JBR 2012-1 by office

00a-Couv-2012(1):Opmaak 1 16/02/12 14:00 Pagina 1

WETTEREN 1

P 702083

Volume 95 Page 1-60

January-February Bimonthly

–

2012

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)

02-voorblz-12-6_Opmaak 1 16/02/12 13:47 Pagina 1

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.

Single issue 38 € 44 €

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

Instructions aux abonnés Le JBR-BTR publie 6 fascicules par an. Les tarifs sont susceptibles de modifications sans préavis, en fonction de l’évolution des prix du marché du papier et des travaux d’impression. Le prix de l’abonnement des membres de la Société Royale de Radiologie est inclus dans le montant de la cotisation. L’abonnement d’un non-membre est à souscrire auprès de l’ARSMB. La souscription d’abonnement ou la commande de numéro isolé doit être exécutée rapidement, l’éditeur ne pouvant pas garantir la livraison d’éditions passées. Les changements d’adresse doivent être signalés 60 jours à l’avance. TARIF: Belgique Autres pays Envoi et port inclus.

Annuel 175 € 200 €

Fascicule 42 € 49 €

Nous vous prions d’adresser toute correspondance à Mme A. Hirsch et d’effectuer tout paiement au compte de l’ARSMB-KVBMG (voir ci-dessous).

Instructies voor abonnees Het JBR-BTR geeft 6 nummers uit per jaar. Het tarief is vatbaar voor wijzigingen zonder voorafgaand bericht, in verhouding tot de evolutie van de papierprijzen en loonkosten in de grafische nijverheid. Het abonnement van de leden van de Koninklijke Vereniging voor Radiologie is begrepen in de bijdrage van het lidgeld. De abonnementen van niet-leden zijn te onderschrijven bij de KVBMG. Jaarabonnementen of bestellingen van losse nummers moet zo snel mogelijk gebeuren, de uitgever waarborgt de levering van de vorige nummers niet voor de abonnementen die te laat werden onderschreven. De adresveranderingen moeten 60 dagen te voren gemeld worden. TARIEF: Jaarlijks Belgie 175 € Andere landen 200 € Verzendingskosten zijn inbegrepen.

Aflevering 42 € 49 €

U wordt vriendelijk verzocht alle briefwisseling te richten aan Mevr. A. Hirsch en alle betalingen te verrichten op het banknummer van ARSMB-KVBMG (zie hieronder).

Association Royale des Sociétés Scientifiques Médicales Belges – (ARSMB), asbl avenue W. Churchill 11/30, B-1180 Bruxelles, Belgique tél.: (02) 374 25 55 fax: (02) 374 96 28

Koninklijke Vereniging van de Belgische Medische Wetenschappelijke Genootschappen – (KVBMG), vzw W. Churchill-laan 11/30, B-1180 Brussel, België tel.: (02) 374 25 55 fax: (02) 374 96 28

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-12-1_Opmaak 1 16/02/12 13:56 Pagina 1

JBR-BTR ♦ 95/1 ♦ 2012 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

The role of diffusion-weighted MRI and ADC values in the diagnosis of gastric tumors. S. Avcu, H. Arslan, O. Unal, M. Izmirli . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Sternocleidomastoid pseudotumor in infancy: a report of 13 cases. I. Hasni Bouraoui, N. Arifa, M. Gaha, W. Kermani, K. Mrad Dali, H. Hmouda, K. Tlili Graiess . . . . . . . . . . . . . .

Trampoline fracture of the proximal tibia in children: report of 3 cases and review of literature. E. Bruyeer, E. Geusens, F. Catry, L. Vanstraelen, F. Vanhoenacker . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Pylephlebitis complicating peridiverticulitis without hepatic abscess: early detection with contrast-enhanced CT of the abdomen. P. Mailleux, Ph. Maldague, B. Coulier . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Soft tissue chondroma of Hoffa’s fat pad. M.I. Ingabire, F.C. Deprez, A. Bodart, T. Puttemans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Sphenoid mucocoele as a complication of fibrous dysplasia of the facial bones. K. De Smet, M. De Maeseneer, A. Talebian Yazdi, Th. Buisseret, J. De Mey . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Two foreign body reactions caused by suture materials: mammograms mimic cancer as a speculated lesion. A. Koktener, K. Akin, D. Kosehan, B. Cakir, H. Haltas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

A bare area of the glenoid misdiagnosed as a cartilage ulceration. M. De Maeseneer, N. Pouliart, F. Machiels, M. Shahabpour, C. Boulet, M. Kichouh, J. De Mey . . . . . . . . . . . . .

Radiation-induced aortic occlusion. G. McNeill, S. Culleton, K. Courtney, W.C. Torreggiani . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Radiological findings in a rare case of eyelid swelling: Pott’s puffy tumor. H.N. Ozcan, S. Avcu, M. Lemmerling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

IMAGES IN CLINICAL RADIOLOGY Single right coronary artery with a “malignant course” of the main coronary artery. P. Mailleux, P. Timmermans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Hypermobile coccyx syndrome. M. Apaydin, K.B. Bayram, M. Varer, A. Oygen, G. Sezgin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Uterine lipoleiomyoma. M. Devooghdt, N. Favoreel, S. Gryspeerdt, B. van Holsbeeck . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Left ventricular non-compaction cardiomyopathy. H.K. Kok, S. Ma, P. Ma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Spontaneous regression of pulmonary sequestration: prenatal and postnatal imaging findings. Y.K. Fan, Y.P. Liu, Y.L.Lin, W.K. Su . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Breast augmentation by injection of free silicone: MRI findings. K. Vanwambeke, I. Wittevronghel, S. Dekeyzer, C. Petre, F.M. Vanhoenacker . . . . . . . . . . . . . . . . . . . . . . . . . . . .

High resolution CT diagnosis of isolated fracture of the malleus handle. D. Volders, Th. Somers, J. Casselman . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Popliteal venous aneurysm. N. Favoreel, M. Devooghdt, J. Marrannes, P. Gellesn, B. Van Holsbeeck . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Aberrant retropharyngeal internal carotid artery associated with retropharyngeal abscess: determination of a safe drainage zone with CT. B. Battal, K. Karaman, S. Akay, M. Tasar . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

The giant seminal vesicle cyst: MRI findings. B. Battal, V. Akgun, B. Karaman . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

01-JBR-contents-12-1_Opmaak 1 23/02/12 09:02 Pagina 2

Proceedings of papers presented at the RBRS Annual Symposium, Brussels, 19.11.2011 . . . . . . . . . . . . . . . . . . . .

Proceedings of ESHNR Annual Meeting, Brugge, 08-10.09.2011 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Abstract of papers for full membership at the Royal Belgian Society of Radiology . . . . . . . . . . . . . . . . . . . . . . . .

Forthcoming Courses and Meetings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Grants of the RBRS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Instructions to Authors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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

cii

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

ciii

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

B R E A S T

I M A G I N G

S O L U T I O N S

The promise of Tomosynthesis Now breast cancer has no where to hide. Hologic has taken another significant leap forward in breast imaging with the introduction of Selenia® Dimensions™ digital mammography system, the first practical tool to deliver on the extraordinary promise of breast tomosynthesis. Selenia Dimensions is the embodiment of state-of-the-art technology and flexibility, delivering: •

Revolutionary fusion imaging capabilities that combine digital mammography and tomosynthesis images in one exam, under one compression

•

Exceptionally sharp images that allow you to visualize the finest details

•

A sophisticated, ergonomic design for streamlined workflow and enhanced comfort for both the technologist and the patient

E-mail: Be-info@hologic.com Visit our website www.hologic.com

HOLOGIC Belgium Leuvensesteenweg 250 A 1800 Vilvoorde - Belgium

02-voorblz-12-6_Opmaak 1 16/02/12 14:10 Pagina 2

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

Editor: J. Pringot Associated Editor: B. Desprechins

President: J.F. De Wispelaere

Managing Editor: P. Seynaeve

Vice-Presidents: R. Hermans, D. Henroteaux

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: B. Desprechins General Secretaries: F. Avni, J. Verschakelen Meeting Secretaries: M. Spinhoven, Y. Lefebvre Treasurers: D. Brisbois, A. Van Steen Coordinators of continuing education: Ph. Clapuyt, 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 Radiology 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 but consist of a synthetic description of the clinical and radiological features as well as the final diagnosis and one major reference. 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 the next page)

02-voorblz-12-6_Opmaak 1 16/02/12 13:47 Pagina 3

– Opinion articles are special articles dealing with controversial topics of specific concern to radiologists. They may include tables and figures, and must provide a references list. – Letters to the Editor and their replies present objective and useful criticism over an article published in one of the lest four issues of the JBR-BTR. They will be published with the name and address of the author. References are necessary, tables and figures are accepted but acknowledgements are not appropriate. – Meeting news are reports of national or international congresses, symposia and meetings of radiology. Full references of the meeting, including date, place and summary of the main topics should be mentioned. Text should be kept to major facts. Figures, tables, references and acknowledgements should not be included. – In memoriams and News are essentially dealt with in the Editorial Office. Contributions may however be submitted under the form of letters addressed to the Editorial Office which will check the adequacy of the information.

General Guidelines for Papers Manuscript Requirements Send 3 copies of the manuscript, including tables and figures (1 original set + 2 copies of the text and 2 original sets + 1 copy of the illustrations) and the corresponding diskette (see below Instructions for Electronic Manuscript Submission). In keeping with sound environmental and economic principles, the JBR-BTR encourages all authors to submit manuscripts printed on both sides of the page. The practice not only will save paper but also will reduce the price of postage required to mail the manuscript. Note that failure to provide an electronic version of manuscript will result in costs to be charged to the author. The original set should mention the personal references of the author. The copies should be nameless (including the figures). Each section of the manuscript begins on a new page in the following order: titre page running title page + key-words, abstract, text, acknowledgements, references, tables and captions for illustrations. Use English or one of the national languages. In the latter case, an English version of the titre, abstract, key-words, legends must necessarily be provided. Note that the author will be charged the costs of translation. Submitted manuscripts may not be covered by a previous copyright. The author will be held responsible for any litigation that might possebly ensue. Manuscripts will be submitted to a review Committee whose decision is final. Authors are usually notified within eight weeks as to the acceptability of their paper. Instructions for Electronic Manuscript Submission

Please send an electronic version of your manuscript either a floppy disk or a CD-rom in conjunction with the traditional paper version or separately as an e-mail with attachments to JBR-BTR@skynet.be. Please follow the general instructions on style/ arrangements and, in particular, the reference style as given in the present “Instructions to Authors”. Note, however, that while the paper version of the manuscript must be presented in the traditional double spaced format, the electronic version will be typeset and should not contain any extraneous instructions. For exemple: use hard carriage returns only at the end of paragraphs and display lines (e.g. titles, subheadings); do not use an extra hard return between paragraphs; do not use tabs or extra space at the start of a paragraph or for list entries; do not indent runover lines in references; turn off line spacing; turn off hyphen-

ation and justification; do not specify pages breaks, page numbers, or headers; do not specify typeface. Care should be taken to correctly enter “one“ (1) and longer case “el“ (l), as well as “zero” (O) and capital “o“ (O). Illustrations and tables will be handled conventionally. However, figures and table legends should be included at the end of the electronic file. Nonstandard characters (Greek letters, mathematical symbols, etc.) should be coded consistently throughout the text. Please make a list of such characters and provide a listing of the codes used. Note that disks and CD-roms will not be returned to authors. Title – Keep it short and relevant. – Title must be followed by the surname(s) and first name(s) (for computer processing purposes, 2 initial letters only will be admitted) of all authors. – The position held by the authors, their academic degrees, the name of the institution to which they belong and/or from which the article originates and the name of the department Head (if required) must be indicated at the bottom of the first page. – The titIe in the national language of the text should be noted after the key-words. – A running title in English should be provided on a separate page. – Two copies of a blind titre page are included, giving only the titre (without the authors names) for use in the review process. Abstract and Key-words Written in English exclusively, the abstract should head the manuscript and summarize the aim, the methods, results and conclusions. It should not exceed 200 words for major papers and 100 words for the other studies. No abbreviation or references are used in the abstract. Three to six key-words from the terms used in the JBR-BTR Subject Index (and/or the most recent three-year cumulative index of Radiology) should be listed. Text The text should be clearly divided in the following sections: introduction, material and methods, results, discussion and conclusion. Abbreviations should be defined in an explanatory note before being used as such. The definitive text should be typed on one side only of a standard size (A4) typewriting paper, in doublespacing throughout and have at least 3 cm margins. The manuscript should not be longer than 16 typewritten pages, including references and summary for a major paper unless otherwise agreed by the Editor (one typewritten page is equivalent to approximately 250 words) and no longer than 6 typewritten pages for the other types of work. Specific guest editorials Specific guest editorials are invited papers written by selected distinguished specialists. They should summarize in concise the stase of the art in one specific field of medical imaging or related sciences in no more than 8 typewritten pages, including either 1 table or illustration (drawing or graph). The bibliography should not exceed 12-15 recent and/or fundamental references. References References should be numbered consecutively in the order in which they appear in the text. Their number should be kept down to 20 for major papers and 8 for case reports and other papers.

They should be given as follows: a) abridged titles of periodicals should conform to those in the Index Medicus. All authors are listed when six or fewer; when seven or more authors, the first three are listed, followed by “et al.”. Ex.: Bomsel F., Couchard M., Henry E.: Respiratory distress in the newborn. J Belge Radiol, 1980, 63: 89-107. b) in the case of books, references should indicate: the authors of the chapter, the title of the chapter, the title of the book, the editor(s), publisher, edition, city, year and specific pages. – Ex.: Isengrin P.: Radiologie stomacale. 3e édition, Arscia, Bruxelies, 1974, p. 22. – Ex.: Weinstein L., Swartz M.N.: Pathogenic properties of invading microorganisms. In: Pathologic physiology: mechanisms of disease. Edited by Sodeman W.A. Jr, Sodeman W.A., Cds. Printed by Saunders, Philadelphia, 1974, pp. 457-472. Quote the name and address of the author to whom the reprints will be sent, at the end of the references. Corresponding author and Reprints The name and address of the corresponding author to should be mentioned affer the references. 25 reprints, are offered free by the JBR-BTR. Tables Tables should be presented on a separate page and numbered in Roman numerals in the order in which they are cited in the text. They should have an English title and legend. Abbreviations should be defined in a foot note. Only commonly admitted measurement standards should be used. Figures and Legends Illustrations should be restricted to the minimum required to show the essentiel features described in the paper. They must be mentioned in the text. Two complete unmounted sets of original figures in labeled envelopes should be provided. All figure parts relating to one patient should have the same figure number. Use capital letters A, B, C, in the ieft longer corner to distinguish figures from one set. Figures should be marked on the back with an arabic numeral indicating the sequence in which they are to be referred to, with a lightly pencilled “top“ indicating their topside and the name of the first author. Never use ink on front or back of any figure. For uniformity purposes, points of interest should be showed on the figures with removable (Letraset) arrows or/and letters, or should be indicated on an accompanying photocopy of the figures, in order to enable our services to use their own characters. Images should be uniform in size and magnification. 1. Radiographs Cost and number: depending on the length of the manuscript (a total of 2 to 6 times 14 ⫻ 15 cm is availabie free of charge). Presentation: glossy prints, no larger than 18/24 cm. It is advisable for films to be centered on the zone of major interest and they should be grouped. Arrows should indicate the important points. 2. Photographs and drawings Four-colour illustrations will be printed at the expense of the authors. Drawing and graphs should be of professional quality. They should illustrate — not duplicate — data given in the text. Legends are typed separately and preceded by the number of the corresponding illustration. Note that illustrations will not be returned to authors.

(*) Pr J. PRINGOT, Avenue W. Churchill 11/30, B-1180 Bruxelles, Belgique (tél.: 02-374.25.55, fax: 02-374.96.28, e-mail: JBR-BTR@skynet.be).

MR Angiography with MultiHance ® :

detection of significant steno-occlusive disease of the abdominal or peripheral arteries • MultiHance® is now also indicated for Contrast-enhanced MR-angiography where it improves the diagnostic accuracy for detecting clinically significant steno-occlusive vascular disease in patients with suspected or known vascular disease of the abdominal or peripheral arteries.(1)

MH_MRA_3-03-08ADV

• 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

Project2_Opmaak 1 6/04/11 11:06 Pagina 1

DÉNOMINATION DU MÉDICAMENT : Dotarem 0,5 mmol/mL, solution injectable. COMPOSITION QUALITATIVE ET QUANTITATIVE : La substance active est l'acide gadotérique. Elle est présente sous forme de gadotérate de méglumine (0,5 mmoles de gadotérate de méglumine/mL). Flacon de 5 mL : Acide gadotérique 1396,6 mg Flacon ou seringue pré-remplie de 10 mL : Acide gadotérique 2793,2 mg Flacon ou seringue pré-remplie de 15 mL : Acide gadotérique 4189,8 mg Flacon ou seringue pré-remplie de 20 mL : Acide gadotérique 5586,4 mg Flacon de 60 mL : Acide gadotérique 16759,2 mg Pour la liste complète des excipients, voir rubrique 6.1. FORME PHARMACEUTIQUE : Solution injectable. Indications thérapeutiques : Chez l’adulte, l’enfant et le nourrisson : imagerie par résonance magnétique. IRM Cérébral et du rachis dont : Pathologies encéphaliques et rachidiennes : tumeurs cérébrales, tumeurs du rachis et des enveloppes, hernies discales, pathologie infectieuse. IRM du Corps entier dont : Pathologies abdominales : tumeurs hépatiques primitives et secondaires, tumeurs pancréatiques. Pathologies rénales : tumeurs et kystes rénaux, suivi de transplantations rénales. Pathologies pelviennes : tumeurs de l’utérus et des ovaires. Pathologies cardiaques : suivi d’infarctus et de transplantations cardiaques. Pathologies mammaires : tumeurs du sein, suivi d’implants. Pathologies ostéo-articulaires : tumeurs osseuses et des parties molles. IRM pour angiographie : Ce médicament est à usage diagnostique uniquement. Posologie et mode d'administration : Posologie : Dans la plupart des cas, la dose recommandée est de 0,1 mmol/kg soit 0,2 mL/kg chez l’adulte, l’enfant et le nourrisson. En neuroradiologie, la dose peut varier de 0,1 à 0,3 mmol/kg. En cas de doute diagnostique après injection de la dose de 0,1 mmol/kg, la dose supplémentaire de 0,2 mmol/kg permet d’orienter le schéma thérapeutique post-examen, dans le cas des tumeurs cérébrales. En angiographie, une deuxième injection de 0,1 mmol/kg peut être justifiée dans certains territoires. Populations particulières : Insuffisants rénaux : Dotarem ne doit être administré aux patients présentant une insuffisance rénale sévère (Débit de filtration glomérulaire DFG < 30mL/min/1,73 m²) et en période périopératoire de transplantation hépatique qu’après une évaluation approfondie du rapport bénéfice/risque et que si les informations diagnostiques sont indispensables et ne peuvent être obtenues au moyen d'une IRM sans rehaussement du contraste (voir rubrique 4.4). S’il est nécessaire d’administrer Dotarem, la dose ne doit pas excéder 0,1 mmol/kg de poids corporel. Ne pas administrer plus d’une dose au cours de l'examen IRM. En raison du manque d’information sur les administrations répétées, les injections de Dotarem ne doivent pas être réitérées sauf si l’intervalle entre les injections est d’au moins sept jours. Sujets âgés (à partir de 65 ans) : Aucune adaptation posologique n’est nécessaire. Utiliser avec prudence chez les sujets âgés (voir rubrique 4.4). Population pédiatrique : Nouveau-nés jusqu’à l’âge de 4 semaines et nourrissons jusqu’à l’âge d’un an : En raison de l’immaturité de la fonction rénale chez le nouveau-né jusqu’à l’âge de 4 semaines et chez le nourrisson jusqu’à l’âge d’un an, Dotarem ne doit être utilisé chez ces patients qu’après une évaluation attentive et à une dose n’excédant pas 0,1 mmol/kg de poids corporel. Ne pas administrer plus d’une dose au cours de l'examen IRM. En raison du manque d’information sur les administrations répétées, les injections de Dotarem ne doivent pas être réitérées, sauf si l’intervalle entre les injections est d’au moins sept jours. Dotarem n’est pas recommandé pour l’angiographie chez les enfants de moins de 18 ans en raison de données insuffisantes sur l’efficacité et la sécurité dans cette indication. Mode d’administration : Le produit doit être administré en injection intraveineuse stricte. Contre-indications : Hypersensibilité à l’acide gadotérique, à la méglumine ou à tout produit contenant du gadolinium. Effets indésirables : Les effets indésirables liés à l’utilisation de l’acide gadotérique sont généralement d’intensité légère à modérée et de nature transitoire. Une sensation de chaleur, de froid ou de douleur au site d’injection sont les réactions les plus fréquemment observées. Lors d’essais cliniques, des céphalées et des paresthésies ont été très fréquemment observées (> 1/10), et des nausées, des vomissements et des réactions cutanées telles qu’une éruption et un prurit l’ont été fréquemment (> 1/100 à < 1/10). Depuis la commercialisation, les effets indésirables les plus souvent rapportés à la suite de l’administration de l’acide gadotérique ont été des nausées, des vomissements, un prurit et des réactions d’hypersensibilité. Les réactions d’hypersensibilité les plus souvent observées ont été cutanées et ont été localisées, étendues ou généralisées. Ces réactions sont le plus souvent immédiates (pendant l’injection ou au cours de l’heure suivant le début de celle-ci) mais sont parfois retardées (une heure à plusieurs jours après l’injection), se présentant en ce cas sous forme de réactions cutanées. Les réactions immédiates se composent d’un ou plusieurs effets qui apparaissent simultanément ou séquentiellement et qui sont le plus souvent des réactions cutanées, respiratoires et/ou cardiovasculaires. Chaque signe peut être un signal d’alarme indiquant un choc débutant et peut très rarement aboutir au décès. Des cas isolés de fibrose systémique néphrogène (FSN) ont été décrits avec l’acide gadotérique, le plus souvent chez des patients ayant conjointement reçu d’autres produits de contraste contenant du gadolinium (voir rubrique 4.4). Les effets indésirables sont mentionnés ci-après par classe de système d’organe et par fréquence selon la convention suivante : très fréquent (≥ 1/10), fréquent (≥ 1/100 à < 1/10), peu fréquent (≥ 1/1000 à 1<1/100), rare (≥ 1/10 000 à < 1/1 000), très rare (< 1/10 000), fréquence indéterminée (ne peut être pas estimée sur la base des données disponibles). Les données présentées proviennent des essais cliniques disponibles ou d’une étude observationnelle qui a inclus 82 103 patients. Effets indésirables par classe de système d’organe : Affections du système immunitaire : Peu fréquent : Hypersensibilité, réaction anaphylactique, réaction anaphylactoïde. Affections psychiatriques. Très rare : agitation, anxiété. Affections du système nerveux : Très fréquent : paresthésies, céphalées. Rare : dysgueusie. Très rare : coma, convulsion, syncope, présyncope, sensations vertigineuses, parosmie, tremblements. Affections oculaires : Très rare : conjonctivite, hyperhémie oculaire, vision floue, larmoiement, œdème des paupières. Affections cardiaques : Très rare : arrêt cardiaque, bradycardie, tachycardie, troubles du rythme, palpitations. Affections vasculaires : Très rare : hypotension, hypertension, vasodilatation, Pâleur. Affections respiratoires, thoraciques et médiastinales : Très rare : arrêt respiratoire, œdème pulmonaire, bronchospasme, laryngospasme, œdème pharyngé, dyspnée, congestion nasale, éternuements, toux, gorge sèche. Affections gastro-intestinales : Fréquent : nausées, vomissements. Très rare : diarrhée, douleurs abdominales, hypersalivation. Affections de la peau et du tissu sous-cutané : Fréquents : prurit, érythème, éruption. Rare : urticaire, hyperhidrose. Très rare : eczéma, œdème de Quincke (angiœdème). Fréquence indéterminée : fibrose systémique néphrogénique. Affections musculo-squelettiques et systémiques. Très rare : contracture musculaire, faiblesse musculaire, dorsalgie. Troubles généraux et anomalies au site d’administration. Fréquents : sensation de chaleur, sensation de froid, douleur au site de l’injection. Très rare : malaise, douleur thoracique, gêne thoracique, fièvre, frissons, œdème du visage, asthénie, gêne au site d'injection, réaction au site de l’injection, œdème au site de l’injection, extravasation au site de l’injection, inflammation au site de l’injection (en cas d'extravasation), nécrose au site de l’injection (en cas d’extravasation), phlébite superficielle. Investigations : Très rare: diminution de la saturation en oxygène. Les effets indésirables suivants ont été observés avec d’autres produits de contraste pour IRM : Affections hématologiques et du système lymphatique. Hémolyse. Affections psychiatriques : Confusion : Affections oculaires : Cécité transitoire, douleur oculaire. Affections de l’oreille et du labyrinthe : Acouphène, otalgies. Affections respiratoires, thoraciques et médiastinales : Asthme. Affections gastro-intestinales : Bouche sèche. Affections de la peau et du tissu sous-cutané : Dermatose bulleuse. Affections du rein et des voies urinaires : Incontinence urinaire, nécrose tubulaire aiguë, insuffisance rénale aiguë. Investigations : Prolongation de PR à l’électrocardiogramme, augmentation de la sidérémie, augmentation de la bilirubinémie, augmentation de la ferritinémie, anomalie des explorations fonctionnelles hépatiques. Effets indésirables chez l'enfant : Les événements indésirables liés à l’acide gadotérique sont peu fréquents chez l’enfant. La probabilité de ces événements est identique chez l’enfant et l’adulte. TITULAIRE DE L'AUTORISATION DE MISE SUR LE MARCHE : Guerbet – B.P. 57400 – F-95943 Roissy CdG Cedex, France. NUMERO(S) D'AUTORISATION DE MISE SUR LE MARCHE : Boîte de 1 flacon de 5 mL : BE 184615. Boîte de 1 flacon de 10 mL : BE 149362. Boîte de 1 flacon de 15 mL : BE 149371. Boîte de 1 flacon de 20 mL : BE 149353. Boîte de 1 flacon de 60 mL : BE 226055. Boîte de 1 seringue pré-remplie de 10 mL : BE 254992. Boîte de 1 seringue pré-remplie de 15 mL : BE 169547. Boîte de 1 seringue pré-remplie de 20 mL : BE 169531. Délivrance : sur prescription médicale. Date de l’approbation du résumé des caractéristiques du produit : 23/01/2012. Date de l’approbation de l’information médicale : 01/02/2012.

NAAM VAN HET GENEESMIDDEL : Dotarem 0,5 mmol/mL, oplossing voor injectie. KWALITATIEVE EN KWANTITATIEVE SAMENSTELLING : Het actieve bestanddeel is gadoteerzuur in de vorm van megluminegadoteraat (0,5 mmol megluminegadoteraat/mL). Injectieflacon van 5 mL : 1396,6 mg gadoteerzuur Injectieflacon of voorgevulde spuit van 10 mL : 2793,2 mg gadoteerzuur Injectieflacon of voorgevulde spuit van 15 mL :4189,8 mg gadoteerzuur Injectieflacon of voorgevulde spuit van 20 mL :5586,4 mg gadoteerzuur Injectieflacon van 60 mL : 16759,2 mg gadoteerzuur Voor een volledige lijst van hulpstoffen, zie rubriek 6.1. FARMACEUTISCHE VORM : Oplossing voor injectie. Therapeutische indicaties : Bij de volwassene, het kind en de zuigeling : Beeldvorming via Magnetische Resonantie (MRI). MRI van de hersenen en de ruggengraat waaronder : pathologie van de hersenen en de wervelkolom : hersentumoren, tumoren van de ruggengraat en de omhulsels, discus-hernia, infecties. MRI van het ganse lichaam waaronder : abdominale pathologieën : primaire en secundaire levertumoren, pancreastumoren, renale pathologieën : niertumoren en -kysten, opvolging van niertransplantaties, pathologieën van het bekken : tumoren van uterus en ovaria, cardiale pathologieën : opvolging van infarct en harttransplantaties, mammaire pathologieën : borsttumoren, opvolging van implantaten, osteo-articulaire pathologieën : tumoren van de beenderen en de weke delen. MRI voor angiografie. Dit geneesmiddel is uitsluitend voor diagnostisch gebruik. Dosering en wijze van toediening : Dosering : De gebruikelijke aanbevolen dosis is 0,1 mmol/kg, hetzij 0,2 mL/kg, zowel bij de volwassene, het kind als de zuigeling. Bij neuroradiologie kan de dosis variëren van 0,1 tot 0,3 mmol/kg. In geval van diagnostische twijfel na injectie van de dosis van 0,1 mmol/kg, laat de bijkomende dosis van 0,2 mmol/kg toe om, na het onderzoek, het therapeutische schema richting te geven in geval van cerebrale tumoren. Bij angiografie kan een tweede injectie van 0,1 mmol/kg gerechtvaardigd zijn voor bepaalde gebieden. Speciale populaties : Nierfunctiestoornis : Dotarem mag bij patiënten met een ernstige nierfunctiestoornis (glomerulaire filtratiesnelheid (GFR) < 30 mL/min/1,73 m²) en bij patiënten tijdens de perioperatieve levertransplantatieperiode alleen worden gebruikt na zorgvuldige afweging van de voordelen en risico’s en na overweging of de diagnostische informatie essentieel is en niet kan worden verkregen met niet-contrastversterkte MRI (zie rubriek 4.4). Indien het nodig is Dotarem te gebruiken dient de dosis niet groter te zijn dan 0,1 mmol/kg lichaamsgewicht. Niet meer dan één dosis mag worden gebruikt bij een MRI. Wegens het ontbreken van informatie over herhaalde toedieningen dient Dotarem niet herhaald te worden toegediend tenzij het interval tussen de injecties tenminste 7 dagen bedraagt. Ouderen (van 65 jaar en ouder) : Een dosisaanpassing wordt niet noodzakelijk geacht. Voorzichtigheid is geboden bij oudere patiënten (zie rubriek 4.4). Pediatrische populatie : Neonaten tot 4 weken oud en zuigelingen tot 1 jaar oud : Door de onvolgroeide nierfunctie bij neonaten tot 4 weken oud en zuigelingen tot 1 jaar mag Dotarem bij deze patiënten alleen na zorgvuldige overweging worden gebruikt met een dosis niet groter dan 0,1 mmol/kg lichaamsgewicht. Niet meer dan één dosis mag worden gebruikt bij een MRI. Wegens het ontbreken van informatie over herhaalde toedieningen dient Dotarem niet herhaald te worden toegediend tenzij het interval tussen de injecties ten minste 7 dagen bedraagt. Daar er onvoldoende gegevens bestaan over de doeltreffendheid en veiligheid in deze indicatie, is Dotarem niet aanbevolen voor angiografie bij kinderen onder 18 jaar. Wijze van toediening : Het product moet via intraveneuze injectie worden toegediend. Contra-indicaties : Overgevoeligheid voor gadoteerzuur, meglumine of andere geneesmiddelen die gadolinium bevatten. Bijwerkingen : De bijwerkingen gebonden aan het gebruik van gadoteerzuur zijn in het algemeen van lichte tot matige intensiteit en van voorbijgaande aard. Een gevoel van warmte, koude of pijn op de plaats van de injectie zijn de meest waargenomen reacties. Tijdens klinische onderzoeken zijn zeer vaak (>1/10) bijwerkingen zoals hoofdpijn en paresthesie waargenomen; bijwerkingen zoals misselijkheid, braken en huidreacties zoals erytheem en jeuk zijn vaak (> 1/100 - <1/10) waargenomen . Sinds het in de handel brengen zijn de vaakst gemelde bijwerkingen na de toediening van gadoteerzuur misselijkheid, braken, pruritus en overgevoeligheidsreacties. Bij overgevoeligheidsreacties zijn de vaakst waargenomen reacties huidreacties die plaatselijk uitgebreid of gegeneraliseerd kunnen zijn. Deze reacties doen zich meestal onmiddellijk voor (tijdens de injectie of binnen een uur na aanvang van de injectie) en soms vertraagd (een uur tot enkele dagen na de injectie) en presenteren zich als huidreacties. Onmiddellijke reacties zijn één of meer effecten die gelijktijdig of opeenvolgend optreden en meestal bestaan uit huidreacties, respiratoire en/of cardiovasculaire reacties. Elk teken kan een waarschuwing zijn van een beginnende shock die zeer zelden tot de dood leidt. Er zijn geïsoleerde gevallen gerapporteerd van nefrogene systemische fibrose (NSF) bij het gebruik van gadoteerzuur, waarvan de meeste bij patiënten die gelijktijdig andere gadoliniumhoudende contrastmiddelen toegediend kregen (zie rubriek 4.4). De bijwerkingen staan hierna vermeld per systeem-orgaanklasse en frequentie, overeenkomstig de volgende richtlijnen: zeer vaak (1/10), vaak (1/100 tot 1<1/10), soms (1/1.000 tot 1<1/100), zelden (1/10.000 tot <1/1.000), zeer zelden (<1/10.000), onbekend (kan niet worden ingeschat op basis van de beschikbare gegevens). Genoemde gegevens zijn afkomstig uit de beschikbare klinische studies , of uit een observationele studie bij 82.103 patiënten. Frequentie bijwerking per systeem-orgaanklasse : Immuunsysteemaandoeningen : Soms: overgevoeligheid, anafylactische reactie, anafylactoïde reactie. Psychiatrische stoornissen : Zeer zelden : agitatie, angst. Zenuwstelselaandoeningen : Zeer vaak : paresthesie, hoofdpijn. Zelden : dysgeusie. Zeer zelden : coma, convulsie, syncope, presyncope, duizeligheid, parosmie, tremor. Oogaandoeningen : Zeer zelden : conjunctivitis, oculaire hyperemie, wazig zicht, toegenomen tranenvloed, ooglidoedeem. Hartaandoeningen : Zeer zelden: hartstilstand, bradycardie, tachycardie, hartritmestoornissen, hartkloppingen. Bloedvataandoeningen : Zeer zelden : hypotensie, hypertensie, vaatverwijding, bleek zien. Ademhalingsstelsel-, borstkas- en mediastinumaandoeningen : Zeer zelden : ademhalingsstilstand, longoedeem, bronchospasme, laryngospasme, faryngeaal oedeem, dyspneu, verstopte neus, niesbuien, hoest, droge keel. Maagdarmstelselaandoeningen : Vaak : misselijkheid, braken. Zeer zelden : diarree, buikpijn, speekselvloed. Huid- en onderhuidaandoeningen : Vaak : pruritus, erytheem, uitslag. Zelden : urticaria, hyperhidrose. Zeer zelden : eczeem, angio-oedeem. Onbekend : nefrogene systemische fibrose. Skeletspierstelsel- en bindweefselaandoeningen. Zeer zelden : spiercontractuur, spierzwakte, rugpijn. Algemene aandoeningen en toedieningsplaatsstoornissen : Vaak : warmtesensatie, koudesensatie, pijn op de injectieplaats. Zeer zelden : malaise, thoracale pijn, ongemak op de borst, koorts, rillingen, oedeem van het gezicht, asthenie, ongemak op de injectieplaats, reactie op de injectieplaats, oedeem op de injectieplaats, extravasatie op de injectieplaats, ontsteking van de injectieplaats (in het geval van extravasatie), necrose ter hoogte van de injectieplaats (in het geval van extravasatie), oppervlakkige flebitis. Onderzoekingen : Zeer zelden : verminderde zuurstofsaturatie. De volgende bijwerkingen zijn gerapporteerd met andere intraveneuze contrastmiddelen voor MRI-onderzoek : Bloed- en lymfestelselaandoeningen : Hemolyse. Psychiatrische stoornissen : Verwarring : Oogaandoeningen. Voorbijgaande blindheid, oogpijn. Evenwichtsorgaan- en ooraandoeningen : Tinnitus, oorpijn. Ademhalingsstelsel-, borstkas- en mediastinumaandoeningen : Astma. Maagdarmstelselaandoeningen : Droge mond. Huid- en onderhuidaandoeningen : Bulleuze dermatitis. Nier- en urinewegaandoeningen : Urine-incontinentie, renale tubulusnecrose, acute nierinsufficiëntie. Onderzoekingen : PR-verlenging op het elektrocardiogram, verhoogd ijzergehalte in het bloed, verhoogd bilirubinegehalte in het bloed, verhoogd ferritinegehalte in het serum, afwijkende leverfunctietest. Bijwerkingen bij kinderen : Ongewenste voorvallen gerelateerd aan gadoteerzuur komen soms voor bij kinderen. Deze voorvallen zijn bij kinderen even vaak te verwachten als bij volwassenen. HOUDER VAN DE VERGUNNING VOOR HET IN DE HANDEL BRENGEN : GUERBET – B.P. 57400 - F-95943 Roissy CdG Cedex, France . NUMMER(S) VAN DE VERGUNNING VOOR HET IN DE HANDEL BRENGEN : Doos met 1 injectieflacon van 5 mL : BE 184615. Doos met 1 injectieflacon van 10 mL: BE 149362. Doos met 1 injectieflacon van 15 mL: BE 149371. Doos met 1 injectieflacon van 20 mL: BE 149353 . Doos met 1 injectieflacon van 60 mL: BE 226055. Doos met 1 voorgevulde spuit van 10 mL : BE 254992. Doos met 1 voorgevulde spuit van 15 mL : BE 169547. Doos met 1 voorgevulde spuit van 20 mL : BE 169531. Aflevering : op medisch voorschrift. Datum van de laatste goedkeuring van de SKP : 23/01/2012. Datum van goedkeuring van de medische informatie : 01/02/2012.

Prix/Prijs Hosp. : Flacon 10 ml: € 31,02- 15 ml : € 44,50 - 20 ml : € 53,81 - 60 ml : € 141,82 PFS 15 ml : € 44,53 - 20 ml : € 53,81

GE Healthcare

At GE, we are committed to helping increase access to healthcare while improving its quality and lowering its cost. Just like physicians everywhere. So by investing in new innovations, we are empowering the world’s healthcare professionals to do what they do best: caring for patients around the world. Every day, doctors are bringing better health to more people — and GE Healthcare technologies are behind them.

GE_Hmag_Ads_1029.indd 2

10/29/10 5:38 PM

avcu-_Opmaak 1 16/02/12 09:47 Pagina 1

JBR–BTR, 2012, 95: 1-5.

THE ROLE OF DIFFUSION-WEIGHTED MR IMAGING AND ADC VALUES IN THE DIAGNOSIS OF GASTRIC TUMORS* S. Avcu1, H. Arslan1, O. Unal1, C. Kotan2, M. Izmirli3 Background: The aim of this study was to investigate the role of diffusion-weighted MR imaging (DWI) in the diagnosis of gastric tumors by means of measuring the apparent diffusion coefficient (ADC) values of these lesions, and making a comparison with the endoscopic biopsy results. Subjects and Methods: Seventy patients having gastric tumor constituted the case group. For the control group 30 healthy individuals were included. Abdominal MRI examinations were performed with a 1,5 Tesla unit. DWI examinations were obtained by single shot spin echoplanar imaging. The ADC was measured based on the tissue of the gastric tumoral entities and normal gastric mucosa in the control group. Results: Mean ADC values were 0,84 ± 0,17 × 10-3 mm2/s and 1,79 ± 0,08 × 10-3 mm2/s in gastric tumor group and in control group, respectively, being statistically significant (p < 0.05). There was no significance among ADC values of adenocarcinoma subgroups. The comparison of the ADC values in the adenocarcinoma and lymphoma cases were also found to be statistically significant. Conclusions: DWI is beneficial in the diagnosis of malignant gastric lesions by the aid of ADC measurements. Although ADC quantification seems to be invaluable in the evaluation of histopathologic subgroups of adenocarcinoma, it can help in the diagnosis of gastric lymphoma. Key-words: Stomach, neoplasms – Stomach, MR.

Diffusion-weighted magnetic resonance imaging (DWI) is an imaging modality being increasingly used in the evaluation of intraabdominal pathologies, particularly after the development of fast sequences such as echoplanar imaging (EPI) (1, 2). Müler et al. first studied DWI in hepatic and splenic pathologies in 1994, and they had some reasonable results (3). This was followed by other studies involving the use of DWI in liver, kidney, and other abdominal pathologies (4, 5). In these studies, apparent diffusion coefficient (ADC) values were calculated, and the difference in these ADC values were stated to be useful in the differential diagnosis of lesions, being significantly decreased in case of malignancy (6, 7). The aim of this study is to investigate the role of diffusion-weighted MR imaging (DWI) in the diagnosis of gastric tumors by means of measuring the ADC values of these lesions, and making a comparison with the endoscopic biopsy results. To date, as far as we are concerned, the use of ADC in the diagnosis of gastric tumors is not studied. Materials and methods A total of 70 patients having gastric tumor [32 females, 38 males;

mean age: 59.86 (25-82) years] constituted the case group. For the control group 30 healthy individuals [13 female, 17 male; mean age: 49.03 (35-63) years] were included. Patients diagnosed to have gastric tumor with endoscopic biopsy were evaluated with conventional MRI and DWI. Gastric tumor patients with a poor general condition, and with metallic instruments incompatible with MRI were not included into the study. Ethics committee approval for the study was obtained. Informed consent was taken from the patients before MRI examination. The patients were encouraged to drink water in order to provide gastric distension to better demonstrate gastric tumors. MR Imaging Routine abdominal MRI examinations were performed with 1.5 Tesla Siemens Magnetom Symphony (Siemens, Erlangen, Germany) MR unit by using phase-array body coil. Axial T2-weighted True-FISP sequence (TR: 4.4sn; TE: 2,2sn; Average: 2; FlipAngel: 80º; Matrix: 256 × 256; Number of Slices: 25; Slice Thickness: 5 mm; FOV: 300; gap between slices: 15%) with breath hold was followed by DWI with

From: Department of 1. Radiology, 2. General Surgery, 3. Radiation Oncology, Faculty of Medicine, Yuzuncu Yil University, Van, Turkey. Address for correspondence: Dr S. Avcu, M.D., Assistant Professor, Yuzuncu Yil Universitesi Radyoloji Anabilim Dali, Kazim Karabekir Cad. 65200, Van, Turkiye. E-mail: serhatavcu@hotmail.com * This study was presented as electronic poster presentation at ESMRMB 2009 Antalya, Türkiye.

single-shot spin echoplanar sequence and selective chemical shift fat supression technique [TR/TE: 3700/76; Matrix: 128 × 128; Number of Slices: 30; FOV: 400; gap between slices: 15%; Slice Thickness: 5 mm; Examination Time: 156 seconds; PAT Factor: 2; PAT mode: modified sensitivity coding parallel acquisition (GRAPPA)] (Table I). The protocol used for echo-planar DWI was trace-b: 50-b: 400-b: 800-ADC, shortly ‘trace diffusion’. MR imaging parameters are summarized in Table I. Image analysis The images obtained by DWI were transferred to a workstation (Leonardo syngo 2002B Siemens Ag Medical Solutions, Berlin, Germany) in order to configure and analyse the ADC maps. The ADC measurements were done from the most hypointense region of the gastric

Table I. — Imaging parameters. TR TE Slice Thickness Slice Gap Average Bandwith Matrix FOV Time Number of Slices Gap between Slices PAT Factor

3700 76 5 mm 1 mm 4 1346 128 × 128 400 156 sec 30 15% 2

avcu-_Opmaak 1 16/02/12 09:47 Pagina 2

tumor by placing circular region of interest (ROI) on the lesion in patient group and from the normal gastric wall in control group. The areas of ROI 45-70 mm2 in the patient group and 3.2-7 mm2 in the control group. The signal intensity changes of the lesions were determined due to their appearance on b = 800 ‘trace’ images and due to their signal on ADC map. The gastric tumors were seen hyperintense on b = 800 images and hypointense on ADC map. The consistency of the diagnoses of gastric cancer based on DWI and ADC measurements were evaluated by comparison with endoscopic biopsy results.

JBR–BTR, 2012, 95 (1)

Table II. — Descriptive statistics for ADC values in gastric tumor group and control group.

ADC

Gastric tumor Normal

Mean

St. Deviation

St. Error

70 30

0.8410 1.7887

0.16632 0.07829

0.01988 0.01429

*(p < 0.05).

Statistical analysis With SPSS programme, one-way ANOVA test was used to compare the ADC values of the gastric tumor cases and the control group. Kruskal-Wallis test was used in the comparison of the ADC values in adenocarcinoma subgroups, while using Mann-Whitney U test for the comparison of gastric lymphoma cases and adenocarcinoma subgroups. The level of significance was accepted as 5%.

Results All the gastric tumors in this study had an increased signal on DWI and decreased signal on ADC maps. Mean ADC values were 0,84 ± 0,17 × 10-3 mm2/s and 1,79 ± 0,08 × 10-3 mm2/s in gastric tumor group and in control group, respectively, which was statistically significant (p < 0.05). In other words, mean ADC values of gastric tumors were significantly lower than that of normal gastric mucosa (Table II). On the other hand, there was no significance among the ADC values of adenocarcinoma subgroups (p > 0.05) (Fig. 1, 2). The comparison of the ADC values in the adenocarcinoma and lymphoma cases were found to be statistically significant, being 0,85 ± 0,16 × 10-3 mm2/s and 1,09 ± 0,08 × 10-3 mm2/s, respectively. The mean ADC values of adenocarcinoma cases was significantly lower than that of lymphoma cases (p < 0.05) (Table III) (Fig. 3). The cut-off value in ROC (Receiver Operator Characteristics) curve for differentiating gastric malignancy and normal gastric wall according to ADC values was found to be 1,12 × 10-3 mm²/sec. Based on this value, the sensitivity was 100% and specificity was 98,6%.

E Discussion Gastric cancer is the second most common malignancy worldwide, and is influenced by geographic, ethnic, and socioeconomic factors. It is seen rather less common in western countries (8-11). It usually has metastatic spread at the time of diagnosis (12). Despite advanced diagnostic modalities, there is still some difficulty in the diagnosis and staging of gastric tumors (13). Diffusion is the randomized microscopic movements of water molecules, and is a sensitive parameter in tissue characterization. In

Fig. 1. — On DWI (A), a lesion on gastric antrum which histopathology revealed adenocarcinoma is seen showing restriction in diffusion (arrows). On ADC map (), the lesion has a mean ADC value of 0,66 × 10–³ mm²/sec. CT (C), histopathologic (D), and endoscopic (E) images of the lesion are shown.

vivo evaluation of diffusion is possible by DWI and ADC measurement. DWI has been widely used in the evaluation of stroke (14). Due to movement artefacts and heterogenous structure of the intraabdominal organs, the use of DWI has been difficult in the abdomen. Following advanced fast imaging sequences in MRI such as echo-planar imaging (EPI), these artefacts were rather eliminated and DWI has been able to be used in the evaluation of abdominal organs (3, 15-17). DWI has for a number of years been a diagnostic tool in the field of neuroradiology, yet only

avcu-_Opmaak 1 16/02/12 09:47 Pagina 3

DIFFUSION-WEIGHTED MRI AND ADC VALUES IN GASTRIC TUMORS — AVCU et al

Fig. 2. — On DWI (A), a lesion on gastric cardia-lesser curvature which histopathology revealed medium-differentiated adenocarcinoma is seen showing restriction in diffusion (arrow). On ADC map (B), the lesion has a mean ADC value of 0,71 × 10–³ mm²/sec. CT (C), histopathologic (D), and endoscopic (E) images of the lesion are shown.

E since the end of the 1990s, with the introduction of echoplanar imaging (EPI) and the use of sequences capable of performing diffusion studies during a single breath hold, has it found diagnostic applications at the level of the abdomen. The inherent sensitivity to motion and the magnetic susceptibility of Dw sequences nonetheless still create problems in the study of the abdomen due to artefacts caused by the heartbeat and intestinal peristalsis, as well as

the presence of various parenchymal-gas interfaces (18). Most studies of abdominal DWI have been performed with ssEPI. The single-shot technique allows one to acquire images within a fraction of a second, effectively freezing physiologic motion (19). A pilot study was performed in two volunteers; DWI without and with pulse triggering (in the same individual) did not show substantial differences in calculated ADC values

or image quality (data not shown). Thus, our investigation was performed with free breathing and without pulse triggering. Repetition times in a pulse-triggered sequence change in patients who are nervous, have an irregular pulse, or both. This can change the signal intensities of the DW MR images with a possible negative effect on the accuracy and image quality of the ADC maps. Obtaining images during normal respiration is a major advantage in the clinical routine (20). Generally in biologic tissues, microscopic motion includes both the molecular diffusion of water and the blood microcirculation in the capillary network, and both diffusion and perfusion affect the ADC values. Selecting “b” values above 400 mm2/sec is shown to better differentiate malignancies from benign lesions. In high-grade tumors, the increased cellular density leads to decreased extracellular volume of the tumor and thus lower ADC values (21, 22). In our study, we measured ADC values using ‘b’ values as: b = 50 mm²/sec, b = 400 mm²/sec, and b = 800 mm²/sec. DWI is reported to be useful in the characterization and diagnosis of the tumors of liver, pancreas, ovary, colon, cervix, urinary bladder, prostate, and breast, with more restriction in diffusion and lower ADC values in malignant tumors than in benign ones (23-25). The results of our study are concordant with these studies. The principle underlying DWI is that the thermal motion of water molecules in extracellular fluid enables the acquisition of images that reflect both histological structure and cellularity and therefore it can detect the changes of tissue structure at molecular level. It also enables the quantitative evaluation of apparent diffusion coefficient (ADC). Compared with benign lesions, diffusion of malignant tumors with high cellular tissue decreased and the ADC value in malignant tumors is lower than that of benign lesions. Several latest studies have shown that ADC has a potential for clinical appreciation in

Table III. — Descriptive statistics for ADC values in adenocarcinoma and lymphoma cases.

Adenocarcinoma Lymphoma * (p < 0.05).

Median

Mean ADC

St. Deviation

Minimum

Maximum

67 3

0.85 1.09

0.83 1.09

0.16 0.08

0.40 1.03

1.10 1.14

avcu-_Opmaak 1 23/02/12 09:06 Pagina 4

JBR–BTR, 2012, 95 (1)

Fig. 3. — On DWI (A), a lesion (arrow) on gastric antrum which histopathology revealed diffuse large cell lymphoma is seen showing restriction in diffusion. On ADC map (), the lesion has a mean ADC value of 1,10x10–³ mm²/sec. CT (C) image of the lesion is shown.

differentiating benign and malignant lesions with good specificity. On the other side, DWI, based on its imaging mechanism, could detect the changes of ADC in different tissues. Measurement of the ADC provides a quantitative estimate of the restrictive nature of the motion of water molecules within tissue for each voxel in a diffusion-weighted image. This study was thus designed to compare the ADC values between malignant lesions and normal gastric mucosa through EPI-DWI. Briefly, the higher the cellular density is, the lower the ADC value will be in DWI, and vice versa. For malignant tumors, they have a relatively high cellular density and therefore will produce a low ADC value on DWI, while for benign lesion, its density is generally low and thus will produce a high ADC value on DWI (20, 23). In our study, mean ADC values were 0,84 ± 0,17 × 10-3 mm2/s and 1,79 ± 0,08 × 10-3 mm2/s in gastric tumor group and in control group, respectively, mean ADC values of gastric tumors being significantly lower than that of normal gastric mucosa (p < 0.05). On the other hand, there was no significance among the ADC values of adenocarcinoma subgroups (p > 0.05). Also, the mean ADC values in the adenocarcinoma group and lymphoma cases were 0,85 ± 0,16 × 10-3 mm2/s and 1,09 ± 0,08 × 10-3 mm2/s, respectively, the mean ADC values of the former being significantly lower than the latter (p < 0.05). As far as we are concerned, our study is the first in the literature studying gastric tumors by quantitative measurement of ADC values. Satashi et al. (13) studied 15 patients with gastric cancer, and

found that DWI could describe highgrade gastric cancer by means of increased signal on DWI and decreased signal on ADC map. One of the most important advantages of DWI is the capability of obtaining numerical data by means of ADC measurement, which can provide an estimation of malignancy potential of the lesions prior to histopathologic examination (24-26). In our study, we found a cut-off value in ROC curve for differentiating gastric malignancy and normal gastric wall according to ADC values, being 1,12x10-3 mm²/sec, with a sensitivity of 100% and specificity of 98,6%. To mention in a few words about the comparative role of PET/CT in the evaluation of gastric cancer, the sensitivity and accuracy of PET/CT were found to be inferior to those of contrast enhanced CT in the diagnosis of regional lymph node metastases, while its sensitivity, accuracy, positive predictive value, and negative predictive value were superior in the diagnosis of distant metastases (27). In conclusion, DWI and ADC values can successfully differentiate gastric tumors from normal gastric mucosa, and we think DWI will have an increasing use in the future in the diagnosis and clinical analysis of gastric tumors. As for the question about the capability of DWI to estimate the nature of the gastric tumors, we think that further studies with a wide range of cases having different histopathologic subgroups should be carried out. References 1. Chien D., Kwong K.K., Gress D.R.: MR diffusion imaging of cerebral infarction in humans. AJNR Am J Neuroradiol, 1992, 13: 1097-102.

2. Tsuruda J.S., Chew W.M., Moseley M.E., Norman D.: Diffusionweighted MR imaging of the brain: value of differentiating between extraaxial cysts and epidermoid tumors. AJNR Am J Neuroradiol, 1990, 11: 925-931. 3. Muller M.F., Prasad P., Siewert B., Nissenbaum M.A., Raptopoulos V., Edelman R.R.: Abdominal diffusion mapping with use of a whole-body echo-planar system. Radiology, 1994, 190: 475-478. 4. Kim T., Murakami T., Takahashi S., Hori M., Tsuda K., Nakamura H.: Diffusion-weighted single-shot echoplanar MR imaging for liver disease. AJR, 1999, 173: 393-398. 5. Namimoto T., Yamashita Y., Mitsuzaki K., Nakayama Y., Tang Y., Takahashi M.: Measurement of the apparent diffusion coefficient in diffuse renal disease by diffusion weighted echo-planar MR imaging. J Magn Reson Imaging, 1999, 9: 832837. 6. Naganawa S., Kawai H., Fukatsu H., Sakurai Y., Aoki I., Miura S., et al.: Diffusion weighted imaging of the liver: technical challenges and prospects for the future. Magn Reson Med Sci, 2005, 4: 175-186. 7. Yamasaki F., Kurisu K., Satoh K., Arita K., Sugiyama K., Ohtaki M., et al.: Apparent diffusion coefficient of human brain tumors at MR imaging. Radiology, 2005, 235: 985-991. 8. Dan Y.Y., So J.B., Yeoh K.G.: Endoscopic screening for gastric cancer. Clin Gastroenterol Hepatol, 2006, 4: 709-716. 9. Parkin D.M., Bray F., Ferlay J., Pisani P. Global cancer statistics, 2002. CA Cancer J Clin, 2005, 55: 74-108. 10. Ferlay J., Bray F., Parkin D.M., Pisani P., eds (2001). Globocan 2000: Cancer Incidence and Mortality. Worldwide (IARC Cancer Bases No. 5), Lyon, IARCPress. 11. Türkdogan MK., Akman N., Tuncer I., Uygan I., Kösem M., Ozel S., et al. Epidemiological aspects of endemic upper gastrointestinal cancers in Eastern Turkey. Hepatogastroenterology, 2005, 52: 496-500. 12. Gore R.M.: Gastric cancer. Clinical and pathologic features. Radiol Clin North Am, 1997, 35: 295-310. 13. Satashi S., Sasaki T., Nakagawa Y., Guiquing Z., Yamamoto F., Yamashita Y.: The usefulness of diffusion-weighted imaging (DWI) for the detection of gastric cancer. Hepatogastroenterology. 2007, 54: 1378-1381. 14. Le Bihan D., Turner R., Douek P., Patronas N.: Diffusion MR imaging: clinical applications. AJR, 1992, 159: 591-599. 15. Mürtz P., Flacke S., Träber F., van den Brink J.S., Gieseke J., Schild H.H.: Abdomen: diffusion-weighted MR imaging with pulse-triggered singleshot sequences. Radiology, 2002, 224: 258-264. 16. Namimoto T., Yamashita Y., Sumi S., Tang Y., Takahashi M. Focal liver masses: characterization with

avcu-_Opmaak 1 16/02/12 09:47 Pagina 5

DIFFUSION-WEIGHTED MRI AND ADC VALUES IN GASTRIC TUMORS — AVCU et al

17.

18.

19.

20.

diffusion-weighted echo-planar MR imaging. Radiology, 1997, 204: 739744. Reimer P., Saini S., Hahn P.F., Brady T.J., Cohen M.S.: Clinical application of abdominal echoplanar imaging (EPI): optimization using a retrofitted EPI system. J Comput Assist Tomogr, 1994, 18: 673-679. Colagrande S., Carbone S.F., Carusi L.M., Cova M., Villari N.: Magnetic resonance diffusionweighted imaging: extraneurological applications. Radiol Med, 2006, 111: 392-419. Chow LC., Bammer R., Moseley ME., Sommer FG. Single breath-hold diffusion weighted imaging of the abdomen. J Magn Reson Imaging, 2003, 18: 377-382. Sugahara T., Korogi Y., Kochi M., Ikushima I., Shigematu Y., Hirai T., et al.: Usefulness of diffusion-weighted MRI with echo-planar technique in the evaluation of cellularity in gliomas.

21.

22.

23.

24.

J Magn Reson Imaging, 1999, 9: 5360. Sinha S., Lucas-Quesada FA., Sinha U., DeBruhl N., Bassett L.W.: In vivo diffusion-weighted MRI of the breast: potential for lesion characterization. J Magn Reson Imaging, 2002, 15: 693-704. Ichikawa T., Haradome H., Hachiya J., Nitatori T., Araki T.: Diffusion-weighted MR imaging with single-shot echoplanar imaging in the upper abdomen: preliminary clinical experience in 61 patients. Abdom Imaging, 1999, 24: 456-461. Kinoshita T., Yashiro N., Ihara N., Funatu H., Fukuma E., Narita M.: Diffusion-weighted half-Fourier single-shot turbo spin echo imaging in breast tumors: differentiation of invasive ductal carcinoma from fibroadenoma. J Comput Assist Tomogr, 2002, 26: 1042-1046. Naganawa S., Sato C., Kumada H., Ishigaki T., Miura S., Takizawa O.:

Apparent diffusion coefficient in cervical cancer of the uterus: comparison with the normal uterine cervix. Eur Radiol, 2005, 15: 71-78. 25. Avcu S., Koseoglu M.N., Ceylan K., Bulut M.D., Unal O.: The value of diffusion-weighted MRI in the diagnosis of malignant and benign urinary bladder lesions. Br J Radiol, 2011, 84: 875-882. 26. Unal O., Koparan H.I., Avcu S., Kalender A.M., Kisli E.: The diagnostic value of diffusion-weighted magnetic resonance imaging in soft tissue abscesses. Eur J Radiol, 2011, 77: 490494. 27. Shimada H., Okazumi S., Koyama M., Murakami K.: Japanese Gastric Cancer Association Task Force for Research Promotion: clinical utility of 18F-fluoro-2-deoxyglucose positron emission tomography in gastric cancer. A systematic review of the literature. Gastric Cancer, 2011, 14: 13-21.

Our selection of new Radiology books! Clinical Cardiac MRI 2/e + online access Bogaert, Dymarkowski et al – Springer – 720pp – March 2012 € 319.95 Imagerie ostéo-articulaire Arthrographie - arthroscanner - Arthro-IRM Laredo et al. – Sauramps Médical – 456pp – Jan. 2012 € 157.40 Head and Neck Cancer Imaging 2/e Hermans – Springer – 413 pp – Jan. 2012

€ 255.75

Teaching Atlas of Mammography 4/e Tabar – Thieme – 312 pp – Jan. 2012

€ 139.99

Principles of Vascular Ultrasound Hutchison - Saunders – 320 pp – Jan. 2012

ACCO Leuven M-Theresiastraat 2 3000 Leuven Tel 016/29.11.00 Fax 016/20.73.89

ACCO Adrénaline 43, Rue Martin V 1200 Bruxelles Tel 02/763.16.86 Fax 02/772.10.04

€ 81.95

ACCO Gent St-Pietersnieuwstr. 105 9000 Gent Tel 09/235.73.00 Fax 09/235.73.01

acco.medical@acco.be www.accomedical.be

hasni bouraoui-_Opmaak 1 24/02/12 11:15 Pagina 6

JBR–BTR, 2012, 95: 6-9.

STERNOCLEIDOMASTOID PSEUDOTUMOR OF INFANCY: A REPORT OF THIRTEEN CASES I. Hasni Bouraoui1, N. Arifa1, M. Gaha1, W. Kermani2, K. Mrad Dali1, H. Jemni1, H. Hmouda1, K. Tlili Graiess1 Sternocleidomastoid tumor of infancy (SCMTI) is a rare cause of benign neck masses in neonates and infants. It has to be differentiated from other congenital space-occupying lesions in the cervical region. Patients and methods: The files of 13 infants with a mean age of 6 weeks, presenting with a lateral neck mass at Sahloul University Hospital in Sousse (Tunisia) between 2007 and 2009 were retrospectively studied. All of them underwent physical and ultrasonographic examination. MRI was performed in only one case. Results: Ultrasonography (US) showed a soft tissue mass of sternocleidomastoid muscle (SCMM), or a homogenously enlarged muscle without any focal mass. MRI revealed a fusiform enlarged muscle. Diagnosis of SCMTI was established in all cases. Conservative treatment was recommended in all cases with physiotherapy in 2 cases. Conclusion: US is the best imaging modality for the diagnosis of SCMTI and the first one to be performed. Additional diagnostic imaging modalities are unnecessary in most of the cases. Key-words: Infants – Head and neck neoplasms, US.

Diagnosis and management of neck masses in infants and children are frequently challenging for radiologists, paediatricians and otolaryngologists. Only a thorough knowledge of the different clinical entities that can cause neck masses in the paediatric population can insure immediate and appropriate treatment. Sternocleidomastoid tumor of infancy (SCMTI), also known as fibromatosis colli, is the most common cause of neck masses in the neonatal period (1). It is a thickening of the sternocleidomastoid muscle (SCMM). It presents mostly between the second and eighth week of life when the parents notice a firm tumor in the neck, which can be followed by a characteristic torticollis (2). US is the best imaging modality for diagnosis. MRI or CT are sometimes performed when diagnosis is uncertain or when this entity is unknown by the clinicians (2). We report 13 cases of SCMTI explored by US, and MRI in one case, in order to facilitate the recognition of this entity. Patients and methods Thirteen cases of SCMTI were diagnosed in our institution during a-three-year period between 2007 and 2009, including 10 boys and 3 girls aged between 2 and 11 weeks with a mean age of 6 weeks when the diagnosis was established. In 9 cases, the mass was discovered by the parents and in the 4 remaining

Fig. 1. — Sternocleidomastoid tumor of infancy in an-8-week old girl. Axial sonography shows faintly heterogeneous mass within the left SCCM.

cases by the pediatrician at the time of the systematic consultation at the 40th day of life. All patients had physical examination, and their families were asked about birth conditions. In 12 cases, it was a low-way delivery, and one patient had been delivered by caesarean section because of breech presentation. Premature birth was noted in 2 cases, but there were no forceps deliveries or difficult labor in all cases. Birth weight ranged between 2,600 and 4,250 g. All patients presented with a neck mass which appeared in the first weeks of life. A torticollis was associated to in 2 cases.

From: 1. Department of Radiology, Sahloul Hospital, 2. Department of Oto-Rhino-Laryngology, Farhat Hached Hospital, Sousse, Tunisia. Address for correspondence: Dr I. Bouraoui, M.D., Department of Radiology, Sahloul Hospital, 4054 Sousse, Tunisia. E-mail: ibtissemhasni@yahoo.fr

US was performed for all of them, and MRI in only 1 case because of uncertain diagnosis. Results The mass was firm and painless. It was located in the left side in 9 cases and in the right side in 4 cases. Torticollis was noted in 2 cases. Neck US showed hypoechogenic or isoechogenic, homogeneous and fusiform mass of the SCMM in 8 cases, and a heterogeneous mass in 2 cases (Fig. 1). In 3 cases, the SCCM was homogeneously enlarged without any focal mass. In these cases, the fibrillar structure of the muscles was maintained (Fig. 2). The tumor was located in the caudal part of the muscle in 10 patients, and in the middle part in the remaining 3 cases. The size of the lesion varied between 2 and 4 cm in great diameter, with a mean of 2,7 cm.

hasni bouraoui-_Opmaak 1 16/02/12 10:05 Pagina 7

STERNOCLEIDOMASTOID TUMOR OF INFANCY â&#x20AC;&#x201D; HASNI BOURAOUI et al

B Fig. 2. â&#x20AC;&#x201D; Sternocleidomastoid tumor of infancy in a-6-week old boy. Sonography shows in (A) homogeneous enlargement of the right SCMM with lymph nodes in the posterior cervical space. In (B) decrease of abnormalities 40 days later.

All tumors were well delineated from the surrounding structures. Cervical vascular structures were normal. In 2 patients, physical examination revealed cervical lymph nodes and one of them required MRI which was performed 15 days later, and showed an enlargement of the right SCMM without focal mass or abnormal enhancement. Lymph nodes disappeared (Fig. 3). Diagnosis of SCMTI was made in all cases. Physiotherapy was recommended as the initial treatment in 2 patients who presented with torticollis. Six patients were followed clinically, and 3 by US during six months. Nine patients had adequate follow up which revealed complete regression of the neck mass and torticollis. The four remaining patients were not followed, and we presume that the mass resolved spontaneously.

Discussion SCMTI is a rare form of infantile fibromatosis that occurs solely in the SCMM with a reported incidence of 0.4% live births (1, 3). The disease is usually unilateral, slightly more common on the right side and affects both sternal and clavicular heads of the muscle. Bilateral involvement is extremely rare (2). SCMTI affects male patients slightly more often than females (4, 5). Most cases show no abnormality at birth, but the SCMTI appears between the second and eighth week of life as a firm, painless, fusiform soft-tissue mass in the lower third to the second third of the SCMM, typically measuring between 1 and 3 cm in diameter (2, 6). The mass may increase in size for several weeks, then stabilizes in size for a few months, and finally decreases

spontaneously by 4 to 8 months of age (6). Torticollis is seen in 14% to 20% of patients due to contraction of the SCMM. It has a characteristic appearance: The head is rotated and tilted toward the side of the mass, and the chin is turned away from the affected side. This is secondary to fibrosis, shortening of the affected muscle, and its inability to keep space with the growth of the normal SCMM (1, 2). Although the exact cause is unclear, it is likely related to birth trauma, with greater than 90% of cases associated with a difficult or forceps delivery (1, 4). One theory contends that traumatic compression of the neck during delivery could result in pressure necrosis or occlusion of the venous outflow system with subsequent development of muscle edema, degeneration of fibers, and fibrosis. Davids and co-workers (7) have suggested that the lesions result from an in utero fetal head position, which causes selective injury to the SCMM. Such injury leads to the development of a secondary compartment syndrome resulting in pressure necrosis and fibrosis within the muscle. A genetic component may also play a role, as 11% of patients had a positive family history (6, 8). In our series, there was not any apparent cause of this disorder in all patients. Ten of them come from the same village, but they were born in four different centers. We believe that a genetic factor might be considered. In most cases, the clinician can make the diagnosis of SCMTI by careful history and physical examination. A detailed obstetrical history should be obtained as there is a well recognized association between SCMTI and primiparous births, breech presentations, forceps deliveries, and difficult labor. Imaging findings in this disorder must be differentiated from other causes of neck masses in this age group. When the abnormality is not recognized, inappropriate and invasive procedures may be performed such as needle biopsy, open biopsy, and even resection of the SCMM. Only recognition of this entity can prevent unnecessary diagnostic and therapeutic procedures (1). US is the best imaging modality for diagnosis and should be the first examination to be performed, due to the proximity of the lesion to the skin and its lack of radiation (1, 2). The lesions measure several centimetres in diameter (9). Various US findings

hasni bouraoui-_Opmaak 1 16/02/12 10:06 Pagina 8

JBRâ&#x20AC;&#x201C;BTR, 2012, 95 (1)

C Fig. 3. â&#x20AC;&#x201D; The same case as Fig. 2. MRI: Coronal (A) and axial (B) T2 weighted images. Homogeneous enlargement of the right SCMM, the left one is normal (arrows). Sagittal T2 weighted images (C) show involvement of the sternal side of the muscle (arrow).

B have been described, ranging from a homogeneously enlarged SCMM without a focal mass to a hypoechogenic mass with ill-defined or well-defined margins in the substance of the SCMM (1, 9). Typically a non homogeneous, echopoor tumor with increased perfusion can be shown (10). With real time sonography, the lesion can be shown to move synchronously with the SCMM (2, 4). MRI or CT are not necessary when both US and clinical findings are compatible with SCMTI. MRI and CT reveal similar features, including fusiform thickening, well-defined margins, and mild mass effect on adjacent structures. The involved

portion of the muscle is better defined on MRI or CT than sonography (10). The tumors are commonly located in the distal 2/3 of the SCMM and show good delineation from surrounding structures (10). MRI may show signal intensity characteristics. On T2-weighted MR images, the enlarged muscle demonstrates diffuse abnormal high signal intensity greater than that of fat, and no focal discrete mass may be noted. Decreased signal intensity of the mass in T2 weighted images can be seen because of presence of fibrous tissue (2). The MR Imaging appearance has been described by Davids and co-workers (7). All cases

in their series demonstrated mild enlargement of the lower third of the SCMM with diffuse abnormal high signal intensity, greater than that of fat on T2-weighted images. None of the cases in their series demonstrated a focal discrete mass. MRI also helps demonstrate lack of involvement of surrounding structures and absence of lymphadenopathy, airway compression, vascular encasement, bone involvement, intracranial/intraspinal extension associated with other neck masses or other features that would suggest a more aggressive process (2, 10). The multiple lymph nodes revealed by US in one of our cases, were not found in MRI performed 2 weeks later. We think that these lymph nodes were associated to another banal inflammatory disorder. Although radiographs are usually normal, lytic lesions within the head of the clavicle at the attachment of the SCMM have rarely been reported (1). If imaging studies show other findings such as inhomogeneous

hasni bouraoui-_Opmaak 1 16/02/12 10:06 Pagina 9

STERNOCLEIDOMASTOID TUMOR OF INFANCY â&#x20AC;&#x201D; HASNI BOURAOUI et al

muscle density or echo pattern, a lesion within the SCMM with irregular margins, a mass extending beyond the margins of this muscle, or significant regional lymphadenopathy, then other alternative diagnoses should be considered. In addition to SCMTI, the differential diagnosis of soft-tissue masses in the neck of a neonate includes sarcoma, lymphoma, cystic hygroma, and branchial cleft cyst. Lesions that are often midline or near the midline include dermoid cyst, teratoma, or thyroglossal duct cyst. However, rapid growth of the tumor and increased thickening of SCMM should raise the possibility of another tumor, such as rhabdomyosarcoma, or a tumor originating from outside the muscle but infiltrating the surrounding structures, such as neuroblastoma (2, 6). Kumar and co-workers (11) think that non invasive diagnosis of SCMTI can be made by fine needle aspiration cytology alone; invasive diagnostic and therapeutic measures are best avoided. Excision biopsy may not be necessary and should be reserved for cases with a strong clinicopathologic suspicion of malignancy. Although pathologic specimens are rarely encountered today, typical changes observed at histologic evaluation include alternating skeletal muscle fibers that have undergone atrophy or degeneration and evolving scar like fibroblastic-myofibroblastic proliferation (3, 8). SCMTI usually resolves with conservative management in most of the cases, including clinical observation after the diagnosis is established on a clinical, radiologic, or less frequently histologic basis (10).

In more than 70% to 90% of cases, lesions regress spontaneously, and secondary contractures resolve within 4 to 8 months (4). Physiotherapy is recommended as the initial treatment. Surgical intervention is required in 10% to 15% of cases, and is indicated in patients with severe refractory disease after 1 year of age to prevent permanent contracture and plagiocephaly (2, 10). Surgical treatment consists of proximal or distal release of the SCMM. Sixteen to seventy percent of patients with persistent torticollis after resolution of the SCMTI will develop cranial or facial asymmetry if the torticollis is not corrected (2, 4, 10). Conclusion SCMTI is a well recognized clinical entity that typically responds to conservative therapy. Diagnosis is often made clinically with a detailed history and physical exam. US is the best imaging modality for diagnosis. Variations in its appearance should be kept in mind and should not prevent the correct diagnosis as long as the abnormality is intramuscular and adjacent soft tissues are normal. MR Imaging and CT are indicated in unusual cases when diagnosis is uncertain, and to evaluate masses that do not respond to therapy. Fine needle aspiration and histologic examination are not necessary and should be reserved for lesions with clinical signs and imaging findings inconsistent with SCMTI. The recognition of this entity can prevent unnecessary diagnostic and therapeutic invasive maneuvers.

References 1. Robbin M.R., Murphey M.D., Temple H.T., Kransdorf M.J., Choi J.J.: Imaging of musculoskeletal fibromatosis. Radiographics, 2001, 21: 585-600. 2. Smiti S., Kulkarni N.M., Singh J.: Case Report: Fibromatosis colli in a neonate. Indian J Radiol Imaging, 2010, 20: 45-46. 3. Sharma S., Mishra K., Khanna G.: Fibromatosis colli in infants. A cytologic study of eight cases. Acta Cytol, 2003, 47: 359-362. 4. Murphey M.D., Ruble C.M., Tyszko S.M., Zbojniewicz A.M., Potter B.K., Miettinen M.: From the archives of the AFIP: musculoskeletal fibromatoses: radiologic-pathologic correlation. Radiographics, 2009, 29: 2143-2173. 5. Enzinger F.M., Weiss S.W.: Soft tissue tumors. 3rd ed. St Louis, Mo: Mosby, 1995. 6. Ekinci S., Karnak I., Tanyel F.C.: Infantile fibromatosis of the sternocleidomastoid muscle mimicking muscular torticollis. J Pediatr Surg, 2004, 39: 1424-1425. 7. Davids J.R., Wenger D.R., Mubarak S.J.: Congenital muscular torticollis: sequela of intrauterine or perinatal compartment syndrome. J Pediatr Orthop, 1993, 13: 141-147. 8. Weiss S.W., ed. Soft tissue tumors. St Louis, Mo: Mosby Elsevier, 2008. 9. Eich G.F, Hoeffel J.C, TschĂ¤ppeler H., Gassner I., Willi U.V.: Fibrous tumours in children: imaging features of a heterogeneous group of disorders. Pediatr Radiol, 1998, 28: 500-509. 10. Ablin D.S., Jain K., Howell L., West D.C. Ultrasound and MR imaging of fibromatosis colli (sternomastoid tumor of infancy). Pediatr Radiol, 1998, 28: 230-283. 11. Kumar B., Pradhan A.: Diagnosis of sternomastoid tumor of infancy by fine-needle aspiration cytology. Diagn Cytopathol, 2010, 20.

bruyeer-_Opmaak 1 16/02/12 10:29 Pagina 10

JBR–BTR, 2012, 95: 10-12.

‘TRAMPOLINE FRACTURE’ OF THE PROXIMAL TIBIA IN CHILDREN: REPORT OF 3 CASES AND REVIEW OF LITERATURE E. Bruyeer1, E. Geusens1, F. Catry2, L. Vanstraelen3, F. Vanhoenacker4 We present three cases of fracture of the proximal tibia in young children who were jumping on a trampoline. The typical radiological findings and the underlying mechanism of trauma are discussed. The key radiological features are: a transverse hairline fracture of the upper tibia often accompanied by a buckle fracture of the lateral or medial tibial cortex, buckling of the anterior upper tibial cortex and anterior tilting of the epiphyseal plate. New types of injuries related to specific recreational activities are recognized. It is often helpful to associate a typical injury with a particular activity. Trampoline related injuries have increased dramatically over the last years. The most common lesions are fractures and ligamentous injuries, in particular a transverse fracture of the proximal tibia. However the radiological findings can be very subtle and easily overlooked. It is therefore important to be aware of the typical history and radiological findings. Key-words: Extremities, injuries – Infants, skeletal system.

Case reports Case 1 An 18-month-old boy presented at the emergency unit because he did not want to walk or bear weight on the left leg. This occurred after jumping on a trampoline. Standard radiograph of the left leg (Fig. 1A) and comparative view (Fig. 1B) were performed and showed a cortical buckle at the anterior portion of the proximal tibia. Case 2 A 2-year-old boy complained of sudden onset of severe pain in the left leg after playing on a trampoline with two older boys. There was no history of a fall. He could not walk or bear weight on the left leg. Standard radiographs of the left knee (Fig. 2A) were performed and showed a transverse impaction fracture of the upper tibia accompanied by a buckle fracture of the anterior tibial cortex. There was also an increased concavity of the notch for the tibial tubercle on the lateral view and anterior tilting of the growth plate. Follow-up radiograph after a few weeks demonstrated endosteal callus in the proximal tibia (Fig. 2B). Case 3 A 4-year-old boy presented at the emergency unit with a history of

jumping on a trampoline, no specific accident happened. He also refused to walk or bear weight on the right leg. He complained of pain around the knee. Standard radiographs of the left leg (Fig. 3A, B) showed a hairline fracture of the upper right tibia and an associated cortical buckle fracture at the anterior portion of the proximal tibia as well as an increased concavity of the notch for the tibial tubercle on the lateral view and slight anterior tilting of the epiphyseal plate. In addition, a cortical buckle of the lateral distal femoral metaphysis was present. Discussion Trampoline related injuries have increased dramatically over the last years. The most common lesions include fractures and ligamentous lesions, more rare injuries of the head and the cervical spine (1). The ‘trampoline fracture’ of the tibia or so called ‘Toddler’s fracture type II’ is a transverse fracture of the proximal tibia. This fracture typically occurs in young children who jump on a trampoline with another person who is heavier. As the heavier person jumps, the trampoline mat recoils upward from its stretched downward position. If the smaller child lands on the upward moving mat at the time

From: 1. Department of Radiology, UZ Leuven, Leuven, Belgium, 2. Department of Radiology, AZ Sint-Maarten, Duffel, Belgium, 3. Department of Radiology, H. Hartziekenhuis, Mol, Belgium, 4. Department of Radiology, UZ Antwerpen, Edegem, Belgium. Address for correspondence: Dr E. Geusens, M.D., Department of Radiology, UZ Leuven, campus Gasthuisberg, department of Radiology, Herestraat 49, B-3000 Leuven, Belgium.

when its elasticity is reversed by recoil and the springs are shortening to their unstretched length, there is significant upward impaction force applied to the descending child’s legs. So a transfer of kinetic energy from the larger mass to the smaller mass occurs (Fig. 4). The ‘trampoline fracture’ of the proximal tibia occurs when the impaction force is applied at the right time and angle on a hyperextended leg, causing compressive forces to the anterior cortex of the tibia and distracting forces over the posterior cortex (2, 3). Typically these children present at the emergency unit and do not want to walk or bear weight after jumping on a trampoline, often without clear evidence that an accident had occurred (2). On physical examination there is a decrease range of motion of the leg. Hyperextension of the knee will be painful and decreased, especially when compared to the other side, which demonstrate that the problem is focused on the knee (4, 5). However, the problem often remains a mystery, until radiographs are obtained. The non systematic use of comparative views can be useful as radiological findings may be subtle. Findings on plain radiographs are variable, ranging from a hairline fracture of the upper tibia often accompanied by a buckle fracture of the lateral or medial tibial cortex, buckling of the anterior upper tibial cortex and/or increased concavity of the notch for the tibial tubercle on the lateral view, and anterior tilting of the epiphyseal plate. All of these findings are not necessarily present in every patient. Buckling of the anterior cortex and/or increased concavity of the notch for the tibial tubercle

bruyeer-_Opmaak 1 16/02/12 10:29 Pagina 11

‘TRAMPOLINE FRACTURE’ OF THE PROXIMAL TIBIA IN CHILDREN — BRUYEER et al

B Fig. 1. — A. Standard lateral radiograph of the left knee shows a cortical buckle at the anterior portion of the proximal tibia. B. Comparative lateral view of the right knee.

B are the predominant findings. In older children or adults, there is impaction of the trabecular and cortical bone, but only minor buckling (4). The three typical radiological findings were present in case 2 and 3. In case 1, a buckling of the anterior upper tibial cortex was the only finding, illustrating that the radiological findings can be subtle. Occasionally associated buckle fractures of the distal femur occur, as seen in case 3.

Fig. 2. — A. Standard lateral radiograph of the left knee shows a transverse impaction fracture of the upper tibia accompanied by a buckle fracture of the anterior tibial cortex, an increased concavity of the notch for the tibial tubercle and anterior tilting of the growth plate. B. Lateral radiograph of the left knee after a few weeks demonstrates callus in the proximal tibia.

This ‘angled buckle’ fracture occurs when the axial forces applied are somewhat lateralized or because of a varus/valgus position at the moment of the impaction force (4).

Treatment consists of routine immobilization. These fractures have a good outcome, without impairment or significant deformities of the tibia and knee (2).

bruyeer-_Opmaak 1 23/02/12 09:59 Pagina 12

JBR–BTR, 2012, 95 (1)

Fig. 3. — A. Lateral standard radiographs of the left leg with a hairline fracture of the upper right tibia, cortical buckle fracture at the anterior portion of the proximal tibia, an increased concavity of the notch for the tibial, and slight anterior tilting of the epiphyseal plate. B. Frontal standard radiographs demonstrate an associated fracture: a cortical buckle of the lateral distal femoral metaphysis.

line jumping and the typical location of the injury. Radiological findings are often subtle and meticulous analysis of the anterior aspect of the upper tibia is mandatory to avoid misdiagnosis. References 1. 2.

Fig. 4. — Mechanism of injury in ‘trampoline fracture’. 4.

Conclusion The upper tibial hyperextension induced buckle fracture in infants, also known as the trampoline frac-

ture is becoming more common, since the introduction of trampoline jumping on garden parties. The key to the diagnosis is the combination of the typical history of the trampo-

Hurson C., Browne K., Callender O., et al.: Pediatric trampoline injuries. J Pediatr Orthop, 2007, 27: 729-732. Boyer R., Jaffe R., Nixon G., Condon V.: Trampoline fracture of the proximal tibia in children. AJR, 1986, 146: 83-85. Menelaws S., Bogacz A., Drew T., Paterson B.: Trampoline-related injuries in children: a preliminary biomechanical model of multiple users. Emerg Med J, 2011, 28: 594-598. Swischuk L.: The limping infant: imaging and clinical evaluation of trauma. Emerg Radiol, 2007, 14: 219-226. Swischuk L.: Musculoskeletal injury in the right leg of a child who jumped a lot on a birthday party. Emerg Radiol, 2009, 16: 331-333.

mailleux-_Opmaak 1 23/02/12 09:07 Pagina 13

JBR–BTR, 2012, 95: 13-14.

PYLEPHLEBITIS COMPLICATING PERIDIVERTICULITIS WITHOUT HEPATIC ABSCESS: EARLY DETECTION WITH CONTRAST-ENHANCED CT OF THE ABDOMEN P. Mailleux1, Ph. Maldague², B. Coulier1 Pylephlebitis is a very rare and dangerous complication of inflammatory abdominal processes, mainly appendicitis (1) and diverticulitis (2). We describe a case of peridiverticular inflammation leading to a extensive phlebitis of the adjacent sigmoid vein, extending to the inferior mesenteric vein up to the proximal portal vein, with distal embolus into the left portal vein. Contrast CT and multiplanar reconstructions allowed early diagnosis, and with antibiotic and anticoagulation therapy, no liver abscess developed. Key-words: Abdomen, acute conditions – Thrombophlebitis.

Pylephlebitis is a very rare and dangerous complication of inflammatory abdominal processes, mainly appendicitis (1) and diverticulitis (2). Many abdominal and extra-abdominal conditions can lead to portal or mesenteric vein thrombosis (3): it has been reported as a complication of hypercoagulation disorders, trauma, cirrhosis, or after splenectomy. It is called pylephlebitis or ascending septic thrombophlebitis when this thrombophlebitis is septic, quite often associated with a primary gastrointestinal inflammatory source. This unusual condition had a reported mortality of more than 50% before the era of the antibiotics. We report here a case of peridiverticular inflammation in the sigmoid, with ascending thrombophlebitis of the sigmoid and inferior mesenteric vein, and distal embolus in the left portal vein.

cutaneous injections of low molecular weigth heparin (LMWH) were started, leading to early biological response (CRP levels at day 4 lowered to 40 mg/l) and slower clinical response. No hepatic abscess developed and the patient left the hospital after 20 days, still on oral antibiotic and anticoagulation therapy.

Discussion Pylephlebitis was a dread-full and often lethal complication of some cases of appendicitis before the utilization of the antibiotics. Diverticular disease has replaced appendicitis as the most common cause of pylephlebitis, with other possible sources including appen-



Case report A 76-year-old lady was admitted for altered clinical status, left flank and left lower abdominal pain, fever (39°C). Blood tests showed highly elevated CRP levels (320 mg/l). In her past history one episode of peridiverticulitis two years earlier, treated without surgery. The abdominal CT performed at admission in the emergency department revealed a large air collection just close to the sigmoid colon, with infiltration of the adjacent fat. The sigmoïd veins were thrombosed, as was the inferior mesenteric vein upto the lower portal vein. And the left intrahepatic portal vein was also thrombosed. Intravenous antibiotic therapy (amoxicillin clavulanate) and sub -

Fig. 1. — Contrast enhanced CT. CT parameters were 120 kV, modulated mAs, 15671.19CTD/vol of mGy, DLP mGy-cm and 8,5 mSev. A : large pericolic aeric cavity (star) with adjacent blurring of the fat and thrombosis (straigth arrows) of the veins in the mesosigmoid fat. B: axial slice at the level of the iliac vessels. Thrombosed sigmoid vein (white arrow). Thrombosed inferior mesenteric vein (black arrow). C: at the level of the pancreas. Thrombus (white arrow) in the area of the confluence of inferior From: 1. Dept of Imaging, 2. Dept of Gastro-enterology, Clinique St Luc, Bouge, mesenteric vein and spenic vein. Distal Belgium. end of the thrombus (arrow head). Address for correspondence: Dr P. Mailleux, Dpt of Imaging, Clinique St Luc, rue St Luc D: thrombus in the left portal vein (arrow) 8, B-5004 Belgium. E-mail: p.mailleux@skynet.be but no intra-hepatic abscess.

mailleux-_Opmaak 1 16/02/12 10:41 Pagina 14

JBR–BTR, 2012, 95 (1)





B 

Fig. 2. — A: curved reconstruction of the same examination. Thrombus in seen in the peripheral branch of the sigmoid vein (small white arrows), extending into the inferior mesenteric vein (large white arrow). Distal end of the thrombus in the lower portal vein (curved black arrow). B: curved reconstruction of the portal vein and left branches. Distal end of the thrombus in the lower portal vein (curved black arrow) and thrombus in the left branches of the portal vein (black arrows). C: CT scan performed 2 years earlier: The large pericolic air-filled cavity was already present (star). D: this organized collection is in communication with the colon lumen through more than one diverticulum (2 are seen on this slice, white arrows).

dicitis, inflammatory bowel disease, ileal diverticulitis, suppurative pancreatitis, bowel perforation and pelvic infections. The addition of local inflammatory processes and infection precipitate the development of a septic thrombosis (3). If undetected, the infection tends to spread through septic emboli into the intrahepatic portal veins. The early hepatic abnormalities consist, as in our patient, of unopacified intrahepatic branches of the portal vein (Fig. 1D) and central or peripheral zones of low attenuation secondary to decreased intrahepatic blood flow. With early medical treatment, those abnormalities will subside, but untreated can lead to one or more hepatic abscess. Long term antibiotic therapy is recommended, especially in case of if liver abscess, often with drainage of these abscesses. Anticoagulotherapy remains controversial but is often used: it did not prevent cavernous transformation

of the portal vein in some series (3). Doppler ultrasound of the main portal vein and branches is very reliable but the analysis of the mesenteric veins is limited in the evaluation of these patients due to its operator dependency and inability to accurately depict vascular anatomy in the presence of overlying bowel gas (radiographics). Especially when, as in our patient, the clinical symptoms are in the left lower quadrant and not in the right hypochondrium. It was claimed that low-dose unenhanced multi-detectors CT has a diagnostic performance similar to that of contrast-enhanced standarddose multi-detector row CT in patients suspected of having acute diverticulitis (4) but t it’s accuracy to exclude this type of serious complicated should still be scrutinized. CT with intravenous injection of iodinated contrast is superior to non contrast CT to detect thrombosis of the

branches of the mesenteric vein or the portal vein. Scanning can be performed at the “portal” phase 70 sec after intravenous injection of iodinated contrast at a rate of 2 or 3 cc/sec but false positive diagnosis of venous thrombosis have been made when scanning was initiated too early after contrast injection. This can be avoided with a “biphasic injection of iodinated contrast” (60 cc at a rate of 2 cc/sec, 30 sec of pause followed by a second injection of 60 cc at a rate of 3 cc/sec and than 20 cc of saline), as in our patient, which allows nice depiction of the arterial vessels with at the same time complete filling of the veins (Fig. 1 and 2A). Diagnostic CT findings are to be searched in close vicinity to the sigmoid colon (thrombosed branch of the inferior mensenteric vein (Fig. 1A) and distally: segmentally thrombosed portal branch (Fig. 2A) or liver abcess. Sequential reading of the axial and coronal slices allows precise analysis of the vessels involved by the thrombus, but, in small vessels such as the inferior mesenteric vein, curved reconstruction can help in recognizing the vessels and their continuity (Fig. 2A, B). Conclusion Unenhanced MDCT can detect acute diverticulitis with a very high accuracy, but complications such as venous thrombosis and portal vein emboli could be difficult to diagnose without intravenous injection. In this case, early diagnosis and early treatment may have helped avoiding the development of intrahepatic abscesses. Multiplanar and curved reconstructions can help recognizing the small thrombosed veins. Bibliography 1.

Chang Y.S., Min S.Y., Joo S.H., Lee S.-H.: Septic thrombophlebitis of the porto-mesenteric veins as a complication of acute appendicitis. World J Gastroenterol, 2008, 14: 4580-4582. 2. Van De Wauwer C., Irvin T.T.: Pylephlebitis Due to Perforated Diverticulitis. Acta Chir Belg, 2005, 105 : 229-230. 3. Balthazar E. J., Gollapudi P.: Septic thrombophlebitis of the mesenteric and portal veins: CT imaging. J Comput Assist Tomogr, 2000, 24: 755-760. 4. Tack D., Bohy P., Perlot I., De Maertelaer V., Alkeilani O., Sourtzis S., Gevenois P.A.: Suspected acute colon diverticulitis: Imaging with low-dose unenhanced multi-detector row CT. Radiology, 2005, 237: 189-196.

ingabire-_Opmaak 1 16/02/12 10:44 Pagina 15

JBR–BTR, 2012, 95: 15-17.

SOFT TISSUE CHONDROMA OF HOFFA’S FAT PAD M.I. Ingabire, F.C. Deprez, A. Bodart, T. Puttemans1 We report mutimodal imaging findings of an extraskeletal chondroma of the Hoffa’s fat pad. Plain radiographic or CT scan studies demonstrate a large soft tissue mass with calcifications and central ossification, characteristic features of these tumors. Magnetic resonance (MR) imaging shows heterogeneous signal due to polymorphic histopathological appearance. Correlation between MR imaging and plain film or CT findings is essential to restrict differential diagnosis. The knowledge of this particular pathology is the key to the diagnosis. Key-word: Chondroma.

Case report A 64-year-old female presented with chronic pain at the anterior and inferior part of her right knee. There was no history of relevant trauma. Initial MRI showed a well delimited mass lesion (4 × 2,7 × 4,6 cm) in the infrapatellar fat pad (IFP), displacing the patellar tendon forward. On T1-weighted spin-echo (SE) sequence, signal intensity was mostly intermediate (similar to adjacent muscle) (Fig. 1A) with some areas of high signal, corresponding to fatty bone marrow. On T2-weighted spin echo sequence, signal intensity was overall high, corresponding to chondroid matrix (Fig. 1B). On both sequences, curves of very low signal were related to calcified or ossified parts. Enhancement areas were seen on fat-suppressed (FS) T1-weighted after intravenous contrast administration (Fig. 1C). A lateral radiograph of the knee (Fig. 2) showed an infrapatellar ossified mass, independent from adjacent bony structures. Ultrasound revealed a well defined hypoechoic lobulated mass with central hyperechoic linear interfaces due to focal ossifications (Fig. 3). On CT, the lesion contained central and peripheral areas of ossification and several zones of calcification surrounded by hypodense tissue (Fig. 4). Based on these morphological features, the diagnosis of a soft tissue chondroma was made, which was confirmed by surgical resection and histological examination. A wellcircumscribed cartilaginous mass was found, surrounded by a capsular fibrous tissue, and mostly composed of chondrocytes and areas of ossification. The microscopic examination revealed focal areas of myxoid

Fig. 1. — Sagittal T1-weighted SE MR-sequence (A) revealed a well delimited mass of the Hoffa’s fat pad with polymorphic features: global low signal, isointense to muscle, and high intensity signal areas corresponding to medullary bone (white star). This mass provoked a bulge of the patellar tendon. Axial T2-weighted image (B) showed the high T2-signal of the cartilaginous component of the soft tissue chondroma (white arrows). Axial T1-weighted post-gadolinium (C) revealed some enhancement areas in the mass (white arrow-heads).

change but no sign of atypia. Surgical excision was performed and the follow-up was uneventful. Discussion Chondroma are benign tumors arising mostly from bones (enchondroma – osteochondroma or exostosis), infrequently in the soft tissues (hand, feet) and rarely in para articular location, most often the knee (1, 2). Three well defined anterior extrasynovial fat pads are described within the knee: two suprapatellar,

From: 1. Department of Radiology, Clinique St-Pierre, Ottignies-LLN, Belgium. Address for correspondence: Dr A. Bodart, M.D., Department of Radiology, Clinique St-Pierre, Ottignies-LLN, Belgium. E-mail: radiologie@clinique-saint-pierre.be

and one infrapatellar (infrapatellar fat pad - IFP), the Hoffa’s fat pad (3, 4). The IFP is most frequently involved in this rare occurrence of extrasynovial intracapsular chondroma. The pathogenesis of this tumor is unclear. Para-articular chondroma, also known as extraskeletal chondroma or soft tissue chondroma, may be a result of metaplasia from mesenchymal cells (2). Some authors consider it as the end stage of Hoffa’s disease (5) resulting from acute or repetitive trauma related to hyperextension, rotational sprains and also genu recurvatum. First, trauma induces inflammation and hemorrhage. Secondly hypertrophy of the inflamed fat pad predisposes to crushing and impingement

ingabire-_Opmaak 1 16/02/12 10:44 Pagina 16

JBR–BTR, 2012, 95 (1)

Fig. 2. — Lateral radiograph of the knee well demonstrated arc-like calcifications and ossified areas (black arrow-heads) in the infrapatellar fat pad, corresponding to variable endochondral ossification predominant in the central areas of the lobulated mass.

Fig. 3. — Ultrasound showed a well delineated hypoechoic tissue corresponding to the cartilaginous component of the soft tissue chondroma, with peripheral and central hyperechoic areas due to peripheral calcifications and central focal ossification (white arrows) observed on radiographic image (Fig. 2).

between the tibia and femur. Fat pad impingement may also occur in absence of prior trauma. At chronic stage, the hypertrophied fat pad is colonized by fibrous tissue which may be transformed into fibrocarti-

lagous tissue. At MRI, soft tissue chondroma may show enhancement after gadolinium IV injection, probably linked to chronic inflammatory mechanisms. Enhancement does not imply malignant transformation.

Histologically, soft tissue chondroma appears as a lobulated mass of hyaline cartilage with variable endochondral ossification (mature trabecular bone) in the central areas. Fibrocartilage, myxoid areas and fibroadipose tissue are equally observed in variable proportion, accounting for the heterogeneous and variable MR appearance. The literature describes many IFP tumors or tumor-like lesions such as primary or secondary synovial chondromatosis, synovial sarcoma, para-articular chondroma, Hoffa’s syndrome, focal pigmented villonodular synovitis, chondrosarcoma, lipoma, ganglion cysts and hemangioma (4). On isolated MR imaging, differential diagnosis is large. Correlation of MR imaging appearances with plain film (6) or CT findings is essential to delineate the degree of ossification, and to restrict the differential diagnosis to paraarticular chondroma, synovial chondromatosis or synovial chondrosarcoma. Ultrasound is not conclusive for the diagnosis. Synovial chondromatosis is a non-neoplasic proliferative and metaplastic pathology of synovium, characterized by intra- or extraarticular multiple nodules consisting in chondrocyte clusters with some ossification (7), rather than a single mass. These nodules are not confined to the IFP (popliteal fossa – suprapatellar recess) (2). Synovial hemangioma is an intraarticular tumour. Fat-pad or soft tissues invasion can occur but without significant mass effect, unlike soft tissue chondroma (3). Phleboliths can be associated but are easily differentiated from chondroma calcifications or ossifications. Soft tissue chondrosarcoma is extremely rare, arising “de novo” in most of cases: only twelve per cent of all chondrosarcomas are developed in a pre-existing lesion (e.g. soft tissue chondroma or osteochondroma, enchondromatosis (Ollier’s disease), fibrous dysplasia, Paget’s disease, irradiated bone or synovial chondromatosis) (8). High-grade tumours show irregular margins. Calcifications of the tumoral matrix may be punctate, flocculent, or have a ring-like pattern, they can be small, or disseminated, dense or subtle (8). Their absence is frequent in aggressive types. Differential diagnosis with benign chondroma is very difficult, most often impossible. Stippled calcifications, irregular, thin or cobweb-like calcifications, rather than regular arciform calcification or

ingabire-_Opmaak 1 16/02/12 10:44 Pagina 17

SOFT TISSUE CHONDROMA OF HOFFA’S FAT PAD — INGABIRE et al

Fig. 4. — Axial CT series (A) demonstrated loss of fat density of the Hoffa’s fat pad and showed a soft tissue lesion with peripheral calcifications (white arrows) and central trabecular ossification area (black or white star). (B) MPR sagittal view, bone window. 3D volume rendering image (C) is helpful for surgical treatment planning.

well delimitated ossification areas, can be suspected of malignant transformation. Ill defined lesion with blurred margins on MR or CT series must be alarming. MRI is an efficient imaging modality to characterize soft tissue tumors but will not always allow differentiating malignant from benign lesions with absolute certitude (9). Resection and histological analysis help to obtain the final diagnosis, showing signs of malignancy like increased cellularity and atypical cells. Conclusion IFP chondroma is a rare entity with specific imaging features, especially on conventional plain films and CT. The knowledge of this particular pathology is the key for the diagnosis and the differential diagnosis. In case of MR first imaging, correlation with plain film or CT findings is essential to delineate the

degree of ossification and to restrict the differential diagnosis. Musculoskeletal pain assessment should always start with conventional plain film imaging. References 1.

Maheshwari A.V., Jain A.K., Dhammi I.K.: Extraskeletal paraarticular osteochondroma of the knee – a case report and tumor overview. Knee, 2006, 13: 411-414. 2. Helpert C., Davies A.M., Evans N., Grimer R.J.: Differential diagnosis of tumours and tumour-like lesions of the infrapatellar (Hoffa’s) fat pad: pictorial review with an emphasis on MR imaging. Eur Radiol, 2004, 14: 2337-2346. 3. Jacobson J.A., Lenchik L., Ruhoy M.K., Schweitzer M.E., Resnick D.: MR imaging of the infrapatellar fat pad of Hoffa. Radiographics, 1997, 17 (3): 675-91. 4. Saddik D., McNally E.G., Richardson M.: MRI of Hoffa’s fat pad. Skeletal Radiol, 2004, 33: 433444.

5. Turhan E., Doral M.N., Atay A.O., Demirel M.: A giant extrasynovial osteochondroma in the infrapatellar fat pad: end stage Hoffa’s disease. Arch Orthop Trauma Surg, 2008, 128: 515-19. 6. Van Dyck P., Gielen J., Vanhoenacker F.M., De Schepper A.M., Parizel P.M.: Imaging of soft tissue tumors: general imaging strategy and technical considerations. JBR-BTR, 2006, 89: 204-224. 7. Gonzales-Lois C., Garcia-de-laTorre P., SantosBriz-Terron A., Vila J., Manrique-Chico J., Martinez-Tello J.: Intracapsular and para-articular chondroma adjacent to large joints: report cases and review of the literature. Skeletal Radiol, 2001, 30: 672-676. 8. Ollivier L., Vanel D., Leclère J.: Imaging of chondrosarcomas. Cancer Imaging, 2003, 4:36-38. 9. Gielen J.L., De Schepper A.M., Vanhoenacker F., Parizel P.M., Wang X.L., Sciot R., Weyler J.: Accuracy of MRI in characterization of soft tissue tumors and tumor-like lesions. A prospective study in 548 patients. Eur Radiol, 2004, 14: 2320-2330.

de smet-_Opmaak 1 16/02/12 14:20 Pagina 18

JBR–BTR, 2012, 95: 18-19.

SPHENOID MUCOCOELE AS A COMPLICATION OF FIBROUS DYSPLASIA OF THE FACIAL BONES K. De Smet, M. De Maeseneer, A. Talebian Yazdi, Th. Buisseret, J. De Mey1 We report on a 28-year-old man with severe headache. Imaging studies included CT and MR. A large sphenoid mucocoele was demonstrated as well as findings compatible with fibrous dysplasia of the facial bones. Both disorders had been previously unknown. Imaging findings suggested that the sphenoid mucocoele was related to an obstruction caused by the expansile bone of fibrous dysplasia. These findings were confirmed surgically. Fibrous dysplasia with subsequent outflow obstruction is an extremely rare cause of sphenoid mucocoele development. Key-word: Mucocele.

A mucocoele is a benign encapsulated expansile mass filled with mucous material. It is lined by respiratory mucosa. It enlarges gradually and may result in erosion of the bony walls of the sinus. One reported cause of the development of a mucocoele is an obstruction of the ostium of the sinus. Mucocoeles occurring in the sphenoid sinus make up 2% of paranasal sinus mucocoeles (1). Fibrous dysplasia is a skeletal developmental abnormality of the mesenchyme caused by a defect in osteoblastic maturation and differentiation. Bone is replaced by fibrous tissue which is variably calcified and may lead to the relatively typical ground glass appearance. Any bone in the body may be affected but sites of predilection in the skull include the frontal, sphenoid, maxillary, and ethmoidal bones (2). Mucocoeles occurring as a complication of tumors or tumorlike lesions are exceedingly rare with only a few cases reported in the literature (3). Case report A 28-year-old man presented to the emergency department with a history of severe occipital headache for two days. He had self medicated with over the counter analgetics but this had been unsuccessful in alleviating the pain. He also reported pain in the neck region irradiating to the right shoulder and hand and tingling in the hand. On further questioning he reported daily headaches for years in addition to a stuffed nose. On physical examination his head was lateroflexed to the right. Paresthesia of the right arm was present but otherwise neurological examination was unremarkable. The results of laboratory tests were normal.

Fig. 2. — Transverse CT image (bone algorithm) shows eroded medial wall of the expanded sphenoid sinus (short arrow). Note ground glass appearance in expanded bone (long arrow) typical of fibrous dysplasia of the skull base. Fig. 1. — Note slightly hypodense mass (arrows) involving the sphenoid sinus area on this transverse non contrast enhanced CT image (soft tissue algorithm).

On the basis of these findings a non-contrast enhanced CT of the skull with multiplanar reconstructions was performed. CT revealed a large slightly hypodense and expansile mass in the sphenoid region (Fig. 1). Erosion of the bony walls of the sphenoid sinus was also present. Findings characteristic of fibrous dysplasia were also depicted in the facial bones and included a ground glass appearance and expansion of the bony structures (Fig. 2, 3). Subsequently an MRI of the skull was performed. On T1-weighted images with intravenous contrast the expansile lesion of the sphenoid sinus appeared hypointense and showed delicate rim enhancement after intravenous contrast administration (Fig. 4). On T2-weighted images the mass appeared hyper intense (Fig. 5).

From: 1. Department of Radiology, UZ Brussel, Brussels, Belgium. Address for correspondence: Dr M. De Maeseneer, M.D., Dpt of Radiology, UZ Brussel, Laarbeeklaan 101, B-1090 Jette. E-mail: michel.demaeseneer@uzbrussel.be

Fig. 3. — Coronally reconstructed multiplanar CT image (bone algorithm). Note the typical ground glass appearance and expansion of the lateral orbital wall and nasal septum (arrows). Anterior part of mucocoele is seen medial to the medial orbital wall (asterisk).

Preoperatively the diagnosis of a sphenoid mucocoele as a complication of fibrous dysplasia of the facial bones was made. The patient was sheduled for transnasal sphenoidotomy. The anterior and inferior wall of the sphenoid sinus were removed allowing drainage of the mucocoele. Preoperative diagnosis was confirmed surgically. Pathological find-

de smet-_Opmaak 1 16/02/12 11:00 Pagina 19

SPHENOID MUCOCOELE AS A COMPLICATION OF FIBROUS DYSPLASIA — DE SMET et al

Fig. 5. — Sagittal T2-weighted MR image. Note hyperintense expansile lesion in the sphenoid sinus (asterisk).

Fig. 4. — Transverse T1-weighted MR image after contrast administration. Note isointense sphenoid sinus mass with rim enhancement (arrows).

ings of the bone fragments confirmed fibrous dysplasia. Postoperative evolution was unremarkable. Discussion Only about 2% (1) of all paranasal sinus mucocoeles are located in the sphenoid sinus. Most are simple mucocoeles, and secondary mucocoeles are exceedingly rare. Only a few cases have been reported and causes include carcinoma, osteoma, ossifying fibroma, fibromyxoma, Paget’s disease (4), and fibrous dysplasia (3). Transsphenoidal hypophysectomy also may be the cause of a sphenoid mucocoele (5). Mucocoeles develop chronically, expanding progressively and sometimes leading to erosion of the bony wall of the sinus. Expansion may sometimes be severe with involvement of adjacent intra- and extracranial spaces. In rare cases posterior rupture may even cause brainstem inflammation (6). The etiology remains somewhat unclear although the initial event is believed to be an obstruction of the draining ostium of the sinus. There are other theories including a cystic dilatation of glandular structures, or a cystic enlargement of embryonic epithelial residual cells. Clinical symptoms of sphenoid sinus mucocoeles are variable and non-specific. This delays the diagnosis in many cases. Most commonly symptoms include headache, visual disturbances, vertigo, facial pain, nasal discharge, and palsy of the

occulomotor and abducens nerves (3). Headache appears to be the most common symptom. Diagnosis is established earlier if there are neurological symptoms. In our patient headache had been present since many years but was now exacerbated for an unknown reason prompting a visit to the emergency department. The other clinical findings were seemingly unrelated but contributed to the decision to perform a CT which ultimately showed the mucocoele. Diagnosis is made with CT and MRI. On CT variable densities may be present in the mucocoele. Precise location and expansile aspect of the lesion are demonstrated. The different densities may be attributable to the protein content and possible surinfection or hemorraghe, but the lesion is usually homogeneous. Typically contrast enhancement is absent except for delicate rim enhancement related to the encapsulated nature of the lesion (3). Such rim enhancement was also present in our patient. Signal intensities on MRI are likewise variable. The difference is attributable to the variability of cyst content (7). MRI is better able to demonstrate the relationship of the mucocoele to adjacent vessels and nerves. Differential diagnosis of cystic sphenoidal lesions includes chordoma, pituitary adenoma, craniopharyngeoma (8), dermoid, and arachnoid cyst (3). A mucocoele should also be differentiated from a simple fluid retention which is much more common. A fluid retention typically does not show an expansile aspect. Fibrous dysplasia can affect virtually any bone in the body and represents a nonheriditary disorder of

unknown cause (2). Bone is replaced by fibrous tissue which is variably calcified and may be more or less radiolucent on radiographs and CT scans. Different forms are recognized including a monostotic, polyostotic, craniofacial form, and cherubism. Typical findings of fibrous dysplasia include the slightly expansile nature of the bony structures and the ground glass appearance. These findings are better demonstrated with CT since MRI is less suited to evaluate bony structures. Treatment of sphenoid mucocoeles is mandatory especially when neurological symptoms are present. It consists of transnasal sphenoidotomy with subsequent drainage of the sinus. In conclusion mucocoeles of the sphenoid sinus are rare lesions. Mucocoeles secondary to tumor or tumorlike lesions are exceedingly rare. In this article we present a case where a sphenoid mucocoele occurred secondary to fibrous dysplasia of the facial bones, which is an exceedingly rare occurrence. CT and MRI allowed the preoperative diagnosis of the sphenoid mucocoele and the involvement of the skull base by fibrous dysplasia. A secondary cause for sphenoid mucocoeles, although very rare, should always be considered. References 1.

2. 3.

Giovannetti F., Filiaci F., Ramieri V., Ungari C.: Isolated sphenoid sinus mucocoele: etiology and management. J Craniofac Surg, 2008, 19: 1381-1384. Kransdorf M.J., Moser R.P., Gilkey F.W.: Fibrous dysplasia. Radiographics, 1990, 10: 519-537. Kösling S., Hintner M., Brandt S., Schulz T., Blochning M.: Mucoceles of the sphenoid sinus. Eur J Radiol, 2004, 51: 1-5. Lee K.S., Rhee C.S., Lee C.H., Min Y.G.: Localized Paget’s disease with mucocoele in the sphenoid sinus. Otolaryngology Head Neck Surg, 2001, 124: 338-339. Buchinsky F.J., Gennarelli T.A., Strome S.E., Deschler D.G., Hayden R.E.: Sphenoid sinus mucocoele: a rare complication of transsphenoidal hypophysectomy. Ear Nose Throat J, 2001, 80: 886-888. Bussche K., Morrish W.F.: Sphenoid sinus mucocoele – rupture causing brainstem inflammation and stroke. Can J Neurol Sci, 2008, 381: 381385. Ruelle A., Pisani R., Andrioli G.: ‘Unusual’ MRI appearance of sphenoid sinus mucocoele. Neuroradiology, 1991, 33: 352-353. Koral K., Weprin B., Rollins N.K.: Sphenoid sinus craniopharyngioma simulating mucocoele. Acta Radiol, 2006, 47: 494-496.

koktener-_Opmaak 1 16/02/12 11:03 Pagina 20

JBR–BTR, 2012, 95: 20-21.

TWO FOREIGN BODY REACTIONS CAUSED BY SUTURE MATERIALS: MAMMOGRAMS MIMIC CANCER AS A SPICULATED LESION A. Koktener1, K. Akin1, D. Kosehan1, B. Cakir1, H. Haltas2 A spiculated breast lesion on mammogram is highly suggestive of malignancy. However, it can be seen on rare occasions in benign conditions including foreign body associated granuloma. We describe two foreign body reactions in the breast caused by suture materials and describe the clinical, radiological and pathological features. Key-words: Breast neoplasms – Granuloma.

Spiculated margin of a breast lesion on mammography is a strong clue of malignancy. However, benign breast lesions showing an architectural distortion with thin lines radiating from its margins can mimic breast cancer. These lesions include radial scar, fat necrosis, postoperative scar, sclerosing adenosis, granuloma (1-3). Surgical material causing foreign body type granulamotous reaction and mimicking malignancy on mammography is a very rare entity (4). We report on two foreign body granulomas associated with suture materials simulating breast cancer on mammograms. Case 1 A 60-year-old woman was admitted to the hospital with mastodynia. She had a history of breast biopsy four years previously. Pathologic examination had showed fibroadenoma. Physical examination revealed no abnormality. Ultrasonographic examination showed retroareolar ill-defined hypoechoic mass with 50 x 30 mm dimensions. Mammogram showed a spiculated mass without microcalcification on the left breast (Fig. 1). According to the American College of Radiology Breast Imaging and Reporting Data Systems (BIRADS), the malignancy risk was high (Category 4). To exclude malignancy the mass was biopsied under ultrasound guidance using 14-gauge tru-cut biopsy needle. Histopathological examination determined foreign body reaction with multinuclear histiocytes including cytoplasmic foreign bodies. Case 2 An 83-year-old woman who had a history of right breast cancer and

Fig. 1. — Case 1. Craniocaudal mammogram of the left breast showed a mass with spiculations in the central part of the breast.

mastectomy four years previously was admitted for breast screening. Her physical examination was normal. She had also undergone biopsy in left breast forty years ago and a benign lesion was diagnosed. Mammograms determined a new spiculated lesion on left breast (Fig. 2). BIRADS Category 4 lesion was not observed on previous mammograms. Ultrasonographic

examination also showed hypoechoic lesion, 4 mm in diameter, with distorsion. Mammography guided wire localization biopsy was performed. It was reported that suture material with abscess formation, histiocytes, granuloma with lymphocytes and foreign body giant cells pathologically. The final diagnosis was foreign body granuloma. Discussion

From: 1. Department of Radiology, 2. Department of Pathology, School of Medicine, Fatih University, Ankara, Turkey. Address for correspondence: Dr A. Koktener, M.D., Department of Radiology, School of Medicine, Fatih University, Alparslan Turkes Cad No: 57 06510 Emek-Ankara, Turkey. E-mail: akoktener@yahoo.com

Local irritant effects of a foreign body may cause granuloma in human body. Silicone granuloma and paraffinomas are the most common reported foreign body

koktener-_Opmaak 1 16/02/12 11:03 Pagina 21

MAMMOGRAMS MIMIC CANCER AS A SPICULATED LESION — KOKTENER et al

Fig. 2. — Case 2. Craniocaudal compressed mammogram of the left breast determined a spiculated lesion with radiodense centre.

10.

11.

granulomas in the breast (5-7). The other reported foreign bodies were suture materials, carbon particles marking of the stereotactic vacumassisted breast biopsy site, gunpowder, gauze sponge, tungsten particles (4, 8-12). Besides foreign body, breast granulomas may be associated with connective tissue disease, tuberculosis, sarcoidosis, Wegener’s granulmatosis and amyloidosis (1315). On mammography, foreign body reaction can be seen as calcifications, or a mass simulating malignancy with partially circumscribed or ill-defined margins or spiculated characteristics (4, 5, 8-11, 16). We described two foreign body granuloma of the breast with clinical, radiological and pathological features. In case 2, mammography showed a new spiculated lesion on the left breast of the woman who had a history of right breast cancer and mastectomy, This new lesion might be late foreign body reaction with granuloma and abscess formations as pathology determined.

Although spiculated margin can be observed both on benign and malign processes, the history of biopsy may be a clue to consider the possibility of foreign body reaction for the radiologist and the surgeon. On the other hand, biopsy is useful to complement the investigation, in particular clinical examination seems normal.

12.

13.

References 1. Franquet T., De Miguel C., Cozcolluela R., Donoso L.: Spiculated lesions of the breast mammographicpathologic correlation. Radiographics, 1993, 13: 841-852. 2. Demirkazik F.B., Gulsun M., Firat P.: Mammographic features of nonpalpable spiculated lesions. Clin Imaging, 2003, 27: 293-297. 3. Pojchamarnwiputh S., Muttarak M., Na-ChiangMai W., Chaiwun B.: Benign breast lesions mimicking carcinoma at mammography. Singapore Med J, 2007, 48: 958-967. 4. Yazici B., Sever A.R., Mills P., Fish D., Jones S., Jones P.: A rare cause of breast mass that mimic carcinoma:

14.

15.

16.

foreign body reaction to amorphous surgical material. Wien Klin Wochenschr, 2007, 119: 497-499. Han B.K., Choe H.Y., Ko Y.H., Nam S.J., Yang J.H.: Foreign body granulomas of the breast presenting as bilateral spiculated masses. Korean J Radiol, 2001, 2: 113-116. Helbich T.H., Wunderbaldinger P., Plenk H., Deutinger M., Breitenseher M., Mostbek G.H.: The value of MRI in silicone granuloma of the breast. Eur J Radiol, 1997, 24: 155158. Khong P.L., Ho L.W., Chan J.H., Leong R.R.: MR imaging of breast paraffinomas. Am J Roentgenol, 1999, 173: 929-932. Tez S., Sen M., Yenidunya S., Tez M.: Foreign body granuloma: a mimic of breast carcinoma. Bratisl Lek Listy, 2009, 110: 366-367. Wakabayashi M., Reid J.D., Bhattacharjee M.: Foreign body granuloma caused by prior gunshut wound mimicking malignant breast mass. Am J Roentgenol, 1999, 173: 321-322. Patrikeos A., Wylie E.J., Bourke A., Frost F.: Imaging of carbon granulomas of the breast following carbon track localization. Clin Radiol, 1998, 53: 845-848. Bessell-Browne R., Beer T., Wylie E.: Tungten particles mimicking the microcalcifications seen in ductal carcinoma in situ. Australas Radiol, 2006, 50: 87-90. Ruiz-Delgado M.L., Lopez-Ruiz J.A., Saiz-Lopez A.: Abnormal mammography and sonography associated with foreign-body giant-cell reaction after stereotactic vacuum-assisted breast biopsy with carbon marking. Acta Radiol, 2008, 49: 1112-1118. Spiera R.F., Gibofsky A., Spiear H.: Silicone gel filled breast implants and connective tissue disease: an overview. J Rheumatol., 1994, 21: 239245. Houpt K.R., Sontheimer R.D.: Autoimmune connective tissue disease and connective tissue diseaselike illness after silicone gel augmentation mammoplasty. J Am Acad Dermatol, 1994, 31: 626-6412. Emekli U., Tumerdem B., Demiryont M.: Rupture of a silicone gel mammary prosthesis and amyloidosis: a case report. Aesthetic Plast Surg, 2002, 26: 383-387. Rosenberg R.F., Siegelman S.S.: Foreign-body granuloma simulating carcinoma on mammography. N Y State J Med, 1976, 76: 445-446.

de maeseneer-_Opmaak 1 23/02/12 09:07 Pagina 22

JBR–BTR, 2012, 95: 22-24.

A BARE AREA OF THE GLENOID MISDIAGNOSED AS A CARTILAGE ULCERATION M. De Maeseneer1, N. Pouliart2, C. Boulet1, F. Machiels1, M. Shahabpour1, M. Kichouh1, J. De Mey1 We report on a 17-year-old girl who developed shoulder pain after a fall on an outstretched arm. CT arthrography and MR imaging demonstrated a cartilage defect centrally located in the glenoid. This was accompanied by an eroded appearance of the underlying bone. Since symptoms persisted over several months it was initially thought this represented a cartilage injury. Subsequently arthroscopy was performed and the abnormality was identified as a bare area of the glenoid. A tear of the superior glenohumeral ligament was depicted and was repaired. The bare area is an oval area denuded of cartilage that is probably developmental and that should be differentiated from true cartilage injuries to avoid unnecessary interventions. An eroded appearance of the underlying bone may occur on imaging, a finding that has not been previously reported. Key-words: Shoulder, MR – Shoulder, arthrography.

In the young, focal cartilaginous lesions of the glenoid and humeral head may occur after shoulder injuries such as dislocations (1). In the elderly, diffuse cartilaginous thinning occurs in the setting of degenerative disease. The shoulder is often examined at first with ultrasound, but with this technique the cartilage can not be visualized. MR imaging allows a better visualization of cartilage defects but ideally CT or MR arthrography are performed to evaluate the cartilage of the shoulder (1, 2). When focal cartilage lesions occur they may be amenable to therapeutic interventions such as ice picking or cartilage transplantation (3). It is important to differentiate a cartilage injury from a developmental abnormality designated the bare area of the glenoid cartilage to avoid unnecessary interventions. Imaging findings can be misleading and as a result unnecessary arthroscopy may be performed. In the present patient, both CT arthrography and MR imaging were interpreted as a cartilage lesion with disruption of the underlying cortex. At arthroscopy, however, a non pathological bare area was found. Case report A 17-year-old girl was referred to the orthopedic clinic for right shoulder pain. According to the patient the symptoms had started 10 months earlier after a fall on an outstretched

arm during athletic activity. Pain was also present in the neck and the entire arm. She experienced pain when sleeping on the affected side. During elevation she subjectively experienced a painful cracking sensation. On clinical examination no limitation of the range of motion was evident. A cracking noise was depicted with certain arm movements. The area of the trapezius muscle and shoulder area were sensitive to palpation. No instability signs were elicited. Jobes test was painful. The findings of other tests included: hyperabduction test, 100°; abduction external rotation test, 90°; and adduction external rotation test, 80°. On the basis of these findings the possibility of a minor instability was entertained. Radiography was unremarkable (Fig. 1). Ultrasound was performed and showed a moderate tendinopathy of the anterior third of the supraspinatus tendon. CT arthrography was performed and the report mentioned the presence of a deep cartilaginous ulceration in the midportion of the glenoid accompanied by slight irregularity of the subchondral bone (Fig. 2). The labrum and rotator cuff appeared normal. Treatment consisted of counceling, hyaluronic acid injections, and physical therapy. These treatments remained unsuccessful and symptoms were still present six months later. MRI of the shoulder was performed and showed a region of focal cartilage abrasion with denuded bone at the middle

From: 1. Department of Radiology, 2. Department of Orthopedic Surgery, UZ Brussel, Belgium. Address for correspondence: Dr M. De Maeseneer, M.D., Department of Radiology, UZ Brussel, Laarbeeklaan 101, B-1090 Jette, Belgium. E-mail: michel.demaeseneer@uzbrussel.be

third of the glenoid. The findings were similar to the previous CT findings. The decision was made to perform arthroscopy and the possibility of performing the ice picking technique was entertained. At arthroscopy a tear of the superior glenohumeral ligament with a HAGL lesion was discovered. The described cartilage lesion on imaging studies, was recognized at arthroscopy as a focal area of cartilage thinning about at the center of the glenoid measuring 1 cm in diameter. It was identified as a bare area of the glenoid and not as a traumatic injury. The superior glenohumeral ligament injury was sutured. Postoperative evolution was unremarkable with resolution of pain symptoms. Discussion The bare area of the glenoid has only been described in very few articles (4). Some texts report the bare area to be relatively common (5). However, we believe they refer to an area were the cartilage becomes thinner in the mid third of the glenoid cavity accompanied by a slight protrusion of the underlying bone. This likely corresponds to the presence of a grey spot (‘tache grisatre’) reported by Testut and Latarjet (6). It has been suggested that this corresponds to an area of increased compressive loading (7). Although the cartilage becomes thinner at the central third of the glenoid cavity, a deep cartilaginous defect, in our experience, is a very uncommon finding. Anatomically the bare area measures 5-10 mm in width, has a slightly blue appearance and may show some fibrillations at the edges (5). It is still debated whether it represents an acquired or developmental abnormality (4).

de maeseneer-_Opmaak 1 16/02/12 11:16 Pagina 23

BARE AREA OF THE GLENOID — DE MAESENEER et al

Fig. 1. — Transverse (A) and coronal (B) CT arthrography image. Note cartilage defect filling with contrast medium (arrow). Also note irregularity of the underlying bone.

Fig. 2. — Coronal proton density weighted MR image. Note defect in the cartilage filling up with a moderate amount of joint fluid (arrow).

No clinical symptoms have been attributed to its presence. Of note, our patient did undergo a traumatic event which would raise the possibility of a traumatic cartilage lesion. The patient in our series was young, corresponding to previously repor-

ted findings (4). The clinical importance lies in the fact that it may be mistaken for focal cartilage trauma in which case clinical symptoms would occur and treatments such as icepicking or cartilage transplantation ( 3) could be considered.

On radiographs no abnormalities of the glenoid joint have been described although there may be some increased sclerosis or a bony bump underlying the area. Ultrasound is unable to show the glenoid cartilage and is better suited for assessment of the structures of the rotator cuff. On CT studies the cartilage is poorly identified and although no reports exist it may be assumed this study would be normal. CT arthrography is probably the most valuable technique to show the bare area. Contrast can be seen entering a smoothly marginated rounded focal cartilage defect about at the center of the glenoid and also the glenoid cortical bone can be evaluated in detail. In our case slight deformity of the underlying bone was seen, although no focal sclerosis was evident underlying the lesion. Consecutive slices can show the defect is very focal. However, without knowledge of the existence of this variant it could still be interpreted as a cartilage injury. Findings would be similar on MR arthrography, but MR would be less suited to evaluate the underlying bone. The cartilage can be visualized on MR imaging studies without intraarticular contrast injection if some fluid is present and hence the bare area can also be appreciated on plain MR images again showing a focal area of cartilage thinning at the center of

de maeseneer-_Opmaak 1 23/02/12 09:11 Pagina 24

the glenoid. At arthroscopy an area of focal cartilage thinning can also be observed. It may show some superficial fibrillations (5). Increased subchondral density has been reported, but was not observed in our case. Instead, we noticed cortical irregularity on CT imaging. Ultrasound is not able to play a role in the recognition of this variant. The bare area should be differentiated from osteochondral defects, glenoid labral articular disruption (GLAD) lesions, and degenerative or traumatic areas of cartilage thinning. Osteochondral defects and GLAD lesions do not typically occur in the central area of the glenoid helping in differentiation. Degenerative cartilage thinning is more diffuse and multiple areas of cartilage abrasion may occur. GLAD lesions involve the anteroinferior labral area and hence are easily differentiated from the bare area. Traumatic cartilage injuries usually occur after dislocations and are

JBR–BTR, 2012, 95 (1)

usually accompanied by labral lesions or Hill Sachs lesion (1) In summary, the bare area of the glenoid should be recognized as a specific entity on CT arthrography, MR, or MR arthrography studies, to avoid misinterpretation as a traumatic cartilage injury and subsequent unnecessary procedures. Irregularity of the underlying cortex can occur, a finding that has not been previously reported. References Hayes M.L., Collins M.S., Morgan J.A., Wenger D.E., Dahm D.L. (2010): Efficacy of diagnostic magnetic resonance imaging for articular cartilage lesions of the glenohumeral joint in patients with instability. Skeletal Radiol (Epub ahead of print). 2. Dietrich T.J., Zanetti M., Saupe N., Pfirrmann C.W., Fucnetese S.F., Hodler J.: Articular cartilage and labral lesions of the glenohumeral joint:l diagnostic performance of 3D water-exitation true FISP MR arthro-

graphy. Skeletal Radiol, 2010, 39: 473480. Kircher J., Patzer T., Magosch P., Lichtenberg S., Habermeyer P.: Osteochondral autologous transplantation for the treatment of full cartilage defects of the shoulder: results at nine years. J Bone Joint Surg (Br), 2009, 91: 499-503. Ly J.Q., Bui-Mansfield L.T., Kline M.J., DeBerardino T.M., Taylor D.C.: Bare area of the glenoid: Magnetic resonance appearance with arthroscopic correlation. J Comput Assist Tomogr, 2004, 28: 229-232. Shoulderdoc.co.uk. Glenoid bare area. Available at www.shoulderdoc.co.uk/article.asp? Article=476. Accessed June 9, 2010.. Testut L., Latarjet A. (1928): Articulation scapulo-humérale. In Testut L., Laterjet A. (eds). Traité d’anatomie humaine, 8th edn. Doin, Paris. Warner J.J., Bowen M.K., Deng X.H., Hannafin J.A., Arnoczky S.P., Warren R.F.: Articular contact patterns of the normal glenohumeral joint. J Shoulder Elbow Surg, 2001, 10: 496497.

JBR–BTR, 2012, 95: 24.

ABSTRACT OF PAPERS FOR FULL MEMBERSHIP CHEST Evaluation of dual-energy CT lung perfusion-maps: a correlation with V/Q scan and lung parenchymal changes M. Lefere, M. Demeter, J. Lambert, F. De Keyzer, J. Coolen, J. Verschakelen, W. De Wever1 Aim: Dual-energy computed tomography (DECT) perfusion maps can be used to visualize pulmonary perfusion in the diagnostic work-up of pulmonary embolism (PE) and other pulmonary diseases. Study purpose is: 1) to quantify inter-observer variability in perfusion map evaluation, 2) to correlate perfusion maps with ventilation-perfusion (V/Q) images, and 3) to correlate perfusion defects (PD) with lung parenchymal changes on DECT-images.

Methods: 26 patients underwent both DECT and V/Q scan to exclude acute PE. DECT perfusion maps were read by two radiologists. Perfusion maps were evaluated on a per-segment basis and classified as homogenous perfusion (HP), wedge-shaped defect (WSD), patchy defect (PaD), circumscribed defect (CD) or artifact. Perfusion maps were correlated with parenchymal abnormalities (normal, emphysema, mosaic perfusion, groundglass opacification (GGO), consolidation) and V/Q findings (normal, perfusion defect (PD) with and without ventilation defect (VD)). Results: There was a good interobserver agreement (kappa = 0,655). Perfusion maps showed HP, WSD, PaD, CD, artifacts in 65.7%, 3.5%, 23.2%, 4.2% and 3.4% respectively. V/Q showed 27.1% PD (24.9% without and 2.2% with VD) for

HP, 50% PD (all without VD) for WSD, 56.6% PD (2.8% without and 53.8% with VD) for PaD and 50% PD (19.2% without and 30,8% with VD) for CD. Normal lung showed 79.1% HP. Emphysematous lung showed 75% PaD. Mosaic perfusion showed 45.4% HP and 36.7% PaD. GGO showed 42.1% HP and 42.1% PaD. Consolidation showed 38.1% HP and 42.9% CD. Conclusion: There is a good interobserver agreement in evaluating DECT perfusion maps. WSD correspond with real perfusion defects. PaD and CD can correspond with perfusion defects, but are more often corresponding with other parenchymal abnormalities. 1. Department of Radiology, University Hospitals Gasthuisberg, Leuven, Belgium.

mcneill-_Opmaak 1 16/02/12 11:18 Pagina 25

JBRâ&#x20AC;&#x201C;BTR, 2012, 95: 25-26.

RADIATION-INDUCED AORTIC OCCLUSION G. McNeill, S. Culleton, K. Courtney, W.C. Torreggiani1 Arterial occlusion is a late complication of radiotherapy usually seen in extracranial vessels following treatment for head and neck malignancy. Determining the etiology behind vessel occlusion can be difficult and involves consideration of several factors. We present a case of radiotherapy induced aortic occlusion and discuss the relevant clinical and imaging factors that allow the diagnosis to be made. Key-word: Radiations, injurious effects, complications of therapeutic radiology.

Case presentation A 42-year-old male smoker with a 15-pack year history presented to the emergency department with a 2-day history of left flank pain and progressive lower limb pain on exertion over several months. He had no urinary or gastrointestinal symptoms. Examination of the abdomen was normal as was full blood count and routine biochemistry. He was normotensive. He was on no medication. His past medical history was unremarkable other than treatment for stage 1 seminoma (pT1 Mx Nx) 9 years previously. A CT of the abdomen and pelvis was performed. Select images are shown (Fig. 1, 2) with coronal MIP images from a subsequent CT angiogram (Fig. 3).

Fig. 1. â&#x20AC;&#x201D; Arterial phase contrast enhanced transverse image of the upper abdomen demonstrates a wedge shaped area of lack of enhancement of the left kidney. No contrast is present in the aorta although contrast in present in the superior mesenteric artery (arrow).

Imaging findings Transverse and coronal image from a CT of the abdomen and pelvis in the arterial phase demonstrate a wedge-shaped area of low attenuation in the mid left kidney. The kidneys are otherwise enhancing normally despite the absence of contrast in the abdominal aorta. Contrast is identified in the superior mesenteric artery (arrow). Coronal reformats demonstrate a cut-off with no contrast in the mid or distal abdominal aorta. Extensive calcification is present in the wall of the abdominal aorta. A CT angiogram was performed and the MIP reformats are shown. Total proximal occlusion of the abdominal aorta with extensive collateralization is demonstrated. Again noted is the presence of mural calcification of the abdominal aorta and common iliac arteries.

Diagnosis A diagnosis of radiation induced total occlusion of the abdominal aorta with segmental infarction of the left kidney was made. The patient had undergone radiotherapy as part of his treatment for testicular carcinoma 9 years previously. The patient was referred to vascular surgery and underwent an aorto-iliac bypass. Discussion Radiation Induced arthrosclerosis is a well-recognized complication of radiotherapy with the majority of cases reported in the extracranial vessels following irradiation for head and neck malignancy (1). Radiation induced arterial injury has several manifestations depending

From: 1. Department of Radiology, AMNCH Tallaght, Dublin 24, Ireland. Address for correspondence: Dr W.C Torreggiani, M.D., Department of Radiology, Adelaide and Meath Hospital , Tallaght , Dublin 24, Ireland. E-mail: william.torreggiani@amnch.ie

on the time interval from treatment (2). In the acute setting arterial rupture or thrombosis can occur. Accelerated atherosclerotic disease is a later complication. Clinically and radiologically it can be difficult to discriminate between radiation induced disease and atherosclerosis. The diagnosis is made after considering a number of factors. The presence of isolated vessel disease in the radiation field with no other evidence of atherosclerotic disease would be suggestive, as would presentation at a young age. Vascular risk factors are often present and are associated with an increased risk of development of radiation induced vascular injury. Butler et al (2) described 3 phases of vessel injury following irradiation. The first phase consists of initial mural thrombosis within the first 5 years following irradiation. The second phase is fibrotic vessel occlusion up to 10 years following irradiation. The final stage is a predisposition to the development of atheroma with periarterial fibrosis associated with a latent interval of 20 or more years.

mcneill-_Opmaak 1 16/02/12 11:18 Pagina 26

JBR–BTR, 2012, 95 (1)

Fig. 2. — Coronal reformat of contrast enhanced CT. No contrast is present in the mid or distal aorta. Extensive calcification is present in the abdominal aorta and iliac arteries.

Different theories for the pathogenesis of arterial occlusion have been proposed with debate over whether radiation causes direct fibrosis or causes molecular changes and subsequent fibrosis (3). Various cytokines have been implicated and suggested to cause endothelial and fibroblast proliferation. Histological analysis of the vessel wall shows endothelial proliferation and degeneration of the media with subsequent cystic medial necrosis. Damage to the vasa vasorum is often present, with resultant fibrosis of the vessel wall and stenosis of the vessel. Other vascular risk factors are often present in these patients although it is the lack of widespread atherosclerotic disease that often permits the diagnosis of radiation induced vascular injury; with disease limited to the field of radiation. Radiation dose is implicate, a study of 14 cases of radiation induced arterial occlusion described a range

Fig. 3. — Maximum Intensity Projection reconstruction of CT angiogram. There is occlusion of the abdominal aorta with the formation of multiple collateral vessels.

of doses from 47 to 70 Gray with standard fractionation (4). Therapy for radiation induced arterial disease includes medical, percutaneous intervention and surgical treatments. Medical treatment involves the aggressive treatment of vascular risk factors. Surgical therapy is often advocated, however the presence of fibrosis secondary to radiation can hinder dissection and careful pre-operative planning is required (5). In non-occluded vessels percutaneous treatment is therefore preferable (6). Restenosis is a frequent problem and regular follow-up imaging is recommended. Radiation induced aortic occlusion is a relatively uncommon finding usually presenting years after therapy. The presence of vascular risk factors such as smoking, diabetes and hypertension are typical. The key radiological finding of radiation-induced arteritis is the limitation of vascular disease to the radiation field.

References 1.

2. 3. 4.

Fonkalsrud E.W., Sanchez M., Zerubavel R., et al.: Serial changes in arterial structure following radiation therapy. Surg Gynecol Obstet, 1977, 145: 395-400. Butler M.S., Lane R.H., Webster J.H.: Irradiation injury to large arteries Br J Surg, 1980, 67: 341-343. Kalman P.G., Lipton I.H., Provan J.L., et al. : Radiation damage to large arteries. Can J Surg, 1983, 26: 88-91. Melliere D., Becquemin J.P., Kassab M., Etienne G., Gaston A.: Natural and corrected history of obliterative radiation arteritis: à propos of 14 cases. J Mal Vasc, 1990, 15: 73-81. Melliere D., Desgranges P., Berrahal D., Allaire E., Cron J., D’Audiffret A., et al.: Radiationinduced aortoiliofemoral arterial arteritis: mediocrity of the long-term results after conventional surgery. J Mal Vasc, 2000, 25: 332-335. Jurado J.A., Bashir R., Burket M.: Radiation-induced peripheral artery disease. Catheterization and Cardiovascular Interventions, Volume 72, Issue 4, pages 563-568, 1 Oct. 2008.

ozcan-_Opmaak 1 16/02/12 11:30 Pagina 27

JBR–BTR, 2012, 95: 27-28.

RADIOLOGICAL FINDINGS IN A RARE CASE OF EYELID SWELLING: POTT’S PUFFY TUMOR H.N. Özcan, S. Avcu, M. Lemmerling Pott's puffy tumor (PPT), or osteomyelitis of the frontal bone, is a rare entity especially in adults. PPT is believed to occur as a complication of fronto-ethmoidal sinusitis or trauma to the frontal bone. We present the computed tomography and magnetic resonance imaging findings in such a rare case of Pott's puffy tumor. Key-word: Bones, infection.

increasing. Local examination of the right eye showed erythema and edema of the eyelid. The rest of the ocular examination was unremarkable with full range of extraocular movements in both eyes. On systemic examination, nasal congestion was observed. The patient was noted to be afebrile with normal vital signs. The remainder of the physical examination was noncontributory. Due to his persistent headache and swelling of the eyelid, a conventional radiological evaluation of the paranasal sinuses was performed. This showed air-fluid levels in the right frontal and maxillary sinuses (Fig. 1A). Accordingly, the patient was treated with antibiotics for a suspected diagnosis of preseptal cellulitis and sinusitis. Although the patient’s complaints did not improve, he only revisited our hospital two months later. A new physical examination revealed inflammatory signs of the paranasal sinuses and persistent edema of the right upper eyelid. The edema was extending to the right frontal region resulting in a soft and

Osteomyelitis of the frontal bone (eponymously known as Pott's puffy tumor) is an extremely rare and potentially life-threatening complication of frontal sinusitis. The entity was first described by Sir Percival Pott, an 18th century neurosurgeon, as a complication of trauma to the frontal bone (1). It is also a recognized complication of frontoethmoidal sinusitis. In the era of modern antibiotics, PPT is a rarely encountered entity, which has been reported in children and adolescents. We present the computed tomography (CT) and magnetic resonance (MR) imaging findings in a case of PPT in a previously healthy young man with a worsening headache and swelling of the upper eyelid. Case report A 27-year-old man visited our ENT department for reasons of headache and swelling of the right upper eyelid for one week. He described the swelling of the right upper eyelid to be insidious but progressively

fluctuant swelling over the forehead. On general examination, he was afebrile, well appearing and well oriented. Neurological evaluation was completely normal. CT scan of the paranasal sinuses was performed with axial, and reformatted coronal and sagittal images (Fig. 1B and 1C), which showed an extensive bony erosion of the superior margin of the right orbit and destruction of the frontal bone. The communication between the orbit and frontal sinus indicates inflammatory changes at the superomedial side of the right orbit. MR examination displayed soft tissue swelling with edema around the superior border of the right orbit, and with slight proptosis (Fig. 2A,B). On the basis of the findings of the clinical and radiological investigations the diagnosis of PPT was made. The patient was initiated on intensive intravenous antibiotic treatment and underwent subsequent endoscopic sinus surgery. No further complications occurred.

Fig. 1. — A. On this conventional X-ray of the sinuses an air-fluid level is seen in both frontal sinuses (arrows), but obliteration is more extensively present on the right side. On these coronal (B) and sagittal (C) reformatted CT images bony erosion is seen of the superior margin of the right orbit (arrows). The communication between the orbit and frontal sinus indicates inflammatory changes at the superomedial side of the right orbit. From: AZ Sint-Lucas Hospital, Department of Radiology, Gent, Belgium. Address for correspondence: Dr H.N. Özcan, Gayret Mah. Istiklal Cad 2/M daire 37 Yeni Mahalle, Ankara, Turkey. E-mail: drhnozcan@yahoo.com

ozcan-_Opmaak 1 16/02/12 11:30 Pagina 28

JBR–BTR, 2012, 95 (1)

Fig. 2. — On the coronal (A) and axial (B) fat-suppressed T1-weighted images after intravenous injection of gadolinium soft tissue swelling with edema around the superior border of the right orbit and of the forehead on the right side is present (arrows) and enhances strongly.

Discussion "But the inflammation of the dura mater and the formation of matter between it and the skull, in consequence of contusion, is generally indicated and preceded by one [sign] I have hardly ever known to fail; I mean a puffy, circumscribed, indolent tumor of the scalp and a spontaneous separation of the pericranium, from the skull under such tumor" (2). Sir Percival Pott originally described the condition as a complication of trauma, but it is more commonly observed as a complication of frontal sinusitis, as is the case in our patient who mentioned no prior trauma. PPT can also be seen a complication of a frontal reconstruction also rarely can occur as complication of dental implantation procedures (34). The condition is described as a frontal bone osteomyelitis resulting in a subperiosteal abscess presenting as a fluctuant mass over the forehead and scalp. In our patient the

presentation was slightly atypical with a most prominent swelling rather present in the eyelid. PPT can be associated with subdural empyema, brain abscess, cortical vein thrombosis and epidural abscess. Because the mucosal venous drainage of the frontal sinus occurs through diploic veins, which communicate with the dural venous plexus, septic thrombi can potentially evolue from foci within the frontal sinus and propagate through this venous system. Thus intracranial involvement is possible with or without direct erosion of the frontal bone (5). In our patient no intracranial complications were seen, and the overall condition of the patient was good. PPT is a quite rare disease and is almost always encountered in the pediatric and adolescent population. Furthermore, with the recent worldwide use of antibiotics, it has only occasionally been reported the last decades. Especially in the past

5 years, the frequency of published pediatric cases has increased. Undiagnosed or partially treated frontal sinusitis may lead to this serious complication, and the apparent increase in incidence rate may suggest that this complication of frontal sinusitis could be underestimated in clinical practice (6). As a conclusion, a high index of suspicion based on the history and clinical examination is necessary to identify this rare but severe condition of a Pott’s puffy tumor. When a patient with preseptal cellulitis either following sinusitis or trauma presents with a fluctuant swelling of the forehead, imaging is suggested with contrast enhanced CT or MRI. This case illustrates that the same alertness can be necessary if a patient only presents with swelling of the eyelid. References 1.

McDermott C., O’Sullivan R., McMahon G.: An unusual cause of headache: Pott's puffy tumour. Eur J Emerg Med, 2007, 14: 170-173. Pott P.: Observations on the nature and consequences of those injuries to which the head is liable from external violence. Hawes Clarke & Collins, London, 1768: 48. Collet S., Grulois V., Eloy P., Rombaux P., Bertrand B.: A Pott’s puffy tumour as a late complication of a frontal sinus reconstruction: case report and literature review. Rhinology, 2009, 47: 79-84. Segal N., Woldenberg I., Puteman M.: Paranasal sinus complications caused by dental implants and complementary procedures. B-ENT, 2009, 5: 153-157. Raja V., Low C., Sastry A., Moriarty B.: Pott’s puffy tumor following an insect bite. J Postgrad Med, 2007, 53: 114116. Kombogiorgas D., Solanki G.A.: The Pott puffy tumor revisited: neurosurgical implications of this unforgotten entity. Case report and review of the literature. J Neurosurg, 2006, 105: 143-149.

image-mailleux-_Opmaak 1 16/02/12 11:33 Pagina 1

JBR–BTR, 2012, 95: 29.

IMAGES IN CLINICAL RADIOLOGY Single right coronary artery with a “malignant course” of the left main coronary artery P. Mailleux1, P. Timmermans2

A 68-year-old patient with abdominal obesity, high cholesterol and family factors, and complaining of atypical chest pain was referred for CT of the coronary arteries to exclude significant stenosis. Cardiac CT was performed in prospective mode with injection of iodinated contrast and the following acquisition parameters: 100 kV, 600 mAs, 13.31 CTD/vol of mGy, DLP 189.56 mGy-cm and total effective dose 2.5 mSev. The scan showed no coronary stenosis but demonstrated absence of the origin of the main left coronary artery in the left sinus of Valsalva. There was one single coronary arising of the right sinus of Valsalva. From that single coronary took of a normal right coronary artery and a long left common coronary (LCA). Fig. A is a Volume Rendering of the coronary arteries, viewed from above: LCA runs in front of the aorta and behind the pulmonary artery (star). LCA than runs into the groove between the anteriorly located pulmonary artery and the aorta posteriorly (Fig. B). The distal main LCA is embedded into the upper interventricular septum (Fig. C) before the division into a small left anterior coronary artery and a normal size circumflex artery. No fixed stenosis is demonstrated but the course of the left main coronary artery in this patient is considered “potentially malignant” for two reasons: the coronary artery can get compressed between the aorta and pulmonary artery and it can also be compressed between myocardial muscle fibres of the septum during the systole. As CT did not show any fixed stenosis, conventional coronarography was not performed. Due to the age of the patient, medical treatment was proposed. Comment

Single coronary artery (SCA) s a very rare congenital anomaly, the incidence in the general population being approximately 0.0190.4%. This variation constitutes approximately < 3% of all coronary anomalies. 40% are associated with other cardiac malformations and are discovered early. Existing classifications (1) are based on the origin of the single vessel, and on the anatomical course of the artery. When the vessel courses anterior to aorta and pulmonary artery and or posterior the aorta, the variations are considered as benign coronary course and usually asymptomatic while they are considered as potentially “malignant” types, when it courses between pulmonary artery and aorta since coronary artery can get compressed between the aorta and pulmonary artery or when it runs between myocardial muscle fibres of the septum (variation also called milking or myocardial bridge), with potential to cause sudden ischemic events and death. Bibliography

Shah J.R., Priya C., et al.: Single coronary artery: Classification and MDCTA diagnosis. Eur J Radiol Extra, 2011, 77 (1): e1-e4.

1. Department of Imaging, 2. Department of Cardiology, Clinique St Luc, Bouge, Belgium.

image-apaydin-_Opmaak 1 27/02/12 09:15 Pagina 1

JBR–BTR, 2012, 95: 30.

IMAGES IN CLINICAL RADIOLOGY Hypermobile coccyx syndrome M. Apaydin1, K.B. Bayram2, M. Varer1, A. Oygen1, G. Sezgin1 A 40-year-old woman referred to the radiology department because of pain in the region of the coccyx. There was no abnormality neither localized tenderness or swelling in the sacrococcygeal region. She had difficulty in defecation but gastrointestinal pathology such as stool test for occult blood was negative. For radiological examination lateral and postero-anterior X-rays and MRI studies were obtained. On the X-rays the distal part of the coccyx was not very clear. It was impossible to make any diagnosis especially in the distal coccygeal area but MRI study showed abnormally invard curve in the distal part of the coccyx (arrow) with iliococcygeal part of the levator ani muscle and precoccygeal soft tissue edema (curved arrow) (A, B). Comment

Hypermobile coccyx , which is one of the leading cause of coccyx pain, appears as an abnormally curved or flexed coccyx exceeding 25°. Four anatomic configurations according to its distal curve have been described by Postacchini and Massobrio. The distal intercocygeal joint angle increases from type 1 to type 4 accordingly. The coccyx sublaxes at the intercoccygeal joint in type 4 (1). Hypermobility is seen in type 3 and 4. While obese patients mainly have posterior subluxation, normal-weight patients mainly have hypermobility. This pathologic instability may give rise to chronic inflammatory changes (1). Hypermobility of the coccyx causes chronic friction of distal sacrum and coccyx resulting in bone and soft tissue oedema. Single position X-ray studies usually are not diagnostic but instability can be detected on dynamic radiographs. The radiographs must be obtained in both the sitting and standing lateral positions of the coccyx and anterior hypermobility > 25° can be measured. Normally a coccyx pivots between 5° and 25° (1). Usually the distal part of the coccyx is difficult to evidence on standart X-ray studies as in our case. Bone scans can show inflammation in a hypermobile coccyx but it this feature is non specific. MRI demontrates indirect signs of instability, such as bone and soft tissue oedema and measurement of the distal intercoccygeal angle can be made easily. In our patient MRI very clearly shows soft tissue edema and an abnormally curved sacrum (A). Distal intercocygeal joint was 40° (between the arrows) (B). MRI helps ruling out the other possible causes of the coccyx pain such as tumor or fracture. Nonsurgical management such as decreased sitting, using seat cushions, streching, manipulation, local steroid or pain killer injections and postural recommendations remains important treatment choices. Our patient was improved after such recommendations with anti-inflamatory treatment like most patients. Coccygectomy may be beneficial for the patients who fail to improve with these conservative treatments. The MRI studies provides excellent anatomical detail and objective findings of organic lesions in coccygeal region. Reference 1.

Patel R., Appannagari A., Whang P.G.: Coccydynia. Curr Rev Musculoskelet Med, 2008, 1: 223-226.

1. Department of Radiology, Izmir Ataturk Education and Research Hospital, 2. Department of Physical Therapy and Rehabilitation, Izmir Ataturk Education and Research Hospital, Izmir, Turkey.

image-devooghdt-_Opmaak 1 23/02/12 09:14 Pagina 1

JBRâ&#x20AC;&#x201C;BTR, 2012, 95: 31.

IMAGES IN CLINICAL RADIOLOGY Uterine lipoleiomyoma M. Devooghdt, N. Favoreel, S. Gryspeerdt, B. van Holsbeeck1

A 74-year-old, postmenopausal woman presented to her urologist with complaints of urge incontinence. Her medical history consisted of a sectio, diabetes mellitus, hypertension and hypercholesterolemia. Clinical examination showed a cystocoele. A bladder and renal ultrasound was performed during consultation revealing right hydronephrosis grade 2 and left hydronephrosis grade 1 (not shown). The bladder was normal. Incidentally a fluid-containing structure was noted measuring 10 cm in diameter (not shown). CT urography showed a cystocoele and a right distal ureteral stone (dotted arrow), explaining the hydronephrosis (Fig. A). The left ovary showed a large septated cystic mass, matching the ultrasound finding (Fig. B, dotted arrow). Furthermore a well-circumscribed, predominantly fatty mass was discovered in the uterus with dimensions of 42 x 34 x 36 mm (Fig. A,B, arrow). MRI T1-weighted images showed a well-defined, uniformly high-intensity uterine mass with discrete septae (Fig. C, arrow). The mass suppressed on the fat-saturated images (Fig. D, arrow). MRI additionally showed the intramural location of the uterine mass and confirmed the thin septae in the cystic mass of the left ovary (not shown). Based on these findings the diagnosis of uterine lipoleiomyoma and mucinous cystadenoma of the left ovary was made. A hysterectomy and adnexectomy was performed. Pathology of the uterine mass revealed 98% mature fat with sporadic areas of well-differentiated smooth muscle cells (Fig. E, F). No mitotic activity was reported. These findings are consistent with a lipoleiomyoma, almost entirely composed of lipocytes. The right adnexal mass consisted of a mucinous cystadenoma.

Comment Uterine lipoleiomyoma is a rare benign tumor of the uterus. Incidence reportedly varies from 0,03 to 0,2%. They are typically found in postmenopausal women and symptoms may include a palpable mass, pelvic pain and uterine bleeding however, most patients, as in our case, are asymptomatic. Uterine lipoleiomyomas are mostly found intramurally in the uterine corpus. However, they can also be found subserosal or elsewhere in the cervix or the broad ligament (1). Histologically they are composed of variable amounts of lipocytes, smooth muscle cells and fibrous tissue. The pathogenesis remains unclear, although fatty metamorphosis of smooth muscle cell is usually assumed. Other theories include misplaced embryonic fat cells, lipocytic differentiation of primitive connective or mesenchymal tissue, perivascular extension of peritoneal or retroperitoneal fat, and fatty infiltration of connective tissue (1). Malignant transformation of uterine lipoleiomyoma has been reported once. A percutaneous needle biopsy under sonography guidance is helpful to differentiate with similar uterine tumors including spindle cell lipoma, angiolipoma, angiomyolipoma, leiomyoma with fatty degeneration, atypical lipoma and well-differentiated liposarcoma. The tumor is considered benign after a 5-year follow-up period, so either watchful waiting or surgical resection is required depending on clinical presentation. Reference 1.

Loffroy R., et al.: Lipoleiomyoma of the Uterus: Imaging Features. Gynecologic and Obstetric Investigation, 2008, 66: 73-75.

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

image-kok-_Opmaak 1 16/02/12 11:43 Pagina 32

JBRâ&#x20AC;&#x201C;BTR, 2012, 95: 32.

IMAGES IN CLINICAL RADIOLOGY Left ventricular non-compaction cardiomyopathy H.K. Kok1, S. Ma2, P. Ma2 A 30-year-old woman presented with dull left-sided chest pain, radiating to her left arm, lasting seconds on each episode. She denied any palpitations or dyspnoea and had no cardiovascular risk factors or family history of sudden death. A twelve-lead electrocardiogram showed normal sinus rhythm at 70/min with no acute changes. Transthoracic echocardiography revealed normal left ventricular size and function, however, note was made of prominent trabeculations in the left ventricle. Subsequent cardiac magnetic resonance (CMR) imaging confirmed the diagnosis of left ventricular non-compaction (LVNC). Short axis two-chamber views showed prominent subendocardial trabeculations and non-compacted myocardium (Fig. A, black arrow) compared to a thinner rim of normal myocardium (Fig. A, white arrow) in the left ventricle at end-diastolic and systolic phases of the cardiac cycle. Four chamber, long-axis views at end-diastole (Fig. C) also showed increased subendocardial left ventriclular trabeculation (green line) compared to whole wall thickness (blue line) and compacted myocardium (yellow line). The end-diastolic ratio of non-compacted to compacted myocardium (NC/C) was 2.6. T2-weighted sequences were normal and there was no evidence of late gadolinium enhancement. Anticoagulation therapy was commenced to prevent thromboembolic complications and annual follow-up was arranged to assess overall left-ventricular function with CMR.

Comment LVNC or left ventricular hypertrabeculation is a rare cause of non-ischaemic cardiomyopathy. It is defined by the presence of a non-compacted myocardial layer in the left ventricle as a result of incomplete endomyocardial embryological development. Clinical features of LVNC include heart failure, ventricular arrhythmias and thromboembolic events from thrombus forming in the prominent trabecular recesses of the left ventricle endocardium (1). LVNC may be asymptomatic or can manifest clinically with cardiac failure, ventricular arrhythmias, thromboembolic events or chest pain. CMR imaging is now the preferred diagnostic modality where an end-diastolic NC/C ratio of > 2.3 has been shown to offer a diagnostic sensitivity of 86% and specificity of 99%. CMR imaging can also help assess the extent, severity and clinical stage of the disease. Management of patients with LVNC revolves around treatment of symptoms of cardiac failure with diuretics and renin-angiotensinalodsterone system antagonists, prevention of arrhythmia related deaths with antiarrhythmics or ICD implantation as well as anticoagulation to prevent complications of systemic embolisation such as stroke and end-organ ischaemia.

C Reference 1.

Oechslin E.N., Attenhofer Jost C.H., Rojas J.R., Kaufmann P.A., Jenni R.: Long-term follow-up of 34 adults with isolated left ventricular noncompaction: a distinct cardiomyopathy with poor prognosis. J Am Coll Cardiol, 2000, 36: 493-500.

1. Department of Radiology, Adelaide and Meath Hospital incorporating the National Childrenâ&#x20AC;&#x2122;s Hospital, Dublin, Ireland, 2. Heart Health Institute, Calgary, Alberta, Canada.

image-fan-_Opmaak 1 16/02/12 11:46 Pagina 1

JBRâ&#x20AC;&#x201C;BTR, 2012, 95: 33.

IMAGES IN CLINICAL RADIOLOGY Spontaneous regression of pulmonary sequestration: prenatal and postnatal imaging findings Y.-K. Fan, Y.-P. Liu, Y.-L. Lin, W.-K. Su1

A 28-year-old woman at 24 weeks gestation was referred to our hospital for evaluation of a fetal lung mass. The differential diagnosis initially included pulmonary sequestration (PS) and microcystic congenital cystic adenomatoid malformation (CCAM), the latter because 2D color Doppler ultrasonography (US) showed no systemic artery feeding into the fetal lung lesion. At 25 weeksâ&#x20AC;&#x2122; gestation, a complementary magnetic resonance imaging (MRI) scan showed a hyperintense left-sided triangular mass with a systemic feeding artery arising from the descending thoracic aorta (Fig. A, arrows), thereby indicating fetal PS. In a thick-slab T2-weighted image, the lesion showed hyperintensity in the left lower thorax (Fig. B, arrows). Follow-up MRI was performed 10 weeks later, and it showed partial regression of the sequestered lung with decreased, inhomogeneous signal intensity (Fig. C and D, arrows). Multidetector computed tomography (MDCT) angiography was arranged for preoperative evaluation on postnatal day 3, and it showed partial regression of the left lower lung PS as compared to prenatal MRI performed at 35 weeksâ&#x20AC;&#x2122; gestation, a systemic feeding artery arising from the descending thoracic aorta (Fig. E and F, black arrows), and venous drainage into pulmonary veins (Fig. E and F, white arrows). The final diagnosis of PS was confirmed by surgery. Comment

PS is a congenital malformation consisting of a nonfunctioning lung tissue. This tissue lacks normal communication with the bronchial system, and it is supplied by aberrant vessels arising from the descending thoracic aorta or other systemic arteries and drained into the pulmonary vein, inferior vena cava, azygos system, or other systemic drainage. Intralobar PS is confined within the normal pulmonary visceral pleura and has been suggested to be an acquired lesion that is caused by recurrent infections. Extralobar PS is characterized by a complete separation of the embryonic tissue that is enclosed in its own pleura, and it is universally accepted to be a congenital anomaly. Prenatally, US is the primary imaging modality for diagnosis and differentiation of PS from CCAM by revealing the feeding artery arising from the aorta to the fetal lung mass. MRI can be a useful complementaE F ry tool to US in differentiating fetal PS by visualizing the systemic feeding artery (1, 2). The characteristic MRI pattern of fetal PS during the second trimester includes a well-defined, triangular, homogeneous, hyperintense mass with intensity more than the normal lung but lower than the amniotic fluid, with the feeding artery and possible drainage veins. Many studies indicate that PS may regress either partially or completely, or stabilize in size in utero. Partially regressed PS tends to show decreased, inhomogeneous signal intensity, while nearly complete regressed PS tends to show a very small-sized mass; thick-slab T2-weighted images are useful for detection of these conditions because of the high water content of the associated lesions (2). Postnatally, various imaging techniques such as conventional angiography, MRI, color Doppler US, and MDCT angiography have been reported to aid the visualization of the abnormal feeding artery of PS. Furthermore, MDCT angiography with 3D rendering images may help in clearly identifying the feeding arteries and draining veins, and thereby could be a potential first-line examination for the preoperative planning or regular follow-up of PS (3). References 1.

Dhingsa R., Coakley F.V., Albanses C.T., et al.: Prenatal sonography and MR imaging of pulmonary sequestration. AJR Am J Roentgenol, 2003, 180: 433-437. 2. Liu Y.P., Chen C.P., Shih S.L., et al.: Fetal cystic lung lesions: evaluation with magnetic resonance imaging. Pediatr Pulmonol, 2010, 45: 592-600. 3. Lee E.Y., Siegel M.J., Sierra L.M., et al.: Evaluation of angioarchitecture of pulmonary sequestration in pediatric patients using 3D MDCT angiography. AJR Am J Roentgenol, 2004, 183: 183-188.

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

image-vanwambeke-_Opmaak 1 16/02/12 11:54 Pagina 1

JBR–BTR, 2012, 95: 34.

IMAGES IN CLINICAL RADIOLOGY Breast augmentation by injection of free silicone: MRI findings K. Vanwambeke1, I. Wittevronghel2, S. Dekeyzer1, C. Petre1, F.M. Vanhoenacker1,3 A 23-year-old Asian women was referred because of bilateral breast tenderness. Her past medical history includes a bilateral breast augmentation by liquid silicone injection at multiple sites at the age of 19. Clinical examination was unremarkable. The axillary nodes were not palpable. Mammography shows multiple nodular densities in both breast dispersed subcutaneously and in the prepectoral area (Fig. A). The breast tissue itself is almost completely obscured by widespread of nodular densities. The penetration of the ultrasound beam was blocked by free subcutaneous silicone presenting as hyperechogenic infiltration with interspersed confluent areas of liquid silicone causing the “snowstorm sign”. Note also the presence of an adjacent cyst in the left breast (arrows) (Fig. B). For evaluation of the adjacent breast tissue, subsequent magnetic resonance imaging (MRI) was performed. On fat suppressed turbo spin echo T2-weighted images (WI) the fibroglandular tissue was hypointense and surrounded by the T2 hyperintense conglomerates of liquid silicone diffusely dispersed in the subcutaneous and prepectoral fat. An additional T2-sequence with fat and water suppression confirmed the persisting high signal of silicone distinguishing it from fluid content of the cyst in the left breast (Fig. C). Gradient echo T1-WI before and dynamic after contrast were performed. On subtraction images only the periphery of the glandular tissue shows some enhancement due to physiological premenopausal hormonal proliferation of the glandular tissue (Fig. D). The timesignal intensity curves showed normal slowly continuous enhancement kinetics of the glandular tissue (type 1 curve). There was no morphological distortion of the breast tissue. A waitful watching policy and meticulous follow-up by MRI was recommended to allow early detection of breast cancer.

Comment Direct injection of liquid silicone into the breasts as method of breast augmentation was once widely used in Asia because it is cheap, quick and simple to perform. This technique has been banned for many years because of the multiple complications. Some cases – however – are still reported in illegal cosmetic procedures. The most frequent minor complications include palpable masses, breast tenderness or pain, asymmetry of deformity due to foreign-body granulomatous reaction and fibrosis. These adverse effects can cause psychological problems D because of fear for cancer. A lot of major complications have been reported. The most frequent is infection and secondary abscess formation because this procedure is done illegally under bad aseptic conditions. Small amounts of silicone can migrate to the axillary lymph nodes and axillary fat, and accumulate into different organs causing embolism or granuloma formation. Deposits of silicone in the lungs are responsible for the “silicone embolism syndrome” presenting with a variety of symptoms, such as dyspnea, fever, cough, hemoptysis, chest pain, hypoxia and altered consciousness. Early diagnosis of breast cancer is impaired by the silicone-induced mastopathy which renders the interpretation of physical findings and conventional imaging methods difficult. Mammography is compromised by the high density and nodular aspect of the silicone granulomas and architectural distortion due to fibrosis. The sonographic appearance of free silicone is called the snowstorm pattern consisting of diffuse intra-and extraparenchymal shadowing. Dynamic contrast-enhanced magnetic resonance imaging of the breasts is the method of choice to investigate the glandular tissue, to exclude and prevent late detection of cancer. The signal intensity of silicone and the formation of foreign-body granulomas is not disturbing the quality of the images. Analysis of the morphology of lesions and contrast kinetics on dynamic enhanced MRI can help in differentiation of cancer from fibrosis or infection. Reference 1.

Yang N., Muradali D.: The augmented breast: A pictorial review of the abnormal and unusual. AJR, 2011, 196: W451-W460.

Department of 1. Radiology, 2. Gynecology, AZ Sint-Maarten, Duffel-Mechelen, Duffel, Belgium, 3. Department of Radiology, Antwerp University Hospital, Antwerp University and Ghent University.

image-volders-_Opmaak 1 16/02/12 11:54 Pagina 1

JBR–BTR, 2012, 95: 35.

IMAGES IN CLINICAL RADIOLOGY High resolution CT diagnosis of isolated fracture of the malleus handle D. Volders1, Th. Somers2, J. Casselman1,3

We report a case of a 48-year-old woman with a sudden-onset unexplained conductive unilateral hearing loss. There was no improvement after a trial with systemic corticosteroids. On otomicroscopy, the right tympanic membrane showed an abnormal outline of the malleus handle. Pneumatic otoscopy revealed excessive movement of the umbo compared with the lateral process. Audiometric testing showed a conductive hearing loss in the right ear, with an average pure-tone audiometry of air conduction of 40 dB and a maximum air-bone gap of 45 dB at 500 Hz. Tuning fork tests confirmed conductive hearing loss. Tympanometry showed increased compliance in the right ear and an absent ipsilateral stapedial reflex in response to a broad-band stimulus. High resolution computed tomography (CT) imaging of the temporal bone was performed by a high-definition CT system (Discovery CT750 HD®, GE, Hounslow, England). MIP (Maximum Intensity Projection) coronal ultrafine (around 0.1 mm) reconstructions of the malleus revealed a small non-displaced isolated fracture of the malleus handle (Fig. A and B). On the left there was a continuous appearence of the middle ear ossicles. During surgery, the isolated fracture of the right malleus handle was visualised and an ossiculoplasty was performed using a hydroxylapatite bone cement (OtoMimix®, Biomet, Jacksonville, Florida) (Fig. C). Postoperatively, average pure-tone audiometry of air condition improved to 30 dB, and maximum air-bone gap improved to 35 dB at 500 Hz. Comment Isolated fracture of the malleus handle is an extremely rare ossicular injury. Most cases described in literature present with suddenonset conductive hearing loss after digital manipulation of the external auditory canal (1). Until now, the standard diagnosis was made on the basis of otomicroscopy, audiometry, tympanometry and laserDoppler vibrometry (2). But thanks to the arrival of high resolution CT imaging, even small non-displaced fractures of the middle ear ossicles, can now be diagnosed for the first time. References

1. Department of Radiology, A.Z. St.-Jan Hospital, Brugge, Belgium, 2. Department of Otolaryngology, A.Z. St.-Augustinus Hospital, Wilrijk, Belgium, 3. Department of Radiology, A.Z. St.-Augustinus Hospital, Wilrijk, Belgium.

Pedersen C.B.: Traumatic middle ear lesions. Fracture of the malleus handle, aetiology, diagnosis and treatment. J Laryngol Otol, 1989, 103: 901-903. 2. Chien W., McKenna M.J., Rosowski J.J., Merchant S.N.: Isolated fracture of the manubrium of the malleus. J Laryngol Otol, 2008, 122: 898-904.

image-favoreel-_Opmaak 1 16/02/12 12:32 Pagina 1

JBRâ&#x20AC;&#x201C;BTR, 2012, 95: 36.

IMAGES IN CLINICAL RADIOLOGY Popliteal venous aneurysm N. Favoreel1, M. Devooghdt1, J. Marrannes1, P. Gellens2, B. Van Holsbeeck1

A 55-year-old man presented to his general practitioner with sudden local discomfort in the left calf. His symptoms were atypical and vague. Subsequently, he was referred for diagnostic imaging. Ultrasound identified a well circumscribed nodular mass in the popliteal fossa with a diameter of approximately 25 mm and a heterogeneous, hypoechoic appearance (Fig. A). The origin of the mass was not entirely clear on US and subsequently a MRI study was performed. A hyperintense mass on T2weighted imaging (WI) was surrounded with a hypo-intense periD pheral rim. The lesion was in the popliteal fossa (Fig. B). Surrounded muscular edema was noted. On T1 WI this lesion showed low central signal intensity with a hyperintense peripheral rim. This rim further intensified following intravenous contrast administration (Fig. C). Sagittal images showed clear continuity of the mass with a thrombosed gastrocnemius vein (Fig. D). The diagnosis of thrombosed popliteal aneurysm of a gastrocnemius vein was made. Further imaging with CT following intravenous contrast administration showed extension of the thrombus in the popliteal vein and into the superficial femoral vein. The patient was treated by intravenous heparin and subsequently underwent surgery, which confirmed the diagnosis. During surgery, the aneurysm was resected and the proximal and distal vein were ligated (Fig. E). A follow-up duplex US the next day showed normal flow in the popliteal vein. The patient was dismissed from the hospital, and placed on warfarin therapy for 3 months. Comment

Venous aneurysms are rare. These lesions are of little clinical significance unless they thrombose. Our case describes a rather atypical popliteal venous aneurysm, arising from a gastrocnemius muscle vein. Normally these aneurysms originate from the popliteal vein itself. The first report of a popliteal venous aneurysm dates back 1968 and since then more than 150 cases have been reported. The last ten years an increase of the number of reported cases has been noted, probably due to better and easier access to imaging. Most venous aneurysms present as incidental findings. Occasionally, the lesion presents as a small mass or as in our case, presents with local symptoms. Only rarely, complications present as pulmonary embolism. The pathogenesis of a venous aneurysm is uncertain. Venous aneurysms probably result from weakness of the venous wall due to inflammation, trauma, degenerative changes, infection, hemodynamic changes or as a consequence of a congenital anomaly. According to the article by Gabrielli et al , surgical repair is mandatory in symptomatic patients and recommended in asymptomatic patients, because anticoagulation can be ineffective in preventing pulmonary embolism (1). Possible complications are local tibial nerve compression, (recurrent) pulmonary embolism, deep venous thrombosis and even death. From an imaging perspective, the mass should be distinguished from popliteal artery aneurysm or pseudoaneurysm, tibiofibular cyst, Bakerâ&#x20AC;&#x2122;s cyst, traumatic popliteal arteriovenous fistula, soft-tissue tumor, peripheral nerve tumor or venous varicosity. The diagnostic method of choice is venous duplex scan and standard ultrasonography. MRI or contrast enhanced CT can be useful before surgery to rule out other pathology and to assess venous anatomy and extent of thrombosis. Reference 1.

Gabrielli R., Vitale S., Costanzo A., Carra A.: Our experience of popliteal vein aneurysm. Interact Cardiovasc Thorac Surg, 2010, 11: 835-837.

1. Department of Radiology, 2. Department of Vascular Surgery, Stedelijk Ziekenhuis Roeselare, Belgium.

image-battal-tasar-_Opmaak 1 16/02/12 12:54 Pagina 1

JBRâ&#x20AC;&#x201C;BTR, 2012, 95: 37.

IMAGES IN CLINICAL RADIOLOGY Aberrant retropharyngeal internal carotid artery associated with retropharyngeal abscess: determination of a safe drainage zone with computed tomography B. Battal1, B. Karaman1, S. Akay1, M. Tasar1

A 60-year-old woman visited the Ear Nose and Throat (ENT) department of our hospital complaining of sore throat that persisted since 2 weeks. She was prescribed oral antibiotherapy, during which she experienced dysphagia and increasing fever. After physical reexamination and endoscopic study, a retropharyngeal abscess was detected and was thought to be due to the bulging of the right posterior pharyngeal wall that has smooth and intact mucosa. Thus, the patient was forwarded to the radiology department for enhanced neck computed tomography (CT) to confirm the diagnosis. On the multidetector neck CT scan, we observed an abscess formation (thick white arrow) with peripheral contrast enhancement, and enlargement of the right retropharyngeal space was also seen (Fig. A). In addition, the CT images also displayed an aberrant course of the right internal carotid artery (ICA) (thin white arrows) that was very close to the right posteromedial wall of the pharynx and contributed to the enlargement of the retropharyngeal space (Fig. B, C). After obtaining detailed anatomical information from the CT examination, abscess drainage from the right superolateral wall of the nasopharynx was performed at the ENT department. No hemorrhagic or other complications were encountered. On control CT examination performed 20 days after drainage, no abscess formation was seen (Fig. D). Comment Aberrant retropharyngeal ICA, also described as ICA transposition or tortuous ICA is a rare cause of retropharyngeal space pulsatile pseudotumor and retropharyngeal space enlargement. Medial dislocation of the ICA into the retropharyngeal space at the level of the posterior pharynx is one of the more commonly described carotid anomalies in the medical literature, and its typical presentation on physical examination is a pulsating submucosal mass along the posterior wall of the pharynx. In elderly patients, the incidence of aberrant course of the ICA has been estimated to be as high as 2%. Symptomatic patients may present with complaints of dysphagia, abnormal voice, or foreign body sensation at the posterior end of the pharynx. Occasionally, this anomaly may be misdiagnosed as a unilateral tonsillitis, peritonsillar abscess, or parapharyngeal neoplasm. Identifying the aberrant course of the ICA is important in surgical and interventional procedures for retropharyngeal spaces. During surgical, interventional procedures and anesthesia-related actions, awareness of the aberrant course of the ICA may prevent vascular damage and massive hemorrhage. It is especially dangerous when the artery comes in contact the tonsillar fossa or the posterior wall of the pharynx, as in our patient. Such incidents may result in massive hemorrhage during tonsillectomy, uvulo-palato-pharyngoplasty, or incision and drainage of a peritonsillar abscess. Detection of this rare aberrant course of the ICA is very important, especially in patients who are candidates for surgeries of the pharynx or drainage of retropharyngeal abscesses. Imaging studies can show and confirm the aberrant course of the ICA, thereby reducing the risk of hemorrhagic complications.

1. Department of Radiology, Gulhane Military Medical School, Ankara, Turkey.

image-battal-karaman-_Opmaak 1 23/02/12 09:15 Pagina 1

JBRâ&#x20AC;&#x201C;BTR, 2012, 95: 38.

IMAGES IN CLINICAL RADIOLOGY The giant seminal vesicle cyst: magnetic resonance imaging findings B. Battal1, V. Akgun2, B. Karaman1 A 73-year-old man suffering from supra-pubic pain, dysuria and urinary retention for 3 months was slightly hypertensive, normoglycaemic, with normal renal biochemical parameters. In digital rectal examination prostate was slightly enlarged, but a cystic mass was palpable arising from the upper boarder of the prostate. He was examined by pelvic magnetic resonance imaging (MRI) with a preliminary diagnosis of pelvic mass or abscess. MRI examination revealed a homogeneous, well demarcated giant cystic mass (arrows) 12 x 8 x 6 cm in size at the posterior of the urinary bladder and superior of the prostate and seminal vesicles (A). The cyst was displacing the rectum, prostate and the urinary bladder. The cystic mass content was slightly hyperintense on T1-weighted images (C) and significantly hyperintense on T2-weighted images when compared to muscle tissue (B). The cyst was associated with seminal vesicles and MR signal features of the cyst content were similar with right seminal vesicle (C). The left seminal vesicle content was hypointense on T1- and hyperintense on T2-weighted images (Fig. B, C). As the patient was not suitable for surgery because of advanced age and poor general condition, diagnostic and therapeutic percutaneous cyst aspiration was performed. While the bladder was completely empty, an 18-gauge needle was passed percutaneously into the cyst, and viscous brown liquid was aspirated (C). The aspirated material was examined histopathologically and the diagnosis of the seminal vesicle cyst was confirmed by the presence of degenerating spermatids.

Comment The seminal vesicle cyst is one of the rarely encountered urological problems, but by ultimate imaging techniques, such as multi detector computed tomography and MRI, the diagnosis of the seminal vesicle cysts has became more frequent. Seminal vesicle cyst may be associated with ipsilateral renal agenesis. Although, the seminal vesicle cysts smaller than 5 cm in diameter are usually asymptomatic, those larger than 12 cm which are also named as giant seminal vesicle cysts, are frequently associated with bladder or colon obstruction. The clinical presentation may be either dysuria or actual (or simulated) infection of the epididymis, prostate, or the cyst itself. In most of the cases, partial or complete obstruction of the ejaculatory duct leading to retention of seminal fluid containing spermatozoa is present. Seminal vesicle cysts should be differentiated from other deep pelvic cysts arising from the genital tract, hydronephrotic pelvic kidneys, abscesses, and benign or malignant tumors of bladder, rectum, sacrum, and lymph nodes by imaging modalities such as urethrography, ultrasonography, computed tomography, and MRI. Complications such as spontaneous rupture of the cyst into the rectum or infection leading to seminal vesicle abscess can be seen. The severity of symptoms which is usually correlated with size of the cyst determines the choice of treatment. Cyst aspiration, transurethral deroofing of the cyst, laparoscopic excision of the cyst are some of the recommended choices but most of the cases with large cysts have been treated by open excision. In diagnosis, revealing of its internal structure, demonstration of its association with the seminal vesicle, revealing the relationship with adjacent structures such as the rectum, urinary bladder and prostate, determination of the treatment method, and post-treatment follow-up of the seminal vesicle cyst, MRI is a definitive imaging method.

C Reference 1.

Pal D.K., Bag A.K., Sarkar S.: Giant seminal vesicle cyst with ipsilateral hypoplastic kidney: Report of a case with review of literature. Indian J Urol, 2006, 22: 64-65.

1. Department of Radiology, Gulhane Military Medical School, Ankara, Turkey, 2. Department of Radiology, Golcuk Military Hospital, Ankara, Turkey.

abstr papers(19/11/11)_Opmaak 1 23/02/12 09:17 Pagina 39

JBR–BTR, 2011, 94: 39-44.

ABSTRACTS OF PAPERS presented at the Annual Symposium of the SRBR - KBVR, on November 19, 2011 SAMENVATTINGEN VAN DE UITEENZETTINGEN voorgesteld aan het Jaarlijks Symposium van de KBVR, op 19 november 2011 RESUMES DES COMMUNICATIONS présentées lors du Symposium Annuel de la SRBR, le 19 novembre 2011 Percutaneous pedicle screw implantation: en route to fully robotic intraoperative 2D/3D fluoroscopy Ch. Raftopoulos1, F. Waterkeyn1, E. Fomekong1, Th. Duprez2 Introduction When dealing with chronic low back pain refractory to medical treatments (LBPR), spine stabilization can be a very effective option. This surgical strategy requires most of the time implantation of pedicle screws (1, 5) which can be performed through either a large open posterior approach, or tubular approaches (minimal open) or even percutaneously (minimally invasive percutaneous) (2, 3, 6). A precise placement of these screws is paramount in particular to avoid any additional nerve root lesion. Working percutaneously reduces the aggression on the patient’s muscular system but increases the difficulty of being intrapedicular. Percutaneous surgery requires improved intraoperative imaging quality control. Our use of percutaneously placed pedicle screws (PPS), led us to test different intraoperative imaging systems reaching a climax of efficiency with the robotic multi-axis 2D/3D fluoroscopy Artis Zeego of Siemens. We report our experience using this system for PPS placement in the treatment of LBPR.

Fig. 1

Fig. 2

Population and method Our first 24 patients showed a mean age of 59 years. One hundred and six PPS were implanted using the Viper 2 fixation system (DePuy Spine, Johnson & Johnson, Arlington, USA) associated when necessary with a TLIF (transforaminal lumbar interbody fusion) procedure (84%) or a posterior lumbar fusion procedure. For complex scoliotic cases, we introduced the data of a preopera-

tive CT into our Dextroscope system (Volumes Interactions, Bracco, Singapore) (4). This system gives surgeons a preoperative virtual 3D view of the treated lumbar spine and helps the surgeon to better plan the surgical procedure. The intraoperative imaging system is an Artis Zeego characterized by the combination of robotic multiaxis C-arm fluoroscopy and a translucent robotic table (Fig. 1). The different memorized positions can

be repeated as often as necessary, and the quality of the 3D sequences is near to a CT. The surgical process, using the Viper system (DePuy Spine, Johnson & Johnson, Arlington, USA) is characterized by nine consecutive steps described elsewhere (Raftopoulos et al, Adv Tech Stand Neurosurg, in press). To check the PPS accuracy using the Zeego, each patient had a control CT postoperatively. To quantify the

abstr papers(19/11/11)_Opmaak 1 16/02/12 13:12 Pagina 40

severity of the PPS pedicle breach, we used a scale of four grades (7): Grade 0, no pedicle breach; grade I, a breach less than two mm; grade II, a breach between two and four mm and, grade III, a breach of more than four mm. Results One hundred and six consecutive PPS were implanted. Pedicle breaches were checked at the two main stages of the surgical procedure (Fig. 2). The rate of guide-wire pedicle breaches was very low (5.7%). All the misplaced wires were corrected. The rate of PPS pedicle breach disclosed by the i3DF was 11.4%. Only five PPS, were relocated. The postoperative CTs disclosed a percentage of PPS pedicle breaches of 4.7%, with all the breaching PPS of grade I except for one grade II and two grade III (lateral breaches, asymptomatic). This series was characterised by the absence of surgical nerve root injuries, surgical revision and other complications.

JBR–BTR, 2012, 95 (1) dimensional fluoroscopy for detecting pedicle screw violations in the thoracic and lumbar spine. Neurosurgery, 2004, 54: 1138-1142.

Department of 1. Neurosurgery and 2. Neuroradiology, Clinique Universitaire St-Luc, Brussels, Université catholique de Louvain, Louvain-la-Neuve, Belgium MR imaging of the spinal bone marrow : age patterns and normal variants B. Vande Berg1 1. Dpt of Medical Imaging, UCL Cliniques Saint Luc, Brussels, Belgium. Imaging of the degenerative lumbar spine : a pattern-bases approach P. Parizel1 1. Dpt of Medical Imaging, UI Antwerpen, Antwerp, Belgium.

Conclusion Placing PPS under control of i3DF images allows to significantly reducing the rate of PPS pedicle breach (4.7% instead of 14.2%) with a most stable osteosynthesis possible and a minimal risk of complication. References 1. Anjarwalla N.K., Morcom R.K., Fraser R.D.: Supplementary stabilization with anterior lumbar intervertebral fusion - a radiologic review. Spine (Phila Pa 1976 ), 2006, 31: 12811287. 2. Foley K.T., Gupta S.K.: Percutaneous pedicle screw fixation of the lumbar spine: preliminary clinical results. J Neurosurg, 2002, 97: 7-12. 3. Raftopoulos C.: Spine neurosurgery in Belgium. World Neurosurgery, 2011, 74: 430-431. 4. Raftopoulos C., Vaz G.: Surgical indications and techniques for failed coiled aneurysms. Adv Tech Stand Neurosurg, 2011, 36: 199-226. 5. Rivet D.J., Jeck D., Brennan J., Epstein A., Lauryssen C.: Clinical outcomes and complications associated with pedicle screw fixation-augmented lumbar interbody fusion. J Neurosurg Spine, 2004, 1: 261-266. 6. Schwender J.D., Holly L.T., Rouben D.P., Foley K.T: Minimally invasive transforaminal lumbar interbody fusion (TLIF): technical feasibility and initial results. J Spinal Disord Tech, 2005, 18 Suppl: S1-S6, 2005. 7. Wang M.Y., Kim K.A., Liu CY., Kim P., Apuzzo ML: Reliability of three-

Spinal dysraphisms A. Rossi1 Learning objectives: To identify the neuroradiological appearance of spinal dysraphisms, to correlate such features with a corresponding embryologic derangement, and to be able to use a clinical-neuroradiological classification scheme in the everyday clinical practice. Embryology and classification: Spinal cord development occurs through three consecutive periods: (i) gastrulation (2nd gestational week): the embryonic disk is converted from a bilaminar into a trilaminar arrangement, with formation of the intervening mesoderm; the notochord is laid down along the midline, identifying the craniocaudal embryonic axis; (ii) primary neurulation (18th-27th day): under the induction of the notochord, the midline ectoderm specializes into neural ectoderm. The initially flat neural plate progressively bends and folds until it fuses in the midline to form the neural tube. The primary neural tube produces the uppermost 9/10 of spinal cord; (iii) secondary neurulation (28th-48th day): a secondary neural tube is laid down caudad to the termination of the primary neural tube. Retrogressive differentiation of the secondary neural tube results in the tip of the conus medullaris and filum terminale.

Defects in one of these three embryological steps produce spinal dysraphisms, characterized by anomalous differentiation and fusion of dorsal midline structures. Spinal dysraphisms may be categorized clinically in two subsets: open and closed spinal dysraphisms. Open spinal dysraphisms: In open spinal dysraphisms (OSD) the placode (non-neurulated neural tissue) is exposed to the environment through a cutaneous defect along the child’s back. OSD include myelomeningocele, myelocele, hemimyelomeningocele and hemimyelocele, and are always associated with a Chiari II malformation. Myelomeningocele is by far the most common of these forms; the placode protrudes through a posterior defect and is elevated above the skin surface due to concurrent dilatation of the subarachnoid spaces. Closed spinal dysraphisms: Closed spinal dysraphisms (CSD) are covered by intact skin, although cutaneous stigmata usually belie their presence. Two subsets may be identified based on whether a subcutaneous mass is present. CSD with tumefaction comprise lipomas with dural defect (lipomyelocele and lipomyelomeningocele), meningocele, and myelocystocele. Lipomas with dural defect are more common; they are differentiated with one another based on the position of the placodelipoma interface, that lies within the spinal canal in lipomyelocele, and outside the spinal canal (ie, into a meningocele) in lipomyelomeningocele. CSD without tumefaction comprise complex dysraphic states (ranging from complete dorsal enteric fistula to neurenteric cysts, diastematomyelia, dermal sinuses, caudal agenesis, and spinal segmental dysgenesis), bony spina bifida, tight filum terminale, filar and intradural lipomas, and persisting terminal ventricle. The most complicated forms (complex dysraphic states), including diastematomyelia, caudal regression, and segmental spinal dysgenesis) are related to faulty gastrulation. Diastematomyelia (literally, split cord) is caused by failure of midline notochordal integration, resulting into two heminotochords that induce two separate hemineural plates. Caudal agenesis and segmental spinal dysgenesis are related to defective notochordal formation, characterized by absence or hypoplasia of a segment of the notochord, in turn resulting into absence or hypoplasia of a corresponding segment of the spinal cord.

abstr papers(19/11/11)_Opmaak 1 16/02/12 13:12 Pagina 41

ABSTRACTS OF PAPERS

Reference 1.

Rossi A., Gandolfo C., Morana G., Piatelli G., Ravegnani M., Consales A., Pavanello M., Cama A., TortoriDonati P.: Current classification and imaging of congenital spinal abnormalities. Semin Roentgenol, 2006, 41: 250-273.

1. Department of Pediatric Neuroradiology, G. Gaslini Children’s Research Hospital, Genova, Italy.

malignancy, acute or repetitive trauma and some pain characteristics. Those that should alert the physician are severe, progressive or constant pain, even during the night, pain that interferes with activity, pain with dysesthesia or pain that radiates suggesting nerve root compression. In young children, clinical presentation can be poor such as refusal to walk and irritability (13). Physical examination

Imaging evaluation of the child with back pain C. Christophe, S. Aouni, N. Damry, S. Pather, F. Ziereisen1 Back pain is quite uncommon in children under 10 years of age but is frequently reported in pre-adolescents and adolescents. The vast majority of back pains is benign or has no definitive cause. It can however reveal relevant congenital or acquired pathologies, such as infectious and neoplastic processes (1-4). Epidemiology Although back pain is an uncommon complaint in young children, the cumulative prevalence of nonspecific musculoskeletal back pain appears high in pre-adolescents and adolescents (5-10). At the age of 18 this prevalence approaches 50 % in girls and 20% in boys (8, 10). Contributing factors include sedentary, practice of high level sports with repeated subclinical traumas, female gender, family history of back pain, anxiety, psychosocial distress and maybe individual susceptibility. Most cases of back pain are mild and non-disabling. Except in a traumatic context, they constitute rarely the motive of visit to the emergency department or to the specialized rheumatic or orthopaedic consultations. If not taken into account, they can evolve to chronicity with fluctuating symptoms (6-8, 11). Careful medical history and physical examination are mandatory to differentiate a benign back pain from symptoms related to a serious underlying condition (4, 12). Medical history Medical history looks for « red flags » suggesting the presence of specific patho-physiologic mechanism such as young age of the child, evidence of neurologic dysfunction, past medical history of infection,

Physical examination should track signs of systemic disease or other underlying condition such as fever, unexplained weight loss, neurologic abnormality (eg, abnormal reflexes, bladder or bowel dysfunction, paraplegia, cauda equina syndrome), limitation of motion, tenderness and postural shift of the trunk (scoliosis, kyphosis, torticollis…). Severe back pain should not indeed be attributed to scoliosis without excluding other causes, especially when the scoliosis is of recent onset, of rapid progress, with left thoracic curve and/or an abnormal neurological examination … Complementary evaluation Only if medical history and physical examination reveal « red flags » for a specific cause or a serious underlying condition, additional diagnostic procedures are indicated. Laboratory evaluation looks for inflammatory or infectious process (eg complete blood count, erythrocyte sedimentation rate, blood culture) and radiologic evaluation is performed, directed by the suspected disease (14). Imaging To date, there have been few prospective studies on diagnostic modalities in pediatric back pain. Plain radiographs of the spine with antero-posterior and lateral views are usually the initial imaging study in prolonged localized pain to search for congenital or acquired bony anomalies but their sensitivity and specificity are often low. Oblique views may be required for the detection of spondylolysis. Bone scan (scintigraphy) is useful in cases of normal plain radiographs. It has a localiser value if there is an hypercaptation, to orientate multiplanar imaging as computed tomography (CT) and Magnetic resonance imaging (MRI) (5).

MRI is the modality of choice in emergency if medullar compression or cauda equina syndrome are suspected. Moreover, MRI becomes more frequently the second imaging modality after plain X-ray films to document non-bony or even bony processes in children. MRI provides a good visualization of the vertebral column (vertebral body and posterior elements) and disc but also the dural sac, the spinal cord, the cauda equina and the paraspinal soft tissues. Imaging of the entire spine may be indicated in young children in whom localization of the abnormal process is often quite difficult. A first simplified MRI approach may include sagittal T1-weighted and T2-weighted with and without fat sat images (STIR) with preliminary knowledge of age-related red marrow replacement by yellow marrow. Total-body MRI may be useful to identify and precise the extension of diseases with multifocal characters such as histiocytosis, hemopathies, recurrent multifocal osteomyelitis. Computed tomography (CT) scan focalized on the lesion can best characterize the bone involvement (osteolysis, osteosclerosis, mixed form …) and states precisely its extension into the body of vertebrae or into its posterior arch. CT can moreover guide percutaneous vertebral biopsy for histological samples. Etiologies There is a wide spectrum of diseases causing back pain in children. It depends upon the referral care clinician and on the studied population. Most back pain seem to be related to benign or nonspecific musculoskeletal diseases whereas the remainder can be attributed to specific causes divided among musculoskeletal, infectious, tumoral and miscellaneous causes (1-4, 12, 14). Musculoskeletal – Aspecific microtraumatic musculoskeletal disease – Spondylolysis and spondylolisthesis – Degenerative disc diseases such as Schmorl’s nodes, Scheuermann kyphosis – Disc herniation – Disc calcification – Idiopathic juvenile osteoporosis – Vaso-occlusive crisis in sickle cell disease – Ankylosing spondylitis – Arthritis of inflammatory bowel diseases…

abstr papers(19/11/11)_Opmaak 1 16/02/12 13:12 Pagina 42

Infectious – – – –

Discitis and spondylodiscitis Acute osteomyelitis Pott’s disease Chronic osteomyelitis, chronic recurrent multifocal osteomyelitis – Epidural abscess – Nonspinal infections (septic sacroiliitis, pyomyositis (psoas), retropharyngeal abscess, pyelonephritis, pelvic inflammatory disease, pancreatitis…)… Tumoral Vertebral Benign: – Eosinophilic granuloma, chordoma, hemangioma…(mostly in the vertebral body), – Osteoid osteoma, osteoblastoma, aneurysmal bone cyst…(mostly in the spinous process) Malignant: – Metastasis – Leukemia, lymphoma – Ewing sarcoma, osteosarcoma… Intramedullary: – Astrocytoma – Ependymoma – Oligodendroglioma… Extradural: – Chloroma – Neuroblastoma with intraspinal invasion Intradural – Subarachnoidal metastases – Dermoid cyst, neuroenteric cyst – Lipoma, – Neurofibroma in neurofibromatosis type 1… Miscellaneous – Spinal and medullar malformations (diastematomyelia, Chiari 1, tethered cord …) – Epidural hematoma – Nephrolithiasis, ureteropelvic junction obstruction – Chronic pain syndromes

JBR–BTR, 2012, 95 (1) 6. Jeffries L.J., Milanese S.F., GrimmerSomers K.A.: Epidemiology of adolescent spinal pain, a systematic overview of the research literature. Spine (Phila Pa 1976), 2007, 32: 26302637. 7. Jones G.T., Macfarlane G.J.: Predicting persistent low back pain in school children: a prospective cohort study. Arthritis Rheum, 2009, 61: 1359-1366. 8. Leboeuf-Yde C., Kyvik K.O.: At what age does low back pain become a common problem? A study of 29.424 individuals aged 12-41 years. Spine, 1998, 23: 228-234. 9. Masieron S., Carraro E., Celia A., Sarto D., Ermani M.: Prevalence of nonspecific low back pain in schoolchildren aged between 13 and 15 years. Acta Paediatr, 2008, 97: 212216. 10. Pellisé F., Balagué F., Rajmil L., Cedraschi C., Aguirre M., Fontecha C.G., et al.: Prevalence of low back pain and its effect on healthrelated quality of life in adolescents. Arch Pediatr Adolesc Med, 2009, 163: 65-71. 11. Hakala P., Rimpelä A., Salmine J.J., et al.: Back, neck, and shoulder pain in Finnish adolescents: national cross sectional surveys. BMJ, 2002, 325: 743. 12. Selbst S.M., Lavelle J.M., Soyupak S.K., Markowitz R.I.: Back pain in children who present to the emergency department. Clin Pediatr (Phila), 1999, 38: 401-406. 13. Karabouta Z., Bisbinas I., Davidson A., Goldsworthy L.L.: Discitis in toddlers: a case series and review. Acta Paediatr, 2005, 94: 15161518. 14. Khoury N.J., Hourani M.H., Arabi M.M., Abi-Fakher F., Haddad M.C.: Imaging of back pain in children and adolescents. Curr Probl Diagn Radiol, 2006, 35: 224-244.

1. Dept. of Radiology, Hôpital Universitaire des Enfants Reine Fabiola, Bruxelles, Belgique.

Diagnostic work up in the setting of back pain and sciatica L. Divano1 Low-back pain and sciatica represent a major problem in public health and have a significant social and economic impact (1). Up to 80% of the population have such an experience at least once in a lifetime (2). In case of an acute onset of lowback pain without neurological signs and without “red flags” background, there is no need for imaging as 90% of those cases resolve spontaneously within one month. After six weeks of medical treatment, the imaging will be necessary only in the case of poor outcome or worsening of the symptoms. The imaging is also indicated if either manipulation therapy or local drug infiltration are considered (3). Emergency Imaging is indicated in the setting of malignancy, possible infection, neurologic deficit, corticosteroid therapy and osteoporotic fractures (‘red flags’). Choice of imaging modalities Plain films The plain films are generally performed in the work up of trauma especially in cervical spine. However, even major dislocation can be missed and generally only minor injury are referred for plain films. The plain films are still used in the evaluation of static abnormalities, especially in young patients (< 20 years) and in older patients (> 55 years) namely because of the high frequency of osteoporotic fractures (Fig. 1). Also keep in mind, the plain films can be falsely reassuring and are

References 1. Bhatia N.N., Chow., G., Timon S.J., Watts H.G.: Diagnostic modalities for the evaluation of pediatric back pain: a prospective study. J Pediatr Orthop, 2008, 28: 230-233. 2. Combs J.A., Caskey P.M.: Back pain in children and adolescents: a retrospective review of 648 patients. South Med J, 1997, 90: 789-792. 3. Feldman D.S., Hedden D.M., Wright J.G.: The use of bone scan to investigate back pain in children and adolescents. J Pediatr Orthop, 2000, 20: 790-795. 4. Kimn H.J., Green D.W. Adolescent back pain. Curr Opin Pediatr, 2008, 20 : 37-45. 5. Hollingworth P.: Back pain in children. Br J Rheumatol, 1996, 35: 1022-1028.

Plain Films: Indications •

Recent trauma

•

Young patients (< 20 y) Static abnormalities, spondylolysis-listhesis, inflammatory and rheumatismal disases (spondylarthritis, late diagnosis)

•

Older patients (> 55 y) Osteoporotic fractures Fig. 1. — Plain films : indications

abstr papers(19/11/11)_Opmaak 1 16/02/12 13:12 Pagina 43

ABSTRACTS OF PAPERS

43 3. Bossard P., Zeitoun F. et Stérin P.: Imagerie de la lombalgie. La lombalgie en 2007 : aspects pratiques XXI EMC journée de l’ANMSR, 8juin 2007.

CT-MR Indications •

•

MRI

– – – – –

trauma (disk anomalies) osteoarthritis (vertebral fractures) canal stenosis

– – – – –

spinal cord lesions tumors / epidural involvement Spondylodiskitis operated disk hernia / expelled fragment canal stenosis

1. Dpt Imagerie Médicale, CHU Brugmann, Bruxelles, Belgium.

Imaging trauma to the spinal cord R. Achten1

Fig. 2. — CT and MR indications

1. Dpt of Radiology, UZ Gent, Ghent, Belgium. Low-Back Pain (LBP) Common LBP > 6 weeks

Specific LBP (red flags)

Traumatic LBP or onset of LBP < 20 y and > 55 y Plain films

MRI CT Fig. 3. — Choice of imaging procedure according to suspected pathology

generally not indicated in the age range between 20 and 55 years. CT scanner Spiral CT with multiplanar reconstructions is the first step modality in the setting of spinal trauma and should be always performed in high energy injury even without neurologic deficit. CT is also superior to MR in the evaluation of bony impingement especially in case of degenerative osteoarthritis and foraminal stenosis. CT scanner, particularly due to its high spatial resolution, allows a fine and precise study of such diseases. MRI When soft tissues pathology or disco-vertebral impingement are suspected, MRI is from far superior to CT. In case of lumbar disk extrusion, CT remains reliable in the most cases. However, when arthrosis, spinal canal stenosis or lack of epidural fat reduce the soft tissues interface, MRI should be advocated. The suspicion of disk recurrence, intradural pathology, infection or neoplasm require an MRI study before and after iv Gd injection (Fig. 2).

Conclusions In case of low-back pain and sciatica the need for imaging is largely dependent on the clinical information. In case of an acute onset of lowback pain without neurological signs and without “red flags” background, generally there is no need for imaging. After six weeks of medical treatment, the imaging will be necessary only in the case of poor outcome. The emergency imaging is indicated in the setting of malignancy, possible infection, neurologic deficit, corticosteroid therapy and osteoporotic fractures. The choice of imaging is dependent on the suspected pathology (Fig. 3). Keep in mind that conventional radiology has limited value even in case of traumatic lesions. References 1.

Carey T.S., Evans A.T., Hadler M.N., et al.: Acute severe low-back pain. A population based study of prevalence and care-seeking. Spine, 1996, 21: 339-344. 2. Centre Fédéral d’Expertise (KCE). Report vol 48B. Lombalgies chroniques, 2006.

Correlations between clinical findings and imaging: What’s significant and what's not? T. Stadnik1 The role of the radiologist should not be limited to description of abnormal findings only. The final report should also conclude which findings may be related to the clinical complaints if any and suggest additional imaging protocol if necessary. This imply the knowledge of imaging guidelines for a given clinical situation, of normal variants which may simulate disease and of abnormal imaging findings which are usually without clear association with the clinical symptoms. In the setting of spine trauma without neurological signs the conventional xr is still frequently performed but may be falsely reassuring and the false negative findings are frequent. A multidetector CT should be preferred in case of diagnostic doubt. In case of spine trauma with neurological signs the scanner should be performed as soon as possible followed by MR especially in case of discordance between CT and clinical findings. The normal variants or congenital anomaly may occasionally simulate disease. The partial butterfly deformity may by mistake for compression fracture. The vascular channel is normally easy to differentiate from fracture because of corticalisation and typical anatomic location. On CT, the conjoined nerve root anomaly may be mistaken for foraminal mass or disc herniation (Fig. 1). The absent cervical pedicle syndrome (Fig. 2) is frequently misdiagnosed as post-traumatic interapofyseal luxation what may result in inappropriate therapy including aggressive traction or surgery.

abstr papers(19/11/11)_Opmaak 1 16/02/12 13:12 Pagina 44

JBR–BTR, 2012, 95 (1)

Fig. 1. — On CT, the conjoined nerve root anomaly may be mistaken for foraminal mass or disc herniation. The MRI is the modality of choice to confirm this anomaly.

The bulging disks, annular enhancing tears and protrusions are frequently found in asymptomatic population and the relation to the symptoms is frequently questionable. In the contrary, the extrusions are only exceptionally found in normal population and generally there’s a good correlation with the lumbar pain and/or sciatica. In the setting of spinal stenosis the bony measurements are of little value and the significant stenosis should be considered in case of disappearance of CSF signal and tortuosities of the compressed nerve roots. The foraminal impingement may be considered only in case of fat disappearance and congruent clinical findings. In case of protrusion only clear mechanical compression/displacement of the nerve root should be

Fig. 2. — The absent cervical pedicle syndrome is frequently misdiagnosed as post-traumatic interapofyseal luxation what may result in inappropriate therapy including aggressive traction or surgery.

correlated with congruent symptoms. If not, perfiral nerve involvement should be considered and additional imaging may be necessary in order to exclude peripheral neuropathy, tumour or impingement. Conclusion: The radiologist should be able to conclude which findings may be related to the clinical complaints if any and suggest additional imaging protocol if necessary. This implies the knowledge of normal variants, which may simulate disease, and of abnormal imaging findings, which are without clear association with the clinical symptoms. The normal variants or congenital anomaly may occasionally simulate disease. The wrong diagnosis may result in inappropriate therapy and serious medico-legal actions.

The bulging disks, annular enhancing tears and protrusions are frequently found in asymptomatic population and the relation to the symptoms is questionable. References 1.

Stadnik T.W., Lee R.R., Coen H.L., Neirynck E.C., Buisseret T.S., Osteaux M.J.: Annular tears and disk herniation: prevalence and contrast enhancement on MR images in the absence of low back pain or sciatica. Radiology, 1998, 206: 49-55. 2. Ernst C.W., Stadnik T.W., Peeters E., Breucq C., Osteaux M.J.: Prevalence of annular tears and disc herniations on MR images of the cervical spine in symptom free volunteers. Eur J Radiol, 2005, 55: 409-414. Epub 2005 Jan 1.

1. Dpt of Radiology, Universitair Ziekenhuis Vrije Universiteit Brussel, Brussels, Belgium.

22-proceedings ESHNR_Opmaak 1 16/02/12 14:22 Pagina 45

JBR–BTR, 2012, 95: 45-58.

PROCEEDINGS OF THE 24TH ANNUAL MEETING AND REFRESHER COURSE OF THE EUROPEAN SOCIETY OF HEAD AND NECK RADIOLOGY (ESHNR), BRUGGE, 08-10.09.2011 PROFERRED PAPERS NEW TECHNICAL POSSIBILITIES IN HEAD & NECK IMAGING: HOW DOES IT WORK? Latest technical advances in CT for head & neck imaging C. Argaud1 Head and Neck imaging presents a combination of challenges related to lesion and fine anatomy visualization and characterization and dose management. Lesion visualization has been improved recently by high definition scanning techniques, which consists of increasing substantially the number of samples acquired throughout the rotation to deliver a very high spatial resolution at all acquisition speeds. Primary application of such techniques has been temporal bone imaging and also neck imaging. These high definition techniques rely on a new detector material, which is 100 times faster than conventional detectors, and allows to more than double the number of projections throughout the rotation and reach a very high resolution without any penalty on the dose delivered to the patient. Lesion characterization in soft tissues has always been a challenge in conventional CT, especially for small lesions. Additional examinations may be required to verify the diagnosis, adding time and cost to the patient’s diagnostic pathway. Gemstone Spectral Imaging (GSI) is a novel, dual energy acquisition that improves the diagnostic power of CT to characterize soft tissue(s). This is achieved by transforming the CT attenuation data into various material densities. The spectral properties of iodine and water can be highlighted for the demonstration of lesion perfusion or to derive virtual non-contrast images from a contrast enhanced examination. The additional information provided by the GSI acquisition enables an improved assessment of lesion structure and perfusion. This has led to a significant breakthrough in the diagnostic power of CT for the characterization of lymph nodes, hemorrhagic lesions and tumors. Mono chromatic KeV images can be generated from the GSI acquisition. These monochromatic data sets are used to improve image quality by reducing artifacts and increasing lesion conspicuity. The monochromatic image depicts how the imaged object would look if the X-ray source produced X-ray photons at a single energy level. Artifacts related to metal implants, coils and clips can be drastically reduced, which makes a quick and easy assessment of vessel patency possible around neuro clips, or allows to better follow-up

patients with spine instrumentation for spinal canal visualization. Lesion characterization can be also improved using large coverage dynamic scanning techniques to study brain perfusion or lymph nodes perfusion pattern. This has led to improvements of thyroid solitary nodes characterization which was well correlated with 99mTc04 thyroid planar imaging. Radiation dose is a major concern in computed tomography (CT) imaging, especially for sensitive organs or populations. Dose management rules have been rewritten by the introduction of iterative reconstruction techniques into the clinical practice. Iterative reconstruction works on the basis of estimating a solution, and then refining it by several iterations. The process of refining consists of increasing the accuracy of the initial computation by modeling the signal generation process. The Adaptative Statistical Iterative Reconstruction (ASiR) from GE Healthcare has been the first iterative reconstruction method available in routine practice. It models noise root causes in the signal generation, refines the current estimate of the solution by modeling photon statistics and the scanned object, and thus subtracts noise in the final image. As a result, dose saving of 50% can be obtained while maintaining or even improving image quality. Some papers report that average dose for cervical spine examinations could be reduced to 1.1 mSv (Linsenmaier et al., ECR 2011) while preserving the image quality. New Model Based iterative Reconstruction techniques (MBiR) go further by modeling the CT system optics in the reconstruction process. As a result, spatial and contrast resolution can be improved while dose is much further reduced. MBiR improves head and neck lesion visualization while reducing the dose at unprecedented levels. Such reconstruction technique would allow scanning at equivalent doses of conventional XRay exams. Conclusion: high definition scanning mode, Gemstone Spectral Imaging and large coverage perfusion techniques have allowed significant improvements in lesion visualization and characterization by bringing function into CT imaging and pushing the limits of anatomy study. Iterative Reconstruction techniques have set a new paradigm in dose management while also improving image quality. 1. CT Advanced Applications Manager, Europe, Middle East & Africa, GE Healthcare.

Diffusion weighted MR Imaging: what you should know F. De Keyzer1 Diffusion-weighted magnetic resonance imaging (DWI) is based on the Brownian motion of water protons in the tissue, and as such provides information on the underlying cell density and structures. DWI aims to make images with different diffusion sensitization (indicated by the b-value, in s/mm2), and the differences between these images can be quantified using the apparent diffusion coefficient (ADC). While the theory of DWI is already known for more than two decades, the clinical applicability of this technique was low due to signal-to-noise and scan time limitations. Nowadays, it is being used for detection and characterization of tumoral tissues, and for followup after treatment in many areas of the body. However, the head and neck area remains one of the most difficult areas for DWI due to the high prevalence of airtissue boundaries, the overall low signal, and the movement and pulsation artefacts that are very common. In order to avoid or minimize these issues, a number of precautions and optimizations are required. In this talk, we will discuss the most important sequence parameters and patient handling effects, which should help in acquiring the best possible DWI images in the head and neck region. We will cover the trade-offs that exist when choosing b-values, matrix sizes, shim blocks and sequences. Knowing the advantages and repercussions of each of these choices should also allow better interpretation of the images and allow better comparison of own results with literature reports. 1. Department of Radiology, University Hospitals Leuven, Leuven, Belgium. New developments in ultrasound and interventional procedures L. Steyaert1 Ultrasound There is a tremendous technical evolution in the diagnostic imaging equipment in recent years, as you noticed from the CT and MRI topics. Ultrasound is the ‘little brother’ compared to the other modalities, but nevertheless a very high tech modality with a comparable technical complexity. The technique looks less impressive because of the smaller machines, and the ‘acceptance’ is more difficult because it is less ‘standardised, and the images are more difficult to read by the referring physician.

22-proceedings ESHNR_Opmaak 1 16/02/12 13:18 Pagina 46

46 The diagnostic result is also more operator dependent than with other modalities, but the diagnostic potential is very high in experienced hands. Ultrasound is not only an effective diagnostic method, but also economical. It is a relatively cheap method: machines, even the high end ones, are cheap compared to CT, cone beam CT, and MRI and even standard (digital) X-ray. They require less personnel, less preparation, no contrast media, and the power consumption (including often necessary cooling) is very low compared to other modalities. Less space is needed for installation, and the exams can be performed bedside if needed. It is not an old fashioned, but a very modern and ‘green’ technique, requiring not only less energy (CO2), but it has no adverse effects like Xray or maybe high energy magnetic fields or radio-waves, or potential short and long term side effect of Iodine or Gadolinium contrast media. Maybe we should consider more a eco-fiendly use of medicine in general… Ultrasound has a very good tissue contrast resolution without the use of contrast media. It is the first choice method for younger patients and for evaluation of a palpable lesion. It is the most frequently used method for guiding interventional procedures. Ultrasound is more and more used in the staging of lymph nodes, combined with FNA. Increased computing power in High end multichannel digital systems (> 512 digital send-receive channels are common) and the development of high frequency ceramic transducers have dramatically improved image quality. The transducer frequency we use is adapted to the field of interest; lower frequencies (e.g. for abdominal work) provide a deeper penetration but less spatial resolution. For superficial structures we use very high frequency probes, and nowadays frequencies over 10MHz are standard, and up to 18MHz is currently used in small parts. This improves the spatial resolution, and is capable of imaging fine detailed anatomic structures. The higher the frequency used the higher the spatial resolution, which is below 0.1 mm. The technique is specifically suitable for soft tissue exams. For superficial applications like in the ENT area, we need a detailed resolution. Areas of interest are salivary glands, thyroid and parathyroid, lymph nodes, vascular structures. Matrix probes, using multiple rows of crystals, can obtain a finer ultrasound beam enabling thinner slices, resulting in better contrast and lass partial volume effect due to slice thickness. Ultrasound is a tomographic technique providing us with a real time imaging in a infinite number of planes and orientations. Harmonic imaging, difficult to obtain with higher frequencies, is certainly one of the major improvements in recent years. It improves the contrast resolution and reduces artifacts, which are the greatest cause of poor image quality.

JBR–BTR, 2012, 95 (1) Spatial and frequency compounding techniques also increase image resolution and decrease artifacts and image noise. Color and Spectral Doppler techniques are very sensitive nowadays, and enable to study vascularisation of soft tissue lesions. Malignant tumors tend to be more vascularised than benign ones, and usually have a higher resistance flow than benign masses. These techniques also enables us to study the vascular structures in the neck; it is a standard technique for imaging carotids and asses stenosis. Elastography is one of the most recent ultrasound development. With this technique it is possible to measure the differences in tissue elasticity or stiffness; as it is well know by palpation, malignant lesions tend to be harder than benign ones, and appear larger because of stromal reaction . This differences can be visualized by elastography. Elastography seems to increase the specifity of mass lesions, and reduces the need for biopsy. Elastographic data can be obtained using tissue Doppler information, or through pixel by pixel correlation (strain imaging). A more recent method measures the (transversal) shear waves that are proportional to the tissue elasticity. High frame rates of over 20.000 images per second are needed for that. It is actually the only method capable of quantifying elasticity in kPa. Malignant tumors show significantly higher values than benign lesions. Ultrasound contrast is a specific product containing microspheres filled with gas; the characteristics of these micro bubbles (smaller than red blood cells) can be altered by the acoustic energy waves, and let us study vascularity of lesions, not only degree of vascularity but also the wash in-wash out characteristics of a lesion. 3D-imaging has become a standard in obstetric ultrasound but is also finding his way in superficial imaging thanks to dedicated 3D probes. From these 3D data sets virtual reconstructions and fly-thru techniques are developed to provide an endoscopic-like visualization. Endoscopic ultrasound techniques, like transoesophageal (TE) or endobronchial (EBUS) and even intravascular techniques with miniature probes have been developed. TE and EBUS can be used to stage mediastinal lymph nodes, and even provide possibilities for US guided cytological sampling. Using magnets and GPS like techniques, fusion imaging is also under development, giving the possibility to have real time comparison with CT or MRI data. Interventional techniques Image guided biopsy techniques are standard procedures nowadays. Surgical open biopsy seems a thing of the past due to the use of very accurate, minimally invasive techniques, and can be virtually considered as malpractice. One area where there has been a lot of evolution in biopsy techniques is breast. Some of

these techniques can also be applied in the field of ENT. Frequently a preoperative histological diagnosis can easily be obtained using US guide needle biopsy. More and more, staging of axillary lymph nodes is performed with ultrasound and guided needle aspiration or biopsy. Hook wire localization can be used to guide surgical biopsy of lymph nodes, e.g. in case of suspicion of lymphoma. Real time US guidance is a big advantage to assure accurate positioning of biopsy needles. FNA is largely abandoned for the diagnosis of solid lesions, in favor of micro biopsy, which gives more histological material for a better and more confident diagnosis. FNA is still valuable for staging lymph nodes, where the retrieval of cellular material is easier. Vacuum biopsy is reserved for more complex lesions in the breast, but could also be used in ENT in some cases. The latest techniques enable multiple biopsies with a single needle insertion, and are safer because there is no forward throw of the needle during the procedure . In conclusion we can say that there are tremendous technical improvements in the different diagnostic imaging procedures that increase the sensitivity and specifity in ENT exams. The value of Ultrasound should not be underestimated. It is also easily available and requires no special preparation. US guided minimally invasive diagnostic biopsy techniques make it possible to have a very reliable diagnostic work-up. 1. Department of Radiology, AZ Sint-Jan Brugge-Oostende av, Bruges, Belgium.

NEW CLINICAL HEAD & NECK APPLICATIONS New CT applications and the value of perfusion CT A. Trojanowska1 Computed tomography (CT) is routinely used for diagnosing and staging of head and neck malignancies. However, evaluation of sole anatomic images has some drawbacks, as early lesion detection remains difficult and benign processes can mimic malignancies. In many cases inflammatory response and oedema cannot be differentiated from tumour itself, what leads to over-interpretation and upstaging of the disease. On the other hand, pattern of infiltration not accompanied by visible anatomic distortion may result with lesion down-staging. Also, imaging post-surgical and postRTG-therapy patients can be challenging due to anatomical alterations and posttreatment changes. For better evaluation of tumour extent dynamic scanning with perfusion imaging (CTP) has been introduced. It quickly became an effective, simple and reliable method for the assessment of neo-angiogenesis, which is typical for tumour.

22-proceedings ESHNR_Opmaak 1 16/02/12 13:18 Pagina 47

PROCEEDINGS ESHNR – 2011 CTP during last years has been widely used to detect cancer, stage it, predict tumour behaviour and assess the response to radio- and chemotherapy. It specially holds promise in better delineation of the extent of tumour, more accurate staging and earlier depiction of squamous cell carcinoma recurrence. Since recent studies have demonstrated that squamous cell carcinomas of head and neck, with increased blood volume/flow are more chemosensitive than other lesions with relative decreased perfusion parameters, perfusion techniques may be particularly useful in determining which patients would benefit from such medical treatment, as opposed to surgical therapies which may not always preserve organ function. Knowledge about new powerful techniques of functional imaging, like CTP, its advantages and proper application, may help to improve the salvage rate and reduce the morbidity of treatment for recurrent head and neck squamous cell cancer, by earlier and more confident detection of both primary and residual/ recurrent disease. 1. Department of Radiology, University Medical School of Lublin, Poland. Value of PET CT and PET MR and their contemporary applications M. Becker1 1. Geneva, Switzerland. Clinical DWI applications: does it always work? V. Vandecaveye1 Diffusion-weighted magnetic resonance imaging (DW-MRI) is a technique that characterizes tissue based on the random displacement of water molecules which is limited by the underlying tissue-specific microstructural barriers. This random water molecule movement is quantified by the apparent diffusion coefficient (ADC), while native high b-value images are used for lesion detection and initial qualitative characterization where possible. ADC-values reflect the amount of signal loss on the DWI images with increasing b-value and show an inverse correlation with tissue cellularity. Many technical improvements including the development of echo-planar imaging (EPI), increase of the main magnetic field, stronger high-quality gradients, improved coil-design and parallel imaging have enabled the use of DW-MRI with diagnostic quality in the head and neck. The main (potential) applications of DW-MRI in the head and neck are oncologic (roughly to be subdivided into detection of unknown primary, nodal characterization and staging and treatment follow-up) and non-oncologic (mainly detection of cholesteatoma). The aim of the presentation is to outline the potential applications and pitfalls (for instance nodal reactivity, abscess, fungal infection and granuloma) of DW-

MRI in the head and neck. Furthermore, the indications will be discussed where DWI is already suitable for clinical use or requiring further development. Also possible solutions for recognizing potential pitfalls and increasing the accuracy of DWI in the head and neck by making image interpretation more straightforward and by adding anatomical imaging criteria or dynamic contrast enhanced MRI (DCE-MRI) as an adjunct tool will be discussed. 1. Department of Radiology, University Hospitals Leuven, Leuven, Belgium. SINUSES: WHAT THE RADIOLOGIST AND SURGEON SHOULD TELL EACH OTHER Surgical anatomy R. Maroldi1 There are three main fields in which imaging provides critical anatomical data for planning endonasal surgery: untreated-inflammatory lesions and their revision, sinonasal neoplasms and skull base lesions. The three fields share the fact that anatomical data are essential to identify variations that increase the risk of damaging dangerous sinusal walls, as the lamina papyracea, the cribriform plate, the sphenoid walls. In fact, inadvertent bone penetration may result in iatrogenic lesions of the orbital content, dura, brain, nerves and vascular intra-extracranial structures. CT is the technique of choice to detect and delineate these bone changes and to identify bone landmarks. The direct demonstration of cranial nerves branches is better accomplished by MR, both for the extracranial course (fissures, fossae, foramina) and the intracranial portion. 1. Which anatomical structures the radiologist should demonstrate and indicate in planning endonasal surgery for untreated sinonasal inflammatory lesions. a. In the last decade, several training plans have been developed for the acquisition of the surgical skills required to master the incremental technical difficulty of the different endonasal surgical procedures. Training programs include fundamentals (and more) of imaging techniques, where CT and MR anatomy is the backbone. b. PACS and imaging-based intraoperative navigation systems have directly pulled the surgeon into the volume-based imaging anatomy. There, multiplanar interaction with the MSCT volume greatly facilitates the surgeon in the identification of key anatomical structures. Of course, reconstructed MPR sections in all 3 planes should always been provided by the radiologist. Nowadays, though more experience and skill have been collected, frontal and sphenoid sinus approaches are still the most challenging.

47 c. Frontal sinus approach. The frontal sinus has the most complex and variable drainage of any paranasal sinus. Its drainage pathway (or frontal recess) is a non-regularspace, funnel-shaped, crossing the anterior ethmoid complex down from the frontal sinus ostium. The ostium is identified on sagittal CT reconstructions as a waist in the hourglass configuration made by frontal sinus and upper frontal recess. The slope of the frontal recess, its bending and size greatly vary. In fact, the anterior outline of the upper recess is subjected to the anatomical variations of the agger nasi cell and frontal cells. Conversely, the posterior edge of the recess is mainly shaped by the ethmoid bulla and frontal bullar, suprabullar, and supraorbital ethmoid cells (if present). The inferior portion of the frontal recess is a narrower corridor formed by the ethmoid infundibulum if the upper uncinate process attaches medially to the skull base, or by the middle meatus if the upper uncinate attaches laterally onto the lamina papyracea. Access to the natural ostium of the frontal sinus is, therefore, quite variable as it is subjected to the changeable degree of pneumatization of the two cellcomplexes lying in the sagittal plane: the agger nasi (anteriorly) and the bulla ethmoidalis (posteriorly), and to a structure on the coronal plane: the uncinate process. iii. Confusing the roof of the frontal cells with the frontal sinus roof may lead to incomplete removal of the cells in the frontal recess (one of the commonest causes of failure of endoscopic sinus surgery) or – conversely – to intracranial penetration. iii. Sagittal and coronal planes are necessary for a detailed demonstration of the recess pathway and its emptying into the ethmoid infundibulum or, directly, into the middle meatus. Axial CT plane sections precise the relationships with the surrounding groups of fronto-ethmoidal cells. iii. The presence of a supraorbital ethmoid cell is a valuable anatomical finding as it alerts about the course of the anterior ethmoidal artery, which runs far from the etmoid roof in this variant. On coronal CT, the radiologist should look for a medial notch of the orbit (anterior ethmoidal foramen), the anterior ethmoidal sulcus on the lateral wall of the olfactory niche and the “mesentery” through the supraorbital ethmoid cell containing the artery. Dehiscences of the bone mesentery are observed in up to 40%.

22-proceedings ESHNR_Opmaak 1 16/02/12 13:18 Pagina 48

48 d. Sphenoid sinus approach. The sphenoid sinus can be both a target for endonasal surgery (mostly because of fungal lesions or mucoceles) or a corridor to reach the sellar and suprasellar areas (in case of pituitary lesions, selected craniopharyngiomas and meningiomas), the middle skull base floor (laterally, mostly for CSF leak through the lateral cranio-pharyngeal canal) or the pre-pontine cistern (posteriorly, mostly to treat chordomas). On CT the radiologist should report about: iii. the type of sphenoid pneumatization (Hamberger’ classification), and the pattern of intrasphenoidal sepimentation. iii. the presence/extent of sphenoid sinus lateral recesses, possible dehiscence of recess roof. iii. the presence of abnormal pneumatization of a posterior ethmoidal cell projecting over the sphenoid sinus (Onodi cell). In this variant, the presence/ extent of bone dehiscences of the optic and internal carotid artery canal should be carefully evaluated. iv. For inflammatory lesions the trans-ethmoidal approach is the one most frequently used. In this approach four primary bone lamellae must be crossed: the uncinate process, the anterior wall of the ethmoid bulla, the ground lamella of the middle turbinate and the anterior wall of the sphenoid sinus. All lamellae are mainly bent in the coronal plane. Therefore, axial and sagittal CT sections are best suited to demonstrate their tilt, shape, and attachment. Other endonasal approaches to the sphenoid sinus are the para-septal, transrostral and trans-ethmoidpterygoid approaches. 2. Which anatomical structures the radiologist should demonstrate and indicate in planning revision surgery following previous FESS for inflammatory lesions. a. In revision surgery a detailed imaging assessment of the post-surgical changes is essential. CT should demonstrate which structures have been resected – and to which extent – and which structures are still present. Imaging should also report about the presence of scar tissue, bending of fragmented residual portions of the middle turbinate, impaired sinusal drainage, incomplete resection of cells. The surgical landmarks used in untreated patients may be useless because of partially or totally resected. In addition, when dealing with recurrent polyposis it may be very difficult on CT to identify residual bone lamellae, as often reabsorbed or distorted by the lesion itself. Therefore, on imaging it is easier to delineate structures

JBR–BTR, 2012, 95 (1) as the maxillary sinus roof, the medial orbital wall or the skull base that should not have been changed/resected by previous surgery. Particular attention should be placed on the identification of dehiscent bone walls. b. Recurrent maxillary sinus impaired drainage post maxillary antrostomy may be caused by scar tissue, by a residual uncinate process or unresected large infraorbital ethmoid cells. Multiplanar CT analysis may demonstrate key anatomical findings as the lateral attachment of the uncinate on lacrimal duct medial wall and its superior insertion. As the revision surgery has to include the ethmoid complex, another landmark to look for on CT is the horizontal segment of the ground lamella of the middle turbinate. This segment is usually spared as it stabilizes the residual middle turbinate preventing its lateralization. Moreover, if the superior turbinate is still intact, and detectable by CT, it should be reported because this structure may act as a landmark to identify the sphenoethmoid recess. 3. Which anatomical structures the radiologist should demonstrate and indicate in planning endonasal, open or combined surgery for malignant neoplasms or skull base lesions. a. Once histology shows a sinonasal neoplasm amenable for surgery, key surgical anatomy includes the demonstration that the tumor does not/or extends through the bony walls of the sinuses. The most critical anatomical landmarks for treatment planning include: iii. the orbital walls, where the most resistant structure is the inner periosteal layer; therefore imaging has to demonstrate that the periosteal lining is still containing the tumor or not; iii. the posterior and anterior maxillary sinus wall. Their involvement by a malignant tumor contraindicates an endonasal endoscopic resection (EER). Open or combined surgery is then required. Other contraindications to EER include extensive lacrimal pathway involvement, diffuse invasion of hard palate, nasal bones, anterior frontal sinus wall and lateral portion of the frontal sinus. iii. the pterygoid process, with its laminae, and the pterygopalatine fossa (PPF) content. The radiologist should look for signs suggesting invasion of the PPF and perineural spread (on CT and MR). Within the pterygoid process are two channels that lead to the intracranial surface of the skull base: the vidian canal and the foramen rotundum. Vidian canal is a critical structure to check as its posterior opening

leads to the horizontal petrous portion of the ICA (and to the greater superficial petrosal nerve); the foramen rotundum and V2 conduct to the trigeminal ganglion and Meckel’s cave; iv. the anterior cranial fossa (ACF) floor. Key anatomical structures are the bony laminae of the ACF floor (cribriform plate, fovea ethmoidalis, ethmoid and sphenoid planum) the dural layer, and the brain. If the tumor does not reach the nasal mucosa investing the ACF floor, endonasal endoscopic resection (EER) is feasible. Involvement of bone and focal infiltration of the dura can still be treated by EER with transnasal craniectomy. When the abnormal dura extends over the orbital roof, a combined cranio-endoscopic resection has to be planned; 4. Which anatomical structures the radiologist should demonstrate and indicate in planning endonasal for skull base lesions. a. In the last decade, endoscopic endonasal surgery has become a more widely accepted option to treat lesions of the skull base. Endonasal extended approaches (EEA) have been organized into different corridors, which lead to specific target areas. The corridors developed in the sagittal plane span from the frontal sinus down to the odontoid. They permit to enter the skull base through the cribriform plate(s), planum ethmoidale and sphenoidale, tuberculum, dorsum sellae, and clivus. b. Lesions that are treated by EEA include pituitary lesions (transellar approach), meningiomas of tuberculum sellae, selected craniopharyngiomas (transtuberculum, transplanum approaches), CSF leak repair, encephalo/meningoceles, olfactory groove meningiomas, sinonasal neoplasms (transcribriform approach), chordomas, chondrosarcomas and petroclival meningiomas (transclival approach). c. In addition to the anatomical data previously indicated in the endonasal surgical planning in sinonasal inflammatory and neoplastic lesions, several complex intracranial structures have to be demonstrated when planning EEA. They encompass the sella and pituitary gland, the cavernous sinus, cranial nerves, carotid branches and basilar, cisterns. This task requires integrating CT with MR sequences. In particular, high-resolution sequences are useful to detail nerves travelling through the CSF (3DFT-CISS, DRIVE) and to delineate small arterial branches or venous structures like clival venous plexus that run close to the skull base (VIBE, THRIVE). 1. Brescia, Italy.

22-proceedings ESHNR_Opmaak 1 16/02/12 13:18 Pagina 49

PROCEEDINGS ESHNR – 2011 Développement - CNRS - UPR3294, Gif-sur-Yvette, France.

Non-tumoral sinus pathology V. Lund1, N. Freling2 1. London, UK, Netherlands.

2. Amsterdam,

The

Sinonasal tumours: what the radiologist and surgeon should tell each other V. Lund1, T. Beale2

1. New York, USA.

Congenital lesions of the neck: US, CT and MR findings J. Delanote1

1. London, UK, 2. London, UK.

MAXILLOFACIAL AND BRANCHIAL ARCH MALFORMATIONS Neural crest in maxillofacial branchial morphogenesis S. Creuzet1

Abnormal development: when and how it gows wrong T. Naidich1

and

The maxillo-mandibular and branchial system is a composite assembly of interconnected skeletal tissues, that together, these structures fulfill multiple requirements. Those collectively embrace the formation of a feeder apparatus and anchorage of the uppermost parts of the digestive and respiratory tracts. These ontogenetic processes develop from varied morphogenetic strategies that subsequently become confluent and intricate. In spite of its complexity, the maxillomandibular and branchial system, as a whole, share the common feature of being an evolutionary novelty, which, to a large extent, depends on the advent of multipotent and invasive cell population, the neural crest (NC). Originating from the margin of the neural plate, NC cells delaminate from the neural primordium and deploy in the entire embryo. The NC durably impacts on cephalic morphogenesis owing to the wide-range of its derivatives: those include neurones, glial cells, endocrine cells, melanocytes, and myofibroblasts to cartilage and bone. The structural principles underlying the maxillomandibular and branchial moprhogenesis have been enlightened by embryonic studies. Investigations carried out by the mean of embryonic chimeras have documented the fate of the three germ layers in head ontogenesis, and enabled a tremendous stride in the understanding of the cell interactions involved in the maxillo-mandibular and branchial development. Furthermore, these studies led to emphasize the pivotal role played by the cephalic NC in this process. The notions that have been gained through embryological experiments have enriched our views on the origin of the vertebrate head and shed light on mechanisms responsible for the growth and patterning of these structures. The presentation reports on the NC contribution to the maxillo-mandibular and branchial development and overviews the major tissue interactions and the underlying molecular mechanisms that are involved in its morphogenesis. 1. Institut de Neurobiologie-Alfred Fessard, Laboratoire de Neurobiologie &

1. Department of Radiology, University Hospitals Leuven, Leuven, Belgium. Congenital neck lesions are an uncommon group of lesions usually diagnosed in infancy and childhood. They can be evaluated with ultrasonography,computed tomography and magnetic resonance imaging ,either alone or in combination. Ultrasound should be considered first for studying suspected congenital lesions. It helps to define the primary nature of the lesion (cyst, solid, lymphadenopathy,..) and provides information about the extent of the mass in the neck. CT and MRI are best indicated for deep or extensive lesions and when ultrasound is inconclusive. They provide essential information on the location that allows preoperative planning. These examinations in young children necessitate general anaesthesia.Children are significantly more sensitive to radiation exposure(CTscan). Congenital neck lesions are primarily benign. The most common congenital lesions in the neck are the thyroglossal duct cysts, the second branchial cleft cysts,the lymphangioma or cystic hygroma and the dermoid cyst. Particular emphasis is applied to the embryological origin and anatomical site of the lesions to aid in differential diagnosis. We discuss the pathology of the different branchial arches: congenital cervical cystic masses among them thyroglossol duct cysts, cystic hygromas, branchial cleft cysts and thymic cysts. We include some external and middle ear anomalies arising from the first and second branchial arch. Further we look at the vascular –lymphatic spectrum and epidermoid-dermoid-teratoma lesions. The clinical manifestations combined with knowledge of the embryology and spatial anatomy of the head and neck often provide clues for the correct diagnosis.

TEMPORAL BONE – WHAT THE RADIOLOGIST AND SURGEON SHOULD TELL EACH OTHER Cholesteatoma imaging today E. Offeciers1, B. De Foer2 Diagnosis of a middle ear cholesteatoma is based on the clinical, audiological and otoscopical evaluation of the patient. Image evaluation of a mid-

49 dle ear cholesteatoma prior to first stage surgery is still performed mainly using CT scan. It will nicely demonstrate the erosion of the ossicles and the bony spur of the epitympanic space as well as its relation to Prussak’s space. Delineation of the tegmen and the lateral semicircular canal can also be performed. Different types of surgery exist. In the canal wall down tympanoplasty, the mastoid is opened with resection of the external auditory canal, eradication of disease and creation of a large resection cavity. The advantage is that this cavity can be monitored nicely. One of the disadvantages is that patients are no longer allowed to swim as contact with water may provoke sudden onset of vertigo due to contact of water with the lateral semicircular canal. In the canal wall up tympanoplasty, the external auditory canal is left intact. This increases the risk of leaving residual cholesteatoma behind so there is the need to stage. In the primary bony obliteration technique, the tympanoplasty cavity is subsequently filled up with a mixture of bone and bone pâté. Ossicular chain reconstruction can be performed in the same stage or during second look surgery. This type of surgery has a lower rate of residual and recurrent cholesteatoma. MR imaging has gained increasing importance in the diagnosis and followup of middle ear cholesteatoma the past few years. Whereas CT is regarded as the primary imaging tool in clinical clear-cut middle ear cholesteatoma to evaluate the extension of the cholesteatoma, MRI has its place in the clinically doubtfull cholesteatoma as well as in the evaluation of the pre second-look patient looking for residual and/or recurrent cholesteatoma. Two types of MR imaging techniques have mainly been used. The delayed gadolinium-enhanced T1-weighted sequences and the non echo-planar diffusion-weighted MR sequences. The rationale of the delayed-gadolinium enhanced T1-weighted sequences is based on the fact that scar tissue and inflammation require time to enhance and that early scanning might result in false positive results. The echo-planar diffusion-weighted MR sequences have been abandoned in favour of the non echo-planar diffusion-weighted due to the higher resolution, the thinner slice thickness and the complete lack of susceptibility artefacts of the latter sequences. On diffusion-weighted sequences, cholesteatoma lightens up as a hyperintense lesion on b-1000 images. It has been proven that the combination of delayed gadolinium-enhanced T1weighted sequence and non echo-planar diffusion-weighted sequences yields no higher sensitivity, specificity, negative and positive predictive value than the non echo-planar diffusion-weighted sequences alone. Imaging of middle ear cholesteatoma can hence be performed using non echo-planar diffusion-weighted sequences alone. Association to T2-

22-proceedings ESHNR_Opmaak 1 16/02/12 13:18 Pagina 50

50 weighted sequences will enhance the capability to locate any hyperintensity on diffusion-weighted sequences. Exception should be made in case of an infected cholesteatoma and in case of suspicion of associated complications. In those cases, the combined protocol including delayed gadolinium-enhanced T1-weighted sequences and non echoplanar diffusion-weighted sequences should be used. Imaging evaluation of patients prior to second-stage surgery should be performed by MRI using non echo-planar diffusion-weighted sequences alone. This inevitably will reduce the number of negative second-look surgery. By doing so, the number of useless CT scan will also diminish, reducing patient’s irradiation.

JBR–BTR, 2012, 95 (1) For the assessment of congenital inner ear malformations and evaluation of the patients before cochlear implantation, the radiologists should be familiar with the surgical techniques and be able to identify clinically and surgically relevant findings that may contraindicate the implantation or alter the surgical methods. 1. Department of Otolaryngology-Head and Neck Surgery, Hacettepe University Medical Faculty, Ankara, Turkey, 2. Department of Radiology, Hacettepe University, Ankara, Turkey. Conductive hearing loss with an intact tympanic membrane J.W. Casselman1,2,3 , E.F. Offeciers4, B. De Foer3

References 1.

De Foer B., Vercruysse JP., Spaepen M., Somers T., Pouillon M., Offeciers E., Casselman J.W.: Diffusion-weighted magnetic resonance imaging of the temporal bone. Neuroradiology, 2010, 52: 785-807. 2. De Foer B., Vercruysse JP., Bernaerts A., Meersschaert J., Kenis C., Pouillon M., De Beuckeleer L., Michiels J., Bogaerts K., Deckers F., Somers T., Hermans R., Offeciers E., Casselman J.W.: Middle ear cholesteatoma: non-echo-planar diffusion-weighted MR imaging versus delayed gadolinium-enhanced T1weighted MR imaging: value in detection. Radiology, 2010, 255: 866-872. 1. University Department of Otorhinolaryngology, AZ Sint-Augustinus Hospital, Wilrijk (Antwerpen), Belgium, 2. Department of Radiology, GZA Hospitals Sint-Augustinus, Wilrijk, Belgium. Congenital inner ear malformations and cochlear implants L. Sennaroglu1, B. Ozgen2 This presentation will review the important aspects of imaging in the evaluation of the patients with congenital inner ear malformations with an emphasis on the imaging before cochlear implantation. The different types of congenital inner ear malformations will be summarized and standard surgical implantation techniques will also be briefly described to familiarize the audience with these anomalies and treatment methods. CT and MR imaging of the temporal bones before implantation will be reviewed with an interactive discussion between radiologist and surgeon, followed by real time movies during implant surgery. Contraindications for the cochlear implantation including cochlear nerve aplasia and absence of the cochlea will be highlighted. Additionally potential sites of surgical complication such as aberrant facial nerve, cases with increased CSF gusher risk will be pointed out.

The above mentioned clinical – radiological approach will be discussed and illustrated in this lecture. 1. Department of Radiology, AZ St-Jan Brugge AV, Brugge, Belgium, 2. University of Ghent, Gent, Belgium; 3. Department of Radiology, and 4. University department of ENT, StAugustinus, Wilrijk, Belgium. HEAD & NECK STRUCTURES AND THEIR CONNECTION WITH CRANIAL NERVES AND NUCLEI Anatomy of the cranial nerves, cranial nerve nuclei and tracts T. Naidich1 1. New York, USA.

The diagnostic methods available in patients with conductive hearing loss with an intact tympanic membrane are: personal and family history, otoscopy, audiology, imaging, surgical inspection and counselling. However, surgical inspection is only performed as a last resort, when all diagnostic efforts have failed to yield a plausible pre-operative diagnosis. The most important symptoms and personal history data that predict trouble are family history (e.g. otosclerosis), age and circumstances at onset of the hearing loss (e.g. childhood-LVA, trauma-luxation of the ossicles), fluctuating hearing loss and autophony (e.g. superior semicircular canal dehiscenceSCCD), recurrent vertigo/dizziness (e.g. fistula due to trauma), history of recurrent middle ear disease (e.g. incus lysis and tympanosclerotic fixation) or surgery. The most important clinical signs that predict trouble are: congenital facial abnormalities (congenital hearing loss) and otoscopic signs of EAC or ME disease (incus lysis or tympanosclerotic fixation, myringosclerosis or scarring of the TM, convexity or deep retraction of the pars flaccida due to cholesteatoma, pulsating drum or color change of the drum due to a dehiscent or aberrant vessel). The most important audiological signs that predict trouble are: fluctuating thresholds (LVA – imaging), unusual form of the audiogram (malleus fixation, LVA, SCCD – imaging), high impedant tympanogram (malleus fixation), stapedial reflex presence (posttraumatic ossicular luxation), tuning forks in contradiction with PTA and a phantom curve. CT can be used to detect the above mentioned causes like otosclerosis, tympanosclerosis, posttraumatic ossicular lesions, incus lysis, minor ear dysplasias and SCCD. MRI can be used to exclude schwannoma or is used when there is suspicion of congenital cholesteatoma or labyrinth dysplasia. Hence, the surgeon and radiologist should discuss whether a CT or MR has to be performed whenever something is “out of tune”.The most important reasons to ask for imaging are: atypical history, cases suspect for congenital hearing loss, suspect otoscopic image, asymmetric BC thresholds, profound mixed loss and suspect tympanometry.

Symptoms-guided imaging cranial nerves and nuclei S. Kollias1

the

The brainstem (mesencephalon, pons, and medulla oblongata) contains the nuclei of the cranial nerves III to XII and their complex connectivity, serves as a conduit for many ascending and descending pathways and cerebellar connections, and is important for many key integrative functions (control of movement, modulation of pain, autonomic reflexes, arousal, and consciousness. In this presentation we will focus on a symptom-based diagnostic approach to lesions involving the cranial nerves (CN) III to XII and their nuclei in the brainstem (with the exception of CN VIII, which will be covered in the following presentation). For tailoring the imaging approach the neuroradiologist needs to be familiar with how neuroanatomical functional units cluster in the brainstem. These units can be divided into cranial nerve nuclei, pigmented nuclei, and tracts. When two of these three anatomical units show impairment simultaneously (i.e., cranial nerve deficit and crossed corticospinal neurological signs), the first place to localize the lesion is within the brainstem. Furthermore, cranial nerve symptoms provide rostral-caudal localization and long tract related symptoms provide medial-lateral localization. Specific clinical symptoms noticed by the neurologist or the ENT surgeon, or sometimes the neuroradiologist, should help in the potential localization of the lesion to specific CN nuclei within the brainstem or along the fibers of the specific CN. The nuclei for CNs III, IV and part of V (sensory) are found in the midbrain. Affliction of the oculomotor n. (III) will manifest with ipsilateral eye deviation down and laterally, ptosis, and dilated pupil unresponsive to light. Lesion involvement of the trochlear n. (IV) may cause diplopia. Trigeminal n. (V) lesions will cause ipsilateral loss of sensation in the mandible (when the lesion is located in the midbrain), in the face (if the lesion

22-proceedings ESHNR_Opmaak 1 16/02/12 13:18 Pagina 51

PROCEEDINGS ESHNR â&#x20AC;&#x201C; 2011 is in the upper pons) and ipsilateral loss of pain and temperature in the face (when the lesion involves the pons and medulla oblongata). The nuclei of CNs VI, VII, VIII and part of V (motor) are located in the pons. Involvement of the abducens (VI) will manifest with palsy of the lateral rectus muscle and medial deviation of the eye. Facial n. (VII) pathologies will manifest with lower motor neuron facial weakness ipsilaterally and loss of taste on the anterior 2/3 of the tongue. Vestibulocochlear involvement is manifested by deafness (indicating a lesion in the cohlear nuclear complex in lower pons) and vertigo, nystagmus and vomiting (when the lesion extends to involve the upper medulla oblongata). The medulla contains the nuclei for the CNs IX, X, XI, XII and a portion of CN V. Symptoms of decreased gag response and loss of taste on the posterior 1/3 of the tongue should prompt examination of the medulla and the subarachnoid spaces along the course of the Glossopharyngeal n. (IX). Lesions of the Vagus n. (X) and Accessory n. (XI) will be indicated by ipsilateral paralysis of the larynx and soft palate, whereas ipsilateral flaccid tongue weakness should prompt examination of the Hypoglossal n. (XII). Multiple brainstem syndromes, most known by eponym, manifest with symptoms related to a lesion involving the CN at the brainstem level. Thus the Weber, Claude, Benedict, Nothnagel and Perinaud syndromes, all resulting from midbrain lesions, have in common palsy of the CN III, causing diplopia on lateral gaze but it can also be disconjugate vertical gaze. Facial palsy (CN VII), and sometimes lateral rectus palsy (CN VI) is associated with Millard-Gubler and Foville syndromes and localize a lesion at the level of the pons. Oropharyngeal deficits arising from a lesion at the level of the medulla are seen with Avellis, Jackson, and Wallenberg syndromes and point towards a pathology of the CN and nuclei IX-XII. The spectrum of pathology entering in the differential diagnosis of lesions involving the nuclei within the brainstem includes mainly focal lesions due to ischemia, neoplasm or demyelination . Less common etiologies include infectious diseases (rombencephalitis, tuberculosis etc), vascular malformation, trauma, hyponatremia, causing central pontine myelinolysis and other less common etiologies. In summary, knowledge of brainstem anatomy and physiology, and the spectrum of clinical presentation are essential for the imaging assessment of patients with symptoms of cranial nerve deficits for tailoring the appropriate examination in high resolution to specific anatomical segments and for correct diagnosis. Suggested reading: 1. Hurley et al.: J Neuropsychatry Clin Neurosci 22:1, Winter 2010. 2. Dickson W.D., et al.: Curr Opin Neurol 23:394-400, 2010.

3. Hattingen E., et al.: Clin Neuroradiol 20:81-97, 2010. 4. Loeliger M., et al.: Journal of Neuropathology and experimental Neurology: 59:822-829, 2000. 5. Maria Rosa Querol-Pascual. Seminars in Ultrasound CT and MRI: 31:220-229, 2010. 6. M. Angeles Fernandez-Gil, et al.: Seminars in Ultrasound CT and MRI: 31:196-219, 2010. 1. Institute of Neuroradiology and Magnetic Resonance Center, University Hospital of Zurich, Switzerland. Auditory and vestibular pathways: in vivo anatomy-pathology J.W. Casselman1,2,3, M. Safronova4, F. Craighero5, B. De Foer3 Most often imaging is focused on the inner ear, internal auditory canal (IAC) or cerebellopontine angle (CPA) when patients present with sensorineural hearing loss (SNHL) or vertigo. In case of SNHL most of the pathology is indeed found in these anatomical areas, however some of the causes can also be located in the brainstem or higher along the auditory pathway or even in the auditory cortex. This is different in patients with vertigo in whom most of the pathology can be found along the afferent and efferent vestibular pathways in the brainstem, cerebellum and supratentorial vestibular pathways. MR is the method of choice to visualise these pathways and it is obvious that the radiologist must know this anatomy. The best MR sequences to show these structures are thin slice proton-density/T2 weighted SE/TSE images or sequences using different echo-times (TE) like the m-FFE or medic sequence. On these latter images the myelinated structures like the pathways have a low signal intensity and can be recognized. Also the auditory and vestiblar cortical areas must be imaged and patholgoy must be excluded. Many different lesions can affect the auditory or vestibular pathways. Infarctions are the most frekwent cause of vertigo at the level of the brainstem and cerebellum. Other lesions which can cause vertigo are tumors, multiple sclerosis, trauma, rhombencephalitis etc. However, similar lesions can also be found at the level of the vestibular cortex, although the clinical correlation is less understood and accepted. Similar lesions can also cause SNHL although this is rarely bilateral and profound. Posterior fossa infarctions are more frequently causing vertigo than deafness. Profound bilateral deafness is most frequently caused by trauma involving the brainstem, auditory pathways or auditory cortex although multiple sclerosis, brainstem tumors and rhombencephalitis can also cause bilateral hearing loss. The normal auditory and vestibular pathways, as they can be seen on MR, will be shown in this lecture and the most frequent lesions involving these pathways and the vestibular and auditory cortex will be illustrated.

51 1. Department of Radiology, AZ St-Jan Brugge AV, Brugge, Belgium, 2. University of Ghent, Gent, Belgium, 3. Department of Radiology, AZ StAugustinus, Wilrijk, Antwerpen, Belgium, 4. Department of Neuroradiology, Hospital Pedro Hispano, Matosinhos Portugal, 5. Department of Radiology, CHU Marseille, France. Imaging the anterior visual pathway P. Demaerel1 This presentation reviews the lesions involving the anterior visual pathway in adults and children. In the majority of the pathological conditions, MR is the only imaging modality although CT may occasionally contribute to the diagnosis. The sensitivity of the MR examination will depend on the quality of the examination, that should be tailored to image the anterior visual pathway adequately. Optic nerve hypoplasia is a common cause of poor vision in childhood. Associated central nervous system malformations can be seen in up to 40%. Septo-optic dysplasia (formerly called de Morsier syndrome) consists of hypoplasia of the anterior visual pathway, absence of the septum pellucidum and thinning of the corpus callosum. Optic nerve glioma can be seen in children and in adults but is more common in pediatric patients and is often associated with neurofibromatosis type 1. Involvement can be limited to the optic nerve(s) or can extend into the optic chiasm and optic tracts. Enhancement has been associated with a more aggressive behaviour but there have been reports on spontaneous disappearance of enhancement too. Imaging plays an important role in the follow up during chemotherapy. Optic neuritis in young adults can be isolated but there is a strong association with multiple sclerosis (first manifestation in approximately 20% of the patients). Optic neuritis is a typical clinical diagnosis but MRI can be requested to exclude other pathology mimicking optic neuritis or as part of the diagnostic workup for MS. The presence or absence of brain lesions offers prognostic information. Optic neuritis can easily be depicted on T2 weighted STIR images. Post contrast images are not necessary except when nonarteritic ischemic optic neuropathy is a possible differential diagnosis, because enhancement is absent in the latter. Optic neuropathy can also be due to infectious, granulomatous and autoimmune disorders but it is ususally not possible to differentiate these entities from demyelinating optic neuritis. Optic nerve sheath meningioma can be a primary tumour or can be due to extension of an intracranial meningioma into the orbital apex. CT can be useful to demonstrate hyperostosis or calcification. Optic nerve contusion can be depicted by MRI. However CT should always first be performed to exclude ferromagnetic foreign bodies.

22-proceedings ESHNR_Opmaak 1 16/02/12 13:18 Pagina 52

52 Common entities that can lead to compression of the anterior visual pathway will be briefly discussed too. 1. Department of Radiology, University Hospital K.U.Leuven, Belgium.

ORAL CAVITY How medical imaging can influence the surgical decision making J. Abeloos1 Today, almost every tumour in the oral cavity is resectable but the surgical dilemma on functional inoperability remains. The functional and cosmetic outcome after ablative surgery in the oral cavity can be enhanced by various types of immediate reconstruction. Therefore medical imaging is besides the clinical inspection very important. The depth of invasion and the extent of the tumour in the soft tissues such as tongue, floor of mouth and buccal mucosa gives an idea of the possible outcome. When lesions in the tongue and the floor of mouth cross the midline, they might need bilateral neck dissections. The invasion of the mandible (cortex and medullar space) let decide about marginal or segmental resection. How far does the resection of the mandible need to be done? The reconstruction will be totally different. On demand fabricated reconstruction plates can facilitate the reconstructions, but an exact medical imaging is mandatory. Different types of invasion and extent will demonstrate the importance of the imaging in planning the reconstructive possibilities and the functional outcome. This gives an idea of the preoperative assessment on the functional inoperability dilemma. The different treatment possibilities are discussed with a multidisciplinary oncology experts group, including speech pathologists who are important for the re-education and play an important role in the decision making. An exact knowledge of the tumour localisation and invasion is necessary in this assessment. In this way the imaging plays an important role and influences the surgical decision making on the treatment. 1. Department Maxillofacial Surgery, Bruges Oncological Head & Neck Centre, A.Z. Sint Jan Brugge, Bruges, Belgium. Imaging of oral cavity cancer – What the surgeon needs to know F. Dubrulle1, F. Bidault2 The accuracy of pretherapeutic staging plays an important role in treatment planning of oral cavity tumors. The initial imaging assessment includes MR imaging with contrast and CT. Both are necessary to provide the clinician with the crucial pretherapeutic

JBR–BTR, 2012, 95 (1) information on deep tumor infiltration: MRI is necessary to appreciate the extension to the tongue, the oral floor but also to the retromolar trigone and the deep spaces. Perineural extension has also to be looked for carefully on MRI. CT is the modality of choice to look for cortical erosion or lyses, whereas MRI is useful to detect bone marrow involvement. An evaluation of the entire upper aerodigestive tract and the cervical lymph nodes has to be realized during this pretherapeutic staging. A thoracic CT is also recommended at the same time. All these findings can profoundly influence the staging and the management, in particular in case of surgery. Thus, it is necessary to know the potential most common routes of spread of squamous cell carcinomas of the oral cavity, and to be aware of the potential false-positive of imaging, in particular regarding the bone marrow signal on MRI, in order not to overestimate the staging. We also shall review the sequences of diffusion and perfusion, particularly for the nodal staging and the evaluation before radio-chemotherapy. 1. Radiological Department, CHRU de Lille, Lille, France, 2. Department of Medical Imaging, Institut GustaveRoussy, Villejuif, France.

What's new with Positron Emission Tomography in oral cavity cancer G. Bonardel, E. Gontier, D. Metivier, C. Dechaud, M. Soret, H. Foehrenbach1 Since its introduction in clinical practice in the 1990's, positron emission tomography (PET), usually with 18F-fluoro2-deoxy-D-glucose (18F-FDG), has become an important imaging modality in patients with cancer. PET, now systematically PET/CT, as metabolic and molecular imaging technique, is more and more involved in the management of head and neck squamous cell carcinoma (HNSCC). In particular, its clinical value in initial staging of neck lymph nodes, metastases or second cancers and in the evaluation of recurrent or residual disease is well established. The metabolic dimension of the technique provides additional prognostic information. FDG-PET is being used frequently on more advanced clinical applications. After chemoradiation, it is used for monitoring the response to therapy to accurately select patients for salvage surgery. The value of PET/CT for radiotherapy planning is still under investigation but it makes a significant difference by identifying malignant normal size nodes, extent of viable tumor and distant disease. Technical innovation, such as hybrid positron emission tomography/magnetic resonance imaging (PET/MRI) provides also both anatomic and metabolic information in the same procedure but its place has still to be define in clinical practice. From the point of view of biological metabolism, new radiopharmaceutical

probes are being developed. Those hold promise for future refinements in this field. 1. Department of Nuclear Medicine, HIA Val de Grâce, Paris, France. How to differentiate recurrence or post therapeutic changes in the oral cavity F. Bidault1, G. Bonardel2 This course reviews the expected imaging findings after treatment of oral cavity squamous cell carcinoma (SCC), and how to differentiate these from complications, and from persistent or recurrent cancer. Follow-up for head and neck SCC is based on clinical, radiological and endoscopic survey. Radiologist must be aware of first location, TNM staging, date and type of treatment. Usual radiological post-radiotherapy changes are: increased enhancement followed by size reduction of salivary glands, oedema of retropharyngeal space and laryngeal soft tissue, thickening and increased enhancement of mucosal space, reticulation of subcutaneous fat, thickening of skin and platysma muscle, atrophy of lymphatic tissue. Changes after surgery depend on surgical resections, neck dissection, type of flap used to reconstruct oral cavity surgical defects. Principal complications are osteonecrosis of the jaw, soft tissue ulceration and fistula. Advanced T or N stage of disease, vascular or lymphatic involvement on pathology, unsatisfactory surgical margins, and long interval between surgery and radiotherapy are risk factors for local recurrence. Main recurrence signs are: growing mass with contrast enhancement (usually at the interface of the operative site and the flap), nodal recurrence (ipsi or contralateral to the primary), bone or cartilage destruction, perineural tumour spread. Authors generally agree about the usefulness of a 3 months imaging follow-up after SCC treatment. CT and MR are both useful and commonly performed. T2weighted images are known to be helpful in distinguishing recurrent tumour from radiation fibrosis (fibrosis usually remained low in signal intensity on T2weighted images, while tumour demonstrated higher signal intensity). Diffusionweighted MR imaging with ADC measurement has promising results in some studies for differentiating residual or recurrent SCC from postoperative or postradiation changes. Localized single voxel magnetic resonance spectroscopy measurements were able to differentiate recurrent disease from post-therapeutic tissue changes in a study. FDG-PET/CT value in the evaluation of recurrent or residual disease is well established. Sonographic examination of radiotherapy treated lymph nodes offers a good sensitivity and NPV, but poor specificity and PPV. 1. Department of Medical Imaging, Institut Gustave-Roussy, Villejuif, France, 2. Department of Nuclear Medicine, HIA Val de Grâce, Paris, France.

22-proceedings ESHNR_Opmaak 1 16/02/12 13:18 Pagina 53

PROCEEDINGS ESHNR – 2011 THE MANCUSO GENERATION “The hardest thing to do is call an imaging study negative”: a critical thinking approach to image interpretation A.A. Mancuso1 Dedication :This lecture is dedicated to Leo. G. Rigler, who taught me that “the hardest thing to do is call a chest x-ray negative”, this concept serving as a guiding principle in my career and as the initial inspiration for this presentation. And to Bill Hanafee for all of his wisdom, leadership and kindness and Paul Ward… who together, created a model of what can be accomplished for interdisciplinary patient care with a spirit of mutual respect and everlasting friendship. And to my good friend and colleague Kathlyn Marsot-Dupuch whose wonderful spirit left us too soon. “The hardest thing to do is call an imaging study negative”. Assuming you believe this statement is true you must understand and accept this concept as rooted in habitual critical thinking and the development of fluid intelligence. Fluid intelligence directly relies of the application of critical thinking skills with those concepts in unison making it possible for one to determine patterns, make connections and solve new problems. Critical thinking is about being both willing and able to evaluate one's thinking. The disposition toward of critical thinking is based on character. The traits of a critical thinker and a complete physician being the willingness to learn and develop the habitual intention to be truthseeking, open-minded, systematic, analytical, inquisitive, confident in reasoning, and prudent in making judgments. There is a reasonable level of consensus among experts that an individual or group engaged in strong critical thinking gives due consideration to: – Evidence through observation – Context of judgment – Relevant criteria for making the judgment well – Applicable methods or techniques for forming the judgment

– Applicable theoretical constructs for understanding the problem and the question at hand This understanding of the interpretive process being best rooted in habitual critical thinking and fluid intelligence development, which then allows us to discard less orderly and potentially error burdened processes such as a primarily gestalt and DDX based educational and reporting/consulting methodologies. In essence the critical thinking model leads us to a fundamentally rules based approach to interpretation and reporting as the basis of our work product. The building blocks of the critical thinking model in imaging include: – A thorough knowledge of the normal anatomy – And normal variants (based on a reliable normative data base when available) – Having clinical information (context) – A rules/structure by which to call study negative – Rejecting interpreting studies only by “Gestalt” or other random processes Following this model some of the goals for our reports become to: – Avoid false negatives-which is a focus of this presentation – Set reasonable expectations about what a negative imaging report means in a specific clinical context – State a degree of confidence (whenever possible) of the negative interpretation for excluding specific pathologies (whether asked or not) This presentation will identify specific clinical contexts with high error rates that are from the following categories: – Interpretive – Process (protocol application) – Error poses unusually high risk to patients As Examples-situations with high error rate for disease exclusion have been chosen – Temporal bone- Anatomically a confined, complex (lots of small structures) region with numerous, diverse indications for study – Invasive fungal sinus disease in immune compromised patients — a critical and usually high acuity situation, that requires exclusion of a

Bill Hanafee in his office at UCLA circa 1970’s preparing teaching and in retirement in north San Diego County likely getting ready to shoot a round of golf with his long time friend and colleague Paul Ward.

53 specific condition with a high degree of confidence – Facial pain and otalgia – “screening” of a relatively large anatomic area, requires numerous observations, diverse pathology – wherein the incidence of identifiable causative pathology is relatively low Our overall goals are to: – Seek ways to make imaging relevant – Ensure close cooperation with referring clinicians – Understand what the clinicians really needed to know from imaging in a very specific clinical context and communicate that information clearly The intended result of applying this continuum of the critical thinking, knowledge and resultant wisdom would be to produce the best possible diagnostic imaging process from acquisition to consulting and reporting. This would include assuring optimal resource utilization, which in turn leads to uniformly high quality images those images eventually facilitating the best possible timely consultations and written reports. Realizing these goals requires access to the entire scope of core knowledge needed to plan, perform and interpret an imaging exam. This includes applied physics, anatomy and pathophysiology. Such core knowledge must then be expanded within the known specific clinical context. Core knowledge might also be applied to a clinical situation never before encountered and, with good fluid intelligence skills (wisdom and judgment), resulting in the correct decision making in what might otherwise be a confounding situation. 1. Department of Radiology, University of Florida College of Medicine, Gainesville FL, USA. Temporal bone imaging: from basics to benchmark (and beyond) B.M. Verbist1,2, M. Lemmerling3 Marc Lemmerling and Berit Verbist spent a visiting fellowship with Prof Dr A.A. Mancuso in 1996 and 2003 respectively. The vast and varied patient population at Shands at the University of Florida allowed them to immerse themselves in all aspects of Head and Neck radiology. Yet they both shared a special interest in the temporal bone. Thanks to the remarkable teaching skills of Tony Mancuso they rapidly increased their knowledge and insights into this fascinating topic. This has shaped their clinical work and teaching and it has laid the foundation to scientific work about middle and inner ear anatomy (Marc Lemmerling) and imaging evaluation of the inner ear in regard to cochlear implantation (Berit Verbist). This joint lecture will reflect on the evolution of temporal bone imaging in the past 2 decades. 1. Department of Radiology, LUMC, Leiden, The Netherlands, 2. Department of Radiology, UMCN, Nijmegen, The Netherlands, 3. Department Radiology, AZ Sint-Lucas, Gent, Belgium.

22-proceedings ESHNR_Opmaak 1 16/02/12 13:18 Pagina 54

54 Imaging of the larynx and hypopharynx: The Gainesville Foundation F.A. Pameijer1 Many reports in literature to date have recognised a positive correlation between tumor volume and prognosis for all subsites of the head and neck. Therefore, pre-treatment volumetric analysis may have predictive value for patient outcome (independently from the currently used TNM classification). Treatment options for patients with squamous cell carcinomas of the larynx and hypopharynx include radical surgery, conservation surgery and definitive radiotherapy (RT). In recent years, chemoradiation therapy has become one of the main options for organ preservation therapy in these patients, with salvage surgery reserved for local recurrence. Even in advanced cancers, modern concomitant chemoradiotherapy can achieve relatively high locoregional control and survival rates. With all these different treatment strategies available, it is crucial to select individual patients for the right therapy. In two reports, published as early as 1990 and 1993, from the University of Florida (UFL) raglottic carcinomas and T3 glottic carcinomas respectively, pre-treatment (volumetric) analysis of CT examinations has been shown to be potentially useful in this selection. After an introduction in the principles of tumor volume determination, the value of (CT-determined) parameters as prognostic factors for treatment outcome of head and neck cancer patients after definitive radiation therapy will be presented. The focus will be on laryngeal and hypopharyngeal carcinomas, emphasizing tumor volume and cartilage sclerosis. Different combinations of these two parameters resulted in CT-bases pretreatment risk profiles that were able to classify individual patients at low-, moderate- and high-risk for local failure after curative RT. Post-RT CT studies can also predict local failure in patients with laryngeal carcinomas treated with definitive RT using a post-RT score, developed at UFL. 1. Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands.

The larynx, hypopharynx and beyond: The Spin-Off R. Hermans1 CT and MRI are well established methods in the initial diagnostic evaluation of head and neck malignancy, and are also widely used for treatment monitoring and follow-up. MRI is the preferred method for imaging certain tumour sites, such as the nasopharynx, skull base and sinonasal cavities. As in other areas of the body, the results obtained with these anatomy-

JBRâ&#x20AC;&#x201C;BTR, 2012, 95 (1) based imaging methods are not always optimal, because of difficulties to identify early disease or small volume lesions, as well as to differentiate tumour from inflammation and/or scar tissue. The localisation and extent of primary squamous cell cancer, one of the most common types of malignant disease in this region, is usually well defined by CT or conventional MRI. However, the characterisation of small neck lymph nodes remains a difficult issue with anatomybased imaging methods. The use of ultrasmall superparamagnetic iron oxide (USPIO) particles, a contrast agent accumulating in normal lymphoid tissue, has shown variable accuracy for nodal staging in the head and neck. Also, the routine use of USPIO-MRI is hampered due to limited availability and logistical problems concerning administration of this contrast agent. Although diffusion-weighted MRI (DWI) is already a long time in use for evaluation of brain diseases, its potential utility for evaluating extracranial neoplastic disease is only recently recognized. For staging neck lymph nodes in squamous cell cancer, high sensitivities and specificities were reported, better than what is obtainable by CT or conventional MRI. This increased accuracy is mainly due to improved detection of subcentimetric nodal metastases. If these results are confirmed, this improved pretherapeutic nodal characterization may result in a closer conformity of the radiation target volume to the anatomical tumour extent, and reduce side effects of treatment when intensity modality radiotherapy is applied. Differentiation of treatment induced tissue changes, especially after (chemo) radiotherapy, and persistent or recurrent cancer, is another topic in which DWI may be very helpful. Studies investigating the role of DWI as prognostic tool during, and very early after treatment, are ongoing. Preliminary results are encouraging, and if confirmed, tailoring treatment according to the very early individual response, as seen on DWI, may become feasible. For several of these possible applications of DWI in head and neck cancer, currently FDG-PET is being used or advocated. However, FDG is not an entirely specific cancer tracer, and false positive finding are not uncommon. The spatial resolution of PET is relatively low, potentially leading to false negative results. DWI is an interesting alternative, as correlation with anatomical MR images acquired during the same study is possible, allowing precise anatomical localisation of the observed abnormalities. DWI also appears to better discriminate between neoplastic disease and inflammatory changes than PET. DWI is a method that can be performed at a lower cost than PET, without the need for an external tracer, and without exposure of the patient to ionising radiation. FDG-PET is, in general, not recommended for the routine diagnostic workup of a head and neck neoplasm. However, FDG-PET should be performed

in case of a clinically unknown cancer, if CT or MRI fail to reveal the primary tumor. Also, in case of evidence of extranodal tumour spread, or if adenopathies are present low in the neck (both factors increase the risk of metastasis), FDG-PET can be used to search for distant disease. 1. Department of Radiology, University Hospitals Leuven, Leuven, Belgium.

CONE BEAM CT Radiation aspects of TMJ Imaging- An update on dose and risk J. Ludlow1 This lecture will identify the risks from ionizing radiation that result from dental and maxillofacial CBCT examinations and discuss alternative ways for measuring exposure and calculating dose. Options in CBCT equipment and how these influence image and dose characteristics will be described. The importance of matching options to the objectives of imaging will be discussed. We will explore ways to reduce the risks from diagnostic imaging. 1. Radiology Section, Department of Diagnostic Sciences and General Dentistry, University of North Carolina, School of Dentistry, Chapel Hill, USA.

Dento-alveolar, implant & orthodontic indications for CBCT imaging R. Jacobs1 During the last decade, there has been an upward trend in using 3D information as an aid to dentomaxillofacial diagnostics and surgical planning. This is further strengthened by the introduction of dental cone beam CT allowing volumetric jaw bone imaging at reasonable costs and doses. CBCT imaging may offer numerous diagnostic potentials and even change treatment strategies in oral health care. This definitely applies to orthodontics, implant surgery and other dentoalveolar diagnostic challenges. An exponential growth of the different CBCT machines available and fast evolutions with respect to dose and image quality have created an almost unbridgeable time gap between reporting of scientific evidence and the actual clinical use of CBCT. Recent studies in the framework of the SedentexCT Euratom project indicate crucial differences in radiation dose, image quality, dimensional accuracy and artefact expression depending on both equipment and patient factors. The impact of those variables to the resulting diagnostic requirements for orthodontics, implant and other dentoalveolar surgery will be discussed. 1. Oral Imaging Centre, K.U.Leuven, Leuven, Belgium.

22-proceedings ESHNR_Opmaak 1 16/02/12 13:18 Pagina 55

PROCEEDINGS ESHNR – 2011 Use of CBCT in dental implant treatment T.A. Larheim1 Since it came available in the late 1990s, CBCT has rapidly and increasingly been used in dentistry. As judged from the literature and own experiences, the imaging modality has been particularly popular for examination of patients selected for implant treatment. The lecture will give an overview of the topic, focusing on pre-operative imaging of the alveolar ridge (size and shape evaluation) and anatomical structures to be avoided during surgery, software programs for treatment planning, as well as stent and ridge augmentation (sinus lift) procedures. Also postoperative imaging will be discussed, in particular related to complications. 1. Department of Maxillofacial Radiology, Faculty of Dentistry, University of Oslo, Norway.

Combination of CBCT imaging & 3D stereophotogrammetry in maxillo-facial deformity S. Bergé1 The three important tissue groups in orthognathic surgery (facial soft tissues, facial skeleton and dentition) can be referred to as a triad. This triad plays a decisive role in planning orthognathic surgery. Technological developments have led to the development of different three-dimensional (3D) technologies such as multiplanar CT, cone beam CT and MRI scanning, 3D photography modalities and surface scanning. An objective method to predict surgical and orthodontic outcome should be established based on the integration of structural (soft tissue envelope, facial skeleton and dentition) and photographic 3D images. None

of the craniofacial imaging techniques can capture the complete triad with optimal quality. This can only be achieved by ‘image fusion’ of different imaging techniques to create a 3D virtual head that can display all triad elements. An overview of current possibilities on image fusion in the craniofacial area will be presented. The focus will be on the value of stereophotogrammetry within this way of working. Lit.: Digital three-dimensional image fusion processes for planning and evaluating orthodontics and orthognathic surgery. Plooij J.M., Maal T.J., Haers P., Borstlap W.A., Kuijpers-Jagtman A.M., Bergé S.J. A systematic review. Int J Oral Maxillofac Surg, 2011 Apr, 40(4): 341-52. 1. Department of Oral and Maxillofacial surgery of the Radboud University Nijmegen, Nijmegen, the Netherlands.

Other and new indications / quality J.W. Casselman1,3,4, G.R.J. Swennen2, J. Abeloos2, D. Volders1, K. Mermuys1, B. De Foer4 Many Cone Beam CT’s (CBCTs) are bought to perform Dentascan and 3DFace/Skull studies. However sinus imaging today became the major application, but other applications as face/nose trauma, TMJ, swallow studies and pharyngography, temporal bone imaging (and cochlear implants), dacryocystography, cervical spine etc. are possible. Newer systems can even replace conventional CT for imaging of the wrist-hand, elbow, ankle-foot and knee. In the MSK field CBCT can also be used to visualise structures around osteosynthetic materials (metal). Most CBCT systems are not able to perform all these different studies and

55 therefore one has to look for a system that is able to provide the locally needed studies. High resolution systems are needed to perform temporal bone studies using more powerful X-ray tubes and with a resolution of at least 0.100 mm or 100 µ. Some of the newer systems are even able to reach resolutions of 75 µ. This high resolution also opened possibilities for CBCT in “endodontology” and “periodontology”. Double rotation systems are needed to perform 3DFace/Skull studies (2 overlapping slabs, stitched together to cover the whole skull). Systems with a gantry are needed to perform studies of peripheral joints. Immobilization is crucial and therefore the necessary time should be invested to position and immobilize the patients, as the slightest movements will destroy the high resolution ≤ 0.2 mm quality. Moreover nurses must perform enough studies per day to become experienced enough especially when they have to perform the whole spectrum of possible studies. Once high quality images are achieved, CBCT can start to replace MDCT in the above mentioned indications. In our institution CBCT even completely replaced conventional multidetector CT for imaging of the temporal bone because CBCT provides significantly higher resolution. The easy access to the system, the very low irradiation dose and the spatial resolution have guaranteed CBCT a strong place between the other imaging systems. Unfortunately, one drawback remains. Acquisition time is routinely between 20 and 40 seconds, too long to perform studies in moving children or elderly patients.

1. Department of Radiology, 2. MaxilloFacial Surgery, AZ St-Jan Brugge AV, Brugge, Belgium, 3. University of Ghent, Gent, Belgium, 4. Department of Radiology St- Augustinus, Wilrijk, Belgium.

22-proceedings ESHNR_Opmaak 1 16/02/12 13:18 Pagina 56

JBRâ&#x20AC;&#x201C;BTR, 2012, 95 (1)

REFRESHER COURSE PART 1 Anatomy of the skull base H.B. EggesbĂ¸1 The skull base is made up of five membranous bones: the frontal, ethmoid, sphenoid, temporal and occipital bone. From above, the skull base can be divided in the anterior, middle and posterior cranial fossae. From below, no clear boundaries are defined. The bony anatomy of the foramina and fissures is best evaluated using CT, while MR is superior for imaging the nerves and vessels passing through and the soft tissue on each side of the skull base. The anterior cranial fossa extends from the posterior wall of the frontal sinus to the roof of the sphenoid sinus (planum sphenoidale and anterior pterygoid processes). The paired frontal bones form the lateral boundaries. The central ethmoid bone contains the deep olfactory fossa with the olfactory nerve (I) fibers passing the cribriform plate. The border between the olfactory fossa and the anterior ethmoid sinus is the thin and vulnerable lateral lamella that attaches superiorly to the roof of the ethmoid sinus (foveolae ethmoidale). Posterior in the anterior fossa, the sphenoid bone contains the optic canal with the optic nerve (II) and ophthalmic artery. The anterior fossa contains the frontal lobes, while the orbits and paranasal sinuses are situated below the skull base. The middle cranial fossa is formed by the basisphenoid, the lesser and greater sphenoid wings. The superior orbital fissure (SOF) is a slit-like opening between the greater and lesser wing, and the inferior orbital fissure (IOF) is the opening between the greater wing and the maxillary bone. The basisphenoid contains the sella turcica limited by the tuberculum sella anteriorly, dorsum sella posteriorly, and cavernous sinus laterally. The oculomotor (III), trochlear (IV), abducens (VI), and ophthalmic nerve (V1) pass through the cavernous sinus before entering SOF. The maxillary nerve (V2) also runs through the cavernous sinus, but leaves through the foramen rotundum into the pterygopalatine fossa. Before continuing through the IOF, the maxillary nerve exchanges nerve fibers in the sphenopalatine ganglion with the greater petrosal nerve that enters the pterygopalatine fossa from the bony Vidian canal. The mandibular nerve (V3) leaves the skull base through the foramen ovale in the base of the greater wing. Posterolateral is the foramen spinosum with the middle meningeal artery. The carotid artery enters the petrous temporal bone from below and runs anteromedially in the carotid canal inside the skull base before entering the foramen lacerum and then the cavernous sinus.

The middle fossa contains the temporal lobes. The retropharyngeal, parapharyngeal, prevertebral, carotid and masticator spaces border the skull base below. The posterior cranial fossa is the largest and deepest fossa formed by the occipital bone and petrous part of the temporal bone. The fossa contains the porus acusticus internus with the facial (VII) and vestibulocochlear (IX) nerves, the jugular foramen with the glossopharyngeal (IX), vagus (X), and accessory (XI) nerves, and the hypoglossal canal with the hypoglossal nerve (XII). The jugular vein runs through the posterolateral part of the jugular foramen. The posterior fossa contains the cerebellum, and the brainstem running through the foramen magnum. 1. Department of Radiology, Aker University Hospital, Oslo, Norway. Pathology of the anterior and central skull base R. Jacobs1 1. Department of Radiology, University Hospitals Leuven, Leuven, Belgium. Temporal bone pathology C. Czerny1 The incidence of imaging of the temporal bone in case of disease has been increasing over the past decades.

Especially, imaging techniques such as Multi-Detector-Spiral-CT (MDCT) and Magnetic Resonance Imaging (MRI) provide substantial information for the correct diagnose of potential abnormalities/diseases. MDCT is performed in the axial plane with coronal/sagittal reconstructed planes. The section thickness should be 2 x 0.6 mm/2 x 0.5 mm, the FOV ~20 cm, the matrix â&#x2030;Ľ 512 x 512, the reconstructed section thickness 0.65-1.0, and a HRCT bone window level setting should be obtained. MRI is performed with a FLAIR or T2w FSE of the head, and a 3D T2w high-resolution thin-section sequence of the inner ear in the axial plane, and a T1w sequence before and after the intravenous application of contrast material in the axial plane and additionally (if necessary) in the coronal plane. Apart from the normal anatomy of the structures of the temporal bone, there are also variants, which should be known. The pathologic entities include congenital malformations of the external, middle, and inner ear. The acquired pathologies consist of inflammatory lesions, cholesteatomas, and tumors as well as posttraumatic changes. In this refresher course the variants, the congenital malformations, and the acquired pathologies of the temporal bone especially of the middle and inner ear will be shown (see figs.). 1. Department of Radiology, University of Vienna, Austria.

Diffusion-weighted MR image of a cholesteatoma

CM-enhanced T1w MR image vestibular schwannoma

22-proceedings ESHNR_Opmaak 1 16/02/12 13:18 Pagina 57

PROCEEDINGS ESHNR – 2011 The parapharyngeal space M.G. Mack1 The parapharyngeal space is a deep space in the neck in the shape of an inverted pyramid with its base attaching to the skull base and the apex reaching the level of the hyoid bone. It is bordered on its medial side by the naso- and oropharynx, on its anterolateral side by the masticator space, on its posterolateral side by the deep lobe of the parotid gland, and on its posteromedial side by the retropharyngeal space. Some authors devide the parapharyngeal space into two compartments on the basis of its relationship to the styloid process or, more precisely, to the tensor-vascular-styloid fascia and used terms such as “parapharyngeal space” that may sometimes be confusing. Some authors limit the parapharyngeal space to the fatty space anterior to the carotid space, while others consider the suprahyoid part of the carotid space to be part of the parapharyngeal space, then often called postytloid compartment of the parapharyngeal space. The importance of the parapharyngeal space also lies in its relationship with the other spaces of the neck The contents of the prestyloid compartment include the minor or ectopic salivary gland, branches of the mandibular division of the trigeminal nerve, internal maxillary artery, ascending pharyngeal artery, and pharyngeal venous plexus, whereas those of the poststyloid compartment (also called carotid space) include the internal carotid artery, internal jugular vein, cranial nerves IX-XII, cervical sympathetic chain, and glomus bodies. Intrinsic and extrinsic parapharyngeal space pathology will be discussed. 1. Department of Diagnostic and Interventional Radiology, University of Frankfurt, Frankfurt Main, Germany.

PART 2 Cranial nerves I-VI M. Lemmerling1 Imaging of the upper cranial nerves is mostly performed with axial and coronal standard T1- and T2-weighted images, in combination with thin sliced heavily T2weighted images to visualize the cisternal nerve segment. Coronal images should always cover the complete peripheral course of the nerve as well as its origin in the brain stem. In selected cases additional sequences are an option (e.g. FLAIR if suspicion of demyelinating disease, DWI for ischemia in the elderly, …). Olfactory nerve (N. I) Coronal images can nicely demonstrate the olfactory bulb and tract. They also show the olfactory cortex in the frontal and temporal cerebral lobes. Trauma with hemosiderin deposits in this cortex is frequently seen in patients with

anosmia. It is consequently interesting to perform a susceptibility-weighted sequence in such patients. Optic nerve (N. II) Coronal images are also very useful to image the second cranial nerve. Frequent indications for optic nerve imaging are suspicion of optic neuritis (mostly related to MS), or optic nerve tumor (most frequent glioma, and sometimes meningioma). Optic neuritis is best seen on coronal T2-weighted images performed with fat suppression techniques, and also on coronal postgadolinium fat suppressed T1-weighted images. Low grade optic nerve gliomas are most frequent in children (often with neurofibromatosis type I). More aggressive ones are seen in adults. Optic nerve sheath meningiomas are rare and most frequently occur in middle age females. Oculomotor, trochlear and abducens nerve (N. III, IV, and VI) These cranial nerves are responsible for eyeball motion. The trochlear and abducens nerve respectively innervate the superior oblique muscle and the lateral rectus muscle. All other eyeball muscles, as well as the levator palpebrae superioris muscle, are supplied by the oculomotor nerve. These 3 nerves run through the cavernous sinus and the superior orbital fissure towards the orbit. Imaging of these nerves is often done in non-diabetic patients with diplopia. Frequently seen anomalies are brain stem ischemia, infectious or malignant meningeal disease along the cisternal course of the nerves, or infectious or tumoral lesions in the cavernous sinus, superior orbital fissure, or orbit. Trigeminal nerve (N. V) The trigeminal nerve is the largest cranial nerve. It transmits sensory information from the face, and provides motor information to the muscles of mastication. Meckel ‘s cave contains the trigeminal ganglion and the trifurcation in the ophthalmic (N. V1), maxillary (N. V2), and mandibular (N. V3) nerves. In patients with trigeminal neuralgia a careful and systematic inspection of many skull base structures is mandatory (Meckel ‘s cave, the cavernous sinus, superior orbital fissure, pterygopalatine fossa, foramen rotundum, foramen ovale, Vidian canal, canals for the palatine nerves, canal for the infraorbital nerve, mandibular alveolar canal, …), as well as inspection of the more peripheral course of the different nerve divisions (masticator space, …). Frequent anomalies are meningiomas, schwannoma, infectious, and metastatic disease. Using a segmental approach based on locations (brain stem, cisternal segment, middle cranial fossa, peripheral course) can help to narrow the differential diagnosis. 1. Department Radiology, AZ Sint-Lucas, Gent, Belgium. Cranial nerves VII-XII F. Veillon1 1. Strasbourg, France.

57 The masticator space M. Lemort1 The masticator space (MS) is part of the deep spaces of the supra-hyoid head and neck delimitated by the different components and reflection sheets of the deep cervical fascia. It includes the masticator muscles, ramus of the mandible and several vascular or nervous structures of interest. A careful examination of this space is of utmost importance for the staging and follow-up of facial and pharyngeal tumours. Access to foramen ovale is possible through the masticator space. Pterygo-palatine fossa, which is part of this space, is a major crossways between intracranial compartment, orbits, nose and oral cavity. Some lesions may also arise from the components of the MS such as schwannomas, bone or soft tissues tumours. This course will covers in depth the anatomy and MR anatomy of the MS and its limits, using both anatomical documents and annotated high-resolution MR sections. It also will review the main primary and secondary pathologies affecting the MS. 1. Institut J. Bordet, Cancer Center of Université Libre de Bruxelles, Brussels, Belgium. The oral cavity and oropharynx S. Golding1 The area comprises: oral cavity (lips, buccal cavity, tongue, oral floor, alveolar ridge and retromolar trigone, and hard palate), and oropharynx (base of tongue, tonsil, soft palate and pharyngeal wall). In imaging practice the most common lesions in practice are dental sepsis, carcinoma, lymphoma, ectopic salivary neoplasms and pharyngeal abscess. Others include benign lesions mimicking neoplasms, neoplasms of musculoskeletal, neurogenic and vascular origin, and thyroglossal remnants. Infection of the teeth or tonsils must always be considered and reactive lymph node hyperplasia is common. Dental radiographs must be obtained in suspected sepsis. MRI may be regarded as the technique of choice in all focal disease of the oral cavity and oropharynx. PET/CT offers advantages, most especially in the detection of clinically occult cervical node metastases. Diagnosis is usually by clinical inspection and biopsy; imaging is rarely required for diagnosis. The major role of imaging is disease staging; this may include staging benign lesions for resection. The internationally accepted staging criteria (TNM System) of this area are based on measurements of visible disease and do not provide good correlation with clinical management. The radiologist should report the extent of disease shown by imaging rather than stating a TNM stage. Other indications for imaging neoplasms are disease monitoring during treatment, and detection of recurrence.

22-proceedings ESHNR_Opmaak 1 23/02/12 10:05 Pagina 58

58 90% of malignant neoplams are squamous carcinoma, the rest being NonHodgkin Lymphoma (5%), and adenoidcystic or mucoepidermoid carcinoma of minor salivary glands in the buccal mucosa and floor of mouth, followed by rare tumours such as angiosarcoma, rhabdomyosarcoma and melanoma. Common sites in the mouth are lips, tongue, oral floor of mouth and alveolar ridge and retromolar trigone. Common sites in the oropharynx are tonsil (50%), base of tongue (20%) and soft palate (10%). Disease in lymph nodes is shown by nodal enlargement. Metastatic nodes

JBR–BTR, 2012, 95 (1) may show uniform or high central T2 signal. Breach in the capsule of the node is an indicator of a poor prognosis. Benign reactive lymphadenopathy is common in the face and neck and may produce false positive impressions of metastasis. MRI is very sensitive to bone marrow involvement and often can be used to evaluate spread into bone but if there is any doubt about cortical involvement high resolution CT should also be obtained. Recurrent carcinoma tends to be detectable within two years after treatment and usually at the margin of the resected area. Interpretation may be difficult. The radiologist should have a high

index of suspicion when there are symptoms, usually local pain. Active inflammation and scarring may mimic the signal characteristics of recurrent neoplasms within six months after treatment. Many recurrent tumours are more readily shown on enhanced images. Common benign lesions, apart from infection, presenting to the radiologist are: ranula; lingual thyroid; thyroglossal cysts; lymphangioma; branchial derivatives; arteriovenous malformations. 1. Department of Diagnostic Imaging, University of Oxford, UK.

JBR–BTR, 2012, 95: 58.

FORTHCOMING COURSES AND MEETINGS NATIONAL MEETINGS 05.03.12 RBRS – Neuroradiology Section Information: nsadeghi@ ulb.ac.be 24.03.12 RBRS – section Bone and Joints, joint meeting with “Nederlandse Vereniging voor Radiologie, sectie Skelet” Mechelen, de Noker Local organizer: Prof. Dr. F.M. Vanhoenacker Information: filip.vanhoenacker@telenet.be or pieter.van.dyck@uza

RBRS- Cardiovascular and Interventional Radiology / RBRS – Bone and Joints Imaging 24.03.12

21.05.12 RBRS – Neuroradiology Section Information: nsadeghi@ ulb.ac.be 01.06.12 RBRS – Section Head and Neck Radiology Joint Meeting with the Nederlandse Vereniging voor Radiologie, sectie HoofdHalsradiologie Hasselt, Radisson Blu Hotel Organization: Dr B. Termote Information: Pr Dr R. Hermans, robert.hermans@uzleuven.be

RBRS – Neuroradiology Section 05.03.12, 21.05.12, 17.09.12, 05.11.12

03.06.12 Fifth congress of senology Oostduinkerke 17.09.12 RBRS – Neuroradiology Section Information: nsadeghi@ ulb.ac.be 05.11.12 RBRS – Neuroradiology Section Information: nsadeghi@ ulb.ac.be

Miscellaneous 03.06.12

RBRS – Head and Neck Section 01.06.12

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

INTERNATIONAL MEETINGS 01-05.03.12 ECR 2012 Vienna, Austria Information: http://www.myers.org 30.03.12 JOURNEE DE PRINTEMPS DE LA SIAD Theme : Tumeurs malignes du foie Paris, France Information: siad@sfradiologie.org 15-18.04.12 THE BREAST COURSE 2012 Lisbon, Portugal Information: info@thebreastpractices.com 20-22.04.12 CEUS 2012 Contrast enhanced ultrasound and new technologies Prague, Czech Republic Information: www.crs.cz / www.ceus.cz

03-06.05.12 27TH CONGRESS OF RADIOLOGY ICR 2012 Sao Paulo, Brasil Information: www.icr2012.org

22.06.12 ESTI EUROPEAN SOCIETY OF THORACIC IMAGING London, UK Information: www.esti-society.org

12-15.06.12 ESGAR 2012 23TH ANNUAL MEETING AND POSTGRADUATE COURSE Edinburgh, UK Information: www.esgar.org

15-19.09.12 CIRSE 2012 Lisbon, Portugal Information: www.cirse.org

16.06.12 9EME JOURNEE DE RADIOLOGIE HEPATOBILIAIRE ET DIGESTIVE DU CH BICETRE PAUL BROUSSE Paris, France Organization: Pr. M.F. Bellin, Dr F. Kunstlinger, Pr. M. Lewin Information: veronique.rey@bct.aphp.fr

19 ou 23.10.12 JOURNÉES FRANÇAISES DE RADIOLOGIE Paris, France Information: sfr@sfradiologie.org 25-30.11.12 RSNA 2012 Chicago, USA Information: www.rsna.org

Grants kopie_Opmaak 1 23/02/12 09:47 Pagina 59

ANNOUNCEMENT STUDY GRANTS OF THE BELGIAN SOCIETY OF RADIOLOGY

BOURSE DE LA SOCIETE ROYALE BELGE DE RADIOLOGIE

BEURS VAN DE KONINKLIJKE VERENIGING VOOR RADIOLOGIE

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.

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.

Règlement

Reglement

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.

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.

2. a) Bourse de voyage :

2. a. Voor de reisbeurs:

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 :

BELGISCHE

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:

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.

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.

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

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

5. a) Bourse de voyage :

5. a. Reisbeurs:

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.

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.

Grants kopie_Opmaak 1 23/02/12 09:47 Pagina 60

b) Bourse de recherche :

b. Researchbeurs:

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

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

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.

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.

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.

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.

8. a) Bourse de voyage :

8. a. Reisbeurs:

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 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 dès son attribution. Le reliquat sera versé après le rapport présenté auprès du Bureau.

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.

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

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

Bourse de la SRBR pour la recherche à l’étranger / KBVR beurs voor Research in het buitenland and Bourse couvrant des frais de these / Beurs terugbetaling onkosten thesis See previous issues of JBR-BTR.

00b-JBR-Adv.index-2011-6_JBR-Adv.index-2003/6 16/02/12 13:58 Pagina 1

Advertising Index ................................... FUJI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . HOLOGIC . . . . . . . . . . . . . . . . . . . . . . . . . . . BRACCO . . . . . . . . . . . . . . . . . . . . . . . . . . . . MEDICOR . . . . . . . . . . . . . . . . . . . . . . . . . . . GUERBET . . . . . . . . . . . . . . . . . . . . . . . . . . . GE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . AVNET . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Pages III IV VI, VIII IX X, XI XII CIV

Advertising Firms Avnet Comm. VA

GE Medical Systems

Siemens n.v./s.a.

Kouterveldstraat 20 1831 Diegem Tel. 02/709 93 13 Fax 02/709 93 33 Mr. S. Stevens

Kouterveldstraat 20 1831 Diegem Victor Cuyckens – Zone Sales Manager BeLux

Business Park Marie Curie Square 30 1070 Brussel/Bruxelles Tel. 02/536 45 70 Fax 02/536 45 77 Mr. G. Descamps

Bracco Imaging Europe n.v./s.a. Belgian Branch Avenue Pasteurlaan 6 1300 Wavre Tel. 010/68 63 76 Fax 010/68 63 63 Mrs. N. Maes

Hologic n.v./s.a. Leuvensesteenweg 250 A 1800 Vilvoorde Tel. 02/711 46 80 Fax 02/725 20 87 Mr. E. Coppens

Fuji Medical Systems Benelux Europark Noord 25 9100 Sint-Niklaas Tel. 03/760 03 33 Fax 03/766 699 Mr. G. Van Acker

Medicor Medical Supplies n.v./b.a. Timmerik 2 3020 Herent Tel. 16 27 18 18 Fax 16 22 44 23

Editor: Professor J. PRINGOT, Koning Leopold III laan 20, B-3001 HEVERLEE Lid van de Unie van de Uitgevers van de Periodieke Pers Membre de l’Union des Editeurs de la Presse Périodique Printed in Belgium by UNIVERSA PRESS, Honderdweg 24 - B-9230 WETTEREN

Project2_Opmaak 1 11/10/11 14:53 Pagina 1

The biggesT For The smallesT deTails. The smallest details count when one has to take an important decision. This is why EIZO developed the RX840 for Class A and B radiology diagnoses. Unique and impressive : an 8 megapixel resolution on a 36 inch monitor. On this enormous surface you will clearly see the fine structures as well in monochrome as in colour. A dual 3 megapixel at full size and more....

◆ ◆ ◆ ◆ ◆

91 cm (36") LCD for diagnosis (class A and B) 8 megapixel resolution in monochrome and colour Long life LED backlights Integrated front sensor for grayscale calibration 5 year warranty with brightness guarantee

More information on www.radiforce.com

YEARS WARRANTY

EIZO RadiForceTM RX840