JBR 2012-3 by office

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WETTEREN 1

P 702083

Volume 95 Page 123-190 May-June

Bimonthly

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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)

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

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JBR-BTR ♦ 95/3 ♦ 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

SHORT REPORTS The following section consists of short case reports published through the courtesy of the Editors of “Radiological Documents” and supported by Guerbet The edition – text and figures – is also available on RBRS website at http:www.rbrs.org Paraganglioma of the cavernous sinus A. Arain, J. Vandevenne, B. Depeuter, J. Smits, F. Weyns, Y. Palmers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124 Intrapelvic hibernoma: an incidental finding B. Arys, A. Van Landeghem, G. Villeirs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126 Alcoholic pancreatitis and midgut malrotation M.A. Barree, L. Spaargaren, L.F. Crobach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128 Small bowel infarction due to mesenteric venous thrombosis R.M. Blom, P. Bracke, H. Brusselaers, H. Degryse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130 Fibroadenoma of the breast with positive PET-scan D.S. Clement, P.J. van Diest, M.A. Fernandez, J.E. Huijbregts, P.A. de Jong . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132 Acute cholecystitis with aneurysm of aberrant right subclavian artery M.D. de Jong, W. Setz-Pels, B.G. Looij, M.J. Rutten . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134 Pseudoaneurysm of the cystic artery L. Dewachter, T. Dewaele, F. Rosseel, I. Crevits, P. Aerts, R. De Man . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136 Dyke-Davidoff-Masson syndrome A. Dilli, I. Gunes Tatar, B. Keyik, B. Hekimoglu . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138 Lymphomatoid granulomatosis F. Dister, B. Ghaye . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140 Epilectic seizure due to neuroglial cyst M. Eyselbergs, F.M. Vanhoenacker, K. De Cuyper, D. Kools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142 Central neurocytoma H.T. Hulsen, W.J. Van Rooij, J.P. Peluso, M. Sluzewski . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144 Huge thymic cyst in an adult N. Karabulut, D. Herek, S¸ Çalı¸skan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146 Torsion of the wandering spleen E. Kocakoc, A. Kayali, T. Ozturk, F. Ozturk, P. Gundogan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148 Round pneumonia R. Köhne, N. Karabulut, D. Herek . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150 Diffuse intestinal ganglioneuromatosis of the ileum I. Lefere, I. Dalle, H. Thieren, S. Decock, K. Ramboer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152 Epipericardial fat necrosis G. Mazzamuto, B. Ghaye . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154 Fragile x-associated tremor/ataxia syndrome A.S. Michel, B. Claikens . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156 Bilateral cervical spondylolysis B. Pilet, B. De Foer, H. Cuykx, M. Pouillon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158 Emphysematous cystitis D. Rommel, B. Ghaye . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160 Nodular regenerative hyperplasia of the liver and portal thrombosis M. Ruhi Onur, A. Kürsad Poyraz, E. Kocakoç . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162 Synovial chondromatosis of the temporomandibular joint R.R. van Dijk, M.J. Rutten . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164

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Lung emphysema caused by marijuana smoking A. Van Landeghem, B. Arys, C. Heyse, R. Gosselin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166 Osteosarcoma of the maxilla F.M. Vanhoenacker, M. Camerlinck, D. De Vuyst, K. Chapelle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168 Medial plica syndrome of the left knee F.J. Wessels, B.C. van der Wal, M. Nix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170 Clear cell sarcoma of the ankle H.W. Wiersma, M.C de Jonge, J. Bras, G.R. Schaap, M. Maas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172

IMAGES IN CLINICAL RADIOLOGY Duplicate inferior vena cava continuing as a hemiazygos continuation draining into the right atrium via persistent left superior vena cava. J. Joskin, N. Bleus, T. Couvreur, L. Tselikas, M. Milicevic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174 Eustachian tube lumen opening into an abnormally pneumatized sphenoid bone. P. Bosschaert, A.-L. Hiel, J. Vilain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175 Idiopathic hypoparathyroidism as a cause of extensive intracranial calcification. S. Khalid, S. Zaheer, S. Wahab, I. Mubarak . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176 Pulmonary Langerhans histiocytosis and eosinophilic granuloma. M. Demeter, Y. Vankan, F. De Somer, D. Perdieus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177 Intestinal intussusception in an infant. C.H. Lee, W.P. Chan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178 Subacute combined spinal degeneration caused by cobalamin deficiency. B. Versyck, T. De Beule, O. Bladt, P. Vanhoenacker . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179 Spontaneous pneumomediastinum: a rare complication of idiopathic pulmonary fibrosis. W.Y. Lee, S. Faruqi, J. Kastelik . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180 Congenital bronchial atresia: a fortuitous diagnosis. V. Balthasar, L. Médart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181 Unusual cause of internal knee derangement. P. Simoni, C. Maréchal, L. Scarciolla, D. Salerno, B. Beomonte Zobel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182 Abstract of papers for full membership at the Royal Belgian Society of Radiology

. . . . . . . . . . . . . . . . . . . . . . . 183

Proceedings of the Foot and Ankle meeting, Leiden, 25.03.2011 (part II) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184 Classified services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189 Forthcoming Courses and Meetings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 190 Instructions to Authors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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

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

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Aegis, Affirm, ATEC, Celero, Discovery, Eviva, Fluoroscan, ImageChecker, MammoPad, MultiCare, Quantra, SecurView, Selenia, Dimensions, Sentinelle, StereoLoc II, Trident and associated logos are trademarks of Hologic, Inc. and/or its subsidiaries in other countries.

02-voorblz-12-6_Opmaak 1 26/06/12 08:45 Pagina 2

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

Editor: J. Pringot Managing Editor: P. Seynaeve

President: J.F. De Wispelaere

Associated Editor: H. Degryse

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: M. Lemort, 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 JBR-BTR 2012, 95-2: p. VI)

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.

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Well-balanced contrast media

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Mastership 1 in detection,

delineation and characterization • about 50 % is eliminated via the renal pathway • about 50 % is eliminated via the biliary pathway.

Optimized Workflow of Liver MRI

• complete patient work up within 20–30 minutes in total • resulting in cost savings and higher patient throughput

NAME OF THE MEDICINAL PRODUCT Primovist 0.25 mmol/ml, solution for injection, pre-filled syringe QUALITATIVE AND QUANTITATIVE COMPOSITION Each ml contains 0.25 mmol gadoxetate disodium (Gd EOB DTPA disodium), equivalent to 181.43 mg gadoxetate disodium. 1 prefilled syringe with 5.0 ml contains 907 mg gadoxetate disodium, 1 prefilled syringe with 7.5 ml contains 1361 mg gadoxetate disodium, 1 prefilled syringe with 10.0 ml contains 1814 mg gadoxetate disodium. Contains 11.7 mg sodium/ ml. PHARMACEUTICAL FORM Solution for injection, prefilled syringe: Clear, colourless to pale yellow liquid free from visible particles. CLINICAL PARTICULARS Therapeutic indications Primovist is indicated for the detection of focal liver lesions and provides information on the character of lesions in T1-weighted magnetic resonance imaging (MRI). This medicinal product is for diagnostic use by intravenous administration only. Posology and method of administration Method of administration Primovist is a ready-to-use aqueous solution to be administered undiluted as an intravenous bolus injection at a flow rate of about 2 ml/sec. After the injection of the contrast medium the intravenous cannula/ line should be flushed using sterile 9 mg/ml (0.9 %) saline solution. Posology The recommended dose of Primovist is for Adults: 0.1 ml per kg body weight Primovist. Repeated use: No clinical information is available about repeated use of Primovist. Additional information on special populations Impaired renal function. Use of Primovist should be avoided in patients with severe renal impairment (GFR < 30 ml/min/1.73m2) and in patients in the perioperative liver transplantation period unless the diagnostic information is essential and not available with non-contrast enhanced MRI (see section 4.4). If use of Primovist cannot be avoided, the dose should not exceed 0.025 mmol/kg body weight. More than one dose should not be used during a scan. Because of the lack of information on repeated administration, Primovist injections should not be repeated unless the interval between injections is at least 7 days. Patients with hepatic impairment: No dosage adjustment is necessary. Paediatric population: The safety and efficacy of Primovist has not been established in patients under 18 years old. Therefore, use of Primovist in this patient group cannot be recommended. Elderly population (aged 65 years and above). No dosage adjustment is considered necessary. Caution should be exercised in elderly patients. Contraindications Hypersensitivity to the active substance or to any of the excipients. Undesirable effects Summary of the safety profile: The overall safety profile of Primovist is based on data from more than 1,900 patients in clinical trials, and from post-marketing surveillance. The most frequently observed adverse drug reactions (≥ 0.5 %) in patients receiving Primovist are nausea, headache, feeling hot, blood pressure increased, back pain and dizziness. The most serious adverse drug reaction in patients receiving Primovist is anaphylactoid shock. Delayed allergoid reactions (hours later up to several days) have been rarely observed. Most of the undesirable effects were transient and of mild to moderate intensity. Tabulated list of adverse reactions The adverse drug reactions observed with Primovist are represented in the table below. They are classified according to System Organ Class (MedDRA version 12.1). The most appropriate MedDRA term is used to describe a certain reaction and its synonyms and related conditions. Adverse drug reactions from clinical trials are classified according to their frequencies. Frequency groupings are defined according to the following convention: common: ≥ 1/100 to < 1/10; uncommon: ≥ 1/1,000 to < 1/100; rare: ≥ 1/10,000 to < 1/1,000. The adverse drug reactions identified only during post-marketing surveillance, and for which a frequency could not be estimated, are listed under ‘not known’. Within each frequency grouping, undesirable effects are presented in order of decreasing seriousness. Adverse drug reactions reported in clinical trials or during post-marketing surveillance in patients treated with Primovist System Organ Class (MedDra): Immune system disorders Not known Hypersensitivity /anaphylactoid reaction (e.g. shock*, hypotension, pharyngolaryngeal edema, urticaria, face edema, rhinitis, conjunctivitis, abdominal pain, hypoesthesia, sneezing, cough, pallor); System Organ Class (MedDra) Nervous system disorders; Common Headache Uncommon Vertigo, Dizziness, Dysgeusia, Paresthesia, Parosmia Rare Tremor, Akathisia Not known Restlessness System Organ Class (MedDra) Cardiac disorders Rare Bundle branch block, Palpitation Not known Tachycardia System Organ Class (MedDra) Vascular disorders Uncommon Blood pressure increased, Flushing System Organ Class (MedDra) Respiratory, thoracic and mediastinal disorders Uncommon Respiratory disorders, (Dyspnea*, Respiratory distress) System Organ Class (MedDra) Gastrointestinal disorders Common Nausea Uncommon Vomiting, Dry mouth Rare Oral discomfort Salivary hypersecretion System Organ Class (MedDra) Skin and subcutaneous tissue disorders Uncommon Rash Pruritus** Rare Maculopapular rash, Hyperhidrosis System Organ Class (MedDra) Musculoskeletal and connective tissue disorders Uncommon Back pain System Organ Class (MedDra) General disorders and administration site conditions Uncommon Chest pain, Injection site reactions, (various kinds)***, Feeling hot, Chills, Fatigue, Feeling abnormal Rare Discomfort Malaise * Life-threatening and/or fatal cases have been reported. These reports originated from post-marketing experience. **Pruritus (generalized pruritus, eye pruritus) ***Injection site reactions (various kinds) comprise the following terms: Injection site extravasation, injection site burning, injection site coldness, injection site irritation, injection site pain Description of selected adverse reactions Laboratory changes such as elevated serum iron, elevated bilirubin, increases in liver transaminases, decrease of hemoglobin, elevation of amylase, leucocyturia, hyperglycemia, elevated urine albumin, hyponatremia, elevated inorganic phosphate, decrease of serum protein, leucocytosis, hypokalemia, elevated LDH were reported in clinical trials. ECGs were regularly monitored during clinical studies and transient QT prolongation was observed in some patients without any associated adverse clinical events. Cases of nephrogenic systemic fibrosis (NSF) have been reported with other gadolinium-containing contrast agents. MARKETING AUTHORISATION HOLDER Bayer SA-NV J.E. Mommaertslaan 14, 1831 Diegem (Machelen) MARKETING AUTHORISATION NUMBER(S): Prefilled syringe 10ml BE281443 DATE OF REVISION OF THE TEXT 2011-09-28 DELIVERY: medical prescription L.BE.12.2011.0718 1 Hammerstingl et al. Diagnostic effi cacy of gadoxetic acid (Primovist)-enhanced MRI and spiral CT for a therapeutic strategy: comparison with intraoperative and histopathologic findings in focal liver lesions ; Eur Radiol 2008; 18:457–467

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Improving diagnosis of major diseases

May 2012 â&#x20AC;&#x201C; Design : ÂŠ

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Guerbet is an international pharmaceutical group specialized in medical imaging. It offers a complete range of contrast agents for MRI, X-ray and interventional radiology. It also supplies injectors and medical devices adapted to medical imaging. Guerbet contributes to progress in diagnosis and enhances the efficacy of therapeutic strategies for patients suffering from cardiac, cancerous and neurological diseases.

Ann Presse A4 mai 2012VA copie.indd 1

15/05/12 10:00

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

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e l t a d Up e dica g in mimag in

Update in Abdominal and Urogenital Imaging Congress Centre Oud Sint-Jan Bruges, Belgium 6-8 September 2012

2012 ABDOMINAL & UROGENITAL

Organising Committee Bart Claikens (Ostend, Belgium) President Pablo R Ros (Cleveland, USA) Visiting-President Patrick Van Wettere (Ostend, Belgium) Vice-President

Faculty Members

Pablo R Ros (Cleveland, OH, USA) Carlo Bartolozzi (Pisa, Italy) Julia Fielding (Chapel Hill, NC, USA) Jurgen Fütterer (Nijmegen, the Netherlands) Bernd Hamm (Berlin, Germany) Koen Mortelé (Boston, MA, USA) Julien Puylaert (The Hague, the Netherlands) Richard Semelka (Chapel Hill, NC, USA) Thomas Vogl (Frankfurt, Germany)

Freddy Avni (Brussels, Belgium) Etienne Danse (Louvain-la-Neuve, Belgium) Filip Deckers (Antwerp, Belgium) Philippe Lefere (Roeselare, Belgium) Bart Op de Beeck (Antwerp, Belgium) Lieven Van Hoe (Aalst, Belgium) Dirk Vanbeckevoort(Leuven, Belgium) Filip Vanhoenhacker (Antwerp-Mechelen, Belgium) Geert Villeirs (Ghent, Belgium)

www.update-medical-imaging.be 15:11

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ANNOUNCEMENT and CALL FOR ABSTRACTS

3rd International CAA Conference

CEREBRAL AMYLOID ANGIOPATHY AND RELATED MICROANGIOPATHIES October 24-26, 2012 Leiden University Medical Center, Leiden, The Netherlands The goal of the conference is to bring together leading international experts in Î˛-amyloid metabolism, vascular biology, neuropathology, stroke genetics, brain imaging, and the clinical manifestations of cerebrovascular disease to present and discuss cutting-edge data in this rapidly developing field. A special focus will be moving the field towards clinical trials of candidate diseasemodifying treatments, in particular by establishing consensus on preclinical animal data and human biomarkers for CAA trials. Other topics of discussion will be early detection methods for presymptomatic CAA and the biological and clinical interactions between CAA and Alzheimerâ&#x20AC;&#x2122;s disease. The atmosphere for discussion is anticipated to be informal and lively, with ample opportunities for forming new collaborations and relationships within the growing CAA scientific and clinical communities.

Registration and information: Registration and information: www.boerhaavenascholing.nl www.boerhaavenascholing.nl Details: www.rbrs.org

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JBRâ&#x20AC;&#x201C;BTR, 2012, 95: 124-125.

PARAGANGLIOMA OF THE CAVERNOUS SINUS A. Arain, J. Vandevenne, B. Depeuter, J. Smits, F. Weyns, Y. Palmers1 Key-word: Paraganglioma

Background: A 15-year-old girl presented in a Dutch hospital with right-sided trigeminal neuralgia. MR-imaging showed a mass lesion in the right cavernous sinus. Differential diagnosis in this hospital was a meningioma or a schwannoma. The patient was referred to the neurosurgery department of our hospital, and resection of the lesion was planned. At surgery, the lesion presented as a subdural bulge surrounded by swollen venous structures. The incision of the dura resulted in profuse hemorrhage of arterial origin, and hemostasis was obtained with difficulty. The tumor showed a fibrillar structure and a strong arterial vascularization which was not concordant with schwannoma. No further exploration of the lesion was performed, and no biopsy was obtained. To clarify the unexpected surgical findings and to reach a diagnosis without biopsy, pre-operative MR-images were reviewed. Digital subtraction angiography (DSA) was performed postoperatively. The lesion did not take up FDG on PET scan. Laboratory results showed increased catecholamines in the urine.

E 1A 1B

1. Department of Medical Imaging, Campus Sint-Jan, Ziekenhuis Oost-Limburg, Genk, Belgium.

Fig.

1C 1D 1E

arain-_Opmaak 1 15/06/12 08:52 Pagina 125

PARAGANGLIOMA OF THE CAVERNOUS SINUS — ARAIN et al

Work-up MRI of the brain (Fig. 1) shows on axial T1weighted image (A) a mass lesion located in the right cavernous sinus. Coronal T2-weighted image (B) demonstrates a heterogeneous lesion with ‘salt and pepper’-appearance, in the right cavernous sinus. Axial contrast-enhanced T1-weighted image (C) visualizes strong contrast enhancement of the lesion. On relative Cerebral Blood Volume (CBV) map of perfusion MRI (D), the relative cerebral blood volume (rCBV) in the lesion is nine-fold increased compared to normal brain parenchyma, suggesting strong angiogenesis. showing nine-fold increased rCBV in the lesion. Axial Time-of-Flight (TOF) image (E) shows presence of arterial flow (white arrows) within the lesion. Postoperative digital subtraction-angiography (DSA) of the cerebral vessels (Fig. 2) shows strong arterial vascularization of the lesion arising both from internal and external carotid artery branches (recurrent sphenopalatine branch of internal maxillary artery) carotid artery. Radiological diagnosis The most likely diagnosis is a large, hypervascular paraganglioma or glomus tumor of the cavernous sinus. The strong arterial vascularization as seen on TOF MR-images, DSA and surgery, together with the ‘salt and pepper’ appearance on T2-weighted MR-images, and the presence of increased catecholamine levels in the urine are the arguments in favor of this diagnosis. Discussion Paragangliomas are highly vascular neoplasms that arise from paraganglia, which serve as chemoreceptors responsible for monitoring changes in blood pH, carbon dioxide concentration, and rate of blood flow. Approximately 90% of the paragangliomas occur in the adrenal gland (pheochromocytoma), the largest collection of chromaffin cells. The remaining 10% arise from extra-adrenal sites. Most of the extra-adrenal paragangliomas arise in the abdomen (85%), with some in the thorax (12%), and some less commonly in the head and neck area (3%). Paragangliomas of the head and neck (HNP) are rare tumors of neural crest origin, comprising about 0.6% of head and neck tumors and about 0.03% of all tumors. They may occur along the paraganglia’s pathway of embryologic migration which extends from the skull base to the pelvic floor. Radiologic evaluation of glomus tumors aids in differentiating them from other neoplastic processes. Paragangliomas usual-

125

ly show a hyperintense signal on T2-weighted MRimages and a distinct contrast enhancement on T1weighted images. In larger lesions, On T1-weighted a “salt and pepper” appearance of the tumor matrix on T1- and/or T2-weighted images is characteristic. Prominent arterial vasculature associated with the main lesion may also be seen on TOF sequence of MR-images. DSA is useful in the diagnosis by providing information about vascularity and feeder vessels. CT is useful as it presents a very sensitive imaging procedure for the diagnosis of bony destructions by the paragangliomas often seen in jugular and tympanic paragangliomas. Histological evaluation is the most reliable way to confirm the diagnosis of paraganglioma. Microscopically irrespective of the site, paragangliomas have a common appearance. The tumor contains all three elements normally present in a paraganglion (i.e., type I, chief cells or granular cells; and type II, the supporting or sustentacular cells and numerous capillaries). Paragangliomas are sometimes associated with secretion of several neuropeptide hormones, such as adrenocorticotropic hormone, serotonin, catecholamine, and dopamine. The incidence of catecholamine secretion is approximately 4%. Frequently, these tumors have a low level of secretion that is not recognized clinically. The treatment options for head and neck paragangliomas include surgical resection, conventional radiation therapy, stereotactic radiosurgery, permanent embolization or a combination of these modalities. The dose commonly recommended for radiation therapy is 45 to 50 Gy; in stereotactic radiosurgery 12 to 18 Gy are usually applied. In this case the surgical resection is not performed to avoid hemorrhagic complications. The patient was referred for radiotherapy. Bibliography 1. Wasserman P.G., Savargaonkar P.: Paragangliomas: classification, pathology, and differential diagnosis. Otolaryngol Clin North Am, 2001, 34: 845-862. 2. Rao A.B., Koeller K.K., Adair C.F.: From the archives of the AFIP. Paragangliomas of the head and neck: radiologic-pathologic correlation. Armed Forces Institute of Pathology. Radiographics, 1999, 19: 1605-1632. 3. Lustrin E.S., Palestro C., Vanheesan K.: Radiographic evaluation and assessment of paragangliomas. Otolaryngol Clin North Am, 2001, 34: 881-893. 4. Boedeker C.C., Ridder G.J., Schipper J.: Paragangliomas of the head and neck: diagnosis and treatment. Fam Cancer, 2005, 4: 55-59.

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JBRâ&#x20AC;&#x201C;BTR, 2012, 95: 126-127.

INTRAPELVIC HIBERNOMA: AN INCIDENTAL FINDING B. Arys, A. Van Landeghem, G. Villeirs1 Key-word: Hibernoma

Background: A 26-year-old female patient underwent an MRI examination of the pelvis for better evaluation of a suspected uterus didelphys. On MR an incidental finding of a large mass was made.

C 1A Fig.

1B 1C

1. Department of Radiology, Ghent University Hospital, Ghent, Belgium

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INTRAPELVIC HIBERNOMA: AN INCIDENTAL FINDING — ARYS et al

Work-up

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On these images the differential diagnosis between a large benign lipoma and a “lipomalike” sarcoma was made. The patient underwent a diagnostic laparoscopy. Biopsies were taken. Histopathologic examination revealed the definitive diagnosis of intrapelvic hibernoma.

the vestiges where brown fat is found in fetuses and infants, such as the periscapular and interscapular region, the neck, axilla and shoulder, thorax, and retroperitoneum. More infrequently they can also be seen in the abdomen, thigh, buttock, popliteal fossa, and intracranial sites. Their incidence is highest in patients in the 3rd or 4th decades of life. Hibernomas manifest as slowly growing, painless, soft tissue masses. They are typically mobile and pliable and can be warm to the touch because of their hypervascularity. Normally these tumors measure 5 to 10 cm in diameter although there have been reports of hibernomas reaching 20 cm in size. MR-imaging characteristics show subtle changes in signal intensities of the hibernoma in comparison to subcutaneous fat tissue between the described cases. In most cases however the mass is slightly hypointense in comparison with the subcutaneous fat on T1-weighted images. On T2-weighted images the mass usually is iso-intense to the subcutaneous fat. Slightly more hypo- or hyperintense variants have nevertheless been described. Mild heterogeneity and internal septations are noted on many sequences, probably due to vascular tissue intermixed with the fatty components of the tumor. Treatment is complete surgical resection. Local recurrence does not occur with complete excision. Malignant transformation or metastatic spread is not reported.

Discussion

Bibliography

A hibernoma is a rare, benign, soft tissue tumor consisting of brown fat. The term was firstly used in 1914 by Gery because of its resemblance to the brown fat in hibernating animals. Hibernomas are also known as ‘lipoma of immature adipose tissue’, ‘lipoma of embryonic fat’ or ‘fetal lipoma’, since the brown fat bears a close resemblance to immature, white adipose tissue. Hibernomas usually occur in

1. Murphey M.D., Carroll J.F., Flemming D.J., et al.: From the Archives of the AFIP. Benign Musculoskeletal Lipomatous Lesions. Radiographics, 2004, 24: 1433-1466. 2. Kallas K.M., Vaughan L., Haghighi P., et al.: Hibernoma of the left axilla: a case report and review of MR-imaging. Skeletal Radiol, 2003, 32: 290-294.

MRI of the pelvis (Fig. 1) shows on coronal T2weighted image (A) a large mass (maximal diameter 11 cm) next to the left pelvic wall (black arrows) and in close vicinity to the obturator and piriform muscles. Part of the mass herniates through the intrapiriform part of the ischiadic foramen (white arrow), along the ischiadic nerve. The mass reveals high signal intensity, and is isointense to the subcutaneous fat. The didelphyc uterus (arrowheads) is displaced to the right by this mass. On axial T1weighed image (B), the mass shows high signal intensities, though slightly hypo-intense in comparison with the subcutaneous fat (arrowhead). On axial T1-weighted image with fat suppression (C), at the same level as in B the mass is of low signal intensity (arrow), though slightly hyperintense in comparison with the subcutaneous fat (arrowhead). Radiological diagnosis

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JBRâ&#x20AC;&#x201C;BTR, 2012, 95: 128-129.

ALCOHOLIC PANCREATITIS AND MIDGUT MALROTATION M.A. Barree1, L. Spaargaren2, L.F. Crobach3 Key-word: Pancreatitis

Background: A 47-year-old male patient was referred to the hospital with severe epigastric pain for 2 days, starting after the celebration of Queenâ&#x20AC;&#x2122;s Day. A chronic intermittent high alcohol intake was suspected. The patient had experienced several similar episodes of pain in the past year. Besides an increased serum amylase and gamma-glutamyltransferase (GGT) there were no other significant abnormalities on clinical and chemical examinations. Abdominal ultrasonography (US) was performed, which showed a slightly enlarged pancreas.

C D 1. Department of Radiology, Medisch Centrum Alkmaar, Alkmaar, The Netherlands, 2. Department of Radiology, 3. Department of Internal Medicine, Diaconessenhuis Leiden, The Netherlands

1 Fig.

2A 2B 2C 2D

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ALCOHOLIC PANCREATITIS AND MIDGUT MALROTATION — BARREE et al

Work-up MRCP (Fig. 1) shows normal aspect of the gallbladder and bile ducts. No stones nor congenital pancreatic duct anomalies are visible. Contrast-enhanced CT scan of the abdomen (Fig. 2) shows on A, transverse section at the level of the pancreas, a normally enhancing, but enlarged pancreas with peripancreatic fat stranding as a sign of pancreatitis. No evidence for pancreatic necrosis or cysts. Abnormal position of the duodenal-jejunal junction: this junction fails to cross the midline and lies on the right side of the abdomen. Transverse section at the level of the mesenteric root (B) demonstrates abnormal position of the superior mesenteric artery (SMA) and the superior mesenteric vein (SMV): the SMV lies to the left of the SMA. Transverse section at the level of the mid-abdomen (C) and MPR image in the coronal plane (D) visualize abnormal position of the large bowel and small intestine: the entire large bowel lies on the left and the small intestine lies on the right side of the abdomen. Radiological diagnosis The diagnosis of alcoholic pancreatitis was made on the basis of clinical history, chemical examinations and the findings on imaging. Congenital malrotation of the midgut was an incidental finding, which may have been of influence on the pancreatitis. Discussion Malrotation of the midgut occurs in approximately 1/500 live births. Midgut malrotation is a result of either incomplete or non-rotation of the fetal intestines around theth superior mesenteric th artery during the 5 to 11 week of embryonic development. Most patients with malrotation present with symptoms within 4 weeks after birth and up to 80% are diagnosed by the age of 1 year. Only a small group of patients – the precise numbers are unclear – remain asymptomatic for life or present at a later stage with acute or chronic vague abdominal pain. Most pediatric patients have acute symptoms with abdominal pain and bilious vomiting due to small bowel obstruction caused by Ladd bands. Ladd bands are abnormal fibrous bands which fixate the bowel to the abdominal wall. Other, less common presentations include malabsorption, peritonitis, biliary obstruction, solid food intolerance, chronic diarrhea from protein losing enteropathy, (recurrent) pancreatitis and vague chronic abdominal pain in older patients. In pediatric patients with suspected malrotation, upper

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gastrointestinal barium series are accurate in the detection of congenital malrotation. In adult patients midgut malrotation is not often considered due to the non-specific presentation and the low frequency in this age group. Therefore, the diagnosis is often made incidentally on routine US, CT or laparoscopy. The radiologist should be aware of this possible condition and be able to recognize some signs that give a clue in the direction of the diagnosis. Like upper gastrointestinal barium studies, CT shows an abnormal position of the bowel. The duodenal-jejunal junction (ligament of Treitz) fails to cross the midline and lies below the level of the duodenal bulb. Another important imaging finding on cross-sectional imaging (CT, US) is the abnormal relationship between the SMA and the SMV in patients with malrotation. An abnormal position of the SMV, either anterior or to the left of the SMA, is suggestive of malrotation but can also be seen in normal patients. In some patients with congenital malrotation there is an underdevelopment or absence of the uncinate process of the pancreas. Volvulus is a serious complication of malrotation which causes small bowel ischemia and is recognized by the whirlpool sign which is caused by the vessels twisting around the mesentery. A dilated duodenum indicates obstruction by Ladd bands. The most common surgical treatment of malrotation with or without volvulus is the (laparoscopic) Ladd’s procedure, first described by William E. Ladd in 1936. This procedure involves a detorsion of the volvulus, division of the Ladd bands and widening of the mesenteric base. Apart from alcohol abuse, malrotation should be considered as a cause of recurrent pancreatitis. In two reported cases of intestinal malrotation and recurrent pancreatitis, the patients were adolescents and successfully treated with laparoscopic Ladd’s procedure. Because our patient was free of complaints at the time of diagnosis, a conservative treatment was followed. Bibliography 1. Pickhardt P.J., Bhalla S.: Intestinal malrotation in adolescents and adults: Spectrum of clinical and imaging features. AJR, 2002, 179: 1429-1435. 2. Gamblin C.T., Stephens R.E.: Adult malrotation: A case report and review of the literature. Current surgery, 2003, 60: 517-519. 3. Sasaki T., Soh H.: Recurrent acute pancreatitis caused by malrotation of the intestine and effective treatment with laparoscopic Ladd’s procedure. Pediatr Surg Int, 2005, 21: 994-996. 4. Durkin E.T., Lund D.P.: Age related differences in the diagnosis and morbidity of intestinal malrotation. J Am Coll Surg, 2004, 206: 658-663.

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SMALL BOWEL INFARCTION DUE TO MESENTERIC VENOUS THROMBOSIS R.M. Blom, P. Bracke, H. Brusselaers, H. Degryse1 Key-word: Veins, mesenteric

Background: A 47-year-old male consulted the emergency department in our hospital with a history of short standing but aggravating peri-umbilical pain. In the past week he had no stools, a loss of appetite combined with episodes of nausea and vomitus. Clinical investigation showed diffuse abdominal tenderness and a distended abdomen. A contrast-enhanced CT scan of the abdomen was performed. During the further clinical work-up an intra-abdominal E. coli sepsis was diagnosed.

D 1A 1B

1. Department of Medical Imaging, AZ KLINA, Brasschaat, Belgium

Fig. 1C 1D

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SMALL BOWEL INFARCTION DUE TO MESENTERIC VENOUS THROMBOSIS â&#x20AC;&#x201D; BLOM et al

Work-up Contrast-enhanced CT scan of the abdomen (Fig. 1) shows on axial image of the abdomen at the level of the superior mesenteric vein (A) engorgement of the mesenteric vein with a central endoluminal filling defect (black arrow). Mesenteric edema is present. Rim enhancing of the wall of the vein is noted. Coronal Maximum Intensity Projection image (MIP) (B) demonstrates a filling defect in the portal vein (black arrowhead). No contrast filling of the superior mesenteric vein (black arrows) is observed. Mesenteric edema is present. Coronal MIP image (C) visualizes a bowel wall thickening of more than 3 mm (white arrow) with poor enhancement of the bowel wall. On the coronal MIP image (D), gas is seen in the mesenteric vein (white arrow). Radiological diagnosis Based on the imaging findings the diagnosis of thrombosis of the superior mesenteric vein and partial thrombosis of the portal vein, with subsequent venous infarction of the adjacent small bowel was made. Discussion Mesenteric venous thrombosis is an uncommon but potentially lethal cause of bowel ischemia. In comparison with arterial occlusive disease, which is much more frequent, venous occlusive disease makes up a much smaller percentage (10-15%) of mesenteric ischemia. Venous ischemia is more frequent in younger patients, whereas arterial ischemia is more frequent in the elderly. The nonspecific clinical signs and symptoms of mesenteric vascular disease delay the diagnosis and contribute to the high mortality and morbidity rates. Because of these high rates and the high sensitivity of contrast-enhanced CT investigations, there is an important role for the radiologist in the diagnosis of this entity. The risk of acute mesenteric venous thrombosis increases in patients with hypercoagulable states. Other pre-existing conditions or risk factors include; visceral infection, portal hypertension, perforated viscus, blunt abdominal trauma, previous abdominal surgery, pancreatitis, smoking

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and/or use oral contraceptives. Malignancy may cause thrombosis because of a hypercoagulable state or by direct extension of the tumor. One of the most frequent causes, well illustrated in our case, is intra-abdominal sepsis. No underlying cause is found in 25-50% of patients diagnosed with mesenteric venous thrombosis. Contrast-enhanced CT scan is the preferred examination technique in case of suspected mesenteric thrombosis, because it permits the combined evaluation of the vascular structures, the bowel wall as well as the adjacent mesentery. Sensitivity rates for contrast-enhanced CT reach at least 90%. CT findings of mesenteric venous thrombosis include, well-defined endoluminal filling defects of low attenuation in contrast with well-defined, rim enhancing venous walls. Collateral circulation, engorgement of the mesenteric veins and mesenteric edema may be present. Associated symptoms of bowel ischemia may be present and include a bowel wall thickening (> 3 mm) as a result of submucosal edema. The thickened wall may appear hyperattenuating due to the venous engorgement. In an advanced stadium of bowel ischemia intestinal pneumatosis may be present. Less commonly in the advanced stadia mesenterial or portal gas can be seen. Management starts with the treatment of the underlying cause and systemic administration of thrombolytic drugs. Acute venous thrombosis has a mortality rate of 30% and a recurrence risk of 25% without a proper anticoagulant therapy. Bibliography 1. Rhee R.Y., Gloviczki P., Mendonca C.T., et al.: Mesenteric venous thrombosis: still a lethal disease in the 1990s. J Vasc Surg, 1994, 20: 688-697. 2. Abdu R.A., Zakhour B.J., Dallis D.J.: Mesenteric venous thrombosis 1911 to 1984. Surgery, 1987, 101: 383-388. 3. Bradbury M.S., Kavanagh P.V., Bechtold R.E., et al.: Mesenteric venous thrombosis: diagnosis and noninvasive imaging. Radiographics, 2002, 22: 527-541. 4. Alvi A.R., Khan S., Niazi S.K., et al.: Acute mesenteric venous thrombosis: improved outcome with early diagnosis and prompt anticoagulation therapy. Int J Surg, 2009, 7: 210-213.

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JBR–BTR, 2012, 95: 132-133.

FIBROADENOMA OF THE BREAST WITH POSITIVE PET-SCAN D.S. Clement1, P.J. van Diest2, M.A. Fernandez1, J.E. Huijbregts3, P.A. de Jong1 Key-word: Breast neoplasms

Background: A 26-year-old female with multiple endocrine neoplasia type 2A presented with an elevated serum calcitonin (710 ng/L, normal range 0-12 ng/L) and carcinoembryonic antigen (CEA, 110 µg/L, normal range 0.0-3.0 µg/L) during routine checkup. Eleven years before, at the age of 15, she was surgically radically treated for a medullary thyroid carcinoma. Otherwise the medical history was unremarkable. There were no palpable abnormalities in the breasts.

B 1A 2A Fig.

Departments of 1. Radiology, 2. Pathology and 3. Nuclear Medicine, University Medical Centre Utrecht, Utrecht, The Netherlands

3B 3A 4A 4B

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FIBROADENOMA OF THE BREAST WITH POSITIVE PET-SCAN â&#x20AC;&#x201D; CLEMENT et al

Work-up On bilateral mammography (Fig. 1) (A, mediolateral view, B, craniocaudal view), an oval wellcircumscribed density is seen on the craniocaudal view medially in the right breast. The mediolateral oblique view at the right side and both views on the left side were unremarkable. Breast ultrasonography (Fig. 2) shows on A an oval well-circumscribed hypodense lesion with a maximal diameter of 16 mm is seen in the right medial upper quadrant. Under ultrasonographic guidance 14 G needle biopsies were obtained for histological analysis (B). On whole body 18F fluorodeoxyglucose PET scan (Fig. 3) (A, reformatted image in the sagittal plane, B, transverse image, a focal area of increased uptake in the medial upper quadrant of the right breast is seen. The maximum standardized uptake value (SUV-max) was 1.8. Histopathology of a PET positive fibroadenoma (Fig. 4) show on A HE staining showing normal stromal cellularity. Immunohistochemistry (B) shows about 5% stained stromal cells.

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a medullary thyroid carcinoma and also a borderline elevated calcitonin who had multiple PET positive fibroadenomas. It has been described that breast carcinomas can excrete calcitonin and CEA, but for fibroadenoma this has not been reported. Because of this previous very similar case report we hypothesise that the fibroadenoma might be the source of CEA and calcitonin elevation. In the biopsy specimen, however, CEA and calcitonin immunohistochemical stains were both negative. The other reported case concerned a 14-year-old girl with a neuroendocrine abdominal tumor and a giant fibroadenoma. It is remarkable that, in the era of increasing use of PET imaging, only very few cases of positive PET scan with fibroadenoma of the breast have been reported and that in all cases the patients were young (14, 16 and 26 years). Apparently, especially fibroadenomas at young age are positive on FDG-PET scans, although the reason remains unclear. Known variables that are associated with PET positivity, such as increased stromal cellularity, high proliferation, and Glut1 expression were not present in this reported case. Bibliography

Radiological diagnosis In a young female with multiple endocrine neoplasia and on positron emission tomography a mass lesion is detected in the right breast. Pathological examination proved the lesion to be a fibroadenoma without signs of malignancy. The percentage of stromal Ki67 positive cells was 5%. Discussion Although breast cancer or metastases to the breast are the most common causes for PET positive breast lesions, rarely also breast fibroadenoma can be a cause of a positive PET scan. To our knowledge this is only the third case of a PET positive fibroadenoma described in the literature. One previous case was interestingly a 16-year-old girl with

1. Basu S., Nair N., Thorat M., et al.: Uptake characteristics of FDG in multiple juvenile cellular fibroadenomata of the breast: FDG-PET and histopathologic correlation. Clin Nucl Med, 2007, 32: 203-204. 2. Cove D.H., Woods K.L., Smith S.C.H., et al.: Tumor markers in breast cancer. Br J Cancer, 1979, 40: 710-718. 3. Won K.S., Gayed I., Kim E.E., et al.: Juvenile fibroadenoma of the breast demonstrated on 111in-octreotide SPECT and 18F-FDG PET/CT. Eur J Nucl Med Mol Imaging, 2007, 34: 440. 4. Bos R., van der Hoeven J.J.M., van der Wall E., et al.: Biologic correlates of 18fluorodeoxyglucose uptake in human breast cancer measured by positron emission tomography. J Clin Oncol, 2002, 20: 379-387.

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JBR–BTR, 2012, 95: 134-135.

ANEURYSM OF ABERRANT RIGHT SUBCLAVIAN ARTERY M.D. de Jong, W. Setz-Pels, B.G. Looij, M.J. Rutten1 Key-word: Arteries, subclavian

Background: A 78-year-old female was referred to our hospital with complaints of chest pain, dyspnea and dysphagia. Her medical history was unremarkable.

C 1 Fig.

1. Department of Radiology, Jeroen Bosch Hospital,’s-Hertogenbosch, The Netherlands

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ANEURYSM OF ABERRANT RIGHT SUBCLAVIAN ARTERY â&#x20AC;&#x201D; DE JONG et al

Work-up Chest X-ray (PA-view) (Fig. 1) shows tortuous and aneurysmatic aspect of the thoracic aorta with a widened superior mediastinum on the right side. Contrast-enhanced CT scan of the thorax (Fig. 2) demonstrates on transverse section at the level of the aortic arch (A) an aneurysm of the aortic arc is visible as well as an aberrant course of the right subclavian artery posterior to the trachea and esophagus. B demonstrates the broad-based aneurysmatic origin of the aberrant right subclavian artery with mural thrombus. On reformatted image in the coronal plane (C) an aneurysmatic origin of the right subclavian artery with a mural thrombus is shown. On three-dimensional CTAngiography (3D-CTA) of the thorax (Fig. 3), the posterior view reveals an aneurysmatic dilatation of the origin of the right subclavian artery and an aneurysmatic and tortuous descending aorta.

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reported in 37% of the cases. Abnormalities of the aortic arc occur early in the embryologic development as a result of incomplete regression of the paired branchial arches. The diverticulum of Kommerell at the base of an ARSA, is believed to be a remnant of the embryonic right aortic arc. The first description of an ARSA was made in 1936 by the radiologist B.F. Kommerell, who observed, during a Barium study of the esophagus, a pulsatile mass compressing the esophagus. Clinical symptoms include dyspnea, dysphagia and weight loss when compression occurs on the trachea and esophagus. However, most patients with ARSA have no related symptoms. Symptoms usually occur when ARSA becomes ectatic and tortuous. In about 80% of the patients the ARSA is located posterior to the esophagus, in 15% between the esophagus and the trachea and in 5% anterior to both.

Radiological diagnosis

Bibliography

The diagnosis of aneurysm of an aberrant right subclavian artery was made, also known as a diverticulum of Kommerell.

1. Fisher R.G., Whigham C.J., Trinh C.: Diverticula of Kommerell and aberrant subclavian arteries complicated by aneurysms. Cardiovasc Intervent Radiol, 2005, 28: 553-560. 2. Aoyagi S., et al.: Aneurysm of aberrant subclavian artery arising from diverticulum of Kommerell. Report of a case with tracheal compression. Eur J Cardio-thoracic Surg, 1997, 12: 138-140. 3. Bakker D.A., et al.: Vascular rings: a rare cause of common respiratory symptoms. Acta Paediatr, 1999, 88: 947-952.

Discussion An aberrant right subclavian artery (ARSA) arises most frequently from the left aortic arc. The entity is also known as an arteria lusoria, which is an uncommon finding with a prevalence of 0.5% (range: 0.4-3.0%). In an ARSA cohort of 22 patients, an associated diverticulum of Kommerell was

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JBRâ&#x20AC;&#x201C;BTR, 2012, 95: 136-137.

ACUTE CHOLECYSTITIS WITH PSEUDOANEURYSM OF THE CYSTIC ARTERY L. Dewachter, T. Dewaele, F. Rosseel, I. Crevits, P. Aerts, R. De Man1 Key-word: Aneurysm, abdominal

Background: A 74-year-old woman was admitted to the emergency department with severe epigastric pain, nausea and dyspnea. On physical examination the epigastric region was tender.

D 1A 1B Fig.

1. Department of Radiology, Heilig Hart Ziekenhuis, Roeselare, Belgium

2A 2B 2C 2D

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ACUTE CHOLECYSTITIS WITH PSEUDOANEURYSM OF THE CYSTIC ARTERY â&#x20AC;&#x201D; DEWACHTER et al

Work-up Ultrasonography of liver and gallbladder (Fig. 1A, arrow) shows distended gallbladder with multiple gallstones and marked wall thickening. An echolucent nodular lesion is embedded in the thickened wall of the gallbladder. On color-Doppler imaging of the hypoechoic nodule in the wall of the gallbladder (Fig. 1B), a subtle arterial flow is detected in the cystic lesion. Contrast-enhanced abdominal CT scan at the level of the upper abdomen (Fig. 2) shows on axial images (A, B, arrow) and on reformatted image in the coronal plane (C) thickened wall of the gallbladder, pericholecystic fat stranding and a strongenhancing nodule (2 cm x 1 cm) embedded in the thickened wall of the gallbladder. This nodule is in contact with the cystic artery. Fig. 2 D is the angiographic reconstruction of the upper abdominal vessels (arrow). Radiological diagnosis Based on the findings on (color-Doppler) ultrasonography and CT scan, the diagnosis of pseudoaneurysm of the cystic artery complicating acute cholecystitis was made. Careful laparoscopic cholecystectomy was performed with successful resection of the pseudoaneurysm. Discussion Pseudoaneurysm of the cystic artery is a rare entity. The majority of cases are complications of laparoscopic cholecystectomy due to excessive use of electrocautery during the dissection, causing thermal injury to the vascular wall. It is also described as a complication of acute or chronic cholecystitis, where it is believed to develop from erosion of the inflamed gallbladder into the wall of the cystic artery. Although the incidence of acute cholecystitis is high, cystic artery pseudoaneurysm remains uncommon, presumably because the surrounding inflammatory process leads to early

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thrombosis of the cystic artery. Pseudoaneurysm of the cystic artery can be an uncommon cause of hemobilia. These patients present with the Quinckeâ&#x20AC;&#x2122;s triad of gastrointestinal bleeding, right upper quadrant pain and jaundice. Imaging is important because delayed diagnosis can lead to severe complications such as hypovolemic shock due to intra-peritoneal bleeding. A correct diagnosis is also important before surgery. On ultrasound the pseudoaneurysm can easily be found as a anechoic rounded area within a thickened gallbladder wall. Color Doppler may show a pulsatile flow, although this is not always easy to detect. The diagnosis can be accurately made by contrastenhanced CT scan. CT shows a strong enhancing lesion in contact with the cystic artery and wall. This modality should replace arteriography for diagnosis. Some authors however combine a diagnostic and therapeutic arteriography with embolisation of the lesion. The latter should be the treatment of choice in the presence of a severe hemorrhage. Nevertheless in most of the cases laparoscopic cholecystectomy is performed. Bibliography 1. De Molla Neto O.L., Ribeiro M.A.F., Saad W.A.: Pseudoaneurysm of cystic artery after laparoscopic cholecystectomy. J Int Hepato Pancreato Biliary Assoc, 2006, 8: 318-319. 2. Lin C.-J., Lee R.-C., Chiang J.-H., et al.: Pseudoaneurysm of the cystic artery in acalculous cholecystitis successfully treated by transcatheter arterial ambolization: a case report. Chin J Radiol, 2007, 32: 41-44. 3. Morio Nakajima M., Hoshino H., Eiji Hayashi E., et al.: Pseudoaneurysm of the cystic artery associated with upper gastrointestinal bleeding. Gastroenterol, 1996, 31: 750-754. 4. Strickland S.K., Khoury M.B., Kiproff P.M., et al.: Cystic artery pseudoaneurysm: A rare cause of hemobilia. Cardiovasc lntervent Radiol, 1991, 14: 183-184.

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JBR–BTR, 2012, 95: 138-139.

DYKE-DAVIDOFF-MASSON SYNDROME A. Dilli, I. Gunes Tatar, B. Keyik, B. Hekimoglu1 Key-word: Brain, atrophy

Background: A 9-year-old boy was referred to the emergency department with seizures. Past medical history revealed an anoxic birth and that the boy had difficulty in learning. Physical examination revealed right-sided hemiparesis. Imaging findings.

C 1A 1B Fig. 1C

1. Department of Radiology Diskapi Yildirim Beyazit Research Hospital, Irfan Bastug Caddesi, Aydınlıkevler, Ankara, Turkey.

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DYKE-DAVIDOFF-MASSONS SYNDROME â&#x20AC;&#x201D; DILLI et al

Work-up MRI examination of the brain (Fig. 1) shows on the axial T1-weighted image (A) and the coronal T2weighted image (B) dilated cortical sulci in the left temporal and parietal region. The left ventricle is dilated. Axial T2-weighted image (C) demonstrates diffuse cerebellar atrophy and overpneumatisation of paranasal sinuses. Radiological diagnosis Based on imaging fingings the diagnosis of Dyke-Davidoff-Masson syndrome was made. Discussion Cerebral hemiatrophy or Dyke-Davidoff-Masson syndrome (DDMS) is a condition characterized by seizures, contralateral hemiplegia or hemiparesis, craniofacial asymmetry and learning difficulties. In 1993 Dyke, Davidoff and Masson described cranial asymmetry on the skull radiographs of nine patients with hemiplegia. Since then this condition was named as the DDMS. Etiological factors can be congenital malformations, vascular occlusion and infection during the prenatal period, birth trauma, anoxia, hypoxia and intracranial hemorrhage during the perinatal period and trauma, infection, prolonged febrile seizure and tumor in the postnatal period. In patients with DDMS due to congenital etiology some compensatory skull changes occur as a result of the adaptation to the atrophy of the brain substance. These compensa-

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tory changes include ipsilateral osseous hypertrophy, hyperpneumatization of the ipsilateral paranasal sinuses, enlargement of mastoid cells, elevated temporal bone, hypoplasia of the anterior/ middle cranial fossa and shift of the midline structures towards the atrophic hemisphere. Ipsilateral compensatory skull changes are not observed in acquired cases. Three patterns of cranial hemiatrophy have been described on MRI: pattern 1 with diffuse cortical and subcortical atrophy; pattern 2 with diffuse cortical atrophy associated with expanded porencephalic cysts, and pattern 3 with old infarction with necrosis in the middle cerebral arterial territory. Our patient showed the characteristics of pattern 1. In patients with DDMS clinical history is important to determine the etiology of the syndrome. Neuroradiologic workup is necessary to evaluate the extent of the condition. Bibliography 1. Aguiar P.H., Liu C.W., Leitao H., et al.: MR and CT imaging in the Dyke-Davidoff-Masson syndrome. Report of three cases and contribution to pathogenesis and differential diagnosis. Arq Neuropsiquiatr, 1998, 56: 803-807. 2. Parker C.E., Harris N., Mavalwala J.: DykeDavidoff-Masson Syndrome: five case studies and deductions from dermatoglyphies. Clin Pediatr, 1972, 11: 288-292. 3. Shen W.C., Chen C.C., Lee S.K., Ho Y.J., Lee K.R.: Magnetic resonance imaging of cerebral hemiatrophy. J Formos Med Assoc, 1993, 92: 9951000.

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JBR–BTR, 2012, 95: 140-141.

LYMPHOMATOID GRANULOMATOSIS F. Dister, B. Ghaye1 Key-word: Lymphomatoid granulomatosis

Background: A 70-year-old non smoker man presented to the pneumologist with persistent dyspnea.

D 1A 1B Fig. 1C 1D

1. Department of Medical Imaging, University Hospital Sart-Tilman, Domaine Universitaire du Sart-Tilman B, Liège, Belgium

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LYMPHOMATOID GRANULOMATOS â&#x20AC;&#x201D; DISTER et al

Work-up CT scan of the thorax (Fig. 1) shows on axial slices (lung window setting) (A,B) multiple welldefined nodules and masses in all lung zones. Maximum intensity projection (MIP) reformatted image in the coronal plane (C) shows preserved pulmonary vessels inside a lesion in the left upper lobe (arrow). Minimum intensity projection (MIP) axial view (D) demonstrates dilated bronchus in a lesion located in the lingula (arrow) and cavitation of a lesion in the left lower lobe. Radiological diagnosis Following transthoracic biopsy under CT guidance, the diagnosis of lymphomatoid granulomatosis was achieved. Discussion Lymphomatoid granulomatosis (LG) was described for the first time in 1972 by Liebow. LG represents 3% of the primary pulmonary lymphomas which represent 3-4% of the extranodal non Hodgkin lymphomas. LG is a polymorphic lymphoid infiltration invading the vascular structures and leading to angiocentric necrosis of the lung parenchyma. The infiltration is composed by large atypical CD20+ B-cells showing the LMP protein of the Epstein Barr Virus, dispersed together with small reactive T-cells. There are three subcategories of LG based on the proportion of the transformed B-cells. Grade 1 shows the lowest and grade 3 the highest amount of atypia. Grades 2 and 3 are considered to be malignant. The symptoms are mainly respiratory, including dyspnea, cough, thoracic pain and hemoptysis. Fever and weight loss can also be present. Beyond lungs, central and peripheric nervous systems, skin, kidneys and mediastinal lymph nodes can be involved. Men and women are equally reached at a

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mean age of 55 years. On chest radiography the lesions appear like nodular opacities with clear or blurred outlines, commonly predominating in the lower lobes. They have a tendency to confluence and excavate, and sometimes to migrate or disappear. On chest CT LG presents as nodular lesions localized along bronchovascular structures, that are multiple in 75% and bilateral in 60 to 80%. Most nodules measure less than 1 cm but diameters up to 10 cm have been reported. The lesions may show preserved air bronchogram and vessels inside the lesions. Distended bronchi inside the lesions have been suggested to be evocative of the diagnosis but the mechanism is still unexplained. Central necrosis is possible with formation of thin-walled cystic lesions. Hilar or mediastinal lymph nodes can be present. The differential diagnosis of multiple pulmonary nodules occasionally presenting with excavation includes: abscesses, septic emboli, Wegener or other granulomatosis, excavating pulmonary neoplastic lesions, necrotising sarcoid granulomatosis, and less frequently BALT lymphoma, ChurgStrauss disease and organizing pneumonia. The diagnosis is not based on imaging but on pathology including demonstration of the Epstein Barr Virus in situ hybridation. Bibliography 1. Wechsler R., Steiner R., Israel H., et al.: Chest Radiograph in lymphomatoid granulomatosis: comparison with Wegener granulomatosis. AJR, 1984, 142: 79-83. 2. Lee J., Tuder R., Lynch D.: Lymphomatoid Granulomatosis: Radiologic features and pathologic correlations. AJR, 2000, 175: 1335-1339. 3. Wislez M., Cadranel J., Cordier J.F.: Lymphomes pulmonaires primitifs. http://germop.univ-lyon1. fr/fr/RPA/pdf/Lpporifn.pdf 4. Dee P., Arora N., Innes D.: The pulmonary manifestations of lymphomatoid granulomatosis. Radiology, 1982, 143 :613-618.

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EPILEPTIC SEIZURE DUE TO NEUROGLIAL CYST M. Eyselbergs1,2, F.M. Vanhoenacker1,2, K. De Cuyper1, D. Kools3 Key-word: Brain, cysts

Background: A 41-year-old woman without a relevant history was admitted to the emergency department after an epileptic seizure.

D 1A 1B

Departments of 1. Radiology and of 3. Neurosurgery, AZ Sint-Maarten, campus Rooienberg, Duffel, Belgium and 2. Department of Radiology, Antwerp University Hospital, Edegem, Belgium

Fig.

2A 2B 2C 2D

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EPILEPTIC SEIZURE DUE TO NEUROGLIAL CYST — EYSELBERGS et al

Work-up CT of the brain (Fig. 1) shows on non-enhanced view (A) a large well-delineated low density lesion adjacent to the occipital horn of the left lateral ventricle. On contrast-enhanced scan (B), there is no enhancement of the lesion. MRI of the brain (Fig. 2) shows on axial T1weighted image (A) a hypointense lesion, similar to cerebrospinal fluid (CSF). Axial T2-weighted image (B) demonstrates a CSF-like fluid content. On axial FLAIR image (C), the signal is partially suppressed. Communication with the lateral ventricles is absent. There are no surrounding signal changes within the perilesional white matter. On Gadoliniumenhanced axial T1-weighted image (D), there is no enhancement of the lesion. Radiological diagnosis Based on the clinical and imaging findings, the diagnosis of a neuroglial cyst was suggested. Follow-up MRI showed slight increase of the lesion’s size. Therefore, neurosurgical drainage with subsequent resection of the cyst wall was performed. At surgical inspection, a smooth unilocular cyst, containing CSF-like fluid was seen. Histologically, the cellular lining of the cyst wall resembled ependymal epithelium, consistent with the diagnosis of a neuroglial cyst. Discussion Neuroglial cysts (NC) are rare benign epithelial lined cysts, accounting for less than 1% of all intracranial cysts. NC can be located anywhere along the neuraxis with predilection for the frontal lobes. These lesions can occur at any age but are most frequently observed in the adult population. Male and female are equally affected. NC are often incidental findings on imaging although symptoms such as headache and epileptic seizures may be present. Neurological deficits depend on location and size of the lesion. A lot of controversy exists about the precise etiology, as reflected in numerous synonyms across the international literature. Sequestration of the embryonic neural tube within the developing white matter or along the choroid fissure seems to represent the most appropriate hypothesis. CT demonstrates a well-delineated unilocular lesion with low density content and

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absence of calcifications. There is no contrast enhancement. Connection with the ventricular system is typically lacking. On MRI the lesion’s content resembles CSF on all pulse sequences. Sometimes, slight hyperintensity is seen on proton density-WI or partial signal suppression is seen on FLAIR sequences. Lesions do not show diffusion restriction and no contrast enhancement can be demonstrated after gadolinium contrast administration. There is no or only minimal perilesional gliosis on FLAIR sequences. Histological examination reveals a fluid containing cavity lined with epithelium ranging from columnar (resembling ependymal lining) to cuboidal cells (resembling plexus choroideus tissue). Immunohistochemical staining demonstrates variable expression of glial fibrillary acidic protein (GFAP) but absence of other markers of neuronal tissue. The differential diagnosis of a unilocular cystic brain lesion is extensive and includes porencephalic cyst and an enlarged Virchow Robin (VR) space. Also, an arachnoid cyst or infectious etiology are possible. A porencephalic cyst communicates with the ventricular system and surrounding signal abnormalities of the brain tissue can be demonstrated. Enlarged VR spaces occur more frequently in clusters than as an isolated unilocular cyst and show predilection for the midbrain. An arachnoid cyst is located extra-axial and lacks epithelial lining. Epidermoid cysts are usually located in the cerebellopontine angle and parasellar regions and exhibit high cholesterol content. On diffusion weighted imaging they clearly demonstrate diffusion restriction. Infectious cysts have a more prominent enhancement pattern and older lesions may calcify. When a neuroglial cyst is suspected on imaging, an initial wait-and-see policy is recommended. In case of progressive disease neurosurgical intervention should be considered with fenestration or drainage of the cyst. Bibliography 1. Kwee R.M., Kwee T.C.: Virchow-Robin spaces at MR imaging. Radiographics, 2007, 27: 1071-1086. 2. Epelman M., Daneman A., Blaser S.I., et al.: Differential diagnosis of intracranial cystic lesions at head US: correlation with CT and MR imaging. Radiographics, 2006, 26: 173-196. 3. Osborne A.G.: Neuroglial cyst In: Osborne. Brain Diagnostic Imaging, Amirsys pp 17: 19-20.

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JBRâ&#x20AC;&#x201C;BTR, 2012, 95: 144-145.

CENTRAL NEUROCYTOMA H.T. Hulsen, W.J. Van Rooij, J.P. Peluso, M. Sluzewski1 Key-word: Neurocytoma

Background: A 40-year-old man presented with short-term memory loss and behavioral changes.There was no previous medical history and neurological examination was normal.

1A Fig.

1. Department of Radiology, St. Elisabeth Hospital, Tilburg, The Netherlands

1B 2A 1C 2B

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CENTRAL NEUROCYTOMA â&#x20AC;&#x201D; HULSEN et al

Work-up MRI of the brain (Fig. 1) shows on axial turbospin-echo T1-weighted image (A) a midline intraventricular tumor with hypointense as well as hyperintense portions. On axial turbospin-echo gadolinium-enhanced T1-weighted image (B), the tumor shows moderate contrast enhancement. On axial turbospin-echo T2-weighted image, the tumor is remarkably hypointense (C). Radiographies of the skull (Fig. 2) include native images before vessel opacification during cerebral angiography (nonsubtracted images), antero-posterior view (A) and lateral view (B) on which extensive diffuse calcification of the tumor is seen. On angiography, the tumor was non-vascular (not shown). Radiological diagnosis Surgery was performed, and the tumor was completely resected. Histological examination revealed a central neurocytoma. Discussion Central neurocytoma are rare and relatively benign intraventricular neuro-epithelial tumors with neuronal differentiation (WHO grade II tumor of neuronal origin). These lesions are usually discovered in young adults, commonly at 20-40 years of age. They represent 50% of the intraventricular tumors in this age group and approximately 10% of all intraventricular masses. Less than 1% of all intracranial neoplasms are central neurocytomas. There is no gender predominance. Most common symptoms include headache, visual changes, mental status changes and seizures. MRI-images of central neurocytoma are usually characteristic. Most neurocytomas occur as exo-

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phytic, well-circumscribed, globular masses that protrude into the ventricles. Large tumors are not uncommon. Calcifi cations are common and can be easily identified on CT scan. The calcifications may be extensive, as was the case in our patient. Central neurocytomas arising in the lateral ventricles typically adhere to the septum pellucidum. Hydrocephalus is common due to obstruction of the foramen of Monro. On T1- and T2-weighted images, central neurocytomas are usually isointense to gray matter. The marked hypointensity on the T2-weighted image in the presented patient is explained by the extensive calcifications. Intratumoral hemorrhage can explain high signal on T1-weighted images, but hemorrhage is not a typical finding in central neurocytoma. Contrast enhancement is usually mild to moderate. From an imaging point of view, differential diagnosis should include oligodendroglioma, ependymoma, subependymoma, subependymal giant cell astrocytoma, choroid plexus papilloma, and intraventricular meningioma. Surgical resection is typically curative and recurrence is uncommon. Bibliography 1. Salzman K.L.: Central Neurocytoma. In: Osborn A., et al. Diagnostic Imaging: Brain. 3rd edition. Salt Lake City. Amirsys, ElsevierSaunders, 2004, 1-6: 80-83. 2. Schmidt M.H., et al.: Central neurocytoma: a review. J Neurooncol, 2004, 66: 377-384. 3. Chen Ch.-L., et al.: Central neurocytoma: a clinical, radiological and pathological study of nine cases. Clin Neurol Neurosurgery, 2008, 110: 129136.

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JBR–BTR, 2012, 95: 146-147.

HUGE THYMIC CYST IN AN ADULT N. Karabulut, D. Herek, S¸. Çalıs¸kan1 Key-word: Thymus, neoplasms

Background: A 28-year-old male smoker (6 pack-years) presented with complaints of dyspnea, cough and chest pain. Physical examination was unremarkable except for decreased respiratory sounds within anterior mid-lung zones bilaterally. Laboratory findings were within normal limits.

D 1 Fig.

1. Department of Radiology, Pamukkale University, School of Medicine, Denizli, Turkey

2A 2B 2C 2D

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HUGE THYMIC CYST IN AN ADULT â&#x20AC;&#x201D; KARABULUT et al

Work-up Chest radiograph (PA view) (Fig. 1) shows a huge mediastinal mass extending into bilateral paracardiac regions. MRI examination of the thorax (Fig. 2) included a contrast-enhanced transverse T1weighted gradient echo image with fat suppression (A), a transverse T2-weighted gradient echo image with fat suppression (B), a contrast-enhanced coronal T1-weighted gradient echo image with fat suppression (C), and a coronal T2-weighted gradient echo image with fat suppression (D) showing a multiloculated cystic anterior mediastinal mass extending outside the confines of the thymus. Furthermore a solid component arising in the right lateral wall is noticed. The septae and the solid nodule enhance after the administration of nonspecific gadolinium chelate. Radiological diagnosis Based on the imaging features, the diagnosis of huge thymic cyst harboring septae and a solid component was favored. Median sternotomy showed a well-defined multiloculated cystic mass with a solid component arising from the thymus. Histopathologic examination revealed that the cyst was lined with squamous and cuboidal epithelium. The tumor on the cyst wall contained proliferating thymic epithelial cells and numerous lymphocytes consistent with thymoma arising in a thymic cyst. Discussion The differential diagnosis of multiloculated cystic mass within the anterior mediastinum includes thymic cysts, dermoid cyst, hydatid cyst, and lymphangioma. The absence of fat and calcifi cation excludes dermoid cyst. Hydatid cysts usually harbor daughter cysts, and lymphangioma may be associated with hemorrhage. Thymic cysts are rare,

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accounting for approximately 3% of all anterior mediastinal masses. Patients are usually asymptomatic, but thymic cysts may cause dyspnea, cough, chest pain or Horner syndrome. The cysts can be classified as congenital or acquired. Congenital cysts develop from the persistent thymopharyngeal canal and are usually unilocular. On the other hand, acquired cysts are multilocular and may extend outside the confines of the thymus. Thymoma arising in a thymic cyst is very rare, and may show intracystic dissemination. Thymomas undergoing an extensive cystic degeneration may present a similar appearance with intracystic thymoma. However, the absence of an epithelial lining in the cyst wall in thymoma can differentiate it from thymic cyst with thymoma. Radiologists should be aware of the fact that thymoma can develop within a thymic cyst. An enhancing mural nodule within a multiloculated cystic mass situated in the anterior mediastinum should favor the diagnosis of thymoma arising in a thymic cyst. Bibliography 1. Davis R.D., Jr, Oldham H.N., Jr, Sabiston D.C., Jr.: Primary cysts and neoplasms of the mediastinum: recent changes in clinical presentation, methods of diagnosis, management and results. Ann Thorac Surg, 1987, 4: 229-237. 2. Sugio K., Ondo K., Yamaguchi M., et al.: Thymoma arising in a thymic cyst. Ann Thorac Cardiovasc Surg, 2000, 6: 329-331. 3. Liang S.B., Ohtsuki Y., Sonobe H., et al.: Multilocular thymic cysts associated with thymoma: a case report. Path Res Pract, 1996, 192: 1283-1287. 4. Kitami A., Kamio Y., Uematsu S., et al.: Thymoma with intracystic dissemination arising in a unilocular thymic cyst. Gen Thorac Cardiovasc Surg, 2007, 55: 281-283.

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JBRâ&#x20AC;&#x201C;BTR, 2012, 95: 148-149.

TORSION OF THE WANDERING SPLEEN E. Kocakoc, A. Kayali, T. Ozturk, F. Ozturk, P. Gundogan1 Key-word: Spleen

Background: A 27-year-old man was admitted to our hospital with a 2-day history of abdominal pain and vomiting. The pain was non-continuous, poorly localized, and non-colicky and non-radiating in nature. Over the prior 2 months, he reported one other similar episode that had resolved spontaneously. Physical examination revealed left upper abdominal quadrant tenderness and a palpable suprapubic mass. His vital signs were stable and laboratory findings were unremarkable. Plain film of the abdomen showed gas filled bowel loops in the splenic fossa.

1A Fig.

C 1. Department of Radiology, Faculty of Medicine, Firat University, Elazig, Turkey

1B 1C

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TORSION OF THE WANDERING SPLEEN — KOCAKOC et al

Work-up Contrast-enhanced CT scan of the abdomen (Fig. 1) shows on reformatted image in the coronal plane (A) absence of the spleen in the left upper quadrant. Transverse section at umbilical level (B) demonstrates enlarged and diffusely hypodense spleen at this level. Transverse section at a more cranial level (C) shows prominent splenic vessels and the surrounding fat with a whorled appearance (‘’whirl sign’’). Radiological diagnosis The clinical and radiological findings were consistent with splenic torsion. Surgery confirmed the diagnosis of torsion of the wandering spleen. Splenectomy was performed, and spleen was found to be infarcted. Discussion Laxity of the peritoneal attachments of the spleen results in splenic hypermobility, known as wandering spleen. Its incidence is less than 2 per 1000 splenectomies. The symptoms are variable and the most common is abdominal pain. Acute wandering spleen torsion can be confused with appendicitis or ovarian torsion. Contrast-enhanced CT is useful for the detection of wandering spleen torsion. It is the

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whorled appearance of the splenic vessels and surrounding fat is called ‘’whirl sign’’ which considered pathognomonic of the condition. Splenic infarction is seen as non enhancing low-attenuation areas on contrast-enhanced CT, thereby providing crucial information concerning the viability of the spleen. Another specific sign of splenic infarction on CT is the “rim sign,” in which the splenic capsule is hyperdense compared with the parenchyma. Treatment of wandering spleen is surgically because conservative treatment is associated with increased complications. Surgical treatment consists of either splenectomy or splenopexy. Bibliography 1. Fujiwara T., Takehara Y., Isoda H., et al.: Torsion of the wandering spleen: CT and angiographic appearance. J Comput Assist Tomogr, 1995, 19: 84-86. 2. Herman T.E., Siegel M.J.: CT of acute splenic torsion in children with wandering spleen. AJR, 1991, 156: 151-153. 3. Raissaki M., Prassopoulos P., Daskalogiannaki M., et al.: Acute abdomen due to torsion of wandering spleen: CT diagnosis. Eur Radiol 1998, 8: 1409-1412. 4. Singla V., Galwa R.P., Khandelwal N., et al.: Wandering spleen presenting as bleeding gastric varices. Am J Emerg Med, 2008, 26: 637.e1-4.

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JBR–BTR, 2012, 95: 150-151.

ROUND PNEUMONIA R. Köhne, N. Karabulut, D. Herek1 Key-word: Pneumonia

Background: A 55-year-old male smoker (60 pack-years) presented to the emergency department with the complaint of high fever and cough for two days. His medical history revealed that he had seizures for ten years and was been suffering from Parkinson’s disease for 3 years. On physical examination he was tachypneic and febrile. Complete blood count revealed elevated white blood cell count (14200/mm3). The results of the serum biochemistry tests were within normal limits.

1 Fig.

C 1. Department of Radiology, Pamukkale University, School of Medicine, Denizli, Turkey

2A 2B 2C

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ROUND PNEUMONIA — KÖHNE et al

Work-up On scout view of the chest (AP view) (Fig. 1) a homogeneous mass in the left mid-lung zone is observed. CT scan of the thorax (Fig. 2) shows on transverse section at the level of the aortic root (mediastinal window setting) (A), transverse section at the level of aortic root (lung window setting) (B), and MPR image, in the coronal plane (lung window setting) (C) a focal area of round consolidation abutting the pleura with surrounding ground-glass attenuation in the lingula.

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canals or by destroying the walls of surrounding is responsible for the nonsegmental pattern. The patients are usually symptomatic including fever, cough, dyspnea and chest pain. Radiologic features of round pneumonia can range from a small dense mass to a large ill-defined rounded opacity. It follows a benign course, and resolves with antibiotics. The radiological findings often mimic those of bronchogenic carcinoma in adults. This is particularly important when the lesion is detected in asymptomatic elderly patients. Clinicians and radiologists must be aware of this pattern of pneumonia to avoid mislabelling it as tumor which may lead to unnecessary interventions.

Radiological diagnosis Based on the clinical and imaging findings, round pneumonia was diagnosed. The patient was hospitalized and treated with a 14-day course of ceftriaxone 2 x 1 gr/day. The consolidation resolved on follow-up CT scan after two weeks. Discussion Round pneumonia, defined as an oval or round shaped consolidation in a nonsegmental pattern, is a rare form of lung infection. Although it is a wellrecognized entity in children, it is rare in adult. Streptococcus pneumoniae is the most common causative microorganism resulting in roun pneumonia. Although the exact pathogenesis is unknown, it is postulated that atypical centrifugal dissemination of the exudative fluid either by travelling through the pores of Kohn and Lambert

Bibliography 1. Camargo J.J., Camargo S.M., Machuca T.N., et al.: Round pneumonia: a rare condition mimicking bronchogenic carcinoma. Case report and review of the literature. Sao Paulo Med J, 2008, 126: 236-238. 2. Wagner A.L., Szabunio M., Hazlett K.S., et al.: Radiologic manifestations of round pneumonia in adults. AJR, 1998, 170: 723-726. 3. Soubani A.O., Epstein S.K.: Life-threatening “round pneumonia”. Am J Emerg Med, 1996, 14: 189-191. 4. Zylberman M., Cordova E., Farace G.: Round pneumonia in adults, an unusual presentation of lung parenchyma infection: a report of two cases and review of the literature. Clinical Pulmonary Medicine, 2006, 13: 229-231.

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JBR–BTR, 2012, 95: 152-153.

DIFFUSE INTESTINAL GANGLIONEUROMATOSIS OF THE ILEUM I. Lefere1, I. Dalle2, H. Thieren3, S. Decock4, K. Ramboer1 Key-word: Ganglioneuroma

Background: A 39-year-old man presented with nonspecific abdominal pain. He was known with neurofibromatosis type I, with history of café-au-lait spots, multiple cutaneous neurofibromas and osteoporosis. Findings on contrast-enhanced CT scan were rather nonspecific, but inflammatory small bowel disease was suspected.

B 1A 2A Fig. 1B 2B

Departments of 1. Radiology, 2. Pathology, 3. Abdominal Surgery and 4. Internal Medicine, Sint-Lucas Hospital, Brugge, Belgium

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DIFFUSE INTESTINAL GANGLIONEUROMATOSIS OF THE ILEUM — LEFERE et al

Work-up Contrast-enhanced CT scan of the abdomen (Fig. 1) shows on transverse image at umbilical level (A) dilatation of the preterminal ileum over a length of 20-30 cm. Diffuse, asymmetric wall thickening of the mesenterial bowel wall of this segment (arrows). The terminal ileal loop appears normal. On reformatted image (coronal plane) (B) multiple nodules are observed in the mesenterium adjacent to thickened wall (arrows). CT enteroclysis (Fig. 2) demonstrates on transverse image at infra-umbilical level (A) the asymmetric aspect of the wall thickening in the preterminal ileum (arrows). Hypovascular tape-like infiltration of the mesenterial fat parallel to the bowel wall is noted. Reformatted image (coronal plane) (B) confirms the nodular infiltration of the mesenterium (arrow). Radiological diagnosis Differential diagnosis in the presented case includes Whipple disease, nonspecific Crohn’s disease and lymphoma or carcinoïd tumor with diffuse infiltration of the ileum. Resection of the small bowel was performed. Pathologic examination revealed submucosal proliferation of neuroid cells and ganglion cells, with extension into the mucosa and serosa. These findings are diagnostic for diffuse intestinal ganglioneuromatosis of the preterminal ileum. Discussion Neurofibromatosis type I or von Recklinghausen disease is a genetic disorder, inherited in an autosomal dominant pattern, with incidence of approximately 1:3000. The disease presents with a broad spectrum of tumoral lesions, predominantly neuro ectodermal or mesenchymal in origin, resulting from abnormal tumor suppression. These lesions may occur in a variety of organs and tissues. In 1025% of patients, the gastro-intestinal tract is involved, the most common abdominal neoplasms in NF1 being neurofibromas. Ganglioneuromas are rare, benign tumors, that arise from sympathetic ganglia. They contain mature Schwann cells, ganglion cells and nerve fibres, and may appear anywhere along the parasympathic plexus and in the adrenal medulla. Rarely, they occur in the gastro -

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intestinal tract. Ganglioneuromas of the bowel may present as solitary lesions, or as multiple polyps affecting the colon and the terminal ileum, termed ganglioneuromatosis polyposis. The polypoid form of ganglioneuromatosis has no proven association with neurofibromatosis or other syndromes. A third form, diffuse ganglioneuromatosis, is associated with syndromes such as neurofibromatosis type I and multiple endocrine neoplasia IIb (MEN IIb). It consists of hyperplasia of the myenteric plexus and infiltration of ganglioneuromatous tissue in the bowel wall. This leads to thickening of the bowel wall, sometimes with transmural extension and eventually stricture formation. In most reported cases, the large intestine is involved, but the terminal ileum and the appendix may also be affected. Affected patients may present with acute intestinal obstruction or nonspecific complaints due to motility disorders. Due to its rarity, diffuse intestinal ganglioneuromatosis is easily missed or misdiagnosed. When the terminal ileum is affected, radiographic findings may show circumferential bowel wall thickening, suggesting Crohn’s disease or intestinal lymphoma. However, recognizing this entity is important, as the only therapeutic option is resection of the affected bowel. Furthermore, bowel involvement can be the first manifestation of neurofibromatosis. In these cases, a correct diagnosis has considerable implications for further management. In the presented case, the preterminal ileum was affected, while the terminal ileal loop and colon remained normal. Another interesting finding in this case are the mesenterial nodules. These were first considered enlarged lymph nodes, but pathological examination revealed they corresponded to ganglioneuromatous proliferations in the mesenterium. Bibliography 1. Levy A.D., Patel N., et al.: Abdominal Neoplasms in Patients with Neurofibromatosis Type 1: Radiologic-Pathologic Correlation. RadioGraphics, 2005, 25: 455-480. 2. Charagundla S.R., Levine M.S., et al.: Diffuse Intestinal Ganglioneuromatosis mimicking Crohn’s disease. AJR, 2004, 182: 1166-1168. 3. Thway K., Fisher C.: Diffuse ganglioneuromatosis in small intestine associated with neurofibromatosis type 1. Ann Diagn Pathol, 2009, 13: 50-54.

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JBRâ&#x20AC;&#x201C;BTR, 2012, 95: 154-155.

EPIPERICARDIAL FAT NECROSIS G. Mazzamuto, B. Ghaye1 Key-word: Fat necrosis

Background: A 64-year-old man presented with acute left chest pain of 3 days duration. The pain increased during palpation of the 6th and 7th anterior intercostal spaces. The physical examination, ECG and laboratory tests were normal.

1A Fig.

1. Department of Medical Imaging, UCL St Luc, Brussels, Belgium

1B 2

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EPIPERICARDIAL FAT NEOCROSIS — MAZZAMUTO et al

Work-up Contrast-enhanced CT scan of the chest on admission (Fig. 1) shows on transverse section at the level of the heart (A) a rounded lesion (arrow) adjacent to the left antero-lateral part of the pericardium. The lesion shows a central area of low attenuation (-80 HU) and is surrounded by a capsule of higher density. The nearby pericardium is slightly thickened. Coronal reformatted image (B) confirms the rounded shape of the lesion (arrow). The thickened pericardium (arrowheads) in contact with the lesion is better demonstrated on this image plane. Follow-up chest CT scan performed 2 weeks later, following anti-inflammatory drug treatment (Fig. 2) demonstrates complete resolution of the lesion. Radiological diagnosis Based on chest CT scan and clinical findings, the diagnosis of epipericardial fat necrosis was made. Control CT after 2 weeks of anti-inflammatory drugs showed disappearance of the lesion. Discussion Fat necrosis can occur in various sites in the organism. It is common in the breast and has also been described in peripancreatic fat in cases of pancreatitis, in epiploic appendagitis, in omental infarction, in the subcutaneous fat, and, less frequently, in the epipericardial fat. The pathologic features of epipericardal fat necrosis are similar to those found in epiploic appendagitis, and consist of encapsulated fat necrosis with inflammatory infiltrate. Pathogenesis remains unknown. Possible mechanisms have been suggested: ischemia due to torsion of epipericardial fat appendage, trauma or even increased thoracic pressure related to a Valsalva’s manoeuvre. In the latter condition, it is assumed that elevation of capillary pressure could lead to hemorrhagic necrosis. CT scan helps to

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determine the nature and define the exact location of the epipericardial mass. CT is diagnostic by demonstrating a fatty lesion with dense strands surrounded by an enhancing capsule, sometimes associated with slight thickening of pericardium, and occasionally pleural effusion. The differential diagnosis includes diaphragmatic hernia (Morgagni’s hernia), liposarcoma, thymolipoma and teratoma. The pain related to epipericardial fat necrosis is characteristically mistaken for a more critical disease, particularly myocardial infarction or pulmonary embolism. In epipericardial fat necrosis the pain is located anteriorly, near the diaphragm and may irradiate to the neck, shoulder, upper arm, axilla, or back. It may last several days to a week, but can recur less intensively for up to a year. The patient may present with dyspnea, tachypnea, and tachycardia. The electrocardiogram characteristically is normal or shows nonspecific ST- or T-wave changes suggesting ischemia, or findings consistent with resolving pericarditis. This case illustrates the typical presentation of epipericardial fat necrosis, a benign condition that is probably underdiagnosed. Radiologists must recognize this entity as, similarly to epiploic appendagitis in the abdomen, CT is diagnostic. Bibliography 1. Jackson R.C., Clagett O.T., McDonald J.R.: Pericardial fat necrosis; report of three cases. J Thorac Surg, 1957, 33: 723-729. 2. Pineda V., Cáceres J., Andreu J., et al.: Epipericardial Fat Necrosis: Radiologic Diagnosis and Follow-Up. AJR, 2005, 185: 1234-1236. 3. Behrendt D.M., Scannell J.G.: Pericardial fat necrosis. An unusual cause of severe chest pain and thoracic “tumor”. N Engl J Med, 1968, 279: 473-475. 4. Lee B.Y., Song K.S.: Calcified chronic pericardial fat necrosis in localized lipomatosis of pericardium. AJR, 2007, 188: W21-24.

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JBRâ&#x20AC;&#x201C;BTR, 2012, 95: 156-157.

FRAGILE X-ASSOCIATED TREMOR/ATAXIA SYNDROME A.S. Michel, B. Claikens1 Key-word: Brain

Background: A 64-year-old male experiences resting and intentional tremor. The complaints aggravated progressively over the last few years and appeared first at the head and later at the upper limbs. In the end, word finding difficulties, broad-based ataxic gait and erectile dysfunction added to the symptoms. Detailed familial history reveals that 2 nephews of the patient are known to have the fragile X syndrome. Genetic analysis of the FMR1 gene shows the patient carries a pre-mutation expressing 75 repeats.

F 1A 1B Fig.

1. Department of Radiology, AZ Damiaan Oostende, Oostende, Belgium

1C 1D 1E 1F

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FRAGILE X-ASSOCIATED TREMOR/ATAXIA SYNDROME â&#x20AC;&#x201D; MICHEL et al

Work-up MRI of the brain (Fig. 1) consisted of axial T2weighted images of the posterior fossa (A-C) that showed increased signal intensity in deep white matter of the cerebellar hemispheres and the middle cerebellar peduncles, while sparing the dentate nuclei of the cerebellum. Slight cerebellar volume loss is also present. Axial flair images (D,E) confirmed the involvement of the white matter inferiorly and laterally to the deep cerebellar nuclei. Sagittal midline T1-weighted image (F) demonstrated minimal atrophy of the pons with more prominent prepontine cistern. Also marked thinning of the corpus callosum is present. Radiological diagnosis The combination of the clinical features and the characteristic findings on MRI of the brain were suggestive of the diagnosis that was confirmed by the genetic testing: the fragile X-associated tremor/ ataxia syndrome. Discussion Fragile X-associated tremor/ataxia syndrome (FXTAS) is a late-onset neurodegenerative disorder occurring in male and rarely in female carriers of a premutation expansion located in the 5â&#x20AC;&#x2122;-untranslated region of the fragile X mental retardation 1 (FMR1) gene. Fragile X syndrome, the most common inherited form of mental retardation, is typically caused by a repeat length greater than 200 in this FMR1 gene. The premutation consists of a trinucleotide CGG repeat length ranging from 50 to 200. Carriers of the FMR1 gene premutation are usually unaffected by the cognitive impairment associated with the full mutation. Approximately 20 to 33 percent of adult male premutation carriers display the FXTAS phenotype, and the prevalence of the premutation carrier state is as high as one in 813 males. Onset is typically at age 50-70 years and includes progressive intention tremor and/or gait ataxia. Additional clinical features of FXTAS can be parkinsonism, executive cognitive deficits, peri-

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pheral neuropathy and erectile dysfunction. Characteristic findings on magnetic resonance imaging (MRI) include, according to the age of the patient, more pronounced cerebral and cerebellar cortical volume loss, thinning of the corpus callosum and volume loss of the pons. White matter disease is almost always present and includes decreased T1 and increased T2 signal intensity in deep white matter of the cerebellar hemispheres and the middle cerebellar peduncles (MCP), while sparing the dentate nuclei of the cerebellum. The abnormal white-matter signal seen in the MCPs on MRI corresponds to spongiform changes associated with mild axonal and myelin loss. White matter disease associated with astrocytic pathology is seen on neuropathological examination, and intranuclear inclusions are present in both neurons and astrocytes in brain and spinal cord. Although the MRI presentation is not unique to FXTAS, its differential diagnoses tend to occur much less frequently: olivopontocerebellar atrophy, specific forms of autosomal dominant cerebellar ataxia, dentatorubral-pallidoluysian atrophy, multiple system atrophy, Wilsonâ&#x20AC;&#x2122;s disease and neurofibromatosis. In older men with late onset cerebellar ataxia and the described characteristic MRI findings, clinicians should strongly consider the genetic testing for the FMR1-gene mutation in order to confirm the diagnosis of FXTAS. Bibliography 1. Brunberg J.A., Jacquemont S., Hagerman R.J.: Fragile X permutation carriers: characteristic MR imaging findings of adult male patients with progressive cerebellar and cognitive dysfunction. Am J Neurorad, 2002, 23: 1757-1766. 2. Brussino A., Gellera C., Saluto A.: FMRI gene permutation is a frequent genetic cause of lateonset sporadic cerebellar ataxia. Neurology, 2005, 64: 145-147. 3. Hagerman R.J., Leavitt B.R., Farzin F., et al.: Fragile-X-associated tremor/ataxia syndrome (FXTAS) in females with the FMR1 premutation. Am J Hum Genet, 2004, 74: 1051-1056.

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JBRâ&#x20AC;&#x201C;BTR, 2012, 95: 158-159.

BILATERAL CERVICAL SPONDYLOLYSIS B. Pilet1, B. De Foer2, H. Cuykx1, M. Pouillon2 Key-word: Spondylolysis

Background: A 42-year-old man, with no significant medical history, was admitted at the emergency department following a road traffic accident. While cycling, the patient had been hit by a car, after which he briefly lost consciousness. Upon admission, he complained of severe headache and pain in his left shoulder and thorax. Physical examination revealed stable vital parameters and a Glasgow Coma Scale of 15/15. There were no neurological deficits.

B 1A 1B

1. Department of Radiology, AZ Turnhout, Turnhout, Belgium and 2. Department of Radiology, GZA Sint-Augustinus, Wilrijk, Belgium

Fig. 2A 2B

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BILATERAL CERVICAL SPONDYLOLYSIS — PILET et al

Work-up

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Based on radiographic and CT findings, the diagnosis of bilateral congenital cervical spondylolysis was made. The patient was admitted for observation and discharged after 2 days. The headache gradually decreased in the following weeks. EEG, performed 14 weeks after the accident, revealed no abnormalities.

pillar, the cervical equivalent of the pars interarticularis in the lumbar spine”. Radiologically, cervical spondylolysis is characterized by a vertical spondylolytic cleft in the involved lateral masses, creating two displaced fragments, each of which has a smooth cortical border. These fragments have a triangular shape, which appears as a “bow-tie” in the sagittal plane. Other frequent radiological features include dysplastic ipsilateral pedicles, dysplastic ipsilateral articular pillars, mild anterolisthesis (less than 3 mm), and spina bifida (occulta) at the same level. Computed tomography is essential to fully evaluate bony abnormalities, including any associated dysplastic and degenerative changes, and to differentiate between unilateral and bilateral lesions. Since the mainstay of the therapy is conservative, it is most important to differentiate cervical spondylolysis from acute (bilateral) fracture or facet dislocation. Corticated margins, the absence of soft tissue swelling, and associated congenital anomalies favour spondylolysis. The traditional “bow tie” appearance of overriding locked facets in facet dislocation can mimic spondylolysis, however in spondylolysis there is no real displacement between superior and inferior facets. Unlike congenitally absent pedicle syndrome, there is no transverse process dysplasia. Magnetic resonance imaging has been reported to be unhelpful for the diagnosis of spondylolysis.

Discussion

Bibliography

Cervical spondylolysis is a rare condition, with less than 200 cases described worldwide, making it much less prevalent than lumbar spondylolysis, which is reported in 5% of the population. Bilateral involvement occurs in up to two-thirds of cases. The sixth cervical vertebra is the most common site of involvement, which accounts for 70% of the reported cases. Clinically, cervical spondylolysis is mostly asymptomatic, although it has been discovered in patients with torticollis, neck pain, and radiculalgia. It is often diagnosed as an incidental finding on routine radiography in the evaluation of minor trauma. Spinal cord compression is extremely rare. The etiology of cervical spondylolysis remains unknown. Forsberg et al defined cervical spondylolysis as “a corticated cleft between the superior and inferior articular facets of the articular

1. van den Hauwe L.: Pathology of the posterior elements. In: Van Goethem J.W.M., Van den Hauwe L., Parizel P.M., eds. Spinal Imaging, Berlin Heidelberg: Springer Verlag, 2007, 153-184. 2. Forsberg D.A., Martinez S., Vogler J.B. III, et al.: Cervical spondylolysis: imaging findings in 12 patients. AJR, 1990, 154: 751-755. 3. Amin M.F., Mollano A.V., Weinstein S.L., et al.: Rare bilateral C6 spondylolysis and spondylolisthesis in an adolescent athlete: evaluation with magnetic resonance imaging and multidetector computerized tomography. Spine, 2006, 31: E823-825. 4. Oh Y.M., Eun J.P., Koh E.J., et al.: Posterior arch defects of the cervical spine: a comparison between absent pedicle syndrome and spondylolysis. Spine J, 2009, 9: E1-5.

Radiography of the cervical spine (lateral view) (Fig. 1) shows a cleft in one or both of the C6 lateral masses (B, white arrow), with minimal displacement of the fragments, and mild anterolisthesis (grade I). Note also the presence of a fracture in the temporo-parietal region of the skull (A,black arrow). CT scan of the cervical spine (Fig. 2) shows on axial image at the C6 level (bone window) (A) frank dysplasia of the right lamina, which is split into two parts by a cortically marginated cleft (white arrow). On axial image at the C6 level (bone window) (B), the left lamina shows the same anomalies as were seen at the right side (white arrow). On reformatted image in the sagittal plane (bone window) (C), note a cleft in the right pars articularis of C6 (white arrow), resulting in two contiguous triangular parts (so-called “bow-tie appearance”). Radiological diagnosis

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JBRâ&#x20AC;&#x201C;BTR, 2012, 95: 160-161.

EMPHYSEMATOUS CYSTITIS D. Rommel, B. Ghaye1 Key-word: Cystitis

Background: A 30-year-old paraplegic man was admitted to the emergency department for hyperthermia, right flank pain and abdominal tenderness. His past medical history revealed a type 2 diabetes mellitus and a cervico-thoracic astrocytoma treated by surgery and radiotherapy. In 2008, he underwent surgery for the placement of a ventriculo-peritoneal derivation for hydrocephalus secondary to meningeal carcinomatosis. The medical treatment included dexamethasone, sodium valproate and levetiracetam for intractable epilepsia. Laboratory tests revealed blood inflammation and urinary infection.

B 1

1. Department of Medical Imaging, Cliniques Universitaires St Luc, Bruxelles, Belgium

Fig. 2A 2B

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EMPHYSEMATOUS CYSTITIS â&#x20AC;&#x201D; ROMMEL et al

Work-up Radiograph of the abdomen (topogram of the CT scan in a supine position) (Fig. 1) shows a marked air-containing bladder distension with linear air density along the bladder wall. Axial CT image at the level of the bladder (Fig. 2A) demonstrates a thickened bladder wall containing linear pockets of gas. An air-fluid level is shown in the bladder lumen. Axial CT image at supra-umbilical level (lung window setting) (Fig. 2B) shows an anterior pneumoperitoneum. Coronal CT reformatted images (lung window setting) (Fig. 2C) visualizes the multiple punctuate gas foci disseminated along the entire bladder wall. Note the extension of gas dissection laterally to the bladder into the extraperitoneal tissues. Radiological diagnosis Based on CT findings the diagnosis of emphysematous cystitis complicated by a pneumoperitoneum was made.

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parenchyma with the presence of gas within the kidney, collecting system and perirenal space. The predisposing factors of EP are the same as in EC. The association between EP and pneumoperitoneum has already been documented). To our knowledge, this is this first case reported to the literature associating isolated EC and pneumoperitoneum. Although EC can be demonstrated or suspected on abdominal plain film, CT is the technique of choice for the diagnosis as it is very sensitive for early detection of intraluminal and intramural gas. This technique can also accurately define the extent and severity of EC. Furthermore, CT can also detect fistulas, intra-abdominal abscesses, adjacent neoplastic disease and other emphysematous intra-abdominal infections such as EP. The treatment for EC involves broad-spectrum antimicrobial therapy and strict control of blood glucose level. In the case of bladder outlet obstruction syndrome, adequate urine drainage with correction of the obstacle is mandatory. In the case of poor response to medical treatment, surgical debridement might be considered. The overall death rate of EC is 7% contrasting with the 50% death rate of EP.

Discussion Emphysematous cystitis (EC) is a rare but severe lower urinary tract infection characterized by the presence of air within the bladder wall. The most common pathogen germ is Escherichia coli (58%), followed by Klebsiella pneumoniae (21%) and Enterobacter aerogenes (5%). Clostridia and fungal species may be occasionally identified.The gas is considered secondary to the presence of gas producing organism and high tissue glucose favouring the production of carbon dioxide (fermentation of glucose). The disease is most common in middle age patient and predisposing factor are diabetes mellitus, neurogenic bladder, urinary outlet obstruction and urethral catheters. EC can be associated with emphysematous pyelonephritis (EP) which is a necrotizing infection of the renal

Bibliography 1. Thomas A., Lane B., Thomas A., et al.: Emphysematous cystitis: a review of 135 cases. BJU Int, 2007, 100: 17-20. 2. Grayson D., Abbott R., Levy A., et al.: Emphysematous infections of the abdomen and pelvis: a pictorial review. Radiographics, 2002, 22: 543-561. 3. Craig W., Wagner B., Travis M.: Pyelonephritis: radiologic-pathologic review. Radiographics, 2008, 28: 255-277. 4. Strofilas A., Manouras A., Lagoudianakis E., et al.: Emphysematous pyelonephritis, a rare cause of pneumoperitoneum: a case report and review of literature. Cases J, 2008, 14; 1: 91.

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JBR–BTR, 2012, 95: 162-163.

NODULAR REGENERATIVE HYPERPLASIA OF THE LIVER AND PORTAL THROMBOSIS M. Ruhi Onur, A. Kürsad Poyraz, E. Kocakoç1 Key-words: Nodular regenerative hyperplasia – MRI, liver

Background: A 35-year-old female presented with upper gastrointestinal tract bleeding. Fifteen years ago, the diagnosis of esophageal varices caused by idiopathic portal venous thrombus was made. Follow-up examinations revealed mild elevation of bilirubin levels and normal alphafetoprotein level on blood tests. Splenectomy had been performed 6 years previously due to portal hypertension caused by portal venous thrombus.

D 1 Fig.

1. Department of Radiology, Firat University HospitalElazig, Turkey

2A 2B 2C 2D

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NODULAR REGENERATIVE HYPERPLASIA OF THE LIVER AND PORTAL THROMBOSIS — RUHI ONUR et al

Work-up On MRI of the liver, Gd- enhanced axial T1weighted image at the level of the portal vein (Fig. 1) , a portal vein thrombus at the confluence level is shown (arrow). MRI of the liver, at the level of lesion in the right liver lobe (Fig. 2) shows on axial T2-weighted image (A) an isointense mass in segment 7 of right lobe in liver (arrow). Intrahepatic bile ducts are dilated. On axial T1-weighted image (B) the liver mass described in Fig. 2A is hyperintense compared to surrounding liver parenchyma. On axial contrast-enhanced T1-weighted image (following intravenous administration of Gadolinium), arterial phase (C), the lesion is enhanced homogenously early (arterial phase) after intravenous Gadolinium administration. On axial contrast-enhanced T1weighted image (following intravenous administration of Gadolinium), venous phase (D), the lesion appears hypointense due to ‘wash-out’, mimicking hepatocellular carcinoma. Radiological diagnosis Histopathologic examination revealed regeneration nodules which were formed by hyperplastic hepatocytes in the absence of parenchymal fibrosis. Based on these findings the diagnosis of nodular regenerative hyperplasia of the liver was made.

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central atrophy, produced by decreased blood flow, is compensated for by proliferation of hepatocytes from the portal region that form regenerative nodules. Clinically, NRH does not cause symptoms and is discovered incidentally unless it is complicated by portal hypertension and its sequelae such as hepatomegaly, splenomegaly, ascites, or esophageal varices. In this patient presence of portal thrombus and portal hypertension was the leading cause of NRH. Ultrasonography commonly reveals large isoechoic hepatic masses with normal echogenicity. On MRI, the nodular lesions appear isointense on T2-WI and hyperintense on T1-weighted images. Lesions enhance early after intravenous contrast administration (arterial phase) with washout in venous phase, hereby mimicking hepatocellular carcinoma (HCC). However low AFP values, lack of high signal intensity on T2-WI images and relative homogenous enhancement allow distinction with HCC. The absence of characteristic high signal scar on the T2-weighted image excludes focal nodular hyperplasia in the differential diagnosis. Adenomas have heterogenous signal on T1and T2-weighted images due to fat or hemorrhage contents and were absent in the liver lesions of the presented patient. Since NRH mimicks benign and malignant focal liver lesions, awareness of imaging findings and association between impairment of portal circulation and NRH may be helpful in the diagnosis.

Discussion Nodular regenerative hyperplasia (NRH) of liver, is a benign proliferative disease which is characterized by multiple regenerative nodules in liver with varying sizes from 0.1 cm to 15 cm. The pathogenesis of NRH is not well known but it has been associated with a variety of systemic diseases including collagen vascular diseases, lymphoproliferative and myeloproliferative disorders. At present, the nodular transformation in NRH is considered to be a consequence of portal blood flow impairment. According to this vascular hypothesis the basic pathologic injury leading to NRH is obliteration and/or thrombus in the portal venous system. The

Bibliography 1. Trenschel G.M., Schubert A., Dries V., et al.: Nodular regenerative hyperplasia of the liver: case report of a 13-yearold girl and review of the literature. Pediatr Radiol, 2000, 30: 64-68. 2. Choi B.Y., Nguyen M.H.: The diagnosis and management of benign hepatic tumors. J Clin Gastroenterol, 2005, 39: 401-412. 3. Wanless I.R., Solt L.C., Kortan P., et al.: Nodular regenerative hyperplasia of the liver associated with macroglobulinemia: a clue to the pathogenesis. Am J Med, 1981, 70: 1203-1209.

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JBR–BTR, 2012, 95: 164-165.

SYNOVIAL CHONDROMATOSIS OF THE TEMPOROMANDIBULAR JOINT R.R. van Dijk, M.J. Rutten1 Key-words: Temporomandibular joint – synovial chondromatosis – MRI

Background: A 70-year-old Caucasian woman presented to an Ear-Nose and Throat (ENT) specialist with a painful swelling in the region of the right parotid gland. The clinical ENT exam revealed no abnormalities.

E 1A 1B 1C Fig.

1. Department of Radiology, Jeroen Bosch Hospital, ‘s-Hertogenbosch, The Netherlands

2C 2D 2E

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SYNOVIAL CHONDROMATOSIS OF THE TEMPOROMANDIBULAR JOINT â&#x20AC;&#x201D; VAN DIJK et al

Work-up CT scan at the level of the temporomandibular joints (TMJ) (Fig. 1) shows on the axial image (A) and reformatted image (B) in the sagittal plane through the right TMJ an expansile but localised lesion in the area of the right TMJ. Multiple, separate and unevenly dispersed small radiopacities in the vicinity of the mandibular condylar head. Reformatted image in the coronal plane, right TMJ (enlarged view) (C) demonstrates a thinning of the temporal bone with the lesion possibly extending to the middle cranial fossa. MRI of the brain and skull base, at the level of the TMJ (Fig. 2) included an axial T1-weighed image (A), an axial T2-weighted image (B), a coronal T1weighed image (C), a coronal T2-weighed image at the level of the right TMJ (D) and a sagittal T2weighed image at the level of the right TMJ (E). Hydrops of the right TMJ and multiple particles within the capsula of the joint is observed. These particles have a low signal intensity both on the T1(A,C) and T2- (B,D,E) weighted images. Sagittal T2weigthed image (E) shows, in concordance with the coronal T2-weighted image (D), synovial proliferation protruding into the base of the skull, extending to the tabula at the outer side of the medial fossa, but the medial fossa itself is not affected. Radiological diagnosis Based on the findings on CT scan and MRI, the diagnosis of synovial chondromatosis of the temporomandibular joint was made. Discussion Synovial chondromatosis (SC) of the temporomandibular joint (TMJ) was first described by Axhausen in 1933. It occurs most commonly in middle-aged women. Clinical symptoms are pain, swelling, and limitation of motion. SC is uncommon, monoarthritic and generally affects the larger joints. It is characterised by the development of highly cellular metaplastic cartilaginous foci in the synovial membrane. It is believed that SC origi-

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nates from embryonic mesenchymal remnants of the subintimal layer of the synovium that becomes metaplastic, calcifies, and breaks off into the joint space. Although there are multiple reports of temporomandibular joint involvement in SC, cases involving base skull erosion to the middle cranial fossa are scarce. Radiographically, SC commonly demonstrates multiple juxtaarticular radiodensities. They range in size from a few millimetres to several centimetres and show varying degrees of mineralisation within each lesion. The cartilaginous foci may cause erosion of the adjacent bone and widening of the joint space. Although it is often misinterpreted as a sign of aggressiveness, this pattern is still compatible with a benign process. TMJ tumors are rare even though many types of bone or joint neoplasms have been described in this location. Benign bone tumors, including osteochondromas, osteomas, and giant cell tumors have been described. Of these, osteochondromas are the most common ones. Malignant bone tumors of the TMJ are particularly rare. Theoretically, a chondrosarcoma arising from synovial chondromatosis of the temporomandibular joint could appear. The articular calcifications are easily detected on CT scan of the skull base. MRI is well suited for detection of SC and particularly helpful in defining the tissue planes between the SC masses surrounding the soft tissue and the extension to the middle cranial fossa. Bibliography 1. Axhausen G.: Pathologie und Therapie des Kiefergelenks. Fortschr Zahnheilk, 1933, 9: 171. 2. Karlis V., Glickman R.S., Zaslow M.: Synovial chondromatosis of the temporomandibular joint with intracranial extension. Oral Surg Oral Med Oral Pathol Oral Radiol Endod, 1998, 86: 664-666. 3. Herzog S., Mafee M.: Synovial chondromatosis of the TMJ: MR and CT findings. Am J Neuroradiol, 1990, 11: 742-745. 4. Ardekian L., Faquin W., Troulis M.J., et al.: Synovial chondromatosis of the temporomandibular joint: report and analysis of eleven cases. J Oral Maxillofac Surg, 2005, 63: 941-947.

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LUNG EMPHYSEMA CAUSED BY MARIJUANA SMOKING A. Van Landeghem, B. Arys, C. Heyse, R. Gosselin1 Key-word: Emphysema, pulmonary

Background: A 33-year-old male of Turkish origin, born in Belgium, presented to the emergency department with left sided chest pain. One week earlier he had been caught in a fight. To exclude fractures of the ribs a radiography of the chest and ribs was performed.

1 Fig.

1. Department of Medical Imaging, University Hospital Ghent, Ghent, Belgium

2A 2B

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LUNG EMPHYSEMA CAUSED BY MARIJUANA SMOKING â&#x20AC;&#x201D; VAN LANDEGHEM et al

Work-up Conventional radiography of the chest (PA view) (Fig. 1) shows bilateral bullae in the upper lobes (arrows and asterisk). These are larger on the left side (asterisk) than on the right. No evidence for rib fractures. High resolution CT scan of the chest (Fig. 2) shows on transverse section (A) paraseptal emphysematous bullae in the lung apices (arrows and asterisk). Reformatted image in the coronal plane (B) demonstrates paraseptal emphysematous bullae in the lung apices (arrows and asterisk). Sparing of the rest of the lung parenchyma is observed. Radiological diagnosis Based on the unusual CT findings and the young age of the patient a history of cannabis smoking was suspected, which was confirmed by the patient. The diagnosis of upper lobe emphysema caused by marijuana smoking was made.

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he had been smoking 5 to 10 joints per day for at least 6 years. 3 years ago he stopped smoking marijuana. Cannabis or marijuana can be used in several forms, the most usual intake is by inhalation. It can be smoked in joints, pipes or special devices. Irrespective of the device, there are some differences when comparing the physical dynamics of smoking marijuana with smoking regular tobacco. Application of larger puffs, with deeper inhalation and greater breath holding time, sometimes accompanied by Valsalva manoeuvres in order to achieve a higher systemic absorption of the active substance THC (delta-9-tetrahydrocannabinol), are sometimes applied. In fact, this smoking technique, in combination with a direct pulmonary toxicity, has been proposed as the mechanism responsible for cases of spontaneous pneumothorax and bullous lung disease reported in young cannabis smokers. In case of severe emphysema in young adults, marijuana abuse has to be considered in the differential diagnosis. Bibliography

Discussion The harmful effects of tobacco smoking are well known. Centrilobular emphysema may develop with a uniform distribution. In young male smokers a more uncommon form of bullous disease has been documented, which has a paraseptal distribution and a marked predisposition for the upper lobes. This pattern of emphysema has been reported in regular marijuana users. Our patient admitted

1. Johnson M.K., Smith R.P., Morrison D., et al.: Large lung bullae in marijuana smokers. Thorax, 2000, 55: 340-342. 2. Lang P.: Cannabis and the lung. Thorax, 2007, 62: 1036-1037. 3. Beshay M., Kaiser H., Niedhart D., et al.: Emphysema and secondary pneumothorax in young adults smoking cannabis. Eur J Cardiothorac Surg, 2007, 32: 834-838.

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JBRâ&#x20AC;&#x201C;BTR, 2012, 95: 168-169.

OSTEOSARCOMA OF THE MAXILLA F.M. Vanhoenacker1,2, M. Camerlinck1,2, D. De Vuyst1, K. Chapelle3 Key-word: Bone neoplasms

Background: A 25-year-old male patient presented with tooth pain and progressive swelling of his left cheek. Dental examination was unremarkable.

C 1

Fig. 2B 2C

Departments of 1. Radiology, AZ Sint-Maarten, Duffel-Mechelen, Duffel, Belgium and 2. Antwerp University Hospital, Edegem, Belgium, 3. Department of Maxillofacial Surgery, AZ Sint-Maarten, Duffel-Mechelen, Duffel, Belgium

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OSTEOSARCOMA OF THE MAXILLA — VANHOENACKER et al

Work-up CT scan of the paranasal sinuses (Fig. 1) shows opacification of the left maxillary sinus, with intralesional mineralized areas and spiculated (“hair-on-end”) type of periosteal reaction (black arrows). MRI of the paranasal sinuses (Fig. 2) shows on A, axial T1-weighted image, a lesion slightly heterogeneous and predominantly isointense to muscle. Note soft tissue extension beyond the posterolateral wall of the left maxillary sinus into the infratemporal fossa (white arrows). On B, axial T2-weighted image, the lesion is heterogeneous appearance with areas of low, intermediate and high signal. Note also soft tissue extension within the infratemporal fossa. On C, axial fatsuppressed contrast enhanced T1-weighted image, the lesion shows marked and heterogeneous enhancement with peripheral papillary projections. The soft tissue component of the lesion is enhancing vividly (white arrows). Radiological diagnosis CT and MRI findings are consistent with an osteosarcoma of the maxilla (gnathic osteosarcoma). Histology after surgical biopsy confirmed a high grade osteosarcoma. Discussion Osteosarcoma (OS) is the most common primary malignant tumor of bone in adolescents and young adults, accounting for approximately 4060% of all primary malignant bone tumors. The tumor may also be the result of malignant transformation of benign lesions such as Paget’s disease, fibrous dysplasia or occurs after previous irradiation. OS of the jaw are designated as gnathic osteosarcomas. They constitute 6-13,3% of all skeletal OS. Gnathic OS is more prevalent between 20-36 years, whereas extragnathic OS is predominantly seen between the ages of 11 and 20 years. Gnathic OS are most commonly located in the body of the mandible, posterior alveolar ridge or maxillary antrum. The main symptoms are swelling and pain, but paresthesias, loosening of teeth, bleeding and nasal obstruction have been reported. Histologically, the main subtype is chondroblastic, followed by the osteoblastic subtype. Radiographically, gnathic OS is similar to conven-

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tional osteosarcoma, with presence of osteoid matrix in 60-80% of cases, aggressive periosteal reaction (such as a spiculated periosteal reaction) and soft tissue extension. Besides areas of sclerosis and mineralization, there are often associated areas of lytic bone destruction. Opacification of the maxillary sinuses is also a frequent finding in maxillary lesions. CT is the preferred imaging modality to demonstrate areas of mineralized osteoid, periosteal reaction and cortical breakthrough. MR imaging is more appropriate to assess both the intraosseous and extraosseous components of the lesion. Lesions are of low to intermediate signal intensity on T1-weighted MR images and are of heterogeneous signal intensity with T2-weighting. Mineralized areas are of low signal, whereas other components are of high signal. Foci of central hemorrhage are of high signal on all pulse sequences. Fat suppressed T1-weighted Gd-enhanced MR images are particularly helpful for delineating local tumor extension. Treatment of gnathic OS is difficult and includes a combination of surgical excision, radiation therapy and chemotherapy. Distant metastases, especially to the lungs, are less frequent than in other osteosarcomas. Current multidisciplinary treatment within a multi-center setting may result in long-term survival in over two-thirds of patients. Unfortunately, local recurrence is common, particularly in maxillary lesions and is often uncontrollable. Involvement of extragnathic sites and failure to achieve radical surgical resection are strong negative prognostic factors, leading to patient death. Bibliography 1. Murphy M.D., Robbin M.R., McRae G.A., et al.: The many faces of osteosarcoma. Radiographics, 1997, 17: 1205-1231. 2. Fernandes R., Nikitakis N.G., Pazoki A., et al.: Osteogenic sarcoma of the jaw: a 10-year experience. J Oral Maxillofac Surg, 2007 Jul, 65: 12861291. 3. Azizi T., Motamedi M.H., Jafari S.M.: Gnathic osteosarcomas: a 10-year multi-center demographic study. Indian J Cancer, 2009 Jul-Sep, 46: 231-233. 4. Kumaravelu C., Sathya Kumar D., Chakravarthy C., et al.: Chondroblastic osteosarcoma of maxilla: a case report and review of literature. J Maxillofac Oral Surg, 2009, 8: 290-293.

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MEDIAL PLICA SYNDROME OF LEFT KNEE F.J. Wessels1, B.C. van der Wal2, M. Nix1 Key-word: Knee, anatomy

Background: A 36-year-old woman presented to the orthopedic department with painful impairment of the left knee. The pain to the medial side of the knee and locking of the knee joint had started after a distortion of the knee during a game of soccer 2 weeks earlier. On clinical examination, the left knee showed a flexion/extension range of 110/0Â°. On palpation and rotation of the knee joint, the patient experienced pain in the medial compartment of the knee. The anterior drawer test was slightly positive (+1); examinations of the other ligaments of the knee were negative.

D 1A 1B Fig.

2A 2B 2C 2D

Departments of 1. Radiology and 2. Orthopedics, Meander Medisch Centrum, Amersfoort, The Netherlands

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MEDIALL PLICA SYNDROME OF LEFT KNEE â&#x20AC;&#x201D; WESSELS et al

Work-up Conventional radiograph of the left knee (Fig. 1) shows on anterior-posterior (AP) view (A) and lateral view (B) a loose, well defined, bone fragment within the knee joint is observed (arrow). Furthermore, a calcification is seen in the distal part of the patellar tendon. MRI of the left knee (Fig. 2) demonstrates on sagittal T1-weighted image (A), sagittal protondensity-weighted image (B), and axial T2-weighted image (C) a linear structure of low signal intensity on the medial side of the femoro- patellar joint (arrow). There are no signs of ligamentar injury. The structure is surrounded by fluid as shown on the T2-weighted image (C), indicating synovial irritation. On sagittal T1-weighted image (D, a calcification/loose bone fragment just cranial to the tibial plateau is seen on this image. Radiological diagnosis The finding of a linear structure at the expected location (see comment below), with low signal intensity on all sequences, corresponds with the presence of a medial plica. MRI showing thickening of the medial plica and irritation of the adjacent synovium, is diagnostic for the medial plica syndrome. The loose bone fragment, seen on both the conventional and MRI examinations, is an incidental finding. It corresponds to an old fracture of the intercondylar eminence. Patient was referred for physical therapy and her complaints resolved after a short period of treatment. Discussion The medial plica, as well as other plicas of the knee, is a normal structure. It represents a remnant

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of a synovial membrane of the embryologic development of the knee. The medial plica originates on the medial side of the knee joint adjacent to the medial part of the patella. It courses in an oblique way, from the superior/mid-patellar medial capsule towards the synovium, covering the medial aspect of the fat pad. Both cadaver studies and studies of arthroscopic findings have shown a presence in 1830% of normal knees. In the case of a medial plica syndrome, the plica causes painful impairment of knee function, with complaints consisting of medial knee pain, crepitus and/or pseudo-locking. Signs of adjacent synovitis or chondromalacia of the medial patellar facet are also highly suggestive for the medial plica syndrome. The medial plica may become symptomatic after injury, and may be associated as well with loose bodies or meniscal pathology. MRI can readily determine the presence of a medial plica. An abnormal plica can be seen as a thickened band of low signal intensity on all sequences. The finding of a thickened medial plica, together with the correct clinical setting, leads to the non-invasive diagnosis of the medial plica syndrome. Initially, conservative treatment by means of physical therapy is preferred. When painful episodes recur, arthroscopic resection may be indicated. Bibliography 1. Garcia-Valtuille R., Abascal F., Cerezal L., et al.: Anatomy and MR imaging appearances of synovial plicae of the knee. Radiographics, 2002, 22: 775-784. 2. Monabang C.Z., De Maeseneer M., Shahabpour M., et al. MR imaging findings in patients with a surgically significant mediopatellar plica. JBR-BTR, 2007, 90: 384-387.

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CLEAR CELL SARCOMA OF THE ANKLE H.W. Wiersma1, M.C de Jonge2, J. Bras3, G.R. Schaap4, M. Maas2 Key-word: Soft tissues, neoplasms

Background: A 48-year-old woman was referred to our hospital for evaluation of a soft tissue mass at her right ankle. At initial presentation, 5 years earlier, her general practitioner thought of a benign lesion and suggested to remove the mass. At the time, no additional imaging was requested. Over the years, the swelling was slowly growing but remained painless. Now, on clinical examination, a mass lesion was seen, located posterior of the lateral malleolus, consisting of a firm mass fixed to the surface underneath. The estimated size of the tumor was 2 x 6 cm, which gave rise to suspicion of a malignancy.

C 1

1. Department of Radiology, Deventer Ziekenhuis, Deventer, The Netherlands, Departments of 2. Radiology, 3. Pathology and 4. Orthopedic Surgery, Academisch Medisch Centrum, Amsterdam, The Netherlands

Fig.

2A 2B 2C

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CLEAR CELL SARCOMA OF THE ANKLE â&#x20AC;&#x201D; WIERSMA et al

Work-up Conventional radiograph of the right ankle (AP and profile views) (Fig. 1) shows normal appearance of bones and joints. MRI of the right ankle and calf (Fig. 2) shows on coronal T1-weighted MR-image (A) a well-circumscribed soft tissue mass posterolateral of the fibula. The mass presents with homogeneous signal intensity, iso-intense to the surrounding flexor hallucis longus muscle. The lesion shows a direct relationship to the peroneal tendon. Coronal contrastenhanced T1-weighted MR-image (B) demonstratetst heterogeneous intense enhancement of the lesion is seen. On axial contrast-enhanced T1weighted MR-image (C) the close relationship of the mass with the peroneal tendons is better demonstrated. Radiological diagnosis The MRI findings are highly suggestive of a soft tissue sarcoma. Tru-Cut biopsy was performed. The histopathological diagnosis was clear cell sarcoma. Discussion Masses around the foot and ankle are uncommon and the benign variants account for 75% of the cases, e.g. ganglion cysts, neurofibroma and lipoma. Clear cell sarcoma (CCS) of tendons and aponeuroses, formerly known as malignant melanoma of the soft tissue, is a rare entity with mass composed of cells of displaying melanocytic differentiation and accounts for 1% of all soft tissue sarcomas. CCS is mainly found in the lower extremities (95%) and especially around the foot and ankle. This tumor presents as a deep-seated mass lesion, with close relationship to tendons or aponeuroses. Most CCS lesions are slowly growing

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and seldomly present with pain or tenderness. The etiology of CCS remains unknown. MRI is the examination of choice in the assessment of soft tissue tumors. On MRI, CCS presents with a slightly increased signal compared to muscle tissue on T1weighted images and a low signal intensity on T2weighted images. These short T1 and T2 relaxation times are said to be caused by the paramagnetic effect of the melanin present in the tumor cells. A certain amount of melanin is needed to give this particular higher signal on T1-weighted images. However, this intracellular melanin is only seldom found in the tumor. If the melanin is absent or present in too small amounts, the tumor can show a homogeneous appearance on T1 and T2-weighted images, thereby mimicking a benign tumor. Therefore, it is important to realize that, when a soft tissue mass is seen on a rare localization or reveals an unusual presentation, and the lesion shows a homogeneous appearance on MRI, CCS is a possible diagnosis. Bibliography 1. Foo L.F., Raby N.: Tumours and tumour-like lesions in the foot and ankle. Clin Rad, 2005, 60: 308-332. 2. Waldt S., Rechl H., Rummeny E.J., et al.: Imaging of benign and malignant soft tissue masses of the foot. Eur Radiol, 2003, 3: 1125-1136. 3. Beuckeleer de L.H., Schepper de A.M., Vandevenne J.E., et al.: MR-imaging of clear cell sarcoma (malignant melanoma of the soft parts): a multicenter correlative MRI-pathology study of 21 cases and literature review. Skelet Radiol, 2000, 29: 187-195. 4. Kransdorf M.J., Murphey M.D.: Radiologic evaluation of soft-tissue masses: a current perspective. AJR, 2000, 175: 575-587.

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IMAGES IN CLINICAL RADIOLOGY Duplicate inferior vena cava continuing as a hemiazygos continuation draining into the right atrium via persistent left superior vena cava J. Joskin1, N. Bleus1, T. Couvreur1, L. Tselikas2, M. Milicevic1 A 59-year-old woman with known breast cancer presented liver lesions. As part of a metastatic workup, a thoracoabdominal enhanced contrast CT was performed. It revealed a persistent left superior vena cava (SVC) which reached the right atrium via an enlarged coronary sinus. This CT-scan also demonstrated the hemiazygos vein which was connected to the left SVC via the left superior intercostal vein. The right SVC was also present (Fig. A). At the abdominal level, CT showed a duplicate inferior vena cava (IVC) which was interrupted at the leveI of the renal hilum and continued as a hemiazygos vein cephalad (not shown). The renal veins drained into the left IVC. There was no corresponding IVC on the right side, except for the hepatic segment which seemed to drain to the right atrium directly by the confluence of the hepatic veins. The anomaly in this case is drawn schematically (Fig. B) and demonstrated in the reformated volume rendering thoracoabdominal CT-scan (Fig. C).

Comment In most cases, congenital venous anomalies have no consequence, but this variant is important to avoid erroneous diagnosis. The enhanced contrast CTscan is the exam of choice to differentiate the venous circulation. A review of the embryogenesis of the thoracic and abdominal venous circulation is essential to understand any developmental anomaly. Embryologically, the anterior cardinal veins drain the cephalic part of the body including the chest and the posterior cardinal veins drain the caudal part including the abdomen. At the thoracic level, the normal right superior vena cava (SVC) is formed by the right anterior cardinal vein. The persistence of the left SVC results from the failure of obliteration of the left anterior cardinal vein (0.3%-0.5% of the normal population, 4,4%-12.9% in the population with congenital heart disease).It usually (92%) drains into the coronary sinus, but it can also drain rarely(8%) into the left atrium, and thus generate a right-to-left shunt. In the vast majority of cases (82-90%) the right SVC is also present with a bridging left brachiocephalic vein in 35-60% of cases. At the abdominal level, the normal inferior vena cava (IVC) is formed by the successive development and regression of posterior cardinal veins. The posterior cardinal veins are functionally replaced by the supracardinal (infrarenal vena cava) and subcardinal (suprarenal vena cava) veins. The right venous system becomes theIVC, which drain into the right atrium and the left venous system usually involutes almost completely. In the case of a double infrarenal IVC with a retroaortic right renal vein and hemiazygos continuation of the IVC, the embryologic development can be explained as follows : first, the double infrarenal vena cava (0,2% to 0,5% of the general population) results of the persistence of the right venous system, second, the hemiazygos continuation of the IVC (> 0.3% of the general population) results from the absence of the right suprarenal vena cava and the persistence of the left anastomosis between the left suprarenal vena cava and the hemiazygos. The hepatic segment of the IVC (right venous system) ordinarily drains independently directly into the right atrium. Third, the right infrarenal vena cava with the right renal vein cross posterior to the aorta to join the left IVC and continue cephalad as the hemiazygos vein. Finally, the hemiazygos vein drains into the left SVC through the accessory hemiazygos and the left SVC drains into the right atrium by way of the enlarged coronary sinus.

C Reference 1.

Kim H.J., Park E.D.: Hemiazygos Continuation of a Left Inferior Vena Cava Draining into the Right Atrium via Persistent Left Superior Vena Cava: Demonstration by Helical Computed Tomography. Cardiovasc Intervent Radiol, 1995,18: 65-67. 1. Department of Radiology, CHU Sart-Tilman, Liege, Belgium, 2. Department of Radiology, Georges Pompidou Hospital, Paris, France.

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IMAGES IN CLINICAL RADIOLOGY Eustachian tube lumen opening into an abnormally pneumatized sphenoid bone P. Bosschaert1, A.-L. Hiel2, J. Vilain2 Morphological abnormalities of left temporal and sphenoid bone were discovered in a 17-year-old boy during a post-traumatic cranial CT scan examination. The patient had not suffered from audiological disorders previously. He did not complain of hearing loss, vertigo or autophony. Further clinical investigations were normal including micro-otoscopy and nasopharyngeal endoscopy. The Valsalva maneuver was correctly performed. Audiometry and tympanometry were without any particularity. These abnormalities consist of a subdivision of the pharyngeal part of the lumen of the Eustachian tube and an abnormal pneumatization of the sphenoid bone. The lower part of the tubal subdivision, proximally slightly larger than normal, opens as usual onto the nasopharynx. The upper part reaches a “mastoid-like” pneumatization of the sphenoid body (Fig. A, B & C: axial, coronal oblique and Minimum Intensity Projection views – arrow and asterisk). The left pterygoid process is also unusually pneumatized and the left temporal bone is more pneumatized than the right. Note that sphenoid sinuses are hypoplastic.

Comment To our knowledge, these anatomical aberrations we observed combined with normal auditory and Eustachian tube function had not been previously reported. The Eustachian tube is structurally quite complex, in particular its nasopharyngeal part. Its lumen, delimited by a respiratory mucosa is surrounded by cartilage, peritubal muscles, and a superior bony support, the sphenoid sulcus. It joins the protympanum, the anterior recess of the tympanic cavity, and the nasopharynx. Its closed resting position protects the middle ear from reflux of nasopharyngeal material and sound. This tube also allows the maintenance of the balance of pressure into the middle ear, optimizes the sound transmission, and protects the inner ear from acoustic trauma and barotrauma. It is recognized that temporal bone pneumatization is very different from one individual to another and between sides, according to air cell tracts expansion in various ways from the mastoid to the petrous apex C during fetal maturation and childhood. The explanation of these abnormalities remains unclear. Lack of communication between the sphenoid sinus and this “mastoid-like” pneumatization suggests a middle ear origin with a large development of the precochlear and superior perilabyrinthine cell tracts. There is also the possibility that an aberrant division of the Eustachian tube close to the sphenopetrosal suture with an extension of the mucosa through the less resistant superior tubal ligament would lead to a consecutive abnormal sphenoid pneumatization. We are unable to determine when the division of the Eustachian tube occurred. If this division occurred during the embryological development, we could expect craniofacial abnormalities but the patient did not exhibit any. Preoperative CT scan in case of pituitary gland surgery by a trans-sphenoidal approach should be carefully looked over in order to avoid dramatic complications. Additionally, an aberrant petrous pneumatization could expose to persistent cerebrospinal fluid leak after cerebrospinal angle surgery and petrous apicitis (Gradenigo’syndrome) in the case of otomastoiditis.

Reference 1.

Jen A., Sanelli P.C., Banthia V., et al.: Relationship of Petrous Temporal Bone Pneumatization to the Eustachian Tube Lumen. The laryngoscope, 2004, 114: 656-660.

Departments of 1. Radiology and 2. Otorhinolaryngology, Clinique St-Pierre, Ottignies-LLN, Belgium.

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IMAGES IN CLINICAL RADIOLOGY Idiopathic hypoparathyroidism as a cause of extensive intracranial calcification S. Khalid1, S. Zaheer1, S. Wahab1, I. Mubarak2

A 60-year-old male was referred to radiology department for head CT for evaluation of seizures of recent onset. CT showed extensive symmetric bilateral calcification in caudate nucleus, putamen, thalami, cerebellum and centrum semiovale (Fig. A,B). A radiological diagnosis of Fahr’s disease was made. During hospital stay, patient developed muscular tetany. Serum calcium was found to be low (7.2 mg/dl; normal range 8.4-10.2 mg/dl). Further tests revealed low serum parathyroid hormone (PTH) level (3.60 pg/ml; normal range 15.0-68.0 pg/dl) and elevated phosphorus level. All possible causes of hypoparathyroidism were evaluated with no positive results. On the basis of clinical, hormonal and radiological findings a diagnosis of idiopathic hypoparathyroidism was made. Patient was started calcium and 1,25-dihydroxy vitamin D. Patient reported no episode of seizures during next two days of hospital stay. He was last seen at 3 months follow up with significant improvement of clinical symptoms and serum calcium level returning to normal range. Comment Fahr’s is a rare neurodegenerative disease characterized by bilaterally symmetrical, extensive intracranial calcifications, especially in the cerebellum and basal ganglia. It is usually idiopathic, but can be associated with endocrine disorders such as hypoparathyroidism, pseudo-hypoparathyroidism, hypothyroidism and hyperparathyroidism (1). Other conditions associated with similar intracranial calcification pattern include infections, toxins (carbon monoxide, lead), metabolic syndrome (Cockayne’s, mitochondrial disorders) and post chemotherapy. Hypoparathyroidism is diagnosed with decreased serum parathyroid hormone and calcium level, increased serum phosphate. Common causes include renal insufficiency, chronic diarrhoea and alkalosis. Idiopathic hypoparathyroidism is a diagnosis of exclusion in a patient with low serum calcium and PTH level; excluding these and other causes of hypoparathyroidism such as surgery and autoimmune diseases (2). Clinical signs and symptoms of hypoparathyroidism are due to hypocalcaemia and increased neuromuscular excitability resulting in tetany, paresthesia, seizures and calcium deposition leading to cataract and intracranial calcification. Intracranial calcification is more common and is seen early in idiopathic hypoparathyroidism. Latent tetany is diagnosed by eliciting Chovstek’s and Trousseau’s sign (2). Diagnosis is confirmed by biochemical analysis of serum calcium and PTH level. Treatment consists of oral or intravenous infusion of calcium and vitamin D. Reference 1.

Acou M., Vanslembrouck J., Deblaere K., Bauters W., Achten E.: Fahr disease. JBR-BTR, 2008, 91: 19.

1. Department of Radiodiagnosis, 2. Endocrinology Centre, Department of Medicine, J N Medical College, Aligarh, India.

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IMAGES IN CLINICAL RADIOLOGY Pulmonary Langerhans cell histiocytosis and eosinophilic granuloma M. Demeter, Y. Vankan, F. De Somer, D. Perdieus1 A forty-tree-year-old female patient presented at the emergency department for low back pain and left hip pain since four weeks, mostly at night, and disabled walking. Neurological examination and laboratory findings were normal. Computed tomography of the lumbar spine showed degenerative discopathy at level L4-L5 and L5-S1, but revealed no other lesions explaining the patient’s acute complaints. Additional plain radiograph of the left hip revealed an oval cyst-like lucent lesion in the left iliopubic ramus with thinning of the adjacent cortical margin (Fig. A). A magnetic resonance imaging (MRI) for further exploration was proposed. The MRI revealed a T1 hypointense lesion surrounded by increased signal intensity on T2 images, consistent to an osteolytic lesion with peri-lesional bone marrow edema, and a concomitant fracture of the iliopubic ramus. SPECTCT confirmed the presence of a lytic bone lesion in the left iliopubic ramus with high tracer intensity (Fig. B), as well as three smaller osteolytic lesions in both ileum bones without tracer uptake. Considering the possibility of bone metastasis, thoracic and abdominal CT examination was performed to rule out a primary tumor. Both lungs showed multiple small cysts with irregular wall thickness, as well as numerous millimetric pulmonary nodules with groundglass and more dense appearance, both localized in the upper and middle lung zones, with sparing of the lung bases and costophrenic angles (Fig. C). The diagnosis of pulmonary Langerhans cell histiocytosis and eosinophilic granuloma was suggested. An ultrasound-guided percutaneous biopsy of the bone lesion in the left iliopubic ramus was performed. Histological and immunohistochemical examination of the biopt revealed a cluster of eosinophilic granulocyts staining for S100 protein and CD1 antigen, a specific Langerhans cell marker. The diagnosis of ‘pulmonary Langerhans cell histiocytosis’ and ‘eosinophilic granuloma’ was confirmed.

Comment Pulmonary Langerhans Cell Histiocytosis (PLCH), previously known as histiocytosis X or eosinophilic granuloma of the lung, is a very rare and uncommon interstitial lung disease, affecting young adults between 20 and 40 years old; women sometimes at older age. In 4% to 20%, eosinophilic granuloma occurs extra-pulmonary, causing a cystic bone lesion, mostly in flat bones, with local pain and pathological fractures as a consequence. The diagnosis is mostly made by chest imaging characteristics and histological confirmation by CD1a positive Langerhans cells in for example bronchoalveolar lavage or surgical lung biopsy. High resolution computed tomography (HRCT) of the lungs shows C a typical pattern of centrilobular stellate nodules and, with advancing disease, multiple thin- and thick-walled cysts, both with a mid to upper zone predominance and sparing of the costophrenic angles. Though HRCT findings are very characteristic, PLCH has to be distinguished from other interstitial lung diseases, like lymphangioleiomyomatosis (LAM) for example. LAM is also a rare cystic lung disease, with thin-walled cysts, present in the lung bases, and without pulmonary nodules, in the contrary to PLCH. One should not mistake the ‘cyst-like’ destruction and honeycombing of idiopathic pulmonary fibrosis with confluent cysts in advanced pulmonary histiocytosis since they can have a similar appearance though different distribution pattern. The etiology of PLCH is still unknown, but smoking – also present in our patient’s medical history – is thought to be a causal factor of the pulmonary presentation of the disease. Therefore, treatment includes first of all smoking cessation. The use of glucocorticoids is proven to be effective; whereas cytotoxic agents are of limited value. In case of solitary eosinophilic granuloma in bone, local radiotherapy and/or curettage is the best therapeutic option. Reference 1.

Tazi A.: Adult pulmonary Langerhans’cell histiocytosis. Eur Respir J, 2006, 27: 1272-1285. 1. Department of Radiology, Imelda Hospital, Bonheiden, Belgium.

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IMAGES IN CLINICAL RADIOLOGY Intestinal intussusception in an infant C.H. Lee1, W.P. Chan1 A 10-month-old baby girl was admitted to our emergency department because of vomiting, poor appetite, irritable crying for 3 days, and one episode of currant-jelly stool. Physical examination revealed hypoactive bowel sounds. Plain abdominal film showed ileus (Fig. A). Abdominal ultrasound study had an indeterminate result due to ileus. A low-dose computed tomography (CT) was then arranged and showed the classic appearance of intussusception, with a target-like lesion (Fig. B, arrow) and coronal reformatted image showed the invagination of the distal ileum into the colon (Fig. C, arrow). Surgical intervention revealed ileo-ileocolic type intussusception, and the lesion was successfully reduced manually. Lymphoid hyperplasia was identified on gross examination. The patient recovered without complication and was discharged on the fifth day after surgery.

Comment This is a typical presentation of intussusception in an infant, which is the most common cause of acute bowel obstruction in infants (1). Accurate assessment, including clinical examination and imaging study, is mandatory in management of childhood intussusception. Plain abdomen radiograph is the initial examination to be done in a case with suspected ileus. In general, most physicians are using ultrasound to diagnose intussusception, followed by air contrast or barium enema for reduction, or immediate operation if the baby appears to be perforated. However, in this case, the risk of perforation is higher with longer duration before presentation despite indeterminate ultrasonographic findings; hence surgical intervention should be considered alternatively. CT scan can be helpful in accurate assessment of intussusception and pneumoperitoneum due to perforation.

Reference

1. Department of Radiology, Taipei Medical University-Wan Fang Hospital, Taipei, Taiwan.

Ko H.S., Schenk J.P., Troger J., Rohrschneider W.K.: Current radiological management of intussusception in children. Eur Radiol, 2007, 17: 2411-2421.

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IMAGES IN CLINICAL RADIOLOGY Subacute combined spinal degeneration caused by cobalamin deficiency B. Versyck1, T. De Beule2, O. Bladt2, P. Vanhoenacker2 A 51-year-old woman consulted the department of neurology with a 5 month-history of progressive numbness and tingling in a glove and stocking distribution. The problems started in both feet, resulting in unsteadiness and difficulty walking. Motor weakness and impairment of sensation of fine touch were also noticed. Laboratory data revealed a vitamin B12 deficiency and nerve conduction studies showed limited polyneuropathy. Magnetic resonance imaging of the cervical spinal cord demonstrated abnormal hyperintense signal changes on T2-weighted imaging of the posterior and lateral columns at the C2-C5 level (Fig. A,B). This is known as a typical finding compatible of SCD caused by a cobalamin deficiency.

Comment

Vitamin B12 deficiency is a systemic disease that affects many organs including the entire nervous system. It is caused by malabsorption in the gastrointestinal tract, insufficient nourishment by food, genetic deficiency of methylmalonyl-CoA mutase enzyme or medically induced (bariatric surgery, nitrous-oxide induced). The spinal cord is often affected first and exclusively although brain, optic nerves and peripheral nerves may also be affected. SCD denotes specifically the vitamin B12 deficiency as the etiologic cause of the spinal cord involvement. The diagnosis is based upon clinical features, laboratory findings of vitamin B12 deficiency, the presence of posterior and lateral column lesions on MRI and the improvement with vitamin B12 replacement. Vitamin B12 plays a key role in the stimulation of myelin formation that speeds transmission of nerve signals. Damage of the myelin sheath causes degeneration of the sensory and motor nerve fibres from the spinal cord. Most affected are the posterior and lateral roots, with posterior column involvement being earlier in onset and more severe than that of the lateral columns and giving rise to the known clinical presentation. B MRI plays a key role in the diagnosis of SCD. Typical MRI finding of subacute combined degeneration are symmetrical abnormal hyperintense signal of the spinal cord on T2-weighted MRI of posterior and lateral columns of cervical and thoracal cords. This abnormal signal detected in advanced cases of vitamin B 12 deficiency reflects increased water content of the tissue (due to vacuole formation and swelling of the tissue). Similar sign is seen in multiple sclerosis or spinal cord infarction. The location and the relative symmetry of these lesions allow the differentiation of the disease from other intramedullary lesions rather than their signal characteristics. T1-weighted images may show decreased signal in the posterior columns and sometimes demonstrate reversible spinal cord swelling. Contrast enhancement is also reported and is explained as the result of disruption of the blood-cord barrier that may occur in advanced stages. There is a correlation between the normalization of the MRI signal and the overall improvement of the clinical picture, which makes MRI an important tool in the treatment follow-up. Therapy leads to remyelination of the affected white matter, the signal intensity returns to normal in parallel with clinical improvement. In severe cases of neuronal damage, total recovery is not always possible. Persisting high signal intensity and an irreversible neurological impairment can be seen even after aggressive treatment. Reference 1.

Ravina B., Loevner L.A., Bank W.: MR findings in subacute combined degeneration of the spinal cord: a case of reversible cervical myelopathy. AJR, 2000, 174: 863-865. 1. Department of Internal Medicine, 2. Department of Radiology and Imaging, OLV Ziekenhuis, Aalst, Belgium.

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IMAGES IN CLINICAL RADIOLOGY Spontaneous pneumomediastinum: a rare complication of idiopathic pulmonary fibrosis W.Y. Lee, S. Faruqi, J. Kastelik1

An 89-year-old woman with idiopathic pulmonary fibrosis (IPF) and a previous right mastectomy and implant for breast cancer presented with worsening breathlessness. There was no history of cough, haemoptysis, chest pain or fever. The chest radiograph (CXR, Fig. A) showed extensive fibrotic changes in both lungs consistent with the known diagnosis of IPF. A computerised tomography (CT) scan of the thorax revealed marked pneumomediastinum (black arrows) extending throughout the length the mediastinum (Fig. B). No subcutaneous emphysema was noted and no obvious cause for the pneumomediastinum was identifiable. There was no history of trauma or evidence to suggest pulmonary or mediastinal infection from gas-forming organisms. There was also no recent history of tracheobronchial or oesophageal interventions and a barium swallow excluded an oesophageal rupture. A diagnosis of spontaneous pneumomediastium (SPM) was made. The patient was managed conservatively. Her dyspnoea gradually improved and she was discharged home. Comment SPM is the presence of air in the mediastinal cavity in the absence of an obvious causative condition. SPM in association with pulmonary fibrosis is uncommon. Chest pain in association with breathlessness is the most common presentation, which in the context of severe IPF can be potentially life threatening. The most common finding is subcutaneous emphysema, which was absent in our patient. Frequent violent cough causing rupture of the alveoli or honeycomb cysts and subsequent tracking of the air along the bronchovascular sheath and accumulation in the mediastinum is thought to be the mechanism. Although a CXR will pick up significant subcutaneous emphysema and/or pneumomediastinum, a CT examination is more sensitive. SPM is usually benign and responds well to conservative treatment.

References 1.

Caceres M., Ali S., Braud R., Weiman D., Garrett H.E.: Spontaneous pneumomediastinum: a comparative study and review of the literature. Ann Thorac Surg, 2008, 86: 962-966.

1. Department of Respiratory Medicine, Castle Hill Hospital, Cottingham, United Kingdom.

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IMAGES IN CLINICAL RADIOLOGY Congenital bronchial atresia: a fortuitous diagnosis V. Balthasar1, L. Médart2 A 25-year-old woman is admitted in the Radiology Department to evaluate by echography a tumefaction in the right axillary region. Multiple lymph nodes are found and the examination is completed by neck computed tomography. The presence of inflammatory lymph nodes associated with a positive serology for Bartonella Henselae led to the diagnosis of «Cat-scratch disease». Fortuitously, we discovered a hypodense left upper lung. A chest CT in breathing in and out revealed bronchial discontinuity of the apicoposterior left upper lobe bronchus. Associated radiological signs were: air trapping in the culmen while breathing out (Fig. A), local hypovascularization, small bronchoceles (Fig. B, arrow) and the presence of two bronchogenic cysts in the upper (Fig. C) and lower mediastinum. The patient is asymptomatic and shows satisfying respiratory volumes and flow rates. No treatment is necessary as long as the patient stays asymptomatic; she will be followed in pneumology consultation annually.

Comment Bronchial atresia is a congenital anomaly of the tracheobronchial tree. It has been described for the first time in 1953. In most case it affects the upper left lobe. It is estimated that 60% of the patients displaying this anomaly are asymptomatic. The atresia is generally discovered as a fortuitous radiologic event. Symptomatology may be persistent cough, recurrent respiratory infections and dyspnea. The pathophysiological mechanism is not clearly known yet. The most probable assumption is an ischemic phenomenon by obstruction of a bronchial artery during the intra-uterine life. This causes a segmental interruption of the bronchial tree which is totally formed at this time. The distal bronchial tree is normal but alveolar number is diminished in the concerned segment, alveoli are distended rather than destructed. This B hyperinflation can be explained by collateral ventilation through the interalveolar pores of Kohn, bronchoalveolar channels of Lambert and interbronchiolar channels. Bronchoceles are typically associated. Bronchial atresia has to be mentioned when a one-sided lung hyperclarity is discovered. The differential diagnosis includes bronchial tumour, Swyer James syndrome, allergic bronchopulmonary aspergillosis, cystic fibrosis or inhalation of a foreign body (1). The best diagnostic test is chest CT. The exploration must be completed with a bronchoscopy which is generally negative and enables the elimination of other bronchial obstructive causes. Associated malformations are possible: bronchogenic cysts (as in this case), sequestration, interauricular communication, patent left superior vena cava, pericardial defect, partial abnormal pulmonary venous C drainage. Management of the patients with bronchial atresia is variable. If the malformation is discovered during childhood, a surgical excision of the concerned lobe can be performed to allow a normal development of the remaining lung. During adulthood, the surgical treatment is meant for patients who present repeated infections. Lobectomy is preferred to segmentectomy. Reference 1.

Gipson M.G., Cummings K.W., Hurth K.M.: Bronchial atresia. Radiographics, 2009, 29: 1531-1535.

1. Medical student, University of Liège, 2. Department of Radiology, CHR Citadelle, Liège, Belgium.

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IMAGES IN CLINICAL RADIOLOGY Unusual cause of internal knee derangement P. Simoni1, C. Maréchal1, L. Scarciolla2, D. Salerno1, B. Beomonte Zobel2

A 25-year-old man was referred to our department by the orthopaedic surgeon for intermittent pain at the medial compartment of his knee after a rugby match. There was no history of direct trauma. At clinical examination the internal compartment was tender. There was no instability or blockage at clinical tests. A computed tomography arthrography (CTA) examination was performed in order to rule out a lesion at the medial knee compartment. A cord-like image is visible anteriorly to the anterior cruciate ligament (white arrows), extending from the anterior horn of the medial meniscus to the intercondylar fossa, alongside of the anterior cruciate ligament (Fig. A, B, C). Imaging findings were confirmed at arthroscopy (Fig. D). Comment

The antero-medial meniscofemoral ligament (AMMFL) is a rare anomaly of the medial meniscus of the knee joint. It usually arises from the anterior horn of the medial meniscus and it runs anteriorly to the inferior two thirds of the anterior cruciate ligament (ACL). It inserts onto the postero-lateral side of the intercondylar fossa, just anterior to the ACL. AMMFL is situated posteriorly to the ligamentum mucosum, which arises from the Hoffa-fat pad and inserts into the anterior outlet of the intercondylar notch. The prevalence of AMMFL is not well known. It has been reported in 1,2% to 15% of general population in different studies. A number of accessory menisco-femoral ligaments (MFL) has been described. Most commonly, the posterior horn of the lateral meniscus is connected to the inner aspect of the medial femoral condyle by two MFL: the first passes anterior to the posterior cruciate ligament (PCL) and is known as the anterior menisco-femoral ligament (aMFL) of Humphry, while the other passes posterior to the PCL and is known as the posterior menisco-femoral ligament (pMFL) of Wrisberg. The presence of these ligaments is due to normal variants in the embryologic development of the knee. Humphrey’s and Wrisberg’s menisco-femoral ligaments are very common with a prevalence of 74% and 69% respectively, while the AMMFL is rarely observed. Notwithstanding the relative rarity of AMMFL, a detailed description of the attachment sites of the proximal and distal parts of the AMMFL has been reported in a small number of case reports. AMMFL has no attachment onto the tibia, neither directly nor through the synovium. Four types have been described: connected to the anterior transverse ligament, connected to the infrapatellar plica, connected to the transverse ligament and the infrapatellar plica, and connected to the coronary ligament (also known as the menisco-tibial ligament). The typical complaint in patients with AMMFL is a pain of the medial compartment of the knee, clinically mimicking a meniscal tear. It has been speculated that medial compartment pain in patients with a AMMFL is related to the traction of AMMFL on the anterior horn of the medial meniscus in flexed position. In our case due to the absence of any other pathological finding, we suggested in our report that the cause of the pain may be to the presence of a AMMFL. On imaging, AMMFL must be distinguished from a torn ACL and displaced meniscal fragment. AMMFL can be resected at arthroscopy in symptomatic cases. Reference 1.

Wan A.C.T., Felle P.: The menisco-femoral ligaments. Clin Anat, 1995, 8: 323-326.

1. Department of MSK Imaging, University Hospital of Liège, Liège, Belgium, 2. Department of Radiology, University Campus Bio-medico, Roma, Italy.

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ABSTRACT OF PAPERS FOR FULL MEMBERSHIP BONE AND JOINTS Imaging of muscle edema M. Eyselbergs1,2, F.M. Vanhoenacker1,2,3 Introduction: Muscle edema (ME) is characterized by an increase in free water content. It can occur as a consequence of numerous causes. MRI is the most powerful technique to detect ME using fat suppressed (FS) T2-weighted images (WI) or STIR sequences. ME can be subdivided according to distribution of the lesions. Diffuse (bilatera lmuscle involvement), focal (one or a contiguous group of muscles involvement) and multifocal (involvement of multipleremotemuscles) ME patterncanbedistinguished (1, 2). Objectives: The objectives of this study are twofold: (1) to determine the most frequent etiology of ME; (2) to present a pictorial overview of the ME pattern and to illustrate the complementary value of FS T2- and T1-WI. Materials and methods: From June 2005 until February 2012, 13800 musculoskeletal MR examinations were performed in our institution of which 2364 MR studies were included in the scientific database. Every MR study was labelled with a radiological diagnosis and/or specific keyword(s). ME was evaluated on (FS) T2-WI. Atrophy and fatty infiltration were evaluated on T1-WI. In our series, 116 cases were identified on FS T2-WI, 9 cases with ultrasound (US), 1 case with US and additional computed tomography (CT) and 1 case with CT only. Results and discussion: The following etiologies were found in our series: traumatic (n = 106), denervation (n = 11), inflammatory (n = 6), infectious (n = 3) and metastasis (n = 1). Proportions were respectively 83%, 9%, 5%, 2% and 1%. The distribution of the ME pattern was the following: diffuse (n = 1), focal

(n = 123) and multifocal (n = 3). In all cases of denervation ME (n = 11), there was a variable grade of muscle atrophy and fatty infiltration. T1-WI were most helpful in case of denervation edema and may add additional information regarding chronicity and reversibility. Conclusion: The two most frequent etiologies of ME are traumatic and denervation. The focal ME pattern is mostly seen, which is in line with the preponderance of the traumatic etiology of ME in our series.

extrahepatic portosystemic shunt (CEPS) in an elderly patient suffering from ammonia encephalopathy. A review about this unusual pathology and its pathogenic origins is made, and highlights that when a therapeutic intervention is indicated, the less invasive should be considered first. With detachable coiling, a safe and durable closure of this kind of shunts is achievable, without surgery. 1. Department of Radiology, Brugmann, ULB-VUB, Brussels.

CHU

References 1.

May D.A., Disler D.G., Jones E.A., Balkissoon A.A., Manaster B.J.: Abnormal signal intensity in skeletal muscle at MR imaging: patterns, pearls, and pitfalls. Radiographics, 2000, 20 Spec No: S295-315. 2. McMahon C.J., Wu J.S., Eisenberg R.L.: Muscle edema. AJR, 2010, 194: W284-292.

Embolization of an unexpected finding in a VHL patient A. Pattyn, L. Divano1

Laureys,

Akkari,

1. Department of Radiology, AZ SintMaarten Duffel-Mechelen, campus Duffel, Duffel, 2. Department of Radiology, University Hospital Antwerp, Edegem, 3. Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium.

The authors report their experience with the diagnosis and the therapeutic embolization of a pelvic extramedullary hemangioblastoma in a young woman suffering from Von Hippel Lindau disease (VHL). To the best of the knowledge of the authors, this is the first ever described case of a pelvic hemangioblastoma, and also the first reported description of therapeutic embolization in this localization.

CARDIOVASCULAR AND INTERVENTIONAL RADIOLOGY

1. Department of Radiology, Brugmann, ULB-VUB, Brussels.

Embolization of a congenital extrahepatic portosystemic shunt ... in a 70-year-old patient G. Boitsios, M. Laureys, K. Akkari, L. Divano1 The authors describe the percutaneous therapeutic occlusion of a congenital

CHU

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JBR–BTR, 2012, 95: 184-188.

CONTINUING EDUCATION PROCEEDINGS OF THE JOINT MEETING RBRS BONE SECTION AND NEDERLANDSE VERENIGING VOOR SKELETARADIOLOGIE, Leiden, The Netherlands, 25.03.2011 – PART II Tumors and tumorlike conditions of the calcaneus: the usual and unusual F.M. Vanhoenacker1,2,3, M. Eyselbergs1,2, A.M. De Schepper2, K.L. Verstraete3 The calcaneus is an uncommon site for involvement by tumors or tumorlike conditions of bone, although any lesion may involve the calcaneus. The purpose of this paper is to highlight the imaging features of common and uncommon tumors and tumorlike conditions occurring in the calcaneus. Typical case studies will illustrate the imaging findings on different imaging modalities. Key-words: Ankle – Foot – Tumors.

Case 1 Clinical information: Thirty-five-year-old man presents after a motor vehicle accident with an ankle trauma.

Findings on medical imaging:

Case 2

Diagnosis:

Clinical information

Based on the typical radiographic findings and location, the diagnosis of prominent vascular remnant in the calcaneus can be made. A subtle subtalar focus of increased T2-signal within the calcaneus is common on MRI of the ankle done for other reasons, and is unlikely to be misinterpreted as a pathological condition. Lesions exceeding a diameter more than 5 mm -however- are only seen in 7% of MR examinations (1). This normal variant should not be misinterpreted as a significant lesion and should not be biopsied. The typical subtalar location within the calcaneus near the insertion of the cervical and interosseous ligaments in an asymptomatic patient is the clue to the correct diagnosis. The lesion is of high signal on T2-WI and of low signal on T1-WI. Subtle penetration of the superior calcaneal cortex may be seen on CT and/or MRI.

Seventeen-year-old after an ankle sprain.

man

presents

Findings on medical imaging: Diagnosis: The diagnosis of a simple bone cyst (SBC) was made. A SBC is a benign fluid-filled lesion that is usually seen in the long tubular bones (proximal humerus and femur), under the age of 20 years. The calcaneus is involved in approximately 3% of all SBC (2). Calcaneal lesions may occur in patients over the age of 20 years.

Fig. 1. — CT scan of the left ankle. CT scan revealed a fracture of the medial and posterior ankle. Incidentally, a well delineated radiolucent lesion was seen in the calcaneus inferior to the angle of Gissane. A. Sagittal reformation. B. On coronal reformation, the lesion seems to be connected with the superior calcaneal cortex by a nutrient foramen (arrow).

B Fig. 2. — MRI of the left ankle. A. Sagittal fatsuppressed T2-weighted image (WI). B. Coronal fatsuppressed T2-WI. The lesion is hyperintense on T2-WI.

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A Fig. 3. — Conventional radiograph of the left ankle. There is a well delineated radiolucent lesion within the subthalamic area of the calcaneus.

Plain radiographs reveal a well-delineated radiolucent lesion within the anterior calcaneus. Pathological fracture is rare at the calcaneus, whereas this complication occurs typically in SBC of the long bones (3). A fallen fragment sign has never been described at the calcaneus. The differential diagnosis with calcaneal pseudocyst or intraosseous lipoma is difficult or even impossible on plain films. MRI is the preferred technique for further lesion characterization. Although a SBC has been designated with the term solitary or unicameral bone cyst, the contour of the lesion may be slightly lobulated. SBC are of low to intermediate signal intensity on T1-WI and of high signal intensity on T2-WI. After administration of intravenous gadolinium contrast, peripheral rim enhancement is seen.

185

C Fig. 4. — MRI of the left ankle. A. Sagittal T2-WI. The lesion is of high signal intensity. B. Axial T1-WI. The lesion is slightly lobulated and is of low signal intensity. C. Sagittal fatsuppressed T1-WI after intravenous gadolinium contrast administration. There is subtle peripheral rim enhancement of the lesion.

Fig. 5. — Conventional radiograph of the left ankle. Geographic osteolytic lesion within the anterior part of the calcaneus.

Case 3 Clinical information: Forty-eight-year-old after ankle sprain.

man

presents

Findings on medical imaging: Diagnosis: Based on the signal characteristics of the lesion, similar to fatty tissue, the diagnosis of intra-osseous lipoma of the calcaneus was made. An intraosseous lipoma is a rare benign bone lesion, accounting for at least 0.3% of lesions. The lesion is probably underreported due to the lack of symptoms (4). The calcaneus is involved in up to 30% of cases (2, 4). Intraosseous lipomas of the calcaneus have the same location as SBC or a pseudocyst of the calcaneus. According to Milgram, three consecutive histopathological stages of evolution exist. Stage 1 is composed of viable fat. Stage 2 lesions comprise a mixture of

viable fat and areas of partial fat necrosis, whereas stage 3 contains diffuse eosinophilic fat necrosis with extensive calcifications, ossifications or areas of myxoid degeneration. The radiographic appearance consists of a well delineated radiolucent lesion, often surrounded by a peripheral rim of sclerosis. In stage 3 lesions, intralesional calcifications or ossifications are present. CT is more sensitive than plain films for detection of these calcified or ossified foci. MRI is superior to detect areas of partial fat necrosis or the development of cystic areas due to myxoid necrosis. The

fatty components are of high signal on T1-WI and of low signal intensity on fat suppressed images. Areas of fat necrosis appear hypointense on T1-WI and hyperintense on T2-WI. The potential relationship between calcaneal pseudocysts (physiological area of trabecular rarefaction within the anterior aspect of the calcaneus, containing fatty bone marrow), an intraosseous lipoma or fatty degeneration within a preexisting benign primary bone tumor (such as a SBC) is still debated (2, 4). This discussion is, however, of no importance because neither of these lesions need any further treatment.

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JBR–BTR, 2012, 95 (3)

C A

Fig. 6. — MRI of the left ankle. A. Sagittal T1-WI and B. Axial T1-WI. The lesion is of high signal intensity, with some small intralesional areas of intermediate signal intensity. C. Sagittal fatsuppressed T2-WI. The signal of the lesion is suppressed, except for some small intralesional areas of high signal intensity.

Fig. 7. — Conventional radiograph of the left ankle. Ill-defined sclerosis at the posterior aspect of the calcaneus.

B A Case 4 Clinical information Twenty-one-year-old man with chronic heel pain. Findings on medical imaging: Diagnosis: Chronic calcaneal osteomyelitis was suggested, which was confirmed after surgical debridement of the soft tissue and posteroinferior calcaneus. Infection of the calcaneus most commonly occurs as a result of puncture wounds, whereas osteomyelitis due to hematogenous spread of infective organisms is predominantly seen in children, but is rare in adults. In patients with diabetes, osteomyelitis is caused by contiguous spread from an adjacent foot ulcer. Plain radiographs show areas of bony destruction, bony sclerosis and soft tissue swelling (5). MRI reveals diffuse bone marrow infiltration of the calcaneal marrow fat. The signal is isointense to muscle on T1-WI and hyperintense on fatsuppressed T2-WI or STIR. The calcaneal cortex may be indistinct and adjacent signal changes

are best seen on fluid-sensitive sequences. Areas of bone and adjacent soft tissue infection enhance after administration of intravenous gadolinium contrast. Areas of abscess formation show peripheral rim enhancement, whereas sequesters do not enhance. Case 5 Clinical information Fifty-three-year-old female presenting with nonspecific heel pain and increased

C Fig. 8. — MRI of the left ankle. A. Sagittal T1-WI. There is diffuse bone marrow edema within the posterior part of the calcaneus. B. Sagittal fatsuppressed T2-WI. The bone marrow edema is better seen as high signal compared to normal fatty bone marrow. Note also some adjacent soft tissue edema at the posteroinferior aspect of the calcaneus. C. Sagittal fatsuppressed T1-WI after administration of intravenous gadolinium contrast. Diffuse abnormal enhancement of the posterior and inferior calaceneus and adjacent soft tissue.

tracer uptake on bone scintigraphy at the left calcaneus. Findings on medical imaging: Diagnosis: Based on the characteristic radiographic findings and the age of the patient, the diagnosis of monostotic Paget’s disease was made. The disease usually affects middle aged or older patients. Three phases of radiographic severity can be distinguished. An early lytic phase may

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A Fig. 9. — The lateral radiograph of the ankle shows slight enlargement of the calcaneus with thickening of the bony trabeculae.

187

be followed by a mixed lytic-sclerotic and a late osteoblastic phase. The radiographic hallmarks include enlargement of the calcaneus, trabecular and cortical thickening (5). Case 6 Clinical information: Eight-year-old male presenting with nonspecific heel pain and increased tracer uptake on bone scintigraphy at the left calcaneus. The patient was referred for MRI. Findings on medical imaging: Diagnosis: After biopsy of both bone and soft tissue components of the lesion and histological examination of the specimen, the diagnosis of Ewing Sarcoma (ES) was made. ES and primitive neuroectodermal tumor (PNET) were originally described as distinct clinicopathologic entities, but are currently considered as part of the same spectrum of neoplastic disorders. Most tumors occur between the age of 5 and 25 years, with a peak between 10 and 20 years. Rarely, the tumor develops in adults older than 30 years. The preferred sites are the long bones of the lower extremity. The calcaneus is a less common site of involvement. On radiographs or CT, ES involving the bone is mostly mixed sclerotic-lytic. The most characteristic finding on MRI is the presence of a large soft tissue mass (6). Current treatment of localized disease consists of initial multiagent neoadjuvant chemotherapy, followed by wide or radical surgery and/or radiotherapy. Calcaneal lesions show poor longterm survival (4, 7). Case 7 Clinical information: Thirteen-year-old girl presenting with nonspecific heel pain was referred for conventional radiographs and MRI of the ankle.

C Fig. 10. — MRI of the left heel. A. Sagittal STIR images. There is inhomogeneous increased signal within the anterior part of the calcaneus and adjacent soft tissue extension within the sinus tarsi. B. Sagittal STIR images at the level of the sustentaculum tali. A huge soft tissue mass at the plantar aspect of the calcaneus is present. C. Sagittal T1-WI. There is a large area of bone marrow replacement within the anterior part of the calcaneus with relative sparing of the posterior part. Note also extension within the sinus tarsi. D. Axial fatsuppressed T1-WI after administration of intravenous gadolinium contrast. There is heterogeneous enhancement of both the osseous and soft tissue mass.

Findings on medical imaging: Diagnosis: After biopsy of both bony and soft tissue components of the lesion and histological examination of the specimen, the diagnosis of osteosarcoma (OS) was made. OS is the most common primary malignant tumor of bone in adolescents and young adults, accounting for approximately 40-60% of all primary malignant bone tumors. Less than 1% of OS arise in the calcaneus (5). The tumor may also be the result of malignant transformation of benign lesions such as Paget's disease, fibrous dysplasia or after previous irradiation. Radiographically, intramedullary calcaneal OS is similar to conventional osteosarcoma, with presence of osteoid matrix, aggressive periosteal reaction

Fig. 11. — Conventional radiograph of the right ankle. The lateral radiograph of the ankle demonstrates osteosclerosis of the posteroinferior aspect of the calcaneus, irregular delineation of the inferior cortex and spiculated periosteal reaction (arrow).

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JBR–BTR, 2012, 95 (3) References 1.

C Fig. 12. — MRI of the right heel. A. Sagittal T1-WI. There is a huge area of bone marrow replacement within the calcaneus and adjacent soft tissue mass at the plantar aspect of the calcaneus. B. Sagittal fatsuppressed PD-WI. The osseous and soft tissue components of the lesion are of high signal intensity. C. Sagittal T1-WI after administration of intravenous gadolinium contrast. There is diffuse enhancement of the lesion within the calcaneus as well as heterogeneous enhancement of the adjacent soft tissue mass (arrows).

3. 4.

B 7.

(such as a sunburst type periosteal reaction) and soft tissue extension. Besides areas of sclerosis and mineralization, there are often associated areas of lytic bone destruction. MR imaging is performed to assess the intra- and extraosseous components of the lesion. Lesions are of low to intermediate signal intensity on T1-WI and are of heterogeneous signal intensity on T2WI. Mineralized areas are of low signal,

whereas other components are of high signal intensity. Foci of central hemorrhage are of high signal on all pulse sequences. Fat-suppressed T1-WI after intravenous administration of gadolinium contrast are particular helpful for preoperative local staging. Treatment of OS includes a combination of preoperative and postoperative chemotherapy, wide surgical excision and radiation therapy (4).

Fleming J.L., Dodd L., Helms C.A.: Prominent vascular remnants in the calcaneus simulating a lesion on MRI of the ankle: findings in 67 patients with cadaveric correlation. AJR, 2005, 185: 1456-1449. Diard F., Hauger O., Moinard M., Brunot S., Marcet B.: Pseudo-cysts, lipomas, infarcts and simple cysts of the calcaneus: are there different or related lesion? JBR-BTR, 2007, 90: 315-324. Van Doninck J., Vanhoenacker F.M., Petré C., Willemen D.: Fallen fragment sign. JBR-BTR, 2010, 93 (2): 109. Rhee J.H., Lewis R.B., Murphey M.D.: Primary osseous tumors of the foot and ankle. Magn. Reson Imaging Clin N Am, 2008, 16: 71-91. Kumar R., Matasar K., Stansberry S., et al.: The calcaneus: normal and abnormal. Radiographics, 1991, 11: 415-440. Vanhoenacker F.M., Van Kerkhove F., Peersman B., Brys P., De Schepper A.M.: Ewing sarcoma/PNET tumors. In: Imaging of bone tumors and tumor-like lesions. Edited by Davies A.M., Sundram M., James S.L.J., Printed by Springer-Verlag, Berlin Heidelberg, 2009, pp. 337-349. Wunder J.S., Paulian G., Huvos A.G., et al.: The histological response to chemotherapy as a predictor of the oncological outcome of operative treatment of Ewing sarcoma. J Bone Joint Surg Am, 1998, 80: 1023-1033.

1. Department of Radiology, AZ SintMaarten Duffel-Mechelen, Rooienberg 25, B-2570 Duffel, Belgium, 2. Department of Radiology, Antwerp University Hospital, Wilrijkstraat 10, B-2650 Edegem, Belgium, 3. Department of Radiology, University Hospital Ghent, UZ Gent, University of Ghent, De Pintelaan, 185, B-9000 Gent, Belgium.

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JBR–BTR, 2012, 95: 189.

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