop, 2006, 130: 410-416. Lou L., Lagravere M.O., Compton S., Major P.W., Flores-Mir C.: Accuracy of measurements and reliability of landmark identification with computed tomography (CT) techniques in the maxillofacial area: a systematic review. Oral Surg Oral Med Oral Pathol Oral Radiol Endod, 2007, 104: 402-411. Andreasen J.O., Pindborg J.J., Hjorting-Hansen E., Axell T.: Oral health care: more than caries and periodontal disease. A survey of epidemiological studies on oral disease. Int Dent J, 1986, 36: 207-214. Alqerban A., Jacobs R., Lambrechts P., Loozen G., Willems G.: Root resorption of the maxillary lateral incisor caused by impacted canine: a literature review. Clin Oral Investig, 2009, 13: 247-255.

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COME BEAM CT IN ORAL HEALTH CARE — JACOBS 30. Flygare L., Öhman A.: Preoperative imaging procedures for lower wisdom teeth removal. Clin Oral Investig, 2008, 12: 291-302. 31. Neugebauer J., Shirani R., Mischkowski R.A., Ritter L., Scheer M., Keeve E., Zöller J.E.: Comparison of cone-beam volumetric imaging and combined plain radiographs for localization of the mandibular canal before removal of impacted lower third molars. Oral Surg Oral Med Oral Pathol Oral Radiol Endod, 2008, 105: 633-642.

32. Yusof W.Z.: Non-syndromal multiple supernumerary teeth: literature review. J Can Dent Assoc, 1990, 56: 147-149. 33. Jacobs R., Willems G.: Inverted eruption of a supplemental lower premolar: report of an unusual case. Int J Paediatr Dent, 2003, 13: 46-50. 34. De Coster P.J., Marks L.A., Martens L.C., Huysseune A.: Dental agenesis: genetic and clinical perspectives. J Oral Pathol Med., 2009, 38: 1-17. 35. Shahbazian M., Jacobs R., Wyatt J., Willems G., Pattijn V., Dhoore E.,

van Lierde C., Vinckier F.: Accuracy and surgical feasibility of a CBCTbased stereolithographic surgical guide aiding autotransplantation of teeth: in vitro validation. J Oral Rehabil, 2010, 37: 854-859. 36. Wörtche R., Hassfeld S., Lux C.J., Müssig E., Hensley F.W., Krempien R., Hofele C.: Clinical application of cone beam digital volume tomography in children with cleft lip and palate. Dentomaxillofac Radiol, 2006, 35: 8894.

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DIALYSIS ARTERIOVENOUS FISTULAS: THE CRITICAL ROLE OF COLOR DOPPLER ULTRASOUND N. Verbeeck1, F. Prospert2, D. McIntyre3, S. Lamy3 Despite being time-consuming and observer-dependent, CDUS is a method of choice for performing and controlling dialysis shunts. It contributes to increasing the number of native AVFs and enables early detection of lesions therefore allowing quick percutaneous or surgical therapy. Key-words: Ultrasound (US), Doppler studies – Fistula, arteriovenous.

The aging of the population induces an increase of the occurrence of vascular and metabolic disorders with an impact on renal function, such as arterial hypertension or diabetes. In the USA, the prevalence of end-stage renal disease (glomerular filtration rate lower than 15 mL/min/1.73m²) doubled during the last decade of the twentieth century; in 1998, slightly more than one American per thousand was suffering from total renal failure. A third of these patients were treated by renal transplantation and two thirds by hemodialysis (1, 2). The amount of hemodialysis patients worldwide rose from 400,000 in 1990 to 1,100,000 in 2000 with a current estimation of more than 2,000,000 (3). The type of treatment of endstage renal disease depends on the patient’s status, the etiology of the disease and the possible associated illnesses. Renal transplantation is of course the treatment of choice but it is not always feasible. When hemodialysis proves necessary, it is ideally performed after construction of a native radiocephalic arteriovenous fistula in the nondominant forearm, a method introduced by Brescia and Cimino in the USA in 1966 (Fig. 1A). Native brachiocephalic fistulas at elbow level develop more easily than their counterparts in the forearm but, beside the fact that they are shorter lived, they induce excessive blood flows more often, generate more distal ischemias and transform into aneurysms more frequently (4, 5). Peritoneal dialysis can be suggested as an alternative mode of therapy, namely for children or patients with a poor cardiac function, but its use is unfortunately limited in time (6). The polytetrafluoroethylene (PTFE) arte-

C Fig. 1. — Diagram showing native radiocephalic fistula (A) and prosthetic shunt (B) with the dialysis needles in place (source: Mayo Foundation for Medical Education and Research). C. Photograph: Hickman double lumen catheter with cross section view.

From: 1. Dpt of Radiology, 2. Dpt of Nephrology, 3. Dpt of Urology, Centre Hospitalier de Luxembourg, rue Barblé, 4, L-1210 Luxembourg, Grand Duchy of Luxembourg. Address for correspondence: Dr N.Verbeeck, M.D., Service de Radiologie, Centre Hospitalier de Luxembourg, rue Barblé, 4, L-1210 Luxembourg, Grand Duchy of Luxembourg. E-mail : Verbeeck.Nicolas@chl.lu

riovenous graft introduced as early as 1976 (Fig. 1B) is a second choice since it implies a higher amount of pernicious thrombotic and infectious events (7, 8, 9). For reasons beyond the scope of our article, the arteriovenous graft has remained the most

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Diagram 2: upper limb arteries: 1. aortic arch, 2. brachiocephalic artery, 3. left common carotid artery, 4. left subclavian artery, 5. right common carotid artery, 6. right subclavian artery, 7. right axillary artery, 8. right brachial artery, 9. right radial artery, 10. right ulnar artery, 11. palmar arches.

widely used method of dialysis in the United States even though, thanks to the Kidney Disease Outcomes Quality Initiative (KDOQI), the tendency is presently reversing in favor of native fistulas (10). The double lumen dialysis catheter (Fig. 1C) devised by R.O.Hickman in 1979 already, should, apart from a limited use, only be considered as a very last solution. Its infectious and thrombotic complications are indeed extremely frequent (11). Presently, a native shunt is the superior option. Japanese physicians have understood it correctly since they dialyze 90% of their patients via a Brescia-Cimino fistula. Their European counterparts follow close with 80% of their hemofiltrations via a native arteriovenous fistula (AVF) whereas their American colleagues are progressing: 25% of native AVFs in 2001 and the figure is steadily increasing (12). Let us stress here that, since the start of renal pathology and whatever the treatment selected, the patient’s venous capital must by all means be pre-

Fig. 3. — Upper limb veins: 1. superior vena cava, 2. brachiocephalic vein, 3. innominate vein, 4. left subclavian vein, 5. right internal jugular vein, 6. left internal jugular vein, 7. right subclavian vein, 8. right axillary vein, 9. right cephalic vein, 10. right basilic vein, 11. right superficial radial vein, 12. right superficial ulnar vein (dotted lines: deep veins of the forearm).

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Fig. 4. — Diagram showing fistula drawing following CDUS.

Fig. 5. — brachial artery triplex: optimal angle, gate size, PRF, focalization and gains.

served in order not to compromise the possible later construction of a hemodialysis access (11). In this article, we will demonstrate the exceptional role of color Doppler ultrasound (CDUS) in preparing the site for dialysis AVFs and for their follow-up. The examination indications and the technical modalities for the use of CDUS have been kept separate for clarity of presentation.

Indications for CDUS before the creation of a native shunt Since a native dialysis AVF requires maturation over several weeks before it can be punctured, when the renal disease reaches stage 4 (glomerular filtration rate between 15 and 29 mL/min/1.73m²) and even earlier if the disease develops more rapidly, the patient is

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A Fig. 6. — A: triplex, with a low frequency abdominal probe, of a normal right subclavian vein: cardio-respiratory modulation of the flux (arrows). B: left side: occlusion of the innominate trunk with demodulation of the subclavian flux (arrows). C: angiographic proof of the occlusion (arrow), due to a dialysis catheter. The stars indicate the collateral network.

referred to the vascular surgeon for a clinical examination of their upper limb vessels (11). If arteries and veins appear suitable for the construction of an AVF, the shunt is created without any further examination (13). Should the vascular structures seem suboptimal, the patient must be referred to a radiologist for CDUS assessment. Obese, female, elderly, diabetic patients as well as those suffering from cardio-vascular disorders will derive the greatest benefit from CDUS assessments (11, 14). Patients with Raynaud’s syndromes, thoracic outlet syndromes and those with a history of previous central vein catheter should also benefit from CDUS assessments (15) even more as this noninvasive and widely available imaging is not expensive (16). It remains, nevertheless, time-consuming and observerdependent (17). Preoperative CDUS not only helps to increase postoperative and primary patencies in native fistulas (18, 19), it also increases the number of native shunts versus PTFE grafts (20). Indications for CDUS in the surveillance of AVFs Surveillance of dialysis shunts aims principally at lowering the frequency of fistulous thromboses whose consequences on the patients’ morbidity and mortality are well-known and which entail important additional costs (2).

A clinical inspection of the fistula at each dialysis session is a first stage in the surveillance program. Venous collapse, decreased thrill, edema in the limb are some warning signs. The second stage of surveillance is the control of dialysis physicochemical parameters. Any disturbance in the arterial or venous pressures in function of the flow, of the urea reduction rate and of the recirculation rate must be noticed (2). Some dialysis centers are equipped with validated instruments linked directly to the hemodialysis network to measure the access blood flow by dilution technique. Any abnormal value should be noted (21, 22). CDUS is the third stage of surveillance. It is recommended when the fistula reveals a clinical problem or when the dialysis parameters are altered (2). Some authors also advise to perform routine CDUS on the pretext of allowing the detection

of stenoses that do not appear at clinical examination or that do not infer a significant decrease in the dialysis outflow (8, 23, 24). The fact that the fistula outflow, as well as the coronary arteries flow, only starts dropping when the shunt diameter is considerably reduced (25), also advocates for a systematic control. Therefore, in our institution, we perform an annual CDUS for each dialysis patient even if no abnormality is assessed during their dialysis sessions. Other authors think that such examination is not relevant since the detected lesions are not meaningful (26). KDOQI does not recommend any time limit and advises to proceed on a case by case basis (2). We do not think, however, that the cost of a yearly CDUS is unacceptable considering the total annual cost of dialysis or that of a fistulous thrombosis. Even if some authors consider angiography as the gold standard in

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Dist 0.031 cm

Fig. 8. — B-mode of a normal intima-media thickness: measurement between the “inner surface” and the first anechoic line.

Fig. 9. — Color Doppler of an upper brachial branching at the level of the mid-humerus (H): the ulnar (U) and radial (R) arteries, the brachial vein (V).

Fig. 7. — A: triplex at the level of an ostial cephalic vein stenosis: obvious acceleration, without aliasing thanks to the 5 MHz probe, at 4.5 m/s. B: angiographic counterpart: cephalic vein (white arrow) stenosis (black arrow), stars indicate the subclavian and innominate veins.

assessing dysfunctioning dialysis fistulas (2, 22, 27), we think that CDUS, possibly linked with magnetic resonance (MR) angiography (cf infra), remains largely sufficient and we keep iodinated contrast enhanced controls for cases requiring percutaneous therapy. Indications for CDUS in case of immature AVFs If a prosthetic arteriovenous graft can be used soon after its creation, it is advisable to allow native AVFs to mature over a period of about six

Fig. 10. — Triplex showing the effect of the releasing (arrow) of a brachial tourniquet on the radial arterial spectrum: the resistive index drops to 0.65 (white circle), a good predictive factor before AVF creation.

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Fig. 11. — B-mode of the internal lumen of a radial artery (thick arrow). The measurement (2 mm, thin arrow) indicates that the prognosis of the shunt is good.

Fig. 13. — Triplex of a cephalic vein with a flow measurement (arrow): appropriate setting of angle, PRF and vessel diameter; 4 cardiac cycles are taken into account.

Fig. 12. — B-mode of a favorable distensibility test: increase of the venous diameter (thick arrows) by 50% (thin arrow) after brachial tourniquet.

weeks before initiation of hemodialysis (28). Successful fistula maturation, which translates into a fitting increase of the vein caliber, results from a clear increase of its flow (29). It is easier for brachiocephalic AVFs than for radiocephalic anastomoses but the latter remain preferable mainly because of their greater longevity (5). Since radiocephalic AVFs tend to reach their maximum flow at 4 weeks (30), a clinical inspection of the shunt is recommended one month after its construction. If the draining vein is badly or not palpable, an assessment CDUS should be carried out to define the reason of its lack of maturation (cf infra) (8, 10). Once it has been treated, the vein must be closely monitored due to

Fig. 14. — Color Doppler of an AVF anastomosis (arrow): the stardust artifact (stars).

quick and frequent phenomena of restenosis (4, 31). Later on the fistula will ‘calm down’ and ensure its durability (5).

ture site, limiting the number of punctures and, more generally, reducing the duration of the intervention (16).

Indications for CDUS prior to therapy

Indications for CDUS per- and postsurgical or percutaneous treatment

It is up to the radiologist or to the surgeon to decide whether or not to have CDUS performed before treating a dialysis fistula. Individual practices vary, however advantages of pre-intervention CDUS include optimizing the selection of the punc-

When the immature AVF of a patient preparing for dialysis with impaired renal function must be treated, it is to be advised to limit the exposure to nephrotoxic iodinated contrast material. Iodine dilution is a first solution; a smart alternative

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Fig. 15. — A: triplex of arterial stenoses: color aliasing and obvious acceleration at more than 3 m/s (arrow). B: angiographic correlation: post-ostial radial artery stenoses (thick arrow) and postanastomotic venous stenosis (thin arrow). C: the fistula after percutaneous treatment.

consists in partially or totally assessing the therapy (dilatation, thrombolysis…) by CDUS without any vascular opacification. Besides, CDUS can prove useful in the operating room when the surgeon performs a banding of an excessively high flow fistula. The radiologist can then measure the flow repeatedly in order to guide the extent of vein caliber reduction. Finally, CDUS cannot be ignored for the post treatment check-up and for the long term surveillance of the treated fistulas that prove potentially frail.

General CDUS technique for upper limb vessels CDUS examination can be performed on a seated patient (8, 15) but we prefer, like J.M. Corpataux (29), to perform the study in the supine position, as much for the patient’s comfort as for the radiologist’s. The barebreasted patient will be installed in a room with a minimum temperature of 20°C (15) and the ultrasound gel should be slightly warmed and spread liberally (10). Most authors admit that a high-frequency

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probe, around 10 MHz, should be used (7). The US unit must be used at full capacity, i.e. in the triplex mode, associating the brilliance mode (B), the color Doppler mode and the pulsed Doppler mode with an angle of insonation between 30 and 60° in order to avoid an alteration of the velocity measurements (32). The study in B-mode is carried out, after an appropriate gain adjustment, on both planes of the vessels, particularly for veins whose diameter is often ellipsoidal. Venous elements should moreover be examined by using a gentle transducer pressure. Let us not forget that the upper limb is arterially fed by the brachial artery via the subclavian artery then the axillary artery. The brachial artery most often divides, at elbow level, into a radial artery and an ulnar artery, which anastomose at the hand (Fig. 2). Venous draining of the upper limb rests on a deep network and a superficial one, linked by perforating vessels. The deep network borders the arterial system with, generally, two veins for each artery. The superficial structure consists, though there exist many anatomical variations, of a radial vein and an ulnar vein that anastomose at the elbow joint to give a cephalic vein and a basilic vein drained respectively by the subclavian and the axillary systems. The central return pathway occurs along the superior vena cava, via the innominate trunk on the left (Fig. 3). Pulsed Doppler spectral analysis is performed with an optimal adjustment of the gain, of the repetition frequency and of the gate size, ideally two thirds of the examined vessel (Fig. 5). The study of central veins remains a problem for sonographers. If the superior vena cava and the innominate trunk are completely out of reach because of aeric and osseous interpositions, their permeability can be checked indirectly. Indeed, in the case of an important stenosis or thrombosis, the cardiorespiratory modulations of the subclavian veins disappear (Fig. 6). In obese patients, a direct study of subclavian veins will prove complicated if a high-frequency transducer is used. Some advocate then to resort to MR or CO2 angiography to spot stenoses (11, 15, 27). In our experience, we almost never resort to MR imaging. Whenever confronted with difficult cases, we use low-frequency abdominal transducers. If their spatial resolution is lower than that of

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Fig. 16. — Arterial stenosis triplex: downstream SUT increase at 160 ms (arrow).

Fig. 17. — Radial steal triplex, the wrist being at left, the elbow at right: blood flow is in the direction of the probe, via the palmar arches.

high-frequency probes, the drawback is balanced by a reduced sensitivity to absorption and, mainly, by a lower susceptibility to phenomena of frequency ambiguity, so much so that the accelerated specters of stenosed veins can be optimally studied (32) (Fig. 7). CDUS technique before AVF creation As it has been explained above, a pre-AVF CDUS must be performed when clinical examination of the upper-limb vessels is inconclusive. It starts with a study of the arterial network where it must exclude any stenosis that would be revealed in B-mode by a reduction in vessel diameter and in Doppler mode by a maximum local velocity increase of more than twice the median systolic velocity of the artery. The intimamedia thickness, which must be under 0.6 mm, is measured at the far wall of the vessel and possible calcifications are spotted (Fig. 8). In the instance of elbow fistulas mainly the absence of upper brachial bifurcation must be checked since it is a source of future dysfunctioning (Fig. 9). A hyperemia test must be carried out and allows checking the adequate reactivity of the arterial system: after releasing a brachial tourniquet fastened during two minutes, the resistive index (S-D/S, automatic calculation) must be lower than 0.7 (14) (Fig. 10). Finally, in the case of wrist fistulas, the minimum luminal diameter of the radial or ulnar artery must ideally be equal to or higher than 2 mm (11) (Fig. 11). The exploration of the venous system starts with a thorough

Fig. 18. — B-mode of an ulnar artery (thin arrow) with an anastomotic stenosis (thick arrow).

mapping, examining very closely the permeability of the central veins, which may be confirmed by MR angiography assessment. The thickness of the walls is recorded and the examiner will verify that, for native wrist AVFs, the draining vein has a diameter of at least 2 mm. Venous distensibility is measured by the tourniquet test: ideally, the diameter of the vein must have increased by 50% after a two-minute application (11, 14) (Fig. 12). The examination report is usefully accompanied by a diagram, even by skin marking (15). We acknowledge this practice may not be practically feasible in all cases but we aim to perform the examination in the presence of the vascular surgeon who will construct the anastomosis.

CDUS technique and criteria for normal AVFs Except when an extensive thrombosis is suspected, the examination should not be carried out right after dialysis. Indeed, flow calculations can be wrong owing to reduced blood volume (2). Moreover, if the examination is performed immediately following hemodialysis, important vascular segments may be hidden under the dressing and it will prove challenging for the echo Doppler to make a distinction between post-puncture spasms and actual stenoses. The absolute criterion for a well functioning dialysis fistula is that it is able to undergo at least six dialysis sessions a month and sustain a

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A Fig. 19. — A:Triplex of a cephalic vein stenosis: color aliasing and spectral acceleration up to 6 m/s (arrow). B: angiographic confirmation of the stenosis (arrow). C: the same vein after percutaneous dilatation.

Fig. 20. — B-mode of a venous aneurysm (star) with partial parietal echogenic clotting (arrows).

blood flow rate of 350 mL/min (8) or – more prosaically – that it ensures a sufficient flow for hemodialysis (11), which can perfectly be confirmed by CDUS. The AVF CDUS must examine the whole shunt in triplex mode. We follow Franco and the KDOQI guidelines and use easy echo Doppler criteria, based on figure 6, that indicate a healthy shunt: 6 weeks after surgery, the fistula flow volume must be at least 600 mL/min and the diameter of the draining vein, at a maximal depth of 6 mm, must be greater than 6 mm. Another criterion of adequacy must be added to this list of basic criteria: the length of the venous segment that is punctured must equal 10 cm or twofold 4 cm (33).

Flow measurements are said to be taken on the feeding artery (2, 34) but we actually check arterial and venous flows, with necessarily an angle of insonation between 30 and 60°. Three to four cardiac cycles are taken into account and turbulence areas are avoided (8). The blood flow is calculated automatically by recent machines by using the classical formula: outflow (in mL/min) = average blood velocity x (πD²/4) x 60, where D represents the vessel diameter in cm (Fig. 13). Let us insist on the fact that, even if they are done by an experienced examiner, Doppler measurements of the blood flow have a margin of error of 5% (35). The minimum blood flow rate in a wrist AVF must ideally be 500 mL/min, i.e.

350 mL/min for the dialysis device and 150 mL/min to keep the fistula patent during hemodialysis sessions. The minimum blood flow in a graft is 650 mL/min and we agree to say that it must be at least 750 mL/min in a native arm fistula (2). The fistula blood flow should always be recorded in the report and will be the standard for all further CDUS as, whatever the cause of AVF dysfunction, any drop of more than 20% in the fistula blood flow by comparison with a former normal examination must be considered suspicious and lead to a more thorough study of the fistula, even to a closer surveillance (11). Let us note that findings of colored tissular signals in the region of the anastomosis are quite normal and are called stardust artifact. They appear on all AVFs and are a result of vibration phenomena (Fig. 14). CDUS criteria of AVF disorders Lesion therapy modalities are mentioned because we consider they are significant for AVF followup, even if the radiologist is not interventional. Cardiac pump problem It is quite evident that a left cardiac failure or an aortic valve stenosis may induce a flow drop in the dialysis AVF. Such very central lesions will be diagnosed thanks to the concomitant demonstration of a systolic upstroke time (SUT) increase in both the fistula and the arterial sectors that are not included in the shunt (36). The treatment of

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Fig. 21. â&#x20AC;&#x201D; B-mode of a variable echogenicity perivenous hematoma (red arrows) entailing a venous stenosis (white arrow).

these pump problems is medical, even cardio-surgical. Stenosis of the subclavian artery In most cases, Doppler echographers cannot reach the ostium of the subclavian artery. A diagnosis of stenosis is then based on the SUT of the subclavian artery at the level of the clavicle. The problem is that the arteriovenous anastomosis itself implies a SUT increase. A correct measurement of this value can be obtained by a simple gesture that consists in shutting the post-anastomotic vein manually during some seconds. A lower than 70 millisecond SUT must be rated as normal (extrapolated from 36).There is no pathological threshold, as far as we know, above this value but a subclavian ostial stenosis must be suspected if the SUT is noticeably higher than the mean SUT in the arteries of the neck, the contralateral upper limb and the lower limbs. Arterial stenosis The indirect Doppler criterion for a significant arterial stenosis is a flow drop. Direct criteria, in B-mode, consist in a higher than 50% decrease of the endoluminal arterial diameter and, in pulsed-wave mode, in a twofold increase of the mean systolic velocity (Fig. 15) together with an increase of the downstream SUT (Fig. 16) (16). In case of tight stenosis, percutaneous transluminal angioplasty, possibly together with a metallic endoprosthesis fixed on a balloon, is the therapeutic treatment of choice (37).

Fig. 22. â&#x20AC;&#x201D; Color Doppler of an anechoic seroma (star) generating a post-anastomotic venous stenosis (arrow).

Arterial steal The steal syndrome is due to a diversion of the arterial flow intended for the limb towards the draining vein of the fistula. Due to an excessive flow rate or to a stenosis of the feeding artery, the flow of the postanastomotic artery is reversed, fed by the palmar arches in the forearm AVFs and by deep lying collaterals in the case of brachial shunts (Fig.17). The intensity of the reversal may vary, similarly to the subclavian steals (32, 38), and the phenomenon rarely has a clinical impact (26%) (7). If it causes distal ischemic symptoms, a surgical or interventional radiologic treatment can be suggested (9). Anastomotic stenoses B-mode sonography displays the narrowing directly whereas the Doppler mode pinpoints an increase of the systolic velocity with local turbulence, a flow drop and, in the color mode, an enhanced stardust artifact (Fig. 18). Anastomotic stenoses are generally viewed as the result of a technical error when they are detected soon after AVF construction and must be managed surgically (37). Venous stenosis Repeated punctures as well as vibrations and turbulences caused by the shunt contribute to the development of venous stenoses. They are the result either of a fibrosis or of an endothelial hyperplasia that can affect valvular zones (9, 16). Their diagnosis rests on the direct visuali-

zation of a more than 50% narrowing of the vascular caliber and of higher local velocities together with or without a decreased flow (Fig. 19). Let us not forget that central venous stenoses prove technically challenging to analyze. The treatment of venous stenosis is identical to that of arterial narrowings except that the endoprostheses that may be used must be selfexpanding (9). If the fistulous flow rate is abnormally high in spite of a venous stenosis, the latter must be monitored carefully but should not be treated in order to avoid excessive flow and a pernicious impact on the heart function. Distal ischemia Distal ischemia is the result of a serious steal syndrome, of a severe arterial stenosis or of a venous stenosis considered sufficient to create an upstream increase in pressure (39). Various etiologic factors can of course be associated and can all be detected by CDUS. The treatment of distal ischemia proves delicate. It derives benefit from surgical techniques as well as from radiological interventions (9). Arteriovenous aneurysms pseudoaneurysms

and

The literature on arteriovenous aneurysms and pseudoaneurysms remains limited. Their diagnosis rests on direct echographic visualization. They are characterized by a diameter more than twice that of the adjacent normal fistula and can show a more or less intense parietal clotting that is potentially throm-

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etiology list is not exhaustive (7). Fistulous occlusion, whether it is incomplete or total, poses a threat since it induces severe endothelial alterations that put the longevity of the fistula at risk, even after a rapid intervention (2). The treatment of a complete thrombosis can be performed by a surgeon or by an interventional radiologist (thrombolysis) and the removal of the possible mechanical obstacle must happen at the same time. AFV nonmaturation

C Fig. 23. — B-mode of venous clottings (long arrows and star) with variable echogenicity. The short arrow in figure 19B shows slightly echogenic low speed residual blood flow.

Fig. 24. — Color Doppler of a maturation pseudo delay: the vein (in blue) is situated too deep, i.e. 8 mm, to be easily punctured (arrow and white circle).

bogenous and emboligenous (Fig. 20). They require surgical treatment, particularly if they develop rapidly (40, 41).

The treatment of such mass syndromes is medical, even surgical when the lesion is severe and potentially associated with a pernicious stenotic effect for the function of the fistula.

Hematoma, seroma, abscess They are often the result of difficult venopunctures and are directly visualized by echography which, in this field, is significantly more efficient than angiography (7). B-mode shows a variable echogenicity structure with a more or less thick wall, potentially responsible for a compressing impact on the draining vein (Fig. 21, 22).

Thrombosis Fistulous thromboses are optimally visualized by B-mode sonography under the form of endovascular material displaying a variable echogenicity and whose hardness is even more patent as it is detected late (32) (Fig. 23). They can be caused by sudden hypotension, dehydration or even a tight venous stenosis, the

Let us remember that, when clinical doubt arises as to fistulous maturation, CDUS should be performed as soon as four weeks after fistula construction. AVF nonmaturation is revealed by an absence of development of the draining vein six weeks after shunt creation (28). It is mainly the result of stenosing arteriovenous lesions or of an excess of collaterals in the venous section. These causes are easily detected sonographically (33, 42). Excess of superficial or perforating collaterals on the draining vein implies a rapid decrease of the fistulous venous flow and henceforth dialysis problems. Surgical ligations are apt to solve the problem. Fistulous immaturity always requires an emergency treatment since the thrombosis occurs early and the shunt proves extremely difficult to reopen (4). What is called maturation pseudo delay is the result of an excessive depth of the draining vein, more than 5 to 6 mm from the skin surface whereas the other characteristics of the AVF remain normal. This abnormal depth is clearly demonstrated in B-mode and makes puncture for dialysis quite arduous (Fig. 24). It requires surgical treatment consisting in a venous transposition with possible resection of fatty tissues. Excess flow When the diameter of the anastomosis is excessive, it no longer plays its role as a natural brake and the fistulous function races out of control (9). CDUS does display the phenomenon whether in B-mode or in Doppler mode where the flow measurement is abnormally high (Fig. 25). It is estimated that a higher than 2 L fistula flow is, owing to complex mechanisms, potentially pernicious for the cardiac function (9). An excessive fistula flow can also trigger a distal ischemia by steal as we have already explained.

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Fig. 25. — Triplex of an excessive AVF outflow at 2.4 L/min. 8.

Excess flow requires an elaborate surgical treatment, starting from ligations and arterial transpositions up to closure of the AVF in the most serious cases (9, 43). Prosthetic graft fistulas We have less experience with prosthetic graft fistulas. They are constructed in the arm essentially, most often with PTFE prostheses and practically do not require a period of maturation (9). We have already underlined the fact that native AVFs must be preferred to prosthetic grafts since the latter are more prone to thrombosis, most often due to a stenosis of the venous anastomosis, but they are sometimes the only solution left for hemodialysis. Anyway, they are a better choice than central catheters (14). CDUS indications for vascular dialysis grafts keep to the same principles as those mentioned for native AVFs. Careful attention must be paid to the analysis of that sensitive area covering the junction between the prosthesis and the vein. Report Next to an exhaustive anatomical description of the AVF, the CDUS examination report must record a flow rate since the latter determines the efficiency of the hemodialysis. The value will be a marker for future examination since any flow rate drop higher than 20% remains suspicious, as we have already underlined. In the presence of problematic shunts, we complete the written report with an explanatory diagram

(Fig. 4) illustrating the abnormalities we have discovered. We are convinced that the diagrams prove most helpful for the whole staff to understand the anatomical and functional particularities of these shunts, consequently improving the long-term prognosis of difficult dialysis fistulas. Conclusion Though it is time-consuming and observer-dependent, CDUS is an available and rather affordable method of choice for the construction and the surveillance of dialysis shunts. It is particularly efficient, mainly in experienced hands, and contributes to increase the number of native AVFs. Besides, it enables to detect lesions quite early and allow a quick percutaneous or surgical therapy resulting in a greater efficiency and a longer sustainability of dialysis shunts. Our policy is to perform CDUS as soon as a clinical problem or a difficulty arises during dialysis. Our uneventful dialysis patients undergo an annual CDUS assessment but we examine them more often in case of anterior fistulous revision. References 1. The National Kidney Foundation Kidney Disease Outcomes Quality Initiative, Guidelines 2000, Introduction (www.kidney.org). 2. The National Kidney Foundation Kidney Disease Outcomes Quality Initiative, Guidelines 2006, Clinical practice guidelines for hemodialysis adequacy, Introduction, Guideline 1 (www.kidney.org). 3. Lysaght M.J.: Maintenance dialysis population dynamics: current trends

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Hemodialysis. Tours, France, June 2010 (www.sfav.org). Verbeeck N., Casters L., Lebrun F.: Arterial duplex and aortic valve stenosis: sensitivity and specificity of findings. J Radiol, 2006, 87: 647-653. Turmel-Rodrigues L.: Stenosis and thrombosis in haemodialysis fistulae and grafts: the radiologist's point of view. Nephrol Dial Transpl, 2004, 19: 306-308. Yilmaz C., Ozcan K., Erkan N.: Dialysis access-associated steal syndrome presenting as bidirectional flow at duplex Doppler ultrasound. AJR, 2009, 193: W568. Raynaud A.: Le traitement radiologique. Cours-Congrès Ajaccio, France, 2009 (www.sfav.org). Lazarides M.: Why, when and how to treat aneurysms. Angio Access for Hemodialysis. Tours, France, June 2010 (www.sfav.org). Malovhr M.: Pre op imaging: how to meet the expectations of the surgeon. Angio Access for Hemodialysis. Tours, France, June 2010 (www.sfav.org). Raynaud A., Novelli L., Bourquelot P., et al.: Low-flow maturation failure of distal accesses: Treatment by angioplasty of forearm arteries. J Vasc Surg, 2009, 49: 995-999. Bourquelot P., Gaudric J., TurmelRodrigues L., et al.: Proximal radial artery ligation (PRAL) for reduction of flow in autogenous radial cephalic accesses for haemodialysis. Eur J Vasc Endovasc Surg, 2010, 40: 94-99.

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ORIGINAL ARTICLES COMPARISON OF COMBINED ORAL AND IV CONTRAST-ENHANCED VERSUS SINGLE IV CONTRAST-ENHANCED MDCT FOR THE DETECTION OF ACUTE APPENDICITIS K. Hekimoglu1, U.M. Yildirim1, E. Karabulut2, M. Coskun1 Objective: The aim of our study was to compare the diagnostic ability of oral added intravenous (IV) contrastenhanced multidetector computed tomography (MDCT) versus only IV contrast-enhanced MDCT in diagnosing of acute appendicitis. Materials and methods: MDCT images of 200 patients were evaluated prospectively in this study. Patients were randomized into one of two groups: Group 1 (Gp1) patients underwent 16-MDCT performed with oral and IV contrast-enhanced and Group 2 (Gp2) subjects underwent 16-MDCT with only IV contrast-enhanced protocol. Final decision was based on histopathologic operative data and follow-up of patients. Results: In Gp1, Reader1 had 96.9% and 98.5% and Reader2 had 84% and 94.7% sensitivity and specificity values respectively. For Gp2, the values for Reader1 were 81% and 94%. For Reader2 in Gp2, the values were 76% and 91%. We achieved higher sensitivity and specificity values with combined contrast administration versus only IV contrastenhanced MDCT imaging. However, there was no statistically significant differences between two readers in the AUC values of each group for the detection of acute appendicitis. Conclusion: It is statistically concluded that oral contrast do not contribute to the a better accuracy. So in the routine practice, oral contrast has not to be recommended. Key-word: Appendicitis.

Acute appendicitis is the most common cause of acute abdominal pain that requires abdominal surgery (1, 2). Appendicitis may present a wide variety of clinical manifestations, and the diagnosis is difficult even by the most experienced clinicians (3). Early diagnosis and intervention to avoid perforation is very important, as is the standard of care. The diagnosis of appendicitis is established through a combination of clinical, laboratory, and radiological features, especially computed tomography (CT) imaging. CT is increasingly used in the evaluation of patients with suspected acute appendicitis with excellent sensitivity and accuracy. By the beginning to use multi-detector row CT (MDCT) systems technology affords a considerable reduction in scanning time and an improvement in image quality with minimal degradation from motion artefacts. Sensitivity and specificity values of abdomen MDCT imaging in acute appendicitis were reported to be 80-100% and 91-99% respectively (4-7). However, controversy still persists about which is the most effective contrast application technique for the evaluation of

appendicitis in CT imaging. A variety of CT approaches have been advocated including unenhanced, IV contrast-enhanced, oral contrast enhanced, rectal contrast enhanced and combination of contrast applications in the diagnosis of appendicitis (7-9). The time to perform a scan varies significantly between these different methods of MDCT imaging. Oral and IV contrast combination may be helpful in some difficult cases for the prompt diagnosis of acute appendicitis. The purpose of our prospective study was to conduct a randomized trial to compare the diagnostic performance of IV and oral contrastenhanced MDCT versus only IV contrast-enhanced MDCT in patients presenting with acute nontraumatic abdominal pain clinically suspected to be secondary to acute appendicitis. Materials and methods The participants were 200 adult patients who presented with clinical signs and symptoms that suggested acute appendicitis. All were enrolled between March 2008 and October

From: 1. Department of Radiology, Baskent University, School of Medicine, Ankara, Turkey, 2. Department of Biostatistics, Hacettepe University, School of Medicine, Ankara, Turkey. Address for correspondence: Dr K. Hekimoglu, M.D., Baskent Universitesi Hastanesi, Radyoloji ABD, Fevzi Cakmak Cad. 10. sok. No: 45, Bahcelievler, Ankara 06490 Turkey. E-mail: korayhekim@yahoo.com.tr

2010. On admission, all patients had right lower or mid quadrant pain, 25% had nausea, 10% had vomiting and low-grade fever. Patients were 18 years old and older with nontraumatic abdominal pain. Thus, we excluded patients with possible contrast allergy, pregnant ones and traumatic cause of abdominal pain. The physicians of emergency department (ED) in screening for and recruiting suggested patients with acute nontraumatic abdominal pain for this study. Two hundred patients (113 men, 87 women; mean age of men, 32 years; mean age of women, 38 years) were included in this research. The patients whom suspected acute appendicitis or other acute pathologies (diverticulitis, small-bowel obstruction, etc.) were sent to radiology department for MDCT scan after had evaluated in ED. All patients were randomized into one of two groups: Group 1 (Gp1) was composed of patients with combined oral and IV contrastenhanced abdominal MDCT, and Group 2 (Gp2) was consisted of only IV contrast-enhanced MDCT patients. Gp1 included 58 men and 42 women with a mean age of 38 years ( range, 18-74 years), and Gp2 consisted of 62 men and 38 women with a mean age of 42 years (range, 20-66 years). This study was approved by the institutional review board of our

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Table I. — Comparison of the CT diagnosis and exact results of two groups for two readers. Reader 1

CT scanned True (+) total cases

True(-)

False (+)

False(-)

Total

Gp1 (IV + Oral contrast contrast) Gp2 ( IV contrast) Total

100 100 200

67 71 138

1 4 5

100 100 200

Reader 2

CT scanned True (+) total cases

True(-)

False (+)

False(-)

Total

Gp1 (IV + Oral contrast contrast) Gp2 ( IV contrast) Total

100 100 200

66 67 133

2 7 9

2 8 10

100 100 200

Faculty. Informed consent obtained from all patients.

was

CT scanning All CT scans had been obtained using 16-section MDCT (Sensation 16, Siemens Medical Solutions, Erlangen, Germany, 2003). All patients within two groups have been scanned in precontrast phase firstly. This procedure is the routine protocol of our radiology department for all abdomen CT patients. In Gp1 for oral positive contrast protocol, patients had been given 1500 mL of water solution with 3% Meglumin (Telebrix 35, Guerbet, France) approximately 60 minutes before MDCT scanning. After precontrast scanning all patients were scanned with IV contrast-media administration. In this protocol, after IV administration of 100 mL of Ioversol (350 mgI/mL, Optiray, Covidien, Tyco, USA) at a rate of 3 mL/sec and after 60 sec delayed portal phase, a CT scan of the entire abdomen from the dome of the diaphragm through the pubic symphysis was performed. The MDCT parameters selected were 5-mm thick slices, 0.75 pitch, 120 kV, and 100 mA. Images of all patients were recorded to CD for archiving as a seperate series for all MDCT studies. Image analysis All CT images were evaluated by two radiologists with over 5 years experience in interpreting MDCT imaging of the abdomen in their daily clinical practice. They were not informed of the results of the imaging findings or of the final diagnosis. The analyses of the images of the 2 groups were based on reviews of soft copies which were available on workstation (Leonardo, Siemens Medical Solutions, Germany, 2002). The radiologists interpreted the

31 21 52

30 18 48

studies using multiplanar reconstruction sections. Each reviewer was given a sequential list of all patients by an independent researcher. Interpretations of the two groups (Gp1 and Gp2) had been done seperately at the same interval to prevent recall bias. Radiologists evaluated the scans for the presence of acute appendicitis with a fivepoint Licert scala according to following scores; 1: definitely abscent, 2: probably abscent, 3: indeterminate, 4: probably present, and 5: definitely present. The primary diagnostic criterias for the diagnosis of acute appendicitis were visualization of a thickened appendix (width > 6 mm), mural thickening, and mural enhancement with or without periappendiceal stranding. With oral contrast-added images, hyperenhancement of the appendix as well as absence of filling appendix lumen with oral contrast was considered another positive criteria. For patients whom did not undergo an operation, medical follow-up data of patients was undertaken by another researcher of study who was blinded to MDCT results to determine clinical outcomes. This process also was made by follow-up information obtained from patient, 1 day and 1 week after discharge from the hospital using telephone questionnaires and medical record reviews. Standard of reference of this study was determined by this process. On the other side, once the interpretations were compared with the standard of reference, radiologists retrospectively detected false-negative and false-positive interpretations by consensus to provide an optimal explanation for each misinterpretations. Precise diagnosis of acute appendicitis was considered only when patients underwent surgical opera-

tion and histopathologic analysis yielded “acute appendicitis”. Statistical analysis Once all interpretations were completed by the two radiologists, by an independent researcher reviewed the data set for determine interobserver agreement. In order to assess interobserver agreement for the evaluation of the two groups, we calculated the Cohen’s kappa statistic for two observers. Agreement between the blinded radiologists was reported in terms of kappa values, those values up to 0.40 indicated poor agreement, values of 0.410.60 indicated moderate agreement, those between 0.61-0.80 indicated good agreement, and values greater than 0.81 indicated excellent agreement. Interpretations scored 1 and 2 were considered negative diagnosis, and score 4 and 5 were considered positive diagnosis. Interpretations scored “indeterminate”-3 were evaluated false-positive or false-negative depending on whether the standard of reference revealed the diagnosis to be absent or present, respectively. Diagnosis of two radiologists were collected and compared with the standard of reference by independent researcher of this study to calculate the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) respectively. Using the Fisher’s exact test, we compared the sensitivity and specificity values of the combined interpretations of two groups for the diagnosis of acute appendicitis. Receiver operating characteristic (ROC) curves were created for comparing of two groups with the results of two radiologists. Areas under the ROC curves (AUCs) were calculated with SPSS analysis program (SPSS for Windows 1, SPSS Inc. Chicago, Ilionis, USA, 2006). AUCs, or Az, that

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Table II. — Results: AUC values. Reader

Group 1 AUC

1 2 p

Group 2

95% CI

0,972 0,962 0,790

AUC

Lower

Upper

0,921 0,909

1,000 1,000

0,993 0,989 0,712

95% CI Lower

Upper

0,982 0,971

1,000 1,000

0,431 0,343

AUC: Area under curve CI: Confidence interval.

Table III. — Results: diagnosis of acute appendicitis. Reader

Sensitivity

Specificity

PPV

NPV

Gp1 Gp2

96.9% (82,0-99,8) 81% (59-94)

98,5% (91,0-99,9) 94% (86-98)

96.9% (82,0-99,8) 84,0% (63,1-94,7)

98,5% (91,0-99,9) 94,7% (86,2-98,3)

Gp1 Gp2

84% (63,1-94,7) 76 % (57-88)

94,7% (86,2-98,3) 91% (82-96)

93,7% (77,8-98,9) 72,0% (50,4-87,1)

97,1% (88,8-99,5) 89,3% (79,5-94,9)

*PPV: Positive predictive value, ** NPV: Negative predictive value, Gp1 patients evaluated with combined (oral and IV) contrast and Gp2 subjects performed with only IV contrast-enhanced. Confidence Interval(CI).

Fig. 1. — Evaluation of acute appendicitis in pre-contrast image (A), IV contrastenhanced image (B) and combined oral and IV contrast-enhanced image (C). Appendicolith is also seen in oral and IV contrast added image (C).

Fig. 2. — Marked enlargement appendix with mild periappendiceal fat stranding, this case was the one of false-positive interpretation. Axial oral contrast-enhanced (A), oral and IV contrast added (B), and coronal reformatted image of oral + IV contrastenhanced images (C).

account for variability among modalities (Gp1 and Gp2), among reviewers (two reviewers), and among cases. Differences between the detection ratios of the two groups were compared by “z test for two proportion”, where a P value of less than 0.05 was considered a statistically significant difference.

Results Twenty-five of the 100 patients in Gp1 and 18 of the 100 patients in Gp2 had a exact diagnosis of acute appendicitis with MDCT and confirmed by histopathologically (Fig. 14) . In the evaluation of reader 1, there were 31 true-positive, 67 true-

negative, one false-positive, and one false-negative interpretations for Gp1. However, there were 21 truepositive, 71 true-negative, and four false-positive and negative interpretations detected for Gp2. For reader 2, there were 30 true-positive, 66 true-negative, two false-positive, and false-negative interpretations for Gp1. Thus, there were 18 truepositive, 67 true-negative, and 7 false-positive and eight false-negative interpretations detected for Gp2 (Table I). However, on retrospective consensus evaluation of the falsepositive misdiagnosis in Gp2 and Gp1, the radiologists thought that the all patients were extremely thin patients and lack of periappendiceal fat could be play a great role in misdiagnosis. In performing ROC curves for two radiologists, AUCs were calculated. For the two readers, the AUCs for the ROC for Gp1 were 0.97 and 0.96. For Gp2, they were both 0.99. P values were calculated by “z test for two proportion”. There was no statistically significant differences between two readers in the AUC values in each group, p values were 0.79 and 0.71 for Gp1 and Gp2 respectively. Also, no statistically significant differences between Gp1 and Gp2 in the AUC values for each reader were found and p values were 0.43 and 0.34 for reader 1 and 2 respectively (Table II). Using Fisher’s exact test, comparison of sensitivity and specificity

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Fig. 3. â&#x20AC;&#x201D; Early acute appendicitis with calcified appendicolith in lumen of inflamed appendix (arrow) with oral and IV contrast-enhanced image (A-B).

Fig. 4. â&#x20AC;&#x201D; Acute appendicitis in a 17-year-old boy with little retroperitoneal fat. Unenhanced CT scan shows undefined visualization of inflamed appendix (A). With application of only oral contrast, the appendix is more defined (B). Finally, with oral and IV contrast administration inflamed appendix (arrow) is seen clearly on axial scan (C).

between the combined interpretations for the diagnosis of acute appendicitis were calculated. Although there was no significant difference in sensitivity or specificity for the diagnosis of acute appendicitis. For Group 1 (Gp1), Reader 1 had 96.9% (95%CI, 82%-99.8%) and 98.5% (95%CI, 91%-99.8%) and Reader 2 had 84% (95%CI, 63.1%94.7%) and 94.7% (95CI, 86.2%98.3%) sensitivity and specificity values respectively. For Group 2 (Gp2), the performance values for Reader 1 were 81% (95%CI, 59%-94%) and 94% (95%CI, 86%-98%). For Reader 2 in Gp 2, the values were 76% (95%CI, 57%-88%) and 91% (95%CI, 82%96%) respectively for the diagnosis of acute appendicitis (Table III) . For evaluation of inter-observer agreement between two radiologists, the kappa value for Gp 1 (0.931) was smilar to that of Gp2 (0.899) kappa value. These values were indicated excellent interobserver agreement between two radiologists.

Discussion Primary diagnostic criteria for acute appendicitis have been defined as visualization of an enlarged appendix greater than 6 mm in diameter. Secondary criterias were wall thickening and enhancement, appendicolith, periappendiceal fat stranding, free fluid in right lower quadrant or pelvis, periappendiceal abscess, small bowel obstruction, and mural thickening of cecum (1). The value of computed tomography (CT) and MDCT imaging in the diagnosis of appendicitis has been the subject of multiple research projects (10-12). Unless completely replaced by phlegmon or abscess, CT should allow for indetification of an enlarged appendix, appearing in a tubular or circular form with axial orientation or coronal reformatting of MDCT images. Various CT protocols have been described recent years but, -no definitive CT contrast application- technique has been

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established for the evaluation of acute appendicitis. Furthermore, different CT or MDCT contrast protocols are used in the same diagnostic department in routine imaging. The major subjects of discussion are the uses and modes of administration of contrast materials (8-10). Most contrast-enhanced CT techniques for diagnosis of acute appendicitis that have been described previously have used materials of oral contrast, rectal contrast, both oral and rectal contrast or a combination of IV and other contrast materials (8-10, 13-16). However, the use of unenhanced CT (without oral and IV contrast media) in patients with suspected appendicitis has also been reported. Malone et al used an unenhanced CT technique and they reported a sensitivity of 87%, a specificity of 97% and an accuracy of 93% for the diagnosis of appendicitis (17). In the evaluation of acute nontraumatic abdominal pain, studies have shown increased sensitivity in the diagnosis of acute appendicitis with the application of IV contrast media. Several investigators (1, 14, 18) have shown that IV contrastenhanced CT is an accurate imaging technique for detecting acute appendicitis. In one of the most-cited references about contrast applications, Rao et al. demonstrated that focused CT of the lower abdomen,- after administration of combined oral and colonic contrast material or colonic contrast material alone, had better diagnostic performance (7, 8). The benefits of oral contrast for diagnosis of acute appendicitis have been questioned and investigators have shown that oral contrast media does not reliably fill the appendicieal lumen of normal patients and, therefore a lack of filling of lumen is not always indicator of acute appendicitis. However, filling of the appendicieal lumen may help to exclude acute appendicitis, this sign is seen almost 61% of normal appendicitis (9). A number of researchers using contrast-enhanced CT with both IV and oral contrast materials reported that sensitivity, specificity and accuracy ranges in their diagnoses of acute appendicitis were 92-98%, 85100%, and 90-99% respectively (13, 14, 18, 19). Anderson et al. demonstrated that, there is no significant difference for diagnosing appendicitis between oral and IV enhanced MDCT with only IV enhanced MDCT by using 64-slice MDCT (20). This conclusion was the same direction of our results.

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However until today, these studies have not shown us a current standardized CT protocol for the diagnosis of acute appendicitis. At our institution, we are using two contrast- media protocols with MDCT for evaluating abdominal imaging. One of these protocol is only IV contrast applied MDCT , and the other one is oral and IV combined enhanced MDCT. Choosing the proper protocol is a decision made by the radiologist of abdominal CT team due to the patient’s urgency, clinical and laboratory findings. Generally oral added protocol will be selected for suspected acute appendicitis cases if the patient could be wait nearly one hour. This period is necessary for optimal enhancing of intestines. General surgery team and anesthesists were generally accepted almost one hour delay for oral contrast imaging especially in suspected appendicitis cases with subacut progress. By the way, highly suspected acute apandicitis with heavy clinical symptoms did not refered to radiology department from emergency room for oral contrast added abdomen CT imaging. We achieved higher sensitivity and specificity values with combined contrast administration than we did with only IV contrast-enhanced MDCT imaging. Due to the filling of the appendix with oral contrast, in Gp 1 false negative cases were significantly lower than in Gp2 cases (1 and 2 interpretations for Gp1 versus 4 and 8 interpretations for Gp2 for reader 1 and 2 respectively). On the other side, Fisher’s exact test demonstrated that, in comparison with sensitivity and specificity of two groups, there was no significant difference for the diagnosis of acute appendicitis. Evaluation of under the ROC curves showed that, there was no statistically significant differences in the AUC values found between the Gp1 and Gp2. We acknowledge several limitations to our study. We were unable to provide exact denominator of all patients evaluated for acute nontraumatic abdominal pain. On the other

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side, radiologists in this research whom evaluated the MDCT images, scrutinized the MDCT images for possible acute appendicitis. Due to this process, increasing of sensitivity and specificity may be done in practice. Another limitation was the only convenience patients enrolled this study, and this given rise to an selected population for this study. In conclusion, it is statistically concluded that oral contrast do not contribute to the a better accuracy. So in the routine practice, oral contrast has not to be recommended. However, in selected patients with thin bodies, oral contrast-added MDCT imaging may be helpful for the diagnosis of acute apendicitis by increasing the sensitivity and specificity level little higher. References 1. Birnbaum B.A., Wilson S.R.: Appendicitis at the millennium. Radiology, 2000, 215: 337-348. 2. Brown J.J.: Acute appendicitis: the radiologist’s role. Radiology, 1991, 180: 13-14. 3. Williams G.R.: Presidental address: history of appendicitis, with anecdotes illustrating its importance. Ann Surg, 1983, 197: 495-506. 4. Brandt M.M., Wahl W.L.: Liberal use of CT scanning helps to diagnose appendicitis in adults. Am Surg, 2003, 69: 727-732. 5. Torbati S.S., Guss D.A.: Impact of helical computed tomography on the outcomes of emergency department patients with suspected appendicitis. Acad Emerg Med, 2003, 10: 823-829. 6. DeArmond G.M., Dent D.L., Myers J.G., et al.: Appendicitis: selective use of abdominal CT reduces negative appendectomy rate. Surg Infect, 2003, 4: 213-218. 7. Rao P.M., Rhea J.T., Novelline R.A., et al.: Helical CT technique for the diagnosis of appendicitis: prospective evaluation of a focused appendix CT examination. Radiology, 1997, 202: 139-144. 8. Rao P.M., Rhea J.T., Novelline R.A., Mostafavi A.A., Lawrason J.N., McCabe C.J.: Helical CT combined with contrast material administred only through the colon for imaging of suspected appendicitis. AJR, 1997, 169: 1275-1280.

9. Funaki B., Grosskreutz S.R., Funaki C.N.: Using unenhanced helical CT with enteric contrast material for suspected appendicitis in patients treated at a community hospital. AJR, 1998, 171: 997-1001. 10. Iwahashi N., Kitagawa Y., Mayumi T., Kohno H.: Intravenous contrastenhanced computed tomography in the diagnosis of acute appendicitis. World J Surg, 2005, 29: 83-87. 11. Raman S.S., Lu D.S., Kadell B.M., Vodopich D.J., Sayre J., Cryer H.: Accuracy of nonfocused helical CT for the diagnosis of acute appendicitis: a 5-year review. AJR, 2002, 178: 13191325. 12. Callahan M.J., Rodriguez D.P., Taylor G.A.: CT of appendicitis in children. Radiology, 2002, 224: 325-332. 13. Anderson B.A., Salem L., Flum D.R.: A systematic review of whether oral contrast is necessary for the computed tomography diagnosis of appendicitis in adults. Am J Surg, 2005, 190: 474-478. 14. Jacobs J.E., Birnbaum B.A., Macari M., et al.: Acute appendicitis: comparison of helical CT diagnosisfocused technique with oral contrast material versus nonfocused technique with oral and intravenous contrast material. Radiology, 2001, 220: 683-690. 15. Walker S., Haun W., Clark J., et al.: The value of limited computed tomography with rectal contrast in the diagnosis of acute appendicitis. Am J Surg 2000;180:450-455. 16. Mullins M.E., Kircher M.F., Ryan D.P., et al.: Evaluation of suspected appendicitis in children using limited helical CT and colonic contrast material. AJR, 2001, 176: 37-41. 17. Malone A.J., Wolf C.R., Malmed A.S., Melliere B.F. Diagnosis of acute appendicitis: value of unenhanced CT. AJR, 1993, 160: 763-766. 18. Balthazar E.J., Megibow A.J., Siegel S.E., Birnbaum B.A.: Appendicitis: prospective evaluation with high-resolution CT. Radiology, 1991, 180: 21-24. 19. Stroman D.L., Bayouth C.V., Kuhn J.A., et al.: The role of computed tomography in the diagnosis of acute appendicitis. Am J Surg, 1999, 178: 485-489. 20. Anderson S.W., Soto J.A., Lucey B.C., et al.: Abdominal 64-MDCT for suspected appendicitis: The use of oral and IV contrast material versus IV contrast material only. AJR, 2009, 193: 1282-1288.

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IMAGING FEATURES OF AGGRESSIVE FIBROMATOSIS IN PSOAS MUSCLE W. Ya-Rong, W. Wei, Z. Jia1 Aggressive fibromatosis (AF) of psoas muscle origin is extremely rare and little is known about its radiological features. We here present such a case in a 24-year-old man with psoas AF and ilium bone involvement. The authors stress the contibutive diagnostic role of MRI. Key-word : Fibromatosis.

Aggressive fibromatosis (AF) is a rare neoplasm that originates in musculoaponeurotic structures. It shows characteristic infiltrative growth features and has a tendency for local recurrence (1). Due to low incidence, only a small number of cases of AF in extremities or in other locations have been reported (1-3). To the best of our knowledge, there is no previous report concerning the CT or MRI features of AF in psoas in the medical literature. Case history and radiological findings A 24-year-old Chinese male was admitted to our hospital with progressive pain in his right back and waist for ten months without obvious incentive. No specific past medical and family histories, no abnormalities in lab examinations and conventional radiographs except mild dyskinesia in the right lower limb were reported. Histopathology of the excised mass confirmed it was AF (Fig. 1). CT images revealed an 8.0 × 6.1 × 4.3 cm soft tissue mass in the right psoas major with lobulated shape and ill-defined margins. This mass squeezed right iliacus muscle inferiorly, embedded incompletely into the right psoas muscle from L3 to S1 (Fig. 2A), had similar CT attenuation to its surrounding muscles (Fig. 2B) and heterogeneous moderate enhancement (Fig. 2C). Additionally, it induced spiculated periosteal reaction on the internal surface of ilium next to sacroiliac joint and local cortical bone erosion on the right auricular surface adjacent to the periosteal reaction (Fig. 2D). T1-weighted MRI showed a mixed low- and moderate-intensity-signal

B Fig. 1. — Histological analysis of two stained tissue slices shows that (A) the tumor has an infiltrative growth pattern and the striated muscle tissue can be seen among tumor cells (Hematoxylin eosin stain; original magnification ×200); (B) most lesion cells show immunoreactivity to vimentin (ABC; original magnification ×400).

From: 1. Department of Radiology, Tangdu Hospital, The Fourth Military Medical University, Xi’an, China. Address for correspondence: Dr Ya-rong Wang, M.D., Department of Radiology, Tangdu Hospital, The Fourth Military Medical University; 1 Xinsi Rd, Baqiao District, Xi’an 710038, China. E-mail: wangyr@fmmu.edu.cn

mass with poor definite contour (Fig. 3A). T2-weighted MRI showed the signal intensity was heterogeneously increased in some parts of this mass. Fat-saturated sequence

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images demonstrated no fat ingredients in the lesion (Fig. 3B). After administration of contrast materials, this lesion displayed a heterogeneous and strong enhancement (Fig. 3D). The homogeneous lowintensity bands which might be considered as fibrosis tissue were detected in all sequences (Fig. 3C and Fig. 4). Discussion To know the etiology of AF is helpful for diagnosis. Although most cases of AF occur in a sporadic form, a minority is associated with some familiar neoplastic syndromes, such as familial adenomatous polyposis (FAP). Gardnerâ&#x20AC;&#x2122;s syndrome, a variant of FAP, is characterized by polyposis, osteoma and various soft tissue

Fig. 2. â&#x20AC;&#x201D; Coronal reconstruction image (A) and axial CT image (B) reveal that a mass with heterogeneous low and mild high density is embedded into the right psoas muscle (arrow). Axial CT image after intravenous administration of Iopamidol (C) shows a heterogeneous moderate enhancement of the lesion (hollow arrow). VR reconstruction of the pelvis (D) shows the spiculated periosteal reaction and the adjacent local bony erosion of cortical bone (thick arrow).

tumors among which AF is included. Mutation of adenomatous polyposis coli gene is considered as its causative agent (4). Pregnancy or estrogen hormone is also a risk agent for development of abdominal AF (5). Besides, trauma, especially surgery, plays an important role in the initiation of fibrous tissue proliferation in abdominal wall and intraabdominal cases (6). CT findings of AF can provide us with accurate information about subtle pressure erosions of adjacent bone, but they are often nonspecific (7). Other diseases like softtissue sarcoma in psoas could have the similar CT appearances (2). Therefore it is impossible to rely on the CT findings of AF to make a definite diagnosis. MRI can not only provide similar information to the CT

findings but can offer us several additional specific characteristics, including (a) bands with low signal intensity across all pulse sequences in lesion, (b) infiltrative growth pattern, (c) crossing fascial boundaries, and (d) no necrosis, fat and calcification inside the tumor, which could help radiologists recognize this entity and make a diagnosis (2, 8). It is very uncommon that calcifications may be present and influence the signal of the tumor (9). Though Lee thought that the first characteristic was nonspecific because it occurred only in 10% cases, it reached a consensus that the remaining three were the typical manifestations of AF (2, 8). This may indicate MRI could play an irreplaceable and crucial role in diagnosing AF of rare origin.

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Fig. 3. — T1-weighted fast spin-echo (450/7.4) (A), T2-weighted fast spin-echo (2117/82) (B) and Short T1 Inversion Recovery (6000/107) transverse 3-T MR images (C) which are obtained before administration of gadolinium contrast material show that a large lobulated mixed-signal–intensity mass arises within psoas muscle and affects the surrounding musculature and bone. And part of it shows intermediate-to-high signal intensity on T1 weighted and high signal intensity on T2 weighted images due to predominant cellularity (arrow). Low signal intensity bands which are believed to stand for fibrosis (hollow arrow) are prominent. These bands are not enhanced on the Liver Acquisition with Volume Acceleration (LAVA) images (D) (hollow arrow). The abutted cortical bone is eroded by the mass but the medullary canal isn’t invaded (thick arrow).

Fig. 4. — Coronal and sagittal T2-weighted fast spin-echo 3-T MR coronal (A) and sagittal (B) image show that the lesion is characterized by low-signal-intensity bands paralleling the muscle fascial planes and psoas tendon (arrow).

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References 1.

Kopczyński J., Mayer M., LatosBieleńska A., Dziki A., Kulig A. Aggressive fibromatosis (desmoid tumors): definition, occurrence, pathology, diagnostic problems, clinical behavior, genetic background. Pol J Pathol, 2006, 57: 5-15. 2. Lee JC., Thomas JM., Phillps S., Fisher C., Moskovic E.: Aggressive Fibromatosis: MRI Features with Pathologic Correlation. AJR, 2006, 186: 247-254. 3. Carneiro C., Hurtubis C., Singh M., Robinson W.: Desmoid tumors of the

JBR–BTR, 2011, 94 (5) right rectus abdominus muscle in postpartum women. Arch Gynecol Obstet, 2009, 279: 869-873. 4. Half E., Bercovich D., Rozen P.: Familial adenomatous polyposis. Orphanet J Rare Dis, 2009, 4: 22. 5. Dequanter D., Gebhart M.: Desmoids tumors. J Chir, 2002, 139: 236-239. 6. Carneiro C., Hurtubis C., Singh M., Robinson W.: Desmoid tumors of the right rectus abdominus muscle in postpartum women. Arch Gynecol Obstet, 2009, 279: 869-873. 7. Hudson T.M., Vandergriend R.A., Springfield D.S., Hawkins I.F. Jr., Spanier S.S., Enneking W.F.,

Hamlin D.J.: Aggressive fibromatosis: evaluation by computed tomography and angiography. Radiology, 1984, 150: 495-501. 8. Feld R., Burk D.L. Jr., McCue P., Mitchell D.G., Lackman R., Rifkin M.D.: MRI of aggressive fibromatosis: frequent appearance of high signal intensity on T2-weighted images. Magn Reson Imaging, 1990, 8: 583-588. 9. Lee Y.S., Sen B.K.: Dystrophic and psammomatous calcifications in a desmoid tumor. A light microscopic and ultrastructural study. Cancer, 1985, 55: 84-90.

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DUODENAL METASTASIS OF ALVEOLAR SOFT PART SARCOMA I. Willekens1,2, C. Paradisi3, L. Sarria3, A. Puertas4, J. Pac4, E. Mayayo4 Aveolar soft part sarcoma is a rare tumor responsible for about 1% of all soft tissue sarcomas, affecting mostly adolescents and young adults. ASPS has curious patterns of metastatic spread, with seldom lymph node involvement. Lung, bone and brain are the most common metastatic places. Small bowel metastasis are infrequent, having found reported only one case of duodenal metastasis with polypous appearance. We describe a case of duodenal metastasis presenting as abdominal mass five years after initial diagnosis of alveolar soft part sarcoma. Key-word: Sarcoma.

Introduction Alveolar soft part sarcoma (ASPS) is an uncommon soft tissue neoplasm affecting mostly adolescents and young adults with a slight female predominance. The tumor grows slowly, but is well-vascularized with a tendency to perform vascular invasion and hematogenous distant metastases. The most common metastatic places are lung, bone and brain. Involvement of gastrointestinal tract is very rare; four cases have been described in literature and only one duodenal metastasis has been reported. Duodenal metastases are very uncommon. We describe a case of duodenal metastasis in appearance of a mass five years after initial diagnosis of alveolar soft part sarcoma.

Case report A 27-year-old woman with a 3 day history of palpitations was admitted to our hospital. She complained of effort related nausea, fatigue, headache, muscular weakness asthenia and one month weight loss. She had history of alveolar soft part sarcoma on her right leg five years ago, treated with radiotherapy. Two years ago she underwent lung metastasis resection, with no evidence of other metastases at the time. Physical examination revealed pale skin and hepatosplenomegalia. Blood sample analysis showed haemoglobin of 5,5 g/dL and hematocrit of 16,8%: anaemia. A multidetector CT abdominal scan without contrast (allergy antecedents) demonstrated a round homogeneous hypodense alteration (mass)

Fig. 1. â&#x20AC;&#x201D; Axial (A) T1-weighted MRI image after contrast shows an isointense mass displacing the pancreatic head. The axial MRI image in arterial phase (B) demonstrates early peripheral enhancement in the pancreatic site of the mass with a central hypointense area. The arrow reveals the normal duodenal external wall. Images C, axial and D, coronal, shows the portal phase with progressive enhancement of the periduodenal well-delineated rounded mass with peripheral enhanced ring.

of the duodenum with pancreas displacement (Fig. 1). Additional imaging was necessary. The MRI study (Fig. 2, 3) was performed with a Signa Excite Xl Twin Speed 1.5T sys-

From: 1. In vivo Cellular and Molecular Imaging, ICMI, Vrije Universiteit Brussel, Brussels, Belgium, 2. Department of Radiology, UZ Brussels, Brussels, Belgium; 3. Department of Radiology, 4. Department of Pathology, Hospital Universitario Miguel Servet, Zaragoza, Spain. Address for correspondence: Dr I. Willekens, M.D., Department of Radiology, UZ Brussel, Laarbeeklaan 101/103, 1090 Brussels, Belgium. E-mail: Inneke.willekens@gmail.com

tem (GE Healthcare, Milwaukee, WI, USA) using FRFSE T2-weighted, FRSPGR (phase and out of phase) and LAVA sequences. MRI showed a 47 mm mass delimited by serosa at the second duodenal portion. The mass was slightly hyperintense with strong central hyperintense area suggesting necrosis and early heterogeneous enhancement in T2weigthed sequence. The necrotic area presented luminal communication to duodenum. No evidence of pancreas head infiltration was

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Fig. 2. â&#x20AC;&#x201D; The coronal T2-weighed image (A) reveals a slight intense mass with central hyperintense area suggesting a necrotic area. Image B is a proton density MRI image with B-factor 0. The proton density MRI image with B-factor 1000 (C) shows high signal at the mass suggesting of a high restriction mass. Image D demonstrates the apparent diffusion coefficient (ADC) of 0.00144, which is a low coefficient.

found. Surgical treatment consisted in laparoscopic Wipple duodenopancreatectomy with removal of the duodenal mass. Histopathological examination demonstrated an ASPS metastasis. The patient underwent a control chest-abdominal CT 2 months later that showed no evidence of tumor, adenopathy nor metastasis. Discussion Alveolar soft part sarcoma (ASPS) was first described by Christopherson et al. in 1952 (1). It is a rare type of soft tissue malignant tumor which accounts for about 1% of all soft tissue sarcomas (2). The disease affects mostly adolescents and young adults, with a lower age at diagnosis compared to other forms of soft tissue sarcoma. The peak incidence is described between 15 and 35 years old (3). There is a female predilection, especially during the first two decades of life (4). In adults it most commonly involves the muscle and

deep soft tissue of extremities, trunk, head, neck and retroperitoneum. Head and neck locations are more commonly affected in children and adolescents (5, 6). ASPS has unusual patterns of metastatic spread (7). Metastasis occurs in about 68% of cases and is primarily haematogenous, with rarely lymph node association (8). The most common metastatic places are lung, bone and brain (9). The gastrointestinal tract is uncommonly affected by ASPS metastases. Only four cases of ASPS intestinal metastases has been reported in literature so far, the first by Sueyoshi in 1996, affecting jejunum with gastrointestinal bleeding associated (10). In 2001, Sabel et al. described a case in small bowel, causing polyposis and intussuseption in a 42-year-old male with previous history of ASPS metastatic to lung and brain (11). Zilber et al. in 2003 found the first case of colic metastases in a 43-year-old woman with a leg primary tumor more than

15 years before and multiple lung and brain metastases. She was found to have caecal metastases, revealed by anaemia, and was treated by laparoscopic right colectomy (12). In 2009, Banihani et al. published a case about a 38-year-old man with a huge abdominal mass infiltrating the omentum. Pathological diagnosis was ASPS. He had metastases in both lungs and the right atrium. Afterwards multiple sessile polyps also appeared in stomach and duodenum with diagnostic biopsy of ASPS. Finally the patient developed brain metastases and died (13). Primary gastrointestinal ASPS is extremely rare. Only one case has been reported in 2000 by Yaziji et al., a primary ASPS of the stomach in a 54-year-old Italian woman without evidence of primary neoplasm elsewhere ten years following the initial diagnosis (14). In metastatic tumors, small bowel involvement is uncommon and has been described in only 2% of autopsy cases. Secondary tumors involving the duodenum can arise from peritoneal dissemination, direct spread from an intra-abdominal malignancy, hematogenous and lymphatic spread (15). Common metastatic malignancies known to involve the small intestines are melanomas, lung cancer (16), cervix carcinoma, renal cell carcinoma, thyroid carcinoma, hepatocellular carcinoma and Merkel cell carcinoma (17). The incidence increases with age and males are more commonly affected. Metastatic lesions of the duodenum mostly locate in the periampullar region, followed by the duodenal bulb. Patients present with abdominal pain, nausea, vomiting and gastrointestinal bleeding (18). The microscopic picture of ASPS is uniform and characterized by a pseudoalveolar pattern with nests of tumor cells separated by sinusoidal vascular channels. The cells have vesicular nucleoli and eosinophilic cytoplasm (3). Magnetic resonance imaging is the best technique for characterization of ASPS. Common MRI findings are high-signal-intensity on T1 and T2-weighted images and multiple intra- and extra-tumoral signal voids. The high-signal-intensity areas of the tumors on T1-weighted sequence can be attributed to slow flowing blood in or around the tumor (19). Presence of metastases at the time of diagnosis carries a poorer prognosis (median survival time of 3 years), while early metastases do

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10.

B 11.

12.

13.

Fig. 3. — An axial CT image without contrast (A) shows a round mass in the pancreatic area. B is the MRI image (B) of the initial ASPS tumor in the leg. The mass shows peripheral enhancement and a central hypodense area suggesting necrosis. The macroscopic image (C) shows macroscopic piece of cephalic duodenopancreatectomy with a 6 cm circumscribed mass within the duodenopancreatic space. Both the 4 cm duodenal ulceration and the area of central necrosis suggest malignancy. Pancreas structure is displaced and the limits of surgical resection are clear. The microscopic image (D) reveals the malignant tumor with a clear alveolar pattern defined by nests of peculiar large sized cells, separated by a delicate slightly vascularized connective tissue. Large polygonal cells with a wide cytoplasm, large nuclei and evident macronucleoli provide polymorphic appearance.

14.

15.

16.

not preclude a long survival time (8). The treatment of choice of ASPS primary and metastatic tumors remains on surgical resection. The benefit of adjuvant chemotherapy and/or radiotherapy has been doubtful (20). In conclusion, ASPS is a rare type of sarcoma that affects mostly the lower limbs. This tumor does rarely metastasize to the gastrointestinal tract. We report the second case of duodenal metastasis, which developed five years after the initial diagnosis. References 1. Christopherson W.M., Foote F.W. Jr., Stewart F.W.: Alveolar softpart sarcoma: structurally characteristic tumors of uncertain histogenesis. Cancer, 1952, 5: 100-111.

2. Weiss S.W., Goldblum J.R.: Enzinger and Weiss’s soft tissue tumors. 4th ed. Philadelphia, Pa: Mosby; 2001: 1509-1521. 3. Enzinger F.M., Weiss S.W.: Malignant tumors of uncertain type. In: Enzinger F.M., Weiss S.W., editors. Soft tissue tumors. St. Louis: Mosby, 1995: 1067-1074. 4. Batsakis J.G.: Alveolar soft-part sarcoma. Ann Otol Rhinol Laryngol, 1988, 97: 328-329. 5. Hunter B.C., Devaney K.O., Ferlito A., et al.: Alveolar soft part sarcoma of the head and neck region. Ann Otol Rhinol Laryngol, 1998, 107: 810-814. 6. Khanna P., Paidas C.N., GilbertBarness E.: Alveolar soft part sarcoma: clinical, histopathological, molecular, and ultrastructural aspects. Fetal Pediatr Pathol, 2008, 27: 31-40. 7. Portera C.A. Jr., Ho V., Patel S.R., Hunt K.K., Feig B.W., Respondek P.M., Yasko A.W., Benjamin R.S.,

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Pollock R.E., Pisters P.W: Alveolar soft part sarcoma: clinical course and patterns of metastasis in 70 patients treated at a single institution. Cancer, 2001, 91: 585-591. Lieberman P.H., Brennan M.F., Kimmel M., et al.: Alveolar soft-part sarcoma: a clinicopathologic study of half a century. Cancer, 1989, 63: 1-13. Casanova M., Ferrari A., Bisogno G., Cecchetto G., Basso E., De Bernardi B., et al.: Alveolar soft part sarcoma in children and adolescents: a report from the soft-tissue sarcoma Italian Cooperative Group. Ann Oncol, 2000, 11: 1445-1449. Sueyoshi T., Kanetuki I., Nishi H., Ohshiro K., Hori A.: A case of gastrointestinal bleeding from metastatic alveolar soft part sarcoma of the jejunum. Nippon Igaku Hoshasen Gakkai Zasshi, 1996, 56: 712-714. Sabel M.S., Gibbs J.F., Litwin A., McGrath B., Kraybill W.B., Brooks J.J. Alveolar soft part sarcoma metastatic to small bowel mucosa causing polyposis and intussuseption. Sarcoma, 2001, 5: 133-137. Zilber S., Brouland J.P., Voisin M.C., Ziza J.M., Desplaces N., Chekulaev D., Hobeika J., Houdart R.: Colic metastases of alveolar soft-part sarcoma: A case report and review of the literature. Ann Diagn Pathol, 2003, 7: 306309. BaniHani M.N., Al Manasra A.R.: Spontaneous regression in alveolar soft part sarcoma: case report and literature review. World J Surg Oncol., 2009, 7: 53. Yaziji H., Ranaldi R., Verdolini R., Morroni M., Haggitt R., Bearzi I.: Primary alveolar soft part sarcoma of the stomach: a case report and review. Pathol Res Pract, 2000, 196(7): 519-525. Willis R.A.: Secondary tumors of the intestines. In The Spread of Tumours in the Human Body 3rd edition. London, England: Butterworth & Co Ltd; 1973: 209-15. McNeill P.M., Wagman L.D., Neifeld J.P.: Small bowel metastases from primary carcinoma of the lung. Cancer, 1987, 59: 1486-1489. Lynch-Nyhan A., Fishman E.K., Kadir S.: Diagnosis and management of massive gastrointestinal bleeding owing to duodenal metastasis from renal cell carcinoma. J Urol, 1987, 138: 611-613. Pavlakis G.M., Sakorafas G.H., Anagnostopoulos G.K.: Intestinal Metastases from Renal cell carcinoma: A Rare Cause of Intestinal obstruction and Bleeding. Mt Sinai J Med, 2004, 71: 127-130. Chen Y.D., Hsieh M.S., Yao M.S., Lin Y.H., Chan W.P.: MRI of alveolar soft-part sarcoma. Comp Med Imag Graph, 2006, 30: 479-482. Sidi V., Fragandrea I., Hatzipantelis E., Kyriakopoulos C., Papanikolaou A., Bandouraki M., Koliouskas D.E.: Alveolar Soft-part sarcoma of the extremity: a case report. Hippokratia, 2008, 12: 251-253.

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TOLOSA-HUNT SYNDROME IN CHILDREN D.E. Benzohra1, N. Damry1, I. Delpierre1, S. Huybrechts, A. Monier2, C. Christophe1 We report a case of Tolosa-Hunt syndrome in a 4-year-old girl. Computed Tomography (CT) and Magnetic Resonance Imaging (MRI) revealed a left cavernous sinus involvement with internal carotid artery occlusion. Clinical signs included left ophthalmoplegia, convulsions and right hemiplegia. Etiopathogenesis of this syndrome is unclear but as in our case, response to corticosteroid therapy is spectacular and avoids unnecessary invasive diagnostic procedures. We underline the importance of cross-sectional imaging in the diagnostic approach. Several other diseases including tumors, vascular lesions and infections can have a similar clinical and/or imaging presentation. However, closely monitored evolution on imaging proves to be decisive in the establishment of final diagnosis of this syndrome. Key-word: Cavernous sinus.

Tolosa-Hunt syndrome (TSH) is caused by proliferation of non specific inflammatory tissue in the cavernous sinus, superior orbit fissure or orbital apex. It manifests by painful ophtalmoplegia and paralysis of one or more oculomotor cranial nerves. TSH is characterized by rapid sustained response to corticosteroid therapy. In 1954, Tolosa reported the first clinical features and revealed a low-grade granulomatous inflammation in an autopsy of a patient with left ophthalmoplegia (1). In 1960, Hunt and al. reported the clinical criteria of Tolosa-Hunt syndrome (2). The evolution of sectional imaging (CT and MRI) has encouraged the International Headache Society (IHS) to include the presence of abnormal inflammation tissue in cavernous sinus and orbital apex by MR in the diagnostic criteria (3). This implies that TSH is no longer diagnosed by elimination.

Fig. 1. — CT after injection of contrast in axial plane (A), with reconstruction in the sagittal and coronal planes (B and C). Presence of a mass up to the cavernous left sinus, capturing the contrast strongly. Note the reduced size of the internal carotid artery (arrow).

Case report A 4-year-old girl presented with several episodes of convulsions. Clinically she had right-sided hemiparesis and contralateral ophthalmoplegia related to sixth nerve palsy. CT scan revealed a soft tissue mass in the left cavernous sinus extending to the skull base and enhancing strongly after contrast injection (Fig. 1). MRI also showed enlargement of the cavernous sinus occupied by abnormal tissue (hypointense on T1 and isointense on T2 compared to gray matter) and

C compression of the left internal carotid artery (Fig. 2). After a few days, the child experienced sudden and complete right hemiplegia. MRI

From: Department of 1. Radiology, 2. Paediatrics, Queen Fabiola University Hospital for Children. Brussels, Belgium. Adress for correspondence: Pr C. Christophe, Dept. of Radiology, Hôpital Universitaire des Enfants Reine Fabiola (Huderf). Avenue J.J. Crocq 15, B-1020 Brussels, Belgium. E-mail: Catherine.christophe@huderf.be

done without delay showed at this time still an occlusion of the intracavernous segment of the internal carotid by the lesion and signs of cytotoxic oedema in watershed areas (hyperintense on diffusion imaging and hypointense on corresponding ADC map) (Fig. 3). These findings were consistent with an ischaemic cerebrovascular accident. Diagnosis of TSH was proposed and the child was started on high-dose corticosteroids for a period of 2 months. After that period, a control MRI showed few sequelae of the ischaemic lesion in the left hemisphere presenting as T2 hyperintensities in the white matter, compatible with gliosis. The soft tissue mass occupying the cavernous sinus had completely disappeared and the internal carotid artery looked patent and of normal size (Fig. 4). Clinically, the child had almost completely recovered from the motor deficits.

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Fig. 2. — T2-weighted (A) and proton density (B). MRI showed a latero-sellar mass bulging the left cavernous sinus with occlusion of the internal carotid in its intracavernous portion.

Fig. 3. — Diffuse involvement of the left deep white matter, hyperintense on diffusion with hypointensity on corresponding ADC map (A), T2 (B) and FLAIR (C) sequences in relation with ischemic lesion in the watershed area of the left internal carotid.

Discussion TSH syndrome is defined as the presence of granulomatous and inflammatory soft tissue in the cavernous fossa, in the orbit apex or in the orbit itself (4). Its etiology remains unclear. As in our case, it is characterized by rapid response to corticosteroids and obviates the need for surgical exploration which can be hazardous due to small amount of pathological tissue and its relative inaccessibility. Clinical presentation which associates ophtalmo-

plegia during more than 2 months and one or more cranial nerve palsy with rapid response to steroid treatment allows the diagnosis to be evoked (5), after having discarded other diseases with a similar presentation. These include aneurysm of the intracavernous segment of internal carotid artery, carotid-cavernous fistula, intra-cavernous meningioma, primitive lymphoma, tuberculosis and sarcoidosis (6). CT or MR angiography can easily exclude an aneurysm of the carotid artery. If complicated, a carotid-cav-

ernous fistula can develop giving rise to exophtalmia and chemosis. In that case, MRI shows ophtalmic and cavernous veins dilatation (7). Although rare in children, cavernous meningioma can give the same symptoms and presents the same features on MRI (hypointense on T1 and strong enhancement after injection) (8). Nevertheless, there is no response to steroid treatment. Primitive lymphoma is rare and usualy bilateral. It can particularly mimic THS as it also responds to steroid therapy (9). However, its

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Fig. 4. — MR angiography (A) sequences demonstrating normal size of the left ICA. FLAIR sequence (B) showed hyperintense gliotic lesions.

diagnosis is usually made on the basis of other systemic signs. The same applies to tuberculosis and sarcoidosis. Progress in cross-section imaging (CT and MRI) has been such that THS is no longer diagnosed by elimination alone. Characteristics of the lesions on MRI should meet precise criteria established by the IHS since 2004. CT and MRI carried out in our patient have shown abnormal tissue (designated by Tolosa as being granulomatous) strongly enhancing after gadolinium injection and causing enlargement of the cavernous sinus with convex bulging of the external borders of the dura-mater. These correspond to the 3 primary criteria of THS on MRI (10). Low intensity on T1 imaging and strong contrast enhancement are in agreement with other case published in the literature (11). As in the first case published by Tolosa in 1954, we found a stenosis of the intra-cavernous segment of one internal carotid artery in our patient. Potentially damaging cerebral lesion stresses on the gravity of this syndrome and on the importance of an early diagnosis. We also

highlight the use of an early and aggressive steroid therapy (5) which, in our case, almost completely resolved the lesions and the symptoms.

Conclusions

TSH is a rarely reported affection in children. Its consequences can be damaging especially by the occurrence of cerebral complications. Early diagnosis can be established by associating the clinical setting and the use of cross-sectional imaging. Steroid therapy can hence be started without delay, with spectacular results.

References 9. 1. Tolosa E.J.: Periarteritic lesion of the carotid siphon with the clinical features of a carotid infraclinical aneurysm. J Neurol Neurosurg Psychiatry, 1954, 17: 300-302. 2. Hunt W.E., Meagher J.N., Zeman W.: Painful ophthalmoplegia. Its relation to indolent inflammation of the cavernous sinus. Neurology, 1961, 11: 56-62. 3. Headache Subcommittee of the International Headache Society. The international classification of

10.

11.

headache disorders ICHD-II. Cephalalgia, 2004, 24: 131. Kwan E.S.K., Wolpert S.M., Hedges III T.R., Laucella M.: TolosaHunt syndrome revisited. Not necessarly a diagnosis of exclusion. AJR , 1988, 150 : 431-438. Cakirer S.: MRI finding in Tolosa-Hunt syndrome before and after systemic corticosteroid therapy. Eur J Rad, 2003, 45: 83-90. Laz Haque T., Miki Y., Kashii S., et al.: Dynamic MR imaging in Tolosa-Hunt syndrome. Eur J Rad, 2004, 51: 209217. Bonneville F., Cattin F., Dietmann J.L., et al.: Imagerie des lésions du sinus caverneux. Formation Médicale Conti nue N°33, SFR, Paris, 2005, p. 367. Ding X.Y., Jaques C., Bogorin A., et al.: Imagerie des lésions du sinus caverneux. Feuillets de Radiologie, 2001, 41: 407-424. Choi HK, Cheon JE, Kim I.O., et al.: Central skull base lymphoma in children: MR and CT features. Pediatr Radiol, 2008, 38: 863-867. Shuknecht B., Sturm V., Huisman T.A.G.M., et al.: Tolosa-Hunt syndrome: MR imaging features in 15 patients with 20 episodes of painful ophthalmoplegia. Eur J Rad, 2009, 69: 445-453. Jain R., Sawhney S., Koul R.L., et al.: Tolosa-Hunt syndrome: MRI appearances. J Med Imaging Radiat Oncol, 2008, 52: 447-451.

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MRI FINDINGS IN GIANT PONTINE CAPILLARY TELANGIECTASIS ASSOCIATED WITH A DEVELOPMENTAL VENOUS ANOMALY H.N. Ozcan1, S. Avcu1, J. De Bleecker2, M. Lemmerling1 We report a 32-year-old woman with an exceptionally large capillary telangiectasia in the brainstem which is associated with a developmental venous anomaly (DVA). Her major problems were nystagmus in both eyes, binocular diplopia, gait abnormalities, cerebellar ataxia, slightly disturbed finger-nose test, an instable Romberg test and obvious dysartria. The diagnosis was made on the basis of specific imaging findings, and the use of gradient echo-weighted images proved to be helpful in making a differential diagnostic decision. Key-word: Telangiectasia.

Cerebral vascular malformations, which include capillary telangiectasias, developmental venous anomalies (DVA), cavernous angiomas and arteriovenous malformations are nonneoplastic developmental anomalies that present a variety of clinical patterns, ranging from asymptomatic to fatal intracranial hemorrhage. We report a case of an exceptionally large capillary telangiectasia in the brainstem, which is associated with a DVA. The use of gradient echo-weighted images proved to be helpful in making a differential diagnostic decision. Case report A 32-year-old woman was admitted to our neurology department with complaints of visual disturbance, slurred speech and gait ataxia. Physical examination revealed nystagmus in both eyes, binocular diplopia, gait abnormalities, cerebellar ataxia, slightly disturbed fingernose test, and instable Romberg test. An obvious dysartria was noted. An EEG was obtained and was negative. All laboratory findings were within normal limits. Magnetic resonance (MR) imaging of the brain was performed using standard spin-echo T1- weighted and T2-weighted, gradient-echo sequences and diffusionweighted images. After intravenous injection of gadolinium axial and sagittal T1-weighted images were made. The T2-weighted images (Fig. 1A) demonstrated a large region with increased signal intensity extending in the midpons and lower pons, and in the upper medul-

Fig. 1. â&#x20AC;&#x201D; A. Axial T2-weighted image: a large hyperintense area is seen in the pons. B. Gradient echo-sequence: low signal intensity is present in the lesion. C. DWI (b = 1000): no diffusion restriction is seen.

la oblongata. The lesion was hardly visible on the unenhanced axial T1weighted images (Fig. 2A), and showed a low signal intensity on the gradient echo-weighted sequence (Fig. 1B). On the diffusion-weighted images (DWI) (b = 1000) no restriction was noted (Fig. 1C). No mass effect was present. After intravenous gadolinium injection diffuse and moderate enhancement was seen on the axial and sagittal T1-weighted images (Fig. 2B, 2C), and the borders of the enhancing region were brushlike. Within the moderately enhancing region an enlarged stronger enhancing central vessel extended to the pial surface. In view of the specific location of the abnormal findings, the absence of mass effect, and with the finding of a larger vessel running through this midbrain portion to the pial region the diagnosis of combined presence of capillary telangiectasia and DVA could be made. In this patient a wait-and-see policy was conducted.

From: Department of 1. Radiology and 2. Neurology, AZ Sint Lucas Hospital, Gent, Belgium. Address for correspondence: Dr H.N. Ozcan, Gayret Mah. Istiklal Cad 2/M daire 37 Yeni Mahalle, Ankara, Turkey. E-mail: drhnozcan@yahoo.com

Discussion The true incidence of capillary malformations or telangiectasias of the brain is difficult to discern because most are likely to be clinically asymptomatic. Estimates from autopsy series suggest they are not uncommon, representing approximately 16% to 20% of all CNS vascular malformations (1). Capillary malformations represent histologically benign collections of dilated capillaries interposed within normal brain parenchyma (2). The area of involvement of the brain is typically small, ranging from several millimetres to 2 centimeters in size (3, 4). With a craniocaudal extention of almost 4 cm the lesion in our case is uncommonly large. Sayama CM et al. (5) reported, brain capillary telangiectasias can cause symptoms, that may actually be related to the size effect of the lesion. When symptoms occur, they are most likely due to the associated vascular malformations, although occasional capillary telangiectasias alone may be symptomatic. Hemorrhage seen in association with capillary telangiectasia almost always arises from an associated vascular malformation and only rarely from the capillary telangiectasia (6, 7).

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the use of gradient echo-weighted images increases the degree of confidence in a diagnosis that cannot be achieved with a biopsy. References

Fig. 2. — A. Axial T1-weighted image: the lesion is hardly visible. B. Axial enhanced T1-weighted image: there is moderate enhancement of the lesion with brush-like borders. A strongly enhancing tubular structures crosses the lesion corresponding to a DVA. C. Sagittal enhanced T1-weighted image: Diffuse and moderate enhancement with a craniocaudal extension over 4 cm.

Common sites of involvement include the pons – as is the case in our patient –, but also cerebral hemispheres and spinal cord (2, 4). In one series of 18 presumed capillary telangiectasias, only two were found outside of the brain stem (temporal lobe and head of caudate nucleus) (3). Furthermore, a case of an unusually large, biopsy-confirmed capillary telangiectasia involving the basal ganglia was also reported by Castillo M et al. (6). Capillary telangiectasias and transitional lesions can be found at the periphery of cavernous angiomas in autopsy series. Because of these similarities, Rigamonti et al conclude that the two lesions represent “a spectrum within a single pathological entity” (8). Barr et al discuss that capillary telangiectasia and cavernous angiomas might represent the spectrum of changes that can occur as a result of venous restriction (3). McCormick et al. suggest that “ elevated venous pressure in a venous angioma leads to ectatic dilated microvasculature, which represents an acquired telangiectasia that evolves toward a cavernous malformation” (9). On the gradient echo-weighted images low signal intensities are seen in the region with capillary telangiectasis. This decrease in signal is explained by the presence of increased intravascular deoxyhemoglobine (3). This signal decrease is an interesting differential diagnostic finding, since it is not seen in case of a low grade glioma, which is the most frequently noted similar lesion

in the brainstem. Moreover low grade gliomas do not enhance and show mass effect. We did not performe susceptibility-weighted imaging (SWI), but SWI was useful for imaging diagnosis as it demonstrated marked signal loss of the lesion, if the lesion did not show characteristic signal loss on conventional gradient-echo images (10). Other differential diagnostic entities in this pontine location are demyelinating disease, infection, infarction or central pontine myelinolysis. In this patient demyelinating disease can almost for sure be excluded since no other abnormal regions were noted, especially not in a periventricular location, infection was improbable on a clinical basis, infarction was excluded on basis of the findings on the DWI. DWI seems to be a useful adjunct for the diagnosis of capillary telangiectasias which will facilitate the differential diagnosis concerning tumorous, inflammatory and ischemic lesions (11). Central pontine myelinolysis was excluded since the abnormal findings extent out of the pontine region and also on clinical basis (no history of alcohol abuse). It cannot enough be emphasized that capillary telangiectatic lesions should not be biopsied because of the hemorrhage risk. In our patient a conservative observational policy was chosen. In conclusion, this report shows that a very large pontine capillary telengiectasia associated with a venous angioma can present without hemorrhage, and illustrates that

1. Chaloupka JC, Huddle DC.: Classification of Vascular Malformations of the Central Nervous System. Neuroimaging Clin North Am, 1998, 8: 295-321. 2. Okazaki H.: Cerebrovascular Disease. In: Fundamentals of NeuropathologyMorphologic Basis of Neurologic Disorders. Edited by Okazaki H. Printed by Igaku-Shoin Medical Publishers, New York, 1989, pp. 27-94. 3. Barr R.M., Dillon W.P., Wilson C.B.: Slow-Flow V ascular Malformations of the Pons: Capillary Telengiectasias? AJNR Am J Neuroradiol, 1996, 17: 7178. 4. Lee R.R., Becker M.W., Benson M.L., Rigamonti D.: Brain Capillary Telangiectasia: MR Imaging Apearance and Clinicohistopathologic Findings. Radiology, 1997, 205: 797805. 5. Sayama C.M., Osborn A.G., Chin S.S., Couldwell W.T.: Capillary Telangiectasias: clinical, radiographic, and histopatological features. Clinical article. J Neurosurgery, 2010, 113: 709-714. 6. Castillo M., Morrison T., Shaw J.A., Bouldin T.W.: MR imaging and histologic features of capillary telangiectasiz of the basal ganglia. AJNR Am J Neuroradiol, 2001, 22: 1553-1155. 7. Bland L.I., Lapham L.W., Ketonen L., Okawara S.H.: Acute cerebellar hemorrhage secondary to capillary telangiectasia in an infant: a case report. Arch Neurol, 1994, 51: 1151-1154. 8. Rigamonti D., Johnson P., Spetzler R., Hadley M., Drayer B.: Cavernous malformations and capillary telangiectasia: a spectrum within a single pathological entity. Neurosurgery, 1991, 28: 60-64. 9. McCormick P.W., Spetzler R.F., Johnson P.C., Drayer B.P.: Cerebellar hemorrhage associated with capillary telangiectasia and venous angioma: a case report. Surg Neurol, 1993, 39: 451-457. 10. Yoshida Y., Terae S., Kudo K., Tha K.K., Imamura M., Miyasaka K.: Capillary Telangiectasia of the brain stem diagnosed by susceptibility-weighted imaging. J Comput Assist Tomogr, 2006, 30: 980-982. 11. Finkerzeller T., Fellner F.A., Trenkler J., Schreyer A., Fellner C.: Capillary telangiectasias of the pons. Does diffusion-weighted MR increase diagnostic accuracy? Eur Radiol, 2010, 74: e112-6.Epub, 2009 May 23.

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ECTOPIC GASTRIC PANCREATITIS: UNUSUAL CAUSE OF EPIGASTRIC PAIN T. De Beule, L. Ardies, L. Van Hoe, P. D’Haenens, P. Vanhoenacker1 Ectopic pancreatic tissue has the same characteristics than normal pancreatic tissue. Therefore it may be affected by the same diseases. We report a rare cause of epigastric pain due to gastric heterotopic pancreatitis. The rare diagnosis was suspected by ultrasound and CT and definitively confirmed by echo-endoscopic guided biopsies. Key-word: Pancreas, abnormalities.

Heterotopic pancreas in the stomach is an uncommon entity. The lesions are small and often asymptomatic, resulting in an incidental finding during autopsy or in CT-imaging for other pathology. This pancreatic tissue can have all the normal characteristics of pancreatic tissue, therefore the same complications as in normal pancreas tissue can occur. Case report A 29-year old female presented to the department of gastroenterology with a six months history of continuous abdominal pain. The pain, unrelated to food-intake, had markedly increased during the last days and was now radiating to the back. A mild epigastric pain was found at physical examination. Laboratory tests were normal except a slight raise of C-reactive protein level at 124 mg/l. Abdominal Ultrasound revealed an anterior submucosal antral gastric mass (Fig. 1) which was confirmed by CT (Fig. 2, 3). At this time the differential diagnosis included GIST tumor, lymphoma, lymphangioma and ectopic pancreatic tissue. After echo-endoscopic examination with multiple biopsies pathological examination revealed ductal and acinary structures with inflammatory infiltration of eosinophilic polynuclear and mononuclear cells. The definite pathological diagnosis consisted of gastric ectopic pancreatitis. Discussion Heterotopic pancreas tissue can occur in the stomach, duodenum or upper part of the jejunum. Less frequent locations are the ileum, bile duct, spleen and even a Meckel diverticulum (1). Heterotopic pancreas is defined as pancreatic tissue

Fig. 1. — Hypo-echogenic mass located in the stomach (arrow)

lacking vascular continuity with the normal pancreatic body. Histologically however, ectopic pancreas completely resembles normal pancreas tissue, and contains pancreatic acini, islets of Langerhans and pancreatic ducts. The incidence in autopsy is very high, however heterotopic pancreatic tissue is less frequently found during life. These lesions are very small and often only an incidental finding on surgery or autopsy (2). The appearance in the stomach consists mostly of a firm yellow, finely lobulated nodule, usually submucosally located and sometimes extending in the muscularis and the serosa (3). The most frequent location of ectopic tissue is along the great curvature of the stomach and in the gastric antrum within 6 cm of the pyloric canal (4). The best imaging method is a helical

From: 1. Department of Radiology and Imaging, OLV Ziekenhuis, Aalst, Belgium. Address for correspondence: Dr T. De Beule, MD, Dept of Radiology, Olv Ziekenhuis, Moorselbaan 164, B-9300 Aalst, Belgium. E-mail: Tom.debeule@gmail.com

CT imaging with negative oral contrast. Ectopic pancreatic tissue has a similar manifestation like other submucosal gastric tumors such as a gastrointestinal stromal tumor (GIST) and leiomyomata. These are the most common gastrointestinal submucosal tumors. There are a few features that can be used for the differentiation of these tumors on a CT (5). Ectopic pancreatic tissue can be divided into three subtypes depending on the histopathological composition (1) predominantly containing pancreatic acini (3), predominantly containing ducts and (3) a mixed type. In one study, ectopic tissue with predominantly acini showed a more homogenous enhancement pattern when compared to tissue with a mixed histological composition (5). There are five major CT characteristics, which allow differentiation of ectopic pancreatic tissue from a GIST or a leiomyoma. The most important differential is the LD (long diameter) / SD (short diameter) ratio which has to be greater than 1,4. Ectopic pancreatic tissue is not a true

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Fig. 2. â&#x20AC;&#x201D; Mass in the antrum/corpus of the stomach (striped arrow) with a LD/SD ratio > 1,5 and a cystic mass in the center of the mass (arrow).

neoplasm but is a hamartoma of flat glandular tissue thereby resulting in a more flattened ovoid shape and a higher LD/SD ratio in comparison to a GIST (5). Only after intraglandular cyst formation, an ectopic pancreas can manifest as a large protruding submucosal mass. Furthermore a GIST tends to be more exophytic in growth in comparison to ectopic tissue which tends to have a more endoluminal growth (6). The degree and the pattern of contrast enhancement reflects the microscopic composition as described above. Leiomyomas show a homogenous enhancement pattern and are predominantly located in the cardia. Ectopic pancreas tissue is predominantly localized in the antrum, pylorus or duodenum (7). A prominent enhancement of the overlying mucosa can be seen exclusively in patients with ectopic pancreas tissue (8). MRCP can also have a diagnostic role in detecting ectopic pancreas tissue by demonstrating an ectopic duct arising from a mesenteric or small bowel mass (9). In most cases heterotopic pancreatic tissue is of no clinical importance, but sometimes complications can occur. A pancreatitis with possible formation of pseudocysts can arise or an adenoma/ insulinoma can be formed. Malignant trans-

Fig. 3. â&#x20AC;&#x201D; The same mass (arrow) in the antrum/corpus of the stomach with submucosal edema (striped arrow).

formations have only rarely been reported (10). In our patient we could definitely depict the mass located in the stomach, which showed an inflammatory change compatible with pancreatitis. Conclusion Ectopic pancreas has an estimated incidence of 0.55 to 14% according to autopsy studies. Although this heterotopic tissue seldom causes clinical symptoms, ectopic pancreatitis of the stomach has been described. On CT-imaging a submucosal mass can be depicted and the differential diagnosis between a stromal tumor and ectopic pancreatitis can be made using criteria LD/SD ratio and localization. This ectopic tissue has the same characteristics as normal pancreatic tissue, therefore the same complications can occur. In our patient the heterotopic tissue inflamed, making its diagnosis much easier. References 1. Dolan R.V., Remine W.H., Dockerty M.B.: The fate of heterotopic pancreas tissue: a study of 212 cases. Arch Surg, 1974, 109: 762-765. 2. Rooney D.R. Aberrant pancreatic tissue in the stomach. Radiology, 1959, 73: 241-244.

3. Lund D.P., Compton C.C.: A 3-weekold girlwith pyloric stenosis and an unexpected operative finding. Massachusetts General Hospital Case Records, case 26. 4. Thoeni R.F., Gedgaudas R.K.: Ectopic pancreas: usual and unusual features. Gastrointest Radiol, 1980, 5: 37-42. 5. Kim J.Y. et al.: Ectopic pancreas: CT findings with emphasis on differentiation from gastrointestinal stromal tumor and leiomyoma. Radiology, 2009, 252: 92-100. 6. Claudon M., Verain A.L., Bigard M.A., et al.: Cyst formation in gastric heterotopic pancreas: report of two cases. Radiology, 1988, 169: 659660. 7. Barbosa J.J., Dockerty M.B., Waugh J.M.: Pancreatic heterotopia: a review of the literature and report of 41 authenticated surgical cases of which 25 were clinically significant. Surg Gyneacol Obstet, 1964, 82: 527542. 8. Cho J.S., Shin K.S., Kwon S.T., et al.: Heterotopic pancreas in the stomach: CT findings. Radiology, 2000, 217: 139-144. 9. Silva A.C., Charles J.C., Liu P.T.: MR cholangiopancreatography in the detection of symptomatic ectopic pancreatitis in the small-bowel mesentery AJR, 2006, 187: W195-197. 10. Ura H., Denno R., Hirata K., Saeki A., Natori H.: Carcinoma arising from ectopic pancreas in the stomach: endosonographic detection of malignent change. J Clin Ultrasound, 1998, 26: 265-268.

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IMAGES IN CLINICAL RADIOLOGY The macaroni sign M. Apaydin1, M. Varer1, G. Sezgin1, U. Yetkin2 A 41-year-old woman was referred to radiology department for the evaluation of sudden paresis in the left side. Brain magnetic resonance imaging (MRI) showed multiple bilateral ischemic regions in the watershed areas. Also, the brain magnetic resonance angiography (MRA) showed bilateral internal carotid artery (ICA) occlusions at the level of the cervical ICA region. Both vertebral arteries were found to be enlarged (arrow) and the retrograde filling of the anterior circulation was observed (Fig. A). For the investigation and the differentiation of the bilateral carotid lesions, the color Doppler ultrasonography was obtained. This study showed homogenous, hypoechoic, circumferential wall thickening of both distal common carotid artery arteries (CCA). The thickening of the arteries wall were like ‘Macaroni’. The wall thickness was 0.17 cm (Fig. B). The tapering of both CCA and total oclusion of both ICA were seen. The carotid MRA revealed collateral circulation from the subclavian arteries to the ECA and 50% stenosis of the left CCA (arrow) and 70% stenosis of the right CCA at its origin. Vertebral arteries were also prominant and there were 50% narrowing in the mid portion of the left subclavian artery (Fig. C). The radiological diagnosis of the Takayasu’s arteritis (TA) was made and the patient was referred to the rheumatology clinic for further diagnosis and work-up.

Comment

TA is an granulomatous vasculitis of medium and large arteries which is commonly seen in young women. This disease has various clinical morbidities, such as arm claudication, decreased arterial pulses, carotidynia and hypertension as well as constitutional symptoms. It has three stages according to the symptomalogy. First, prepulsenessless period with systemic constitutional inflammatory complaints; second, vascular pain period characterized with carotidynia, and fibrotic period with ischemia and vascular murmurs. Diagnosis is made based on the widely accepted criteria of the American Collage of Rheumatology. The difference of systolic arterial pressure in both arms of more than 10 mm Hg, claudication of one extremity, weak brachial pulse, murmurs on the aorta and brachiocephalic arteries, younger than 40-year old and large artery involvement of the aorta and primary branches are the main diagnostic clues. At least three of these findings must have to be met for the diagnosis of the TA. TA mostly involves the aortic arch and its branches in about 75% of the cases. The most consistent finding for a diagnosis of C Takayasu’s arteritis is angiographically determined bilateral occlusion of the subclavian and common carotid arteries. Occlusion of large arteries supplying the cephalic structures, without neurological symptoms, is a characteristic of this disease. In our case, there were bilateral ICA occlusions, both vertebral arteries compensated blood supply to the brain. Rare ultrasonographic finding, previously described by Maeda et al., as the “macaroni sign”, is pathognomonic for TA (1). This finding is secondary to the mononuclear and giant cell infiltration of the media and adventitia of the medium and large sized arteries that leads external elastic lamina degeneration with intimal proliferation. Color Doppler US is diagnostic for TA. Ultrasonography and angiography are complementary methods for the diagnosis. While angiography shows extended areas of luminal changes, ultrasonography enables the characterization of the wall changes in a limited area. Reference 1.

Maeda H., Handa N., Matsumoto M., Hougaku H., Ogawa S., Oku N., Itoh T., Moriwaki H., Yoneda S., Kimura K., et al.: Carotid lesions detected by B-mode ultrasonography in Takayasu’s arteritis: "macaroni sign" as an indicator of the disease. Ultrasound Med Biol, 1991, 17: 695-701.

1. Department of Radiology, Izmir Ataturk Education and Research Hospital, 2. Department of Cardio-Thoracic Surgery, Izmir Ataturk Education and Research Hospital, Turkey.

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IMAGES IN CLINICAL RADIOLOGY Prenatal MRI of an esophageal duplication cyst with polyhydramnios and right pleural effusion L. Yu-Peng, L. Yi-Lan, S. Wen-Ko1 A 28-year-old woman at 32 weeks of gestation was referred to us for evaluation of a fetal mediastinal cystic mass detected during prenatal ultrasonography. MRI revealed a fluid-filled tubular structure extending from the carina along the presumed course of the fetal esophagus (Fig. A and B, arrows), polyhydramnios, and right pleural effusion (Fig. B, arrowhead). The diagnosis of esophageal duplication cyst was confirmed at the operation carried out after delivery.

Comment An esophageal duplication cyst is the second most common duplication in the gastrointestinal tract, the first being ileal duplication (1), and can rarely be diagnosed in the fetus (2). The mass effect of duplication cysts on the adjacent lung or esophagus may cause respiratory distress or dysphagia in neonates and infants. A large esophageal duplication cyst in fetuses may manifest with polyhydramnios and pleural effusion due to compression of the fetal esophagus and mediastinum and consequently cause obstruction of the physiological swallowing of amniotic fluid by the fetus. A tubular appearance, signs of gastrointestinal obstruction (polyhydramnios), and peristaltic movements on prenatal ultrasound and MRI may help in differentiating this cyst from other mediastinal cystic lesions such as type I congenital cystic adenomatoid malformation of the lung, bronchogenic cysts, thoracic neuroblastoma, teratoma, and neurenteric cysts (2). References

Hur J., Yoon C.S., Kim M.J., et al.: Imaging features of gastrointestinal tract duplications in infants and children: from oesophagus to rectum. Pediatr Radiol, 2007, 37: 691-699. 2. Conforti A., Nahom A., Capolupo I., et al.: Prenatal diagnosis of esophageal duplication cyst: the value of prenatal MRI. Prenat Diagn, 2009, 29: 531-532.

1. Department of Radiology, Mackay Memorial Hospital, Hsinchu, Taiwan. Mackay Medicine, Nursing and Management College, Taipei, Taiwan.

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IMAGES IN CLINICAL RADIOLOGY Cesarean scar pregnancy: MRI features J. Marrannes1

A 34-year-old woman, gravida 4, para 2, presented at the emergency room with severe abdominal pain and red vaginal bleeding. Medical history revealed 2 previous cesarean sections at term gestation. Laboratory findings showed an elevated b-HCG consistent with an estimated gestational age of 6-7 weeks. Transabdominal ultrasound showed a well-circumscribed, thick-walled cystic mass within the lower part of the anterior myometrium. In the central cystic cavity a small mural nodule with discrete pulsatile flow was noticed. Subsequently a pelvic MRI exam was performed confirming the presence of the thick-walled, well-circumscribed mass in the lower part of the uterine wall (Fig. A). The mass extended beyond the expected contour of the uterus and no overlying myometrial tissue could be identified at the anterior border. At the cranial and posterior border of the mass a non-enhancing, T2 hypointense fibrous band was noticed, consistent with scar tissue of the two previous cesarean sections (Fig. B). The wall of the mass was T2 hyperintense, T1 iso-intense and showed a strong and heterogeneous enhancement following intravenous administration of gadolinium (Fig. C). The central portion of the mass was T2 hyperintense, T1 hypo-intense and showed no contrast enhancement. The cavity of the uterus was filled with T1 hyperintense, hemorrhagic fluid. A corpus gravidarum was seen on the left side. These findings were consistent of an ectopic pregnancy in a cesarean scar. Patient was successfully treated with a combination of chemotherapy and bilateral uterine artery embolization followed by a planned hysterectomy several weeks later. Comment

Ectopic pregnancy most frequently occurs in the ampullary portion or isthmic region of the fallopian tube. Extratubal locations, such as in the cervix, the ovary, the myometrium or abdominal cavity are uncommon. Pregnancy developing in a previous cesarean scar is very unusual. Review of several cases noted that endometrial and myometrial disruption and scarring caused by the cesarean incision are the main predisposing factors. Poor development of the lower uterine segment, such as in breech presentation, may predispose to incomplete healing of the scar and subsequent implantation of pregnancy in it. Multiple cesarean sections are also risk factors contributing to the development of larger cesarean scar defects. Two different types of pregnancy in a cesarean scar can be put forward. The first consists of an implantation of the gestational sac on a scar with progression in the uterine cavity. The second is a deep implantation of the gestational sac in a cesarean scar defect with progression towards rupture and bleeding. Evaluation of the integrity of the anterior uterine wall at the level of the gestational sac is therefore of crucial importance. As soon as the diagnosis of cesarean scar pregnancy is determined, termination should be considered due to the risk of uterine rupture and consequent life-threatening hemorrhage. Reference 1.

Rotas M.A., Haberman S., Levgur M.: Cesarean scar ectopic pregnancies: etiology, diagnosis, and management. Obstet Gynecol, 2006, 107: 1373-1381.

1. Department of Radiology, Stedelijk Ziekenhuis Roeselare, Roeselare, Belgium.

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IMAGES IN CLINICAL RADIOLOGY Diverticulum of the bladder simulating ovarian cyst: pitfalls in the differential diagnosis A.J. Kruse1,2, F.C.H. Bakers3, R.F.P.M. Kruitwagen1,2

A 69-year-old Para 2 attended the outpatient department for an ultrasound scan of the pelvis. Her medical history revealed 3 lower urinary tract infections in the preceding months. Vaginal ultrasound of the pelvis showed a multilocular cyst measuring 17 x 17 x 17 cm, apparently originating from one of the adnexa and ascites. Coronal (A) and transverse CT scan (B) of the pelvis demonstrates a cystic mass, initially interpreted as an adnexal mass, suspicious for ovarian malignancy. There were septations within the mass (arrows). Retrospectively, this scan shows the bladder neck (triangles), and bladder diverticulum (A) connected to the bladder (B). Serum CA125 level was 22.8 u/ml. Her risk of malignancy index was 207, and an exploratory laparotomy was performed. After catheterization, up to 2600 ml of urine was drained out. At laparotomy, the internal genital organs were found to be normal and no masses were seen. Cystoscopy showed a trabeculated bladder with a large wide necked diverticulum arising from the left. The urethra and bladder neck were normal. Comment

In postmenopausal women, most of the cystic masses in the pelvis originate from the ovaries (1). Vesical diverticulae are rare and most are acquired and secondary to obstruction distal to the vesical neck. Retrospectively, the radiologist was unaware of the recurrent urinary tract infections. Ten independent radiologists were asked to review the CT scan, only 5 of them were aware of the recurrent urinary tract infections. Interestingly, 4 of 5 radiologists in the “aware group” and only 1 of 5 radiologists in the “unaware group” reviewed the cystic pelvic mass as a bladder diverticulum. This shows that it is important that the radiologist should be well informed. Although rare, bladder diverticulum should be considered in the differential diagnosis of a cystic pelvic mass, especially when a patient has recurrent urinary tract infections. Integrating the clinical findings and the different imaging modalities in our patient may have prevented unnecessary laparotomy. Reference 1.

Wang C.W., Chang Y.L., Horng S.G., Chueh H.Y., Soong Y.K., Chiu H.C.: Pitfalls in the differential diagnosis of a pelvic cyst: Lessons from a postmenopausal woman with bladder diverticulum. Int J Clin Pract, 2004, 58: 894-896.

1. GROW, School for Oncology and Developmental Biology, University of Maastricht/ Maastricht University Medical Center, Department of 2. Obstetrics and Gynaecology, 3. Radiology, Maastricht University Medical Center, Maastricht, The Netherlands.

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IMAGES IN CLINICAL RADIOLOGY Sinus venosus ASD K. Boeren1, Y. De Bruecker1, J. Roosen2, D. Perdieus1

A 32-year-old man presented at the cardiology department for a routine check-up. He had no symptoms, particularly no cardiological symptoms. Clinical examination and ECG revealed no abnormalities. Transthoracic echocardiography showed a mild dilatation of the right heart. Further functional evaluation of the right heart was performed with MRI to evaluate the presence of a left to right shunt as a possible cause of right heart dilatation. We used the phase-contrast technique to measure the flow in the left ventricular outflow tract (Qs = 4,6 l/min) and right ventricular outflow tract (Qp = 13 l/min). The Qp/Qs ratio measured 2.88, indicating a severe left to right shunt. Anatomical work up included a cardiac CT. It showed a dilated right heart (Fig. A) with a large defect in the upper atrial septum (Fig. B) contiguous with the superior vena cava, which is a sinus venosus type of atrial septal defect (SVASD). There was also an anomalous drainage of the right upper lobe pulmonary vein in the superior vena cava (Fig. C). Comment

There are 4 types of ASD: septum primum, septum secundum, patent foramen ovale and sinus venosus defect (SVASD). SVASD is located posterior to the foramen ovale and near the superior vena cava. Atrial septal defects lead to volume overload of the right heart with right heart dilatation and eventually pulmonary hypertension as a complication. SVASD is a rare type of ASD and is almost always associated with anomalous connection of the right upper pulmonary vein into the superior vena cava, which aggravates the left to right shunt. Diagnosis can be made by several diagnostic imaging techniques. Echocardiography is a good and non-invasive option but for better anatomical detail cardiac CT or cardiac MRI can be used. MRI also had the benefit to give functional information in addition to anatomical information. The mainstay of the therapy is surgical correction. Repair of SVASD is more complex than repair of the other types of ASD. A patch will redirect the blood flow from the right upper lobe pulmonary vein into the left atrium with closure of the interatrial communication and also correcting the anomalous pulmonary venous drainage. Adults with a left to right shunt of more than 2 benefit from surgical repair. Reference 1.

Wang Z.J., et al.: Cardiovascular shunts: MR Imaging Evaluation. Radiographics, 2003, 23: S181-S194.

1. Department of Radiology, 2. Department of Cardiology, Imelda Hospital, Bonheiden, Belgium.

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IMAGES IN CLINICAL RADIOLOGY Melorheostosis of the foot J. De Cock, K. Mermuys, S. Van Petegem, B. Houthoofd, K. Van De Moortele, K. Vanslambrouck1 A 48-year old male patient of Arabic origin presented to the orthopedic consultation with a history of slow progressive pain, joint stiffness and swelling of the left foot. Local tenderness was present and a painful, hard mass was clearly palpable. Conventional radiography (Fig. A) revealed undulating and sclerotic enlarged areas (candle wax-appearance) in the lateral cuneiform bone, the third metatarsal bone and the proximal, intermediate and distal phalanx bone of the third row. Cortical hyperostosis was also apparent in the middle phalanx and metatarsal bone of the second row. Areas of extraosseous bone formation could be seen, most clearly adjacent to the metatarsal head and the middle phalanx of the third row. A diagnosis of melorheostosis was made. A CT-scan, which is not strictly required to make the diagnosis, confirmed the radiographic findings (Fig. B). The patient was treated conservatively. Comment

Melorheostosis was first described by Leri and Joanny in 1922. It is a rare, non-hereditary disease. Characteristically, the cortical lesions are progressive and may result in narrowing of the medullary canal and stenosis of an adjacent lumen, foramen, or of the spinal canal. Motor or sensory nerves may be compressed and become symptomatic. The cortical hyperostosis may extend into nearby joints and cause loss of motion. Extensive soft tissue masses may develop, most of which are adjacent to the involved bone, but some may be unconnected to the bone. The soft tissue masses become more ossified over time. Patients with meloreostosis may have associated lesions such as vascular malformations, neurofibromatosis, hemangioma, arterial aneurysms, linear scleroderma, tuberous sclerosis, hemangiomas, and focal subcutaneous fibrosis. The cause of meloreostosis is unknown, but one theory proposed is that the lesions arise from an abnormality of the sensory nerve of the affected sclerostome. A single bone may be involved (monostotic) or several bones may be involved (polyostotic). The affected bones are usually related to the same sclerotome. Isolated cases of malignancy have been reported in association with melorheostosis. Melorheostosis is usually apparent in early childhood and even in the first few days of life. In children the condition affects mainly the bones of the extremities and pelvis, and may result in limb length inequality, deformity, or joint contractures. About 50% of persons affected will develop the symptoms by 20 years of age. The condition occurs in both sexes. Melorheostosis has an estimated incidence of 0.9 cases per million persons. Biopsy shows a variable degree of marrow fibrosis, along with markedly irregular bone constituted of mixed areas of lamellar and woven bone. A mixture of osteocartilaginous, fibrovascular, and adipose tissue is seen in the soft tissue masses. The clinical course is slowly progressive. Severe symptoms may require treatment by sympathectomy or even amputation. Reference 1.

Kalbermatten N.T., Vock P., RĂźfenacht D., Anderson S.E.: Progressive melorheostosis in the peripheral and axial skeleton with associated vascular malformations: imaging findings over three decades. Skeletal Radiol, 2001, 30: 48-52.

1. Department of Radiology, A.Z. St.-Jan Hospital, Bruges, Belgium.

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ABSTRACT OF PAPERS FOR FULL MEMBERSHIP AT THE ROYAL BELGIAN SOCIETY OF RADIOLOGY Indications for embolisation with the Amplatzer® Vascular Plug 4 C. Kenis1, M. Camerlinck1, T. Van der Zijden1, J. Maes1,2, O. D’Archambeau1,2 Purpose: To expand the indications for the use of the Amplatzer® Vascular Plug 4 (VP4) instead of other embolization materials such as coils or glue, by evaluating our own experience and reviewing the literature. Materials and methods: A complete review of the literature was made and the results of our own experience with 11 embolization procedures were summarized. These included 2 embolizations of the iliac artery (EIA for a retroperitoneal

bleeding and IIA for an arteriovenous fistula), 5 of the gastroduodenal artery (in preparation of selective internal radiotherapy), 1 of the pulmonary artery (arteriovenous malformation), hepatic artery (aneurysm), renal artery (arteriovenous fistula) and splenic artery (for the reduction of venous flow in a patient with progressive swelling of gastric varices). Results: In our patient group the plug was successfully placed in 10 out of 11 patients without complications. In 1 case, the plug couldn't be placed because of excessive resistance entering the coeliac trunk using a flexible 4F catheter. One additional coil was needed during the embolization of the splenic artery in order to obtain a satisfying

reduction of flow. The occlusion times ranged from 1 to 10 minutes. Only a few studies describe the use of the VP4. Varying indications are reported. Most of them discuss the benefits of using the plug over coils or glue in certain situations. Conclusion: The VP4 can be used in a broad range of indications and in most cases it allows a fast and safe embolization. The cost-benefit of using the VP4 over other materials has to be determined in each case separately. 1. Department of Radiology, Antwerp University Hospital, Edegem, 2. Department of Radiology, GZA Sint-Augustinus Ziekenhuis, Wilrijk, Belgium.

POSTGRADUAAT RADIOLOGIE VAN DE VLAAMSE UNIVERSITEITEN PROGRAMMA 2011-2012

20 oktober 2011 (20.00 u) Abdominale radiologie (auditorium G010 Jan Fabre, UA Campus Middelheim) 24 november 2011 (20.00 u) Osteo-articulaire radiologie (auditorium Brouwer, Faculteit G & F)

VUB

15 december 2011 (20.00 u) Mammografische beeldvorming (auditorium C, UZ Gent)

19 januari 2012 (20.00 u) Urgentieradiologie (auditorium G010 Jan Fabre, UA Campus Middelheim)

16 februari 2012 (20.00 u) Neuroradiologie (auditorium GA3, Onderwijs & Navorsing, UZ GHB)

KUL

19 april 2012 (20.00 u) Thoraxradiologie (auditorium Brouwer, Faculteit G & F)

VUB

24 mei 2012 (20.00 u) Pediatrische beeldvorming (auditorium C, UZ Gent)

PROCARE newsletter_Opmaak 1 21/10/11 11:13 Pagina 1

JBR–BTR, 2011, 94: 304.

PROCARE NEWSLETTER

Since a few years, the RBRS supports PROCARE, the PROject on CAncer of the Rectum. For performing high image quality MR rectal cancer staging, scan parameters were developed and demonstrated during workshops. Further all radiologists were encouraged to include their patients in the Procare database. The rather low degree of participation by the radiologists justifies this renewed request to all radiologists to actively participate in Procare by uploading their rectal cancer cases and using high quality MR imaging. This will definitely reinforce the position of the radiologists in the Belgian health care system! For more information, visit the following websites: Procare http://www.kankerregister.be/, the role of the radiologists http://tinyurl.com/3rhsgl6, the presentation of the Procare project manager Tamara Vandendael during BWGE 2011 http://tinyurl.com/3umpb8j the Procare manual http://tinyurl.com/3epyfaz. The technical recommendations for high quality MR imaging of the rectum are attached. On behalf of the Procare steering committee and the RBRS/KBVR/SRBR, Didier Bielen

CLASSIFIED SERVICES

Institut Jean-Godinot – REIMS Centre Régional de Lutte Contre le Cancer pour Champagne-Ardenne/Aisne (78 lits, 20 places en ambulatoire, 32.000 consultations/an) (membre du groupe UNICANCER http://www.unicancer.fr ) Agréé pour le DESC d’imagerie en cancérologie Doté de deux plateaux techniques récents dont:

• le Centre Sein Godinot situé au centre ville, spécialisé en radiosénologie et interventionnel-sein, • Un scanner et un IRM neufs • la Radiologie Générale au sein de l’Institut,

un 4

ème

recrute RADIOLOGUE

Ses projets: • Poursuivre l’essor de l’imagerie de recherche clinique • Développer la radiologie interventionnelle • Eventuellement prendre la responsabilité du service Contacts: Professeur Hervé CURÉ, Directeur Général Tel.: 33 (0)3 26 50 44 87 – E-mail: herve.cure@reims.unicancer.fr service RH: 33 (0)3 26 50 44 67 – E-mail: anne.holmes@reims.unicancer.fr Institut Jean-Godinot 1, avenue du Général Koenig 51056 REIMS CEDEX Tel.: (Belgique): 0477 637504

20-forthc. courses-94(3)_Opmaak 1 13/10/11 15:33 Pagina 1

JBR–BTR, 2011, 94: 305.

FORTHCOMING COURSES AND MEETINGS NATIONAL MEETINGS 19.11.11 Annual RBRS symposium 2011 Imaging of the spine and the spinal cord : state-of-the-art Organization: Dr B. Desprechins

10.12.11 MRI of the knee 2011 Brussels, UCL St Luc Information: www.rbrs.org

16.12.11 RBRS – Cardiovascular and Interventional Radiology Information: Dr M. Laureys, marc.laureys@chu-brugmann.be

06.12.11 RBRS – Chest Radiology Brussels, UCL St Luc Information: benoit.ghaye@uclouvain.be walter.dewever@uzleuven.be

10.12.11 Minisymposium Angiografische interventies in de gynaecologie Wilrijk, Sint Augustinus Information: www.rbrs.org

03.06.12 Fifth congress of senology Oostduinkerke

Annual Symposium 2011: 19.11.11 RBRS – Cardiovascular and Interventional Radiology 16.12.11

RBRS – Breast Imaging 03.06.12 RBRS – Chest Radiology 06.12.11

Detailed and real time information is available on RBRS website at www.rbrs.org

INTERNATIONAL MEETINGS

08.11.11 11TH WORLD FEDERATION OF INTERVENTIONAL AND THERAPEUTIC NEURORADIOLOGY CONGRESS South Africa, Cape Town Information: www.wfitn2011.org

27.11-02.12.11 RSNA ANNUAL MEETING Chicago, USA Information: www.rsna.org

RBRS – Cardiac Imaging 01.10.11

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306

ANNOUNCEMENT STUDY GRANTS OF THE BELGIAN SOCIETY OF RADIOLOGY

BEURS VAN DE KONINKLIJKE VERENIGING VOOR RADIOLOGIE

BELGISCHE

BOURSE DE LA SOCIETE ROYALE BELGE DE RADIOLOGIE

Door de KBVR wordt een beurs ten bedrage van € 2975 ter beschikking gesteld aan elk van de 7 universitaire opleidingscentra voor radiologie. Deze zijn: KUL, RUG, VUB, UIA, UCL, ULB, ULg. Deze beurs zal dienen om ofwel de reiskosten te dekken van een studiereis uitgevoerd door één van haar leden ofwel om kosten voor research te dekken uitgevoerd door één van haar leden.

La Société Royale Belge de Radiologie met à la disposition de chacun des 7 centres universitaires de radiologie (KUL, RUG, UCL, VUB, UIA, UCL, ULB, ULg) une bourse d’un montant de 2975 €. Celle-ci est destinée à couvrir les frais de voyage d’étude d’un de ses membres ou à couvrir les frais d’un travail de recherche d’un de ses membres.

Reglement

Règlement

1. Als kandidaat komt in aanmerking iedere arts of doctor in de genees-, heel- en verloskunde die een opleiding volgt of gevolgd heeft tot specialist in de radiologie aan één van de Belgische universiteiten met inbegrip van de hieraan verbonden niet-universitaire stagecentra. De kandidaat moet titulair lid zijn van de KBVR.

1. Sera prise en considération la candidature de tout docteur en médecine, accomplissant ou ayant accompli sa formation de spécialiste en radiodiagnostic dans une université belge ou un centre de stage non-universitaire y attaché. Le candidat doit être membre titulaire de la SRBR.

2. a. Voor de reisbeurs:

2. a) Bourse de voyage :

de kandidaat legt een studieproject voor aan het bureau van de KBVR dat door de titularis van de leerstoel radiologie van zijn universiteit is goedgekeurd. Ingeval de kandidaat een gedeeltelijke of volledige opleiding volgt in één van de niet-universitaire stagecentra dient zijn aanvraag goedgekeurd te worden door zijn stagemeester en de titularis radiologie van de universiteit waaraan het stagecentrum verbonden is of van de universiteit waar de kandidaat zijn einddiploma van doctor in genees-, heel- en verloskunde heeft gehaald. b. Researchbeurs: de kandidaat legt een researchproject voor aan het bureau van de KBVR dat door de titularis van de leerstoel radiologie van zijn universiteit is goedgekeurd. Dit project dient welomschreven te zijn zowel naar inhoud als naar nodige werkingsmiddelen. 3. a. Reisbeurs: als studieprojecten komen bij voorkeur in aanmerking: een verblijf van ongeveer 2 maanden in een buitenlands centrum voor radiologie met het oog op het verwerven of verdiepen van een bijzondere ervaring in één of andere radiologische onderzoeksmethode of met het oog op het verbeteren van de kennissen van de kandidaat in één of ander domein van de radiologie. b. Researchbeurs:

Le candidat déposera un projet d’étude approuvé par le responsable du département de radiologie de son université. Si la formation s’effectue en tout ou en partie dans un centre de stage non-universitaire, la demande sera préalablement approuvée par le maître de stage ou encore par le responsable du département de radiologie de l’université ayant délivré au candidat son diplôme de docteur en médecine, chirurgie et accouchements.

b) Bourse de recherche : Le candidat déposera un projet de recherche approuvé par le titulaire de l’enseignement de radiologie de son université auprès du Bureau de la SRBR. Ce projet structuré comprendra la description de la recherche ainsi que les moyens nécessaires. 3. a) Bourse de voyage : Le choix se portera préférentiellement sur des projets d’études effectués lors d’un séjour d’environ deux mois dans un centre de radiologie étranger, dans le but d’acquérir ou de perfectionner une expérience particulière de l’une ou l’autre méthode d’investigation radiologique ou dans le but d’améliorer les connaissances du candidat dans l’un ou l’autre domaine de la radiologie. b) Bourse de recherche :

als project komt in aanmerking een welomschreven studie in één of ander domein van de radiologie waarvan mag verwacht worden dat ze een belangrijke bijdrage levert tot de radiologische wetenschap en dat ze zal leiden tot een publicatie in een reviewed tijdschrift.

Peut être pris en considération le projet s’inscrivant dans le domaine de la radiologie susceptible de représenter une contribution importante aux sciences radiologiques et qui est susceptible d’être publié dans une revue internationale à comité de lecture sélectif.

4. Zowel voor de reisbeurs als voor de researchbeurs dient het project voorgelegd te worden aan het bureau van de KBVR.

4. Les demandes de bourse de voyage et de bourse de recherche seront soumises au Bureau de la SRBR.

5. a. Reisbeurs:

5. a) Bourse de voyage :

binnen de 5 maanden na het beëindigen van de buitenlandse stage brengt de studiebeurslaureaat mondeling verslag uit bij het bureau van de KBVR over zijn studiereis. De reisbeurslaureaat verbindt er zich toe een wetenschappelijke bijdrage met betrekking tot zijn project te publiceren in het JBR-BTR.

Endéans les cinq mois suivant la fin de stage à l’étranger, le lauréat de la bourse d’étude présentera un compte-rendu oral de son voyage d’étude au Bureau de la SRBR.

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b. Researchbeurs:

b) Bourse de recherche :

binnen het jaar na het toekennen van de beurs brengt de kandidaat verslag uit bij het bureau van de KBVR.

Dans l’année suivant l’attribution de la bourse, le candidat présentera un rapport auprès du Bureau de la SRBR.

6. De periode tijdens dewelke de aanvragen kunnen ingediend worden en dienen toe te komen bij de Algemene Secretarissen loopt tot en met 31 december van het lopende jaar.

6. Les demandes doivent être introduites au 31 décembre de l’année en cours. Les candidatures seront adressées à l’un des Secrétaires Généraux de la SRBR.

7. Een beslissing over een ingediend project dient door het bureau van de KBVR genomen te worden ten laatste binnen de 4 maand na het indienen.

7. L’approbation du projet par le Bureau de la SRBR sera notifié au candidat au plus tard quatre mois après la réception du projet.

8. a. Reisbeurs:

8. a) Bourse de voyage :

de helft van de studiebeurs zal uitbetaald worden voor het vertrek van de kandidaat. De overige helft wordt uitbetaald nadat de kandidaat verslag heeft uitgebracht bij het bureau. b. Researchbeurs:

La moitié du montant de la bourse sera versée avant la date du départ du boursier. Le solde sera libéré après présentation du compte-rendu de son séjour au Bureau de la SRBR. b) Bourse de recherche :

de helft van de beurs zal uitbetaald worden bij het toekennen. De overige helft wordt uitbetaald nadat de kandidaat verslag heeft uitgebracht bij het bureau.

La moitié du montant de la bourse sera versée dès son attribution. Le reliquat sera versé après le rapport présenté auprès du Bureau.

9. De studiebeurs wordt uitbetaald aan het diensthoofd die het geld bezorgt aan de kandidaat.

9. Le montant de la bourse sera versé au maître de stage, qui le mettra à la disposition du boursier.

KBVR BEURS VOOR RESEARCH IN HET BUITENLAND

BOURSE DE LA SRBR POUR LA RECHERCHE À L’ÉTRANGER

Door de KBVR wordt een beurs ten bedrage van € 25.000 ter beschikking gesteld aan Belgische radiologen om gedurende 1 jaar in een buitenlandse universitaire dienst van radiologie research te verrichten binnen het domein van de radiologie.

La SRBR instaure une bourse d’un montant de 25.000 € mise à disposition de la communauté radiologique belge dans le but de réaliser une recherche relevant du domaine de l’imagerie médicale dans un hôpital universitaire étranger.

Reglement

Règlement

1. Als kandida(a)t(e) komt in aanmerking iedere erkende specialist in de radiologie die op het ogenblik van de aanvraag actief betrokken is in de radiologische research aan een Belgische universiteit. De kandida(a)t(e) dient de Belgische nationaliteit te hebben en op het ogenblik van de aanvraag een doctoraat in de medische wetenschappen behaald te hebben of deel te nemen aan het programma voor het behalen van dit doctoraat (certificaat van de faculteit is vereist). De kandida(a)t(e) moet zijn/haar research activiteiten bovendien bewijzen d.m.v. vroegere publicaties in internationale tijdschriften, voordrachten op internationale symposia, het eventueel verworven hebben van andere beurzen of prijzen. De kandida(a)t(e) moet titulair lid zijn van de KBVR.

1. Les candidat(e)(s) seront radiologues reconnus faisant preuve dune activité de recherche dans une Université Belge. Ils (elles) seront de nationalité belge et faire preuve qu’au moment de la candidature ils (elles) ont obtenu ou ont entrepris un programme de recherche en vue de l’obtention d’un doctorat en sciences médicales ou d’une thèse d’agréation (une attestation de la faculté de médecine sera requise). Les candidat(e)(s) fourniront un curriculum attestant de travaux publiés dans des revues internationales à comité de lecture, de présentations à des réunions internationales et de l’obtention éventuelles de prix ou de bourses. Les candidat(e)(s) doivent être membre titulaire de la SRBR.

2. De beurs kan 1 maal toegekend worden aan elk van de 7 universitaire opleidingscentra voor radiologie en dit in de periode tussen 1/1/2011 en 31/12/2011.

2. La bourse peut être attribuée 1 fois à chaque Université belge, les candidatures devant être introduites entre le 01-01-2011 et le 31-12-2011.

3. De kandida(a)t(e) legt een document (minimaal 4 getypte pagina’s) voor aan het bureau van de KBVR waarin het concept en de doelstellingen van het 1 jaar durende research project worden uitgelegd en waarin ook de research faciliteiten van het buitenlands centrum worden beschreven. Dit buitenlands centrum moet algemeen erkend zijn als kwalitatief hoogstaand. In het document wordt ook een gedetailleerde omschrijving gegeven van het geplande werkschema dat alleszins minstens 70% labowerk dient te omvatten. Het document dient vergezeld van een brief van het diensthoofd van het buitenlands centrum waarin duidelijk gesteld wordt dat zowel kandida(a)t(e) als research project aanvaard zijn. Verder dient er ook een brief te zijn van het diensthoofd radiologie van de Belgische universiteit waar de kandida(a)t(e) op het ogenblik van de aanvraag research verricht en waarin vermeld wordt dat de aanvraag gesteund wordt.

3. Les candidat(e)(s) déposeront à l’appui de leur candidature un document (minimum 4 pages à simple interligne) décrivant les buts et modalités de leur recherche d’un an et décrivant les conditions de recherche de l’institution d’accueil qui devra être reconnue comme étant de haut standard. Le document détaillera le shéma de la recherche entreprise qui comportera au moins 70% d’activité de recherche pure, à l’exclusion de prestations cliniques. Le documents sera accompagné d’une attestation du responsable du service d’accueil établissant la validité de la recherche et l’acceptation du (de la) candidat(e). De plus le chef de service du service universitaire d’origine attestera des activités de recherche du (de la) candidat(e) et du soutien de l’institution d’origine.

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4. Een beslissing over een ingediend project dient door het bureau van de KBVR genomen te worden ten laatste binnen de 4 maand na het indienen.

4. La décision sur les projets introduits sera prise au plus tard 4 mois après le dépôt des documents.

5. Zes maanden na de start van het project dient de kandita(a)at(e) een tussentijds rapport te versturen naar het bureau van de KBVR waarin de stand van het project en de voorlopige resultaten van de reeds gedane wetenschappelijke studies worden weergegeven. Bij het einde van het project dient een volledig en uitvoerig rapport gemaakt. Verder dienen er door de kandida(a)at(e) twee artikels geschreven te worden, één voor publicatie in het Belgische Tijdschrift van Radiologie en één voor publicatie in European Radiology

5. Le(la) Candidat(e) devra envoyer un rapport intermédiaire auprès du Bureau de la Société à l’échéance des six mois écoulés après l’attribution de la Bourse. Ce rapport devra décrire le stade d’avancement et les résultats préliminaires de l’étude. Un rapport définitif sera envoyé au Bureau après complétion de l’étude. En outre, le (la) titulaire de la bourse rédigera deux articles pour publication, l’un à l’intention du Journal Belge de Radiologie (JBR-BTR) l’autre à l’intention d’European Radiology.

6. Betaling

6. Payement

€ 12.500,00 zal uitbetaald worden 1 maand voor het vertrek van de titularis. € 6.250,00 wordt uitbetaald na 6 maanden, nadat de kandida(a)t(e) het tussentijds verslag heeft verstuurd naar het bureau. € 6.250,00 na het beëindigen van het project, op het ogenblik dat het eindrapport is voorgebracht en dat de 2 manuscripten afgewerkt en verstuurd zijn. De studiebeurs wordt uitbetaald aan de dienst radiologie of aan de universiteit die het geld bezorgt aan de kandida(a)t(e).

€ 12.500,00 seront payés 1 mois avant le départ du (de la) titulaire de la bourse. € 6.250,00 seront payés au 6e mois, après le dépôt du rapport intermédiaire € 6.250,00 seront payés après la complétion du projet et dépôt du rapport définitif et lorsque les deux articles seront écris et envoyés. Le montant de la bourse sera versé au service d'origine ou son Université qui la payera au ( à la) titulaire.

BEURS TERUGBETALING ONKOSTEN THESIS

BOURSE COUVRANT DES FRAIS DE THESE

Door de KBVR wordt een beurs ten bedrage van € 1.850 ter beschikking gesteld aan radiologen, titulaire leden van de vereniging die vanaf het jaar 1998 een doctoraats- of aggregaatsthesis (echter geen biomedische thesis) hebben verdedigd. Het doel van deze beurs is de onkosten gemaakt voor het drukken van deze thesis te vergoeden.

La SRBR crée une bourse de 1860 € à l’intention des docteurs en médecine, spécialistes en radiologie, membres de la Société, qui ont présenté à partir de 1998 une thèse de doctorat ou d’agrégation. Cette bourse est destinée à couvrir les frais d’impression de cette thèse.

Reglement

Règlement :

1. Als kandidaat komt in aanmerking iedere doctor in de genees-, heel- en verloskunde die een opleiding volgt of gevolgd heeft tot specialist in de radiologie aan één van de Belgische universiteiten met inbegrip van de hieraan verbonden niet-universitaire stagecentra. De kandidaat moet titulair lid zijn van de KBVR.

1. Le candidat doit être docteur en médecine, avoir acquis la spécialisation en radiologie ou être en formation dans une université belge, y inclus les stages non universitaires. Le candidat doit être membre titulaire de la SRBR.

2. De kandidaat legt de gedrukt thesis voor tezamen met een onkostennota die de uitgaven voor het drukken van de thesis bewijst.

2. Le candidat doit déposer l’épreuve imprimée de sa thèse accompagnée de la facture d’impression.

3. De aanvraag dient voorgelegd te worden aan het bureau van de KBVR en door dit orgaan te worden goedgekeurd.

3. La demande est introduite au Bureau de la SRBR qui doit approuver la demande.

4. Het uitgekeerd bedrag staat in functie van bewezen onkosten en bedraagt maximaal € 1.850.

4. Le montant est attribué en fonction des justificatifs avec une demande maximale de € 1.850.

5. De beslissing over het toekennen van de beurs dient door het bureau van de KBVR genomen te worden ten laatste binnen de 4 maanden na het indienen.

5. Le Bureau de la SRBR statuera sur l’attribution de la bourse dans les quatre mois suivant l’introduction.

6. De studiebeurs wordt uitbetaald aan het diensthoofd die het geld bezorgt aan de kandidaat.

6. Le paiement de la bourse sera versé au chef de service de l’institution universitaire , qui le mettra à la disposition du boursier.

7. De factuur van de drukkosten kan gemaakt worden op naam van de dienst waartoe de kandidaat behoort of op naam van de KBVR.

7. La facture des frais d’impression peut être libellée au nom du service auquel appartient le candidat ou au nom de la Société Royale Belge de Radiologie.

00b-JBR-Adv.index-2011-5_JBR-Adv.index-2003/6 24/10/11 08:30 Pagina 1

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Pages III V VI VII, VIII IX X XI XII XIII XIV CIV

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