JBR 2012-6 by office

Wetteren 1

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P 702083

volume 95 Page 345-398

November-December

â&#x20AC;&#x201A; Bimonthly

â&#x20AC;&#x201C;

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) 00a-Couv-2012(6).indd 1

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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.

Single issue 38 € 44 €

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

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

Annuel 175 € 200 €

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

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

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

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

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

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

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JBR-BTR ♦ 95/6 ♦ 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 Pictorial essay: Multidetector CT of hepatic artery pathologies D. Karaosmanoglu, B. Erol, M. Karcaaltincaba . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 345 Mycotic aneurysm of the right iliac artery: imaging diagnosis and correlation with pathological findings G.C. Colin, J.-L. Dargent, E. Agneessens, V. Scavée, J.-P. Haxhe, P. Bosschaert . . . . . . . . . . . . . . . . 350 Susac’s syndrome: a clinical and radiological challenge I. Raets, G. Gelin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 355 An unusual cause of subtalar pain and instability: accessory calcaneus C. Boulet, M. De Maeseneer, H. Everaert, M. Kichouh, J. De Mey, M. Shahabpour . . . . . . . . . . . . 357 Synovial chondrosarcoma arising from synovial chondromatosis of the knee M.-S. Yao, C.-M. Chang, C.-L. Chen, W.P. Chan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 360 Spontaneous otogenic pneumocephalus and pneumatocoele O. Soenen, J.W. Casselman, B. Lerut . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 363 TECHNICAL NOTE Usefulness of percutaneous cholangiography combined with CT in post-operative patients with hepato-biliary surgery T. Kirchgesner, C. Hubert, E. Danse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 366 IMAGES IN CLINICAL RADIOLOGY Gastroepiploic artery aneurysm M. Incedayi, A.K. Sivrioglu, M. Saglam, G. Sonmez, E. Ozturk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 367 Recurrent sarcoidosis after lung transplantation K. Ramakers, W. De Wever, J. Coolen, J. Verschakelen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 368 Proximal iliotibial band enthesopathy M. Posadzy-Dziedzic, F.M. Vanhoenacker . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 369 Tunnel enlargement and recurrent graft tear after ACL reconstruction K. Petrovic, F.M. Vanhoenacker, O. Nikolic, P. Vandenberk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 370 Renal angiomyolipoma rupture C.H. Lee, W.P. Chan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 371 Collateral systems in superior vena cava occlusion C. Balliauw, M. Koolen, J. Verschakelen, W. De Wever . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 372 Lymphoma of the sigmoid colon presenting with clinical signs of a diverticulitis J. Grossner . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 373 Calcific tendinopathy of the pectoralis major insertion with intracortical protrusion of calcification M.T. El-Essawy, F.M. Vanhoenacker . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 374 Primary lymphoma of iliac bone M.T. El-Essawy, F.M. Vanhoenacker, H. Van Dijck, M. Ferrante . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 375

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Bone marrow involvement in sarcoidosis F. Van Den Bergh, J. Wagemans, A. Snoeckx, K.L. Verstraete, F.M. Vanhoenacker . . . . . . . . . . . . . . 376 Scurvy in a 3-year-old boy: MRI features J. De Cock, M. Renard, M. Smet, L. Breysem . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 377 Ewing’s sarcoma of the rib in a child S. Van Petegem, L. Jans, V. Lambrecht, W. Huysse, K. Verstraete . . . . . . . . . . . . . . . . . . . . . . . . . . . 378 Suggestive MR features of Whartin’s tumor with correlation between diffusion-weighted imaging and pathology I.B. Aremu, Ph. Grandjean, M. Hamoir, B. Weynand, Th. Duprez . . . . . . . . . . . . . . . . . . . . . . . . . . . . 379

Proceedings of the meeting “Update in abdominal and urogenital imaging”, Bruges, 6-8 September 2012 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 380 Announcements from the Museum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 366 Forthcoming Courses and Meetings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 397 Instructions to Authors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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

cii

Advertising index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ciii

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

02-voorblz-12-6_Opmaak 1 18/12/12 14:02 Pagina 2

Editor: J. Pringot

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

Managing Editor: P. Seynaeve

President: J.F. De Wispelaere 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 individual 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 p. 398)

Steeds een stap verder Wij verleggen de grenzen van de borstbeeldvormingstechnieken

2D-mammografie

Borsttomosynthese

C-View™

Na de invoer van de digitale mammograaf Selenia© Dimensions© met tomosynthese, gaat Hologic met de TomoHD vandaag nog een stap verder in de borstbeeldvormingstechniek. TomoHD™ is gebaseerd op een nieuw reconstructie-algoritme C-View™ voor het creëren van een synthetisch 2D-beeld van de gegevens van de tomosynthese die zijn verkregen met behulp van Selenia Dimensions; hiervoor is geen 2D-opname vereist, wat daarmee de compressietijd verlaagt en de dosimetrie vermindert. Met deze innovatieve technologie moet het op een dag mogelijk zijn om de conventionele 2D-opnames in het kader van de opsporing en diagnose overbodig te maken. De doelstellingen van het TomoHD systeem zijn: • De compressietijd en bijgevolg, de stralingsdoses verminderen • Traditionele 2D-mammogrammen emuleren met behoud van belangrijke details van de opnameplakken in de tomosynthese, wat resulteert in heldere, duidelijker, beter contrasterende verkalkingen en beter gedefinieerde structuren • De 2D-beelden van vorige onderzoeken vergelijken met synthetisch samengestelde beelden die samen met de plakken uit de tomosynthese bekeken worden

Hologic NV Europa: BE-info@hologic.com | www.hologic.com | Tel: +32.2.711.46.95 © Copyright Hologic 2012 Hologic, C-View, Dimensions, Selenia en TomoHD zijn handelsmerken en/of geregistreerde handelsmerken van Hologic, Inc. en/of zijn dochterondernemingen in de VS en/of andere landen.

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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PICTORIAL ESSAY MULTIDETECTOR CT OF HEPATIC ARTERY PATHOLOGIES D. Karaosmanoglu1, B. Erol2, M. Karcaaltincaba3 The hepatic artery can be involved by a variety of pathology and diseases. Today MDCT enables high quality imaging of the hepatic artery using axial, MIP and volume rendered images. We illustrate MDCT findings of anatomical variations, aneurysm, dilatation, dissection, arteriovenous fistula, thrombosis and stenosis. Aneurysms can be saccular, fusiform and multiple and may develop due to atherosclerosis, vasculitis, trauma and biopsy. Dilatation of hepatic artery can be seen in portal hypertension, Osler-Weber-Rendu disease and hemangiomatosis. Hepatic artery can be occluded after trauma and transplantation. Dissection develops due to atherosclerosis, Marfan and Ehler Danlos syndromes and during pregnancy. Arteriovenous fistula can be congenital and acquired. We conclude that various hepatic artery pathologies can be confidently diagnosed by MDCT. Key-words: Aneurysm, hepatic - Hepatic artery, CT – dissection.

Imaging of the visceral vascular structures non-invasively with the development of MDCT is one of the most important forward leaps in radiology in the last decade. With the improvement of the MDCT technology any arterial and venous vascular structure of the abdomen can be easily detected and treatment planning can be done in a straightforward manner. Compared to conventional catheter angiography, MDCT imaging of the vascular tree is sometimes more contributory to the patient’s treatment plan. Pathologies of the hepatic artery are not rare and in some specific situations may be utmost important for the patient’s morbidity and even mortality. In this manuscript, we have tried to provide an overview to pathologies of the hepatic artery in terms of MDCT findings. Anatomical variations Exact delineation of the hepatic artery and its branches is a significant factor for the success of liver transplantation, especially for the grafts from living donors. Sufficient arterial flow via the hepatic artery is one of the most important factors for the survival of the graft. MDCT is increasingly being used for the evaluation of the hepatic artery in the pre-transplant phase (1). With the use of the MDCT, other vascular structures related to the liver can

Fig. 1. — Normal hepatic artery anatomy with volume rendered (VR) images. The common hepatic artery then bifurcates (black arrow) into the gastroduodenal artery (asterisk) and proper hepatic artery. The proper hepatic artery bifurcates into the right and left hepatic arteries (white arrows).

also be quickly examined in a single imaging study within a remarkably short period of time. Michel’s classification is the conventional method for the evaluation the vascular variations, and in this system only 55% of the hepatic arteries show the classic branching (1) (Fig. 1). Left hepatic

From: 1. Department of Radiology, Massachusetts General Hospital Harvard Medical School, Boston MA, USA, 2. Department of Radiology, Antalya Education and Research Hospital, Antalya, Turkey, 3. Department of Radiology, Hacettepe University, Faculty of Medicine, Ankara, Turkey. Address for correspondence: Dr. M. Karcaaltincaba, M.D., Liver imaging team, Liver Imaging Team, Department of Radiology, Hacettepe University School of Medicine, Sihhiye, Ankara, 06100, Turkey. E-mail: musturayk@yahoo.com

artery arising from the left gastric artery and the replaced right hepatic artery from the superior mesenteric artery are the most common arterial variations (i.e. Michel’s type II and III, respectively) and may be seen in 10% and 11% of the subjects. Hepatic artery originating directly from the abdominal aorta is an uncommon presentation (0.2-3%) but an important finding for the surgeon (2-4) (Fig. 2). Apart from these anatomical variations, a replaced right hepatic artery can give rise to splenic artery (Fig. 3). For pre-transplant imaging, the calibration of the hepatic arteries may also be easily evaluated.

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Fig. 2. — A. Common anatomical variants of the hepatic artery. Coronal MIP images of the right hepatic artery (arrow) originating from superior mesenteric artery. B. Coronal MIP images show the left hepatic artery (arrow) originating from the left gastric artery (arrowhead). C. Axial CT images showing the hepatic artery (arrow) originating directly from abdominal aorta (arrowhead).

Fig. 4. — Diffuse aneurysmal dilatations of the common (white arrows) and proper (black arrows) hepatic arteries.

Fig. 3. — VR image shows a replaced right hepatic artery (arrows) from superior mesenteric artery supplying splenic artery.

Aneurysm of the hepatic artery Hepatic artery is the fourth most frequent site of peripheral arterial aneurysms after aorta, iliac artery and splenic artery (5). Among the underlying predisposing factors atherosclerosis, trauma, inflammation and iatrogenic factors may be counted (6). With the increased use of cross-sectional imaging and diagnostic and therapeutic interventions of the liver increased the incidence of the detection of this abnormality (7). Almost 75-80% of the hepatic artery aneurysms are extrahepatically located at different locations on the course of the artery and they are generally solitary (8) (Fig. 4). Athero-

sclerotic aneurysms are typically extrahepatic, while intrahepatic aneurysms and pseudoaneurysms are generally related to trauma and biopsy. The aneurysms of the hepatic artery may vary in size and may have a diameter of 14 cm, with a median diameter of 3.6 cm (9) (Fig. 5). The reported indications for treatment of common hepatic artery aneurysms are: symptomatic aneurysms, aneurysms larger than 2 cm, non-atherosclerotic aneurysms and multiple aneurysms (9). Surgery and endovascular intervention are the main treatment modalities. Intrahepatic hepatic artery aneurysms are generally secondary to surgical or percutaneous interventions and

the appropriate treatment of this aneurysm must be tailored on individual basis (Fig. 6). Vasculitis is among the causes of the aneurysms of the hepatic artery. The aneurysms may be seen as diffuse multiple or solitary. Several infectious and inflammatory vasculites including polyarteritis nodosa and systemic lupus erythematosus may cause visceral arterial aneurysms including the hepatic artery (10) (Fig. 7). Dilatation of the hepatic artery Dilatation of the hepatic artery may be secondary to several different disorders; however portal hypertension and cirrhosis are the most common causes. Dilatation and spiraling of the hepatic artery (corkscrew appearance) is the classic finding of portal hypertension (Fig. 8).

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Fig. 5. — Giant aneurysm of the hepatic artery (arrows) in a 69 year-old patient with a history of hypertension. Patient had no history of trauma or surgery. The calcified plaques at the wall identifies the origin of the pathology as atherosclerotic.

Fig. 8. — Prominent increase in caliber of the hepatic arteries (arrowheads) with spiraling (corkscrew appearance, arrows) in a patient with severe portal hypertension due to chronic portal vein thrombosis. Also note early bifurcation of hepatic artery as an anatomic variation.

Fig. 6. — Aneurysmal dilatation (arrow) of the segment 8 branch of the hepatic artery. The patient underwent non-focal liver biopsy six weeks before the procedure, most likely iatrogenic. The patient was completely asymptomatic, CT was done for an unrelated reason.

Fig. 9. — Diffuse dilatation of the common hepatic artery (arrows) in a 26-year-old female patient with a history of OslerWeber-Rendu syndrome. Note the absence of corkscrew appearance of the artery in contrast to patients with portal hypertension.

Fig. 7. — 23-year-old patient with a history of treatment resistant systemic lupus erythematosus. Multiple stenoses (black arrows) and aneurysmal dilatations (white arrows) of the intraparenchymal branches of the hepatic artery are shown.

Osler-Weber-Rendu disease is another rare cause of dilatation of the hepatic artery (Fig. 9). The dilatation of the artery may be extra or intrahepatic and sometimes both (11). Multiple telengiectasias in

the liver parenchyma is another interesting finding in this uncommon abnormality. Diffuse hepatic hemangiomatosis is rare and usually detected in newborns with associated abdominal

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Fig. 10. — Coronal MIP (A) and VR images (B) show dilated hepatic artery (arrowhead) and multiple hemangiomas (arrows) in a patient with hemangiomatosis.

Fig. 12. — Complete absence of contrast enhancement in the hepatic artery at the hepatic hilum (arrow) consistent with short segment thrombosis in a patient with hepatic transplant (performed 2 days before imaging). VR image shows collateral filling of left hepatic artery (arrowhead) (A). Prior color Doppler US was unable to demonstrate the arterial signal at the hilum in another patient. Coronal MIP image shows the exact location of the stenosis (black arrow) (B). Catheter angiography confirmed the diagnosis.

Fig. 11. — Arterial phase coronal MIP image shows enhancing and dilated portal vein (black arrows), dilatation of the hepatic artery (white arrows) and with multiple ectatic vascular structures (asterisk) in between these two vessels consistent with arterioportal shunt.

clinical findings are highly variable ranging from asymptomatic cases to severe findings of portal hypertension, eventually resulting in death. APF may be congenital, post-traumatic and iatrogenic (12). When the rare congenital cases are set aside, most of the patients are traumatic or iatrogenic. Clinical diagnosis is mainly done with imaging. Color Doppler US, CT and MRI may all be used in the diagnosis. Catheter angiography may also be used for detection and treatment. On arterial phase images, enhancement and dilatation of the portal vein and multiple ectatic vascular structures are the main findings (Fig. 11). Increased blood flow to the portal system is most likely the cause of the hyperkinetic portal hypertension (12). Endovascular treatment is the main treatment modality for these patients with highly successful results. Hepatic artery thrombosis or stenosis

Fig. 13. — Axial CT (A) and coronal MIP images (B) show aortic dissection extending from celiac artery (arrows) to hepatic artery and of their branches (arrows).

distension and sometimes with congestive heart failure. It is generally associated with skin involvement and isolated forms are rare (1). Hepatic artery can be dilated in a patient with associated hepatic hemangiomatosis (Fig. 10). The underlying etiology for hepatic

artery dilatation is most likely the increased arterial circulation of the liver. Arterioportal fistula Arterioportal fistula (APF) is a rare cause of portal hypertension. The

The rate of hepatic artery complications after liver transplant ranges between 5-20% are among the most problematic problems in the early phase of the post-transplant period (13, 14). The hepatic artery thrombosis or stenosis are the predominant disorders affecting the hepatic artery in the posttransplant period. Hepatic artery thrombosis is a potentially complicating pathology that may end up with liver failure (75-88%) and death may ensue in 57% of these patients (15). The hepatic artery is very significant for the liver parenchyma and bile duct system, particularly in the early post-operative period. Early detection of this abnormality is of

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paramount importance for prompt intervention and potential salvage of the graft. Generally color Doppler US is the first imaging modality in the early phase with its great versatility that allows bedside evaluation. In the past, catheter angiography was the main evaluation method for hepatic artery; currently CT and MR angiography are preferred for diagnosis. CT angiography is highly useful compared to MRI with its quick application and highly accurate results. MRI also demands strong patient cooperation for accurate imaging which may be hard to obtain in a patient in early postoperative period. Classical imaging finding in CT angiography is the absence of contrast filling in the presumed trajectory of the hepatic artery right anterior to portal vein in the hepatic hilum (Fig. 12). With isotropic multiple reformatted images the exact location of the stenosis or thrombosis may be detected and useful guidance for endovascular or surgical intervention may be supplied. Additionally other vascular or visceral organ abnormalities that may mimic arterial complications may also be easily detected. Hepatic artery dissection Dissection of the abdominal visceral arteries are rare clinical occurrence and may be iatrogenic or due to continuation of the abdominal aortic aneurysm (16) (Fig. 13). Arterial dissection is essentially the separation of two layers of the arterial wall secondary to intramural hematoma (17). Patients may be asymptomatic or may present with signs of ischemia of the affected vascular territory. Dissection of the hepatic artery is rare and may present with jaundice (16). Apart from the iatrogenic dissections several underlying diseases may cause the dissection of visceral artery aneurysms like, atherosclerosis, collagen vascular disorders, Marfan

syndrome, Ehler Danlos syndrome, pregnancy and syphilis (18). MDCT angiography appears to be the most useful modality for this diagnosis. Conclusion MDCT angiography is a very robust and versatile imaging modality which allows highly accurate and prompt information about the pathologies of the hepatic artery. With the ability of imaging the trajectory of hepatic artery in almost every plane with isotropic data, it is relatively straightforward for the radiologists to recognize these abnormalities and inform the referring clinician in a very time efficient manner. Obtaining both arterial and venous phase images may increase the diagnostic accuracy of MDCT, allowing both the evaluation of the hepatic vasculature and the other abdominal mimickers. In this article, we summarized the role of MDCT in a variety of clinical disorders of the hepatic artery and increased the acquaintance of the practicing radiologists.

References 1. Duran C., Uraz S., Kantarci M., et al.: Hepatic arterial mapping by multidetector computed tomographic angiography in living donor liver transplantation. J Comput Assist Tomogr, 2009, 33: 618-625. 2. Lippert H., Pabst R.: Arterial variations in man: Classification and Frequency. Munich, Springer-Verlag, 1985. 3. Nakamura H., Uchida H., Kuroda C., et al.: Accessory left gastric artery arising from left hepatic artery angiographic study. Am J Roentgenol, 1980, 134: 529-532. 4. Van Damme J.P., Bonte J.: Vascular anatomy in abdominal surgery. Stuttgart, Georg Thieme Verlag, 1990. 5. Stanley J.C., Wakefield T.W., Graham L.M., Whitehouse W.M. Jr., Zelenock G.B., Lindenauer S.M.: Clinical importance and management of splanchnic artery aneurysms. J Vasc Surg, 1986; 3: 836-840.

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6. O’Driscoll D., Olliff S.P., Olliff J.F.: Hepatic artery aneurysm. Br J Radiol, 1999, 3: 836-840. 7. Jeans P.L.: Hepatic artery aneurysms and biliary surgery: two cases and a literature review. Aust N Z J Surg, 1988, 58: 889-894. 8. Bachar G.N., Belenky A., Lubovsky L., Neuman-Levine M.: Sonographic diagnosis of a giant aneurysm of the common hepatic artery. J Clin Ultrasound, 2002, 30: 300-302. 9. Abbas M.A., Fowl R.J., Stone W.M., et al.: Hepatic artery aneurysm: factors that predict complications. J Vasc Surg, 2003, 38: 41-45. 10. Choy C.W., Smith P.A., Frazer C., Jeffrey G.P.: Ruptured hepatic artery aneurysm in polyarteritis nodosa:a case report and literature review. Aust NZ J Surg, 1997, 67: 904-906. 11. Buscarini E., Buscarini L., Civardi G., Arruzzoli S., Bossalini G., Piantanida M.: Hepatic vascular malformations in hereditary hemorrhagic telengiectasia:imaging findings. Am J Roentgenol, 1994, 163: 1105-1110. 12. Lu Z.Y., Ao J.Y., Jiang T.A., Peng Z.Y., Wang Z.K.: A large congenital and solitary intrahepatic arterioportal fistula in an old woman. World J gastroenterol, 2009, 15: 1656-1659. 13. Cavallari A., Vivarelli M., Bellusci R., Jovine E., Mazziotti A., Rossi C.: Treatment of vascular complications following liver transplantation: multidisciplinary approach. Hepatogastroenterology, 2001, 48: 179-183. 14. Wang X.H., Yan L.N., Zhang F., et al.: Early experiences on living donor transplantation in China:multicenter report. Chin Med J, 2006, 119: 10031009. 15. Stange B.J., Glanemann M., Nuessler N.C., Settmacher U., Steinmüller T., Neuhaus P.: Hepatic artery thrombosis after adult liver transplantation. Liver Transpl, 2003, 9: 612-620. 16. Woolard J.D., Ammar A.D.: Spontaneous dissection of the celiac artery: a case report. J Vasc Surg, 2007, 45: 1256-1258. 17. Foord A.G., Lewis R.D.: Primary dissecting aneurysms of peripheral and pulmonary arteries: dissecting hemorrhage of media. Arch Pathol, 1959, 68: 553-577. 18. Matsuo R., Ohta Y., Ohya Y., et al.: Isolated dissection of the celiac artery – a case report. Angiology, 2000, 51: 603-607.

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MYCOTIC ANEURYSM OF THE RIGHT ILIAC ARTERY: IMAGING DIAGNOSIS AND CORRELATION WITH PATHOLOGICAL FINDINGS G.C. Colin1, J.-L. Dargent2, E. Agneessens1, V. Scavée3, J.-P. Haxhe3, P. Bosschaert1 We report the case of a 55-year-old woman who presented at the emergency department with hypogastric pain, fever, clinical signs of sepsis and a critical inflammation syndrome in her blood test values. CT-scan of the abdomen demonstrated an infected aneurysm of the right iliac artery. The patient underwent surgery with a favorable outcome. Histological examination of resected artery was performed and compared to the CT features. The authors review the literature and stress the importance of early diagnosis and treatement. Key-word: Aneurysm, mycotic.

Infectious aneurysms are almost invariably of bacterial origin. It is a rare life-threatening disease, with a mortality reaching 67% in the absence of an early treatment (1), due to hemorrhage and uncontrolled sepsis. Clinical and biological findings are not specific and the diagnostic is often delayed. In the presence of fever and sepsis, CT is the imaging method of choice as several features may indicate the infectious origin and distinguish from atherosclerotic aneurysms.

Case report A 55-year-old woman was admitted in our institution because of fever and abdominal pain. Upon admission, she presented with tachycardia (110 bpm) and slightly decreased blood pressure (110/70 mmHg). Infection of the lower urinary tract was suspected at first. Blood tests showed an important inflammatory syndrome with increased C-reactive protein (CRP) levels (34 mg/dL, normal: < 1 mg/dL). However, urine analysis did not disclose any abnormal findings. A CT-scan of the whole abdomen was performed (Fig. 1). CT revealed an important infiltration of the retroperitoneal fat surrounding the distal part of the abdominal aorta as well as the proximal portion of the right iliac artery. The density of the infiltrated fat was evaluated at 20 HU, which was hardly compatible with blood. The infiltration also involved the pelvic retroperitoneal space. After contrast

B Fig. 1. — Abdominal CT examination without contrast injection. A. Axial view of the origin of iliac arteries shows massive infiltration of retroperitoneal fat by fluid (mean density: 20 UH) with loss of border on the right psoas muscle (*). Before the vertebral body, density is slightly higher, at 40 HU (arrowhead). B. Axial view of the inferior pelvis: massive infiltration of the inferior retroperitoneal fat.

injection (Fig. 2), CT demonstrated a large aneurysm that was located in the proximal part of the right iliac

From: 1. Department of Radiology, Clinique St-Pierre Ottignies, Belgium, 2. Department of Pathology, IPG Gosselies, Belgium, 3. Department of Surgery, Clinique St-Pierre Ottignies, Belgium. Address for correspondence: Dr G.C. Colin, M.D., Department of Radiology, Clinique St-Pierre Ottignies, B-1340 Ottignies, Belgium. E-mail: geoffreycolin1@hotmail.com

artery and measured 44 x 31 mm in axial view. Based on these clinical and radiological findings, the diagnosis of infected aneurysm of the right iliac artery was rendered. The patient was surgically treated 3 days after admission. She is alive and doing well 2 years after the operation.

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A C Fig. 2. — Abdominal CT examination after intravascular contrast injection (arterial phase), axial (A) and coronal MIP (B) views and VRT (C). Saccular shaped aneurysm (44 x 31 mm) of the right iliac artery (*) surrounded by fat infiltration. A hypoattenuating ring is seen around the aneurysm (white arrows). Poor atheromatosis of arteries and absence of calcification and thrombus in the aneurysm are noted.

B Discussion Infected aneurysms are uncommon disorders. In fact, they represent less than 1% of all aortic aneurysms (2). First described by Sir William Osler in 1895, they were during a long time called “mycotic” aneurysms. They are almost always of bacterial origin. Staphylococcus aureus is the most frequent pathogen implicated in this particular disease (MSSA and MRSA), followed by Salmonella species and Streptococcus species. In contrast, Salmonella species are much more common in East Asian countries (2, 3). Notably, fungi are found exceptionally in mycotic aneurysms. The currently accepted term “infected aneurysm” is therefore more appropriate. Historically, bacterial endocarditis has been the most predisposing condition. However, due to the widespread use of antibiotics, immunosuppression is the main risk factor and is present in 50 to 70% of

cases (4): chronic renal failure, diabetes mellitus, corticotherapy or malignancy. Intravenous injection of drugs is another risk. In most instances, infection produces the aneurysm. Rarely does an infected aneurysm result from the infection of a pre-existing aneurysm. Different mechanisms have been described to explain the entry of the bacteria in the vascular wall, including embolization within the vasa vasorum, direct infection of the intima (owing to a pre-existing intimal defect), infection by contiguity from a neighboring infectious process, and direct inoculation (iatrogenic or traumatic). Patients are almost always symptomatic, but the diagnosis is often delayed because symptoms are not specific. Pain is the most frequent symptom; observed in 65 to 90% of cases (3-5). Other symptoms include fever of unknown origin (50%), chills, and sepsis. The classic triad of fever, pain and pulsating abdominal mass is very uncommon (3, 4). Blood test

often shows elevated CRP and leucocytosis. Blood cultures may be negative in up to 50% of patients. In our particular patient, PB cultures were positive for Staphylococcus aureus on two occasions. In earlier angiographic studies, infected aneurysms did no have specific features that distinguish them from atherosclerotic aneurysms except for sudden appearance, rapid progression or uncommon location (6, 7). Indeed, the infra-renal aorta is a typical localization but combined involvement of other parts of the aorta (thoracic, thoraco-abdominal and supra-renal) account for the majority of cases. In opposition, 85% of atherosclerotic aneurysms are localized in the infra-renal aorta. At present, multidetector CT angiography is the best imaging method for infected aneurysms, because of its availability and rapidity in emergency cases. In fact, several CT-scan features may indicate an infectious origin in aneurysms: at a very early stage, before aneurysmal formation, the arterial wall becomes irregular. A peri-arterial edema is often present, usually appearing as a hypoattenuating fat stranding or a concentric rim (2, 8). A mass may develop in the peri-arterial soft tissue, displaying homogeneous or heterogeneous enhancement after contrast injection. Such peri-arterial changes persist after the develop-

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Fig. 3. — Correlation with the microscopic view. A. Axial section of the whole arterial wall (Hematoxylin eosin staining, magnification x 50). The intima (I) is thickened by necrosis. In the tunica media (M) the layer of circumferential smooth muscle cells is completely disorganized and is necrotic. The adventice (A), still recognizable by residual adipocytes (arrow), is also involved by necrosis. Both internal and external elastic lamina have disappeared. Results show the arterial wall to be widely thickened and the main component is necrosis and infiltration by bacteria and white blood cells (black arrowheads). The hypoattenuating ring around the aneurysm (mean density: 20 HU) is probably the thickened arterial wall by necrosis. B. A Gram staining illustrates cocci (magnification: x 400, white arrows). Blood cultures were twice positive for Staphylococcus Aureus.

Fig. 4. — Views of the peripheral part of the arterial wall. Hematoxylin eosin staining, magnification x 100 (A) and x 200 (B). The outest part of the tunica adventitia displays fibrotic changes (black arrows), containing a necrotic area (*) rich in inflammatory cells (black arrowheads) and bacteria (white arrowheads). It represents the outer limits of inflammatory changes, like the shell of an abscess.

ment of the aneurysm and actually represent the most common radiological finding. The shape of mycotic aneurysms is typically saccular, often with lobular contours. The wall of infected aneurysms does not contain atheromatous calcifications in more than 70% of cases, which is in sharp contrast with aneurysms associated with atheromatosis (2, 8). In case of preexisting aortic wall calcifications, a disruption of these calcifications may occur in close proximity to the infected aneurysm. The absence of any identifiable mural thrombus seems to be a reliable sign in favor of an infectious origin, prob-

ably due to the rapidity of the aneurysmal process. A less common occurrence is the presence of gas pockets located within the aortic wall or within the surrounding tissues. Although rarely found, this feature is very specific, appearing early before aneurysm formation (9). Vertebral body changes may also be seen but are uncommon. In our patient, many of these characteristics were present (Fig. 1, 2). Microscopic examination of the resected artery demonstrated a marked destruction of the vascular wall, accompanied by numerous gram-positive cocci, a finding con-

sistent with the presence of Staphylococcus aureus in blood cultures. The tunica media was still present but barely recognizable, due to liquefactive necrosis. Likewise, the internal layer of the adventitia was involved by the necrotic process (Fig. 3). Infected aneurysm is usually defined as a pseudo-aneurysm, because the artery dilatation does not comprise tree layers like arterial wall, but instead tunica adventitia and adjacent connective tissues. In our patient, the three layers of the vascular wall contained necrotic areas, which resulted in a larger

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Fig. 5. — Comparison with abdominal CT examination after intravascular contrast injection at venous phase. A. Axial view. Ring enhancement at portal phase in the periphery of the hypoattenuating mantle, features which are typically found in cases of abscess (white arrows). B. Axial view a few centimeters higher. Repercussion on the adjacent structures. We see a complete thrombosis of the inferior vena cava (*) that is in the infectious process, with the medial part of this wall disappearing (arrowhead). The vein was not found during open surgery.

thickness than normal. The hypoattenuating concentric peri-aortic rim described as “edema” may probably correspond to this thickened but necrotic vascular wall, a finding that may also explain a hypoattenuating aspect on CT-scan images. Furthermore, we also noted a peripherical ring enhancement in the concentric rim of edema adjacent to the right primitive iliac artery, at the portal phase. This finding was previously considered as abscess formation in the retroperitoneum (7). In our patient, the outer part of tunica adventitia was walled off by a fibrous capsule that contained leukocytes mixed with necrotic debris and gram-positive cocci. This is believed to correspond to the peripherical ring enhancement which is more visible at the portal phase (Fig. 4, 5). The development of infectious aneurysms is usually rapid, within a few weeks or less. As a result, these aneurysms are prone to precocious rupture, which is the initial clinical presentation in 20% of cases with clinically hypovolemic shock and heavy pain in the back area. The aneurysmal free rupture is associated with imaging features: retroperitoneal fat infiltration by hyperattenuating fluid (blood) and active intravascular contrast extravasation (10). Moreover, 47 to 75% of aneurysms are in impending or contained rupture (1, 5, 10), as usually described by the surgeon at the operation. This simply means that the wall of the infected aneurysm is widely necrotic but still contains the rupture. Contained rupture is a surgical and pathological diagnosis but

not an imaging one: indeed, imaging studies merely illustrate the free rupture of the aneurysm. To our knowledge, additional investigations that should be performed in case of infected aneurysm are not well defined. However, the origin of bacteriema should be determined, as far as possible. In this regard, our patient was immunocompetent and did not take any intravenous drug. Transesophageal echography, Tc99 white blood cell scan, and oral examination did not reveal any anomaly. Therefore, the origin of bacteriema in our patient still remains unknown. The usefulness of PET-CT in such situation needs to be defined. Surgical repair is the definitive therapeutic procedure following antibiotic therapy. Perioperative antibiotics usually are administered during 6 weeks. There is no current consensus regarding the benefit of lifelong antibiotics. The optimal surgical management remains controversial and under debate. Two types of repair are available, including in situ stent graft interposition after extensive debridement, or extraanatomic bypass. The theoretical advantage of extraanatomic bypass is a reconstruction remote from the infection. However, high incidences of complications have been reported in this technique. In situ grafting is therefore considered as a safe option in many patients (5)). Perioperative mortality varies according to series but reaches approximately 20%. In this regard, there is no significant difference between the two types of surgical

repair (4). In many studies, in situ repair was preferred, whenever feasible (4, 5, 11, 12). Endovascular aneurysm repair (EVAR) may also represent a less invasive alternative, especially in patients with comorbidity (5). Our patient was surgically treated with venous in situ homograft, after failure of an extraanatomic graft using a femoro-femoral (left to right) crossover bypass with Goretex. Conclusion We reviewed several CT signs that characterize infected aneurysm: a saccular shape, the absence mural calcifications and thrombosis, disruption of calcification wall. We correlated the features observed with histologic findings that appear to be more specific in order to better define them. The peripheral ring enhancement visible at the portal phase corresponds to the fibrous capsule at the outer part of the adventice, the beginning of an abscess formation around the destroyed arterial wall. These signs explain why it is termed a pseudo-aneurysm, as there remains no functional arterial wall, even if the three layers (intima, media, tunica adventitia) are still present. In fact, every mycotic aneurysm is in “impending rupture” even if no intravenous contrast extravasation is present. Physicians should understand the seriousness of these features in order to make a correct diagnosis, especially in the early stages of this disease, to ensure prompt therapy.

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References 1. Macedo T.A., Stanson A.W., Oderich G.S., Johnson C.M., Panneton J.M., Tie M.L.: Infected aortic aneurysms: imaging findings. Radiology, 2004, 231: 250-257. 2. Lee W-K., Mossop P.J., Little A.F., Fitt G.J., Vrazas J.I., Hoang J.K., Hennessy O.F.: Infected (mycotic) aneurysms : spectrum of imaging appearances and management. Radiographics, 2008, 28: 1853-1868. 3. Woon C.Y.L, Sebastian M.G., Tay K-H., Tan S.-G.: Extra-anatomic revascularization and aortic exclusion for mycotic aneurysms of the infrarenal aorta and iliac arteries in an Asian population. Am J Surg, 2008, 195: 6672. 4. Oderich G.S., Panneton J.M., Bower T.C., Cherry K.J., Rowland C.M., Noel A.A. et al.: Infected aortic aneurysms: aggressive presentation,

7. 8.

complicated early outcome, but durable results. J Vasc Surg, 2001, 34: 900-908. Dubois M., Daenens K., Houthoofd S., Peetermans W.E., Fourneau I.: Treatment of mycotic aneurysms with involvement of the abdominal aorta: single-centre experience in 44 consecutives cases. Eur J Vas Endovasc Surg, 2010, 40: 450-456. Gonda R.L., Gutierrez J.O.H., Azodo M.V.U.: Mycotic aneurysms of the aorta: radiologic features. Radiology 1988, 168: 343-346. Weintraub R.A., Abrams H.L.: Mycotic aneurysms, AJR 1968, 102: 354-362. Azizi L., Henon A., Belkacem A., Monnier-Cholley L., Tubiana J.-M., Arrive L.: Infected aortic aneurysms: CT features. Abdom Imag, 2004, 29: 716-720. Yang C.-Y., Liu K.-L., Lee C.-W., Tsang Y.-M., Chen S.-J. : Mycotic aortic aneurysm presenting initially as

an aortic intramural air pocket. AJR, 2005, 185: 463-465. 10. Rakita D., Newatia A., Hines J.J., Siegel D.N., Friedman B.: Spectrum of CT findings in rupture and impending rupture of abdominal aortic aneurysms. Radiographics, 2007, 27: 497-507. 11. Brossier J., Lesprit P., Marzelle J., Allaire E., Becquemin J.-P., Desgranges P.: New bacteriological patterns in primary infected aorto-iliac aneurysms: a single-centre experience. Eur J Vasc Endovasc Surg, 2010, 40: 582-588. 12. Kyriakides C., Kan Y., Kerle M., Cheshire N.J., Mansfield A.O., Wolfe J.H.N.: 11-Year experience with anatomical and extra-anatomical repair of mycotic aortic aneurysms. Eur J Vasc Endovasc Surg, 2004, 27: 585-589.

Successor to Diagnostic Neuroradiology

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One of the all-time bestselling neuroradiology texts. In this highly anticipated 950-page volume, Anne Osborn applies her special touch to make complex topics visually appealing and easy to understand. It wraps the “must know” aspects of brain imaging together with spectacular pathology examples, relevant anatomy, and the most up-to-date techniques in brain imaging. Osborn’s Brain is organized for curriculum-based learning. Osborn begins with critical topics, such as trauma, to help the reader learn in the order that is most practical for a resident or practicing radiologist. Indeed, this volume helps readers learn how to think about diagnoses, types of diagnoses, and the various pathologies that can affect the brain. Even as Osborn “takes readers by the hand” to introduce them to the world of brain imaging, she includes new concepts and diagnoses that will intrigue the most sophisticated neuroradiologist. ACCO Leuven M-Theresiastraat 2 3000 Leuven Tel. 016/29.11.00 Fax 016/20.73.89

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SUSAC’S SYNDROME: A CLINICAL AND RADIOLOGICAL CHALLENGE I. Raets1, G. Gelin2 We describe a patient with Susac’s syndrome presenting with the triad of encephalopathy, branch retinal artery occlusion and hearing loss. MRI has some characteristic features and can be helpful in establishing the diagnosis, particularly in an early stage before the classic triad is complete. Besides MRI often allows to differentiate this rare disorder from more common neurologic diseases like multiple sclerosis. Key-word: Brain, diseases.

Case report A 34-year-old woman presented initially with acute vertigo. MRI of the brain at this stage was normal. Two months later, still suffering from persistent instability, she developed headache and a visual field scotoma in the right eye. Fluoangiography demonstrated an occlusion of a retinal branch artery. In spite of treatment with steroids she presented two months later with bilateral deafness, tinnitus, increasing headache and confusion. At that time the diagnosis of Susac’s syndrome (SS) became clear. Extensive laboratory studies, including CSF electrophoresis for oligoclonal bands, were negative. Pd and T2 weighted MRI demonstrated linear and nodular hyperintense lesions in the central part of the corpus callosum (CC) (Fig. 1A, B), and hyperintensities in the crus posterius of the left internal capsula (Fig. 1C). On subsequent studies small T1 hypointense lesions became visible in the CC (Fig. 1D). Gadolinium administration visualised leptomeningeal enhancement on T1 and FLAIR imaging (Fig. 2A, B). Treatment with steroids and cyclophosphamide controlled the disease activity only partially and had to be continued for two years. Discussion SS is a rare microangiopathy of unknown etiology, causing microinfarcts in the brain, the retina and the inner ear. Those are responsible for the clinical triad of encephalopathy, visual scotomas, vertigo and hearing loss (1). Encephalopathy is characterized by headache, confusion, behavioral changes, memory loss, ataxia and pyramidal dysfunction (2). Once the triad completed,

Fig. 1. — A and B. Axial Pd and T2 imaging showing small linear (‘spokes’) and large nodular (‘snowballs’) hyperintense lesions in the central part of the corpus callosum. C. Axial T2 with multiple nodular hyperintensities in the crus posterius of the internal capsula (“string of pearls”). D. Axial T1 demonstrating small hypointensities in the splenium of the corpus callosum (callosal holes).

diagnosis becomes relatively easy, but all the elements are almost never present from onset (3). Auditory or visual disturbances are often the initial presentation. Young women between 20 and 40 years are most often afflicted, but SS is not limited

From: 1. Department of Neurology, 2. Department of Radiology, Ziekenhuis OostLimburg, Genk, Belgium. Address for correspondence: Dr I. Raets, M.D., Department of Neurology, Ziekenhuis Oost-Limburg, Schiepse Bos 6, B-3600 Genk, Belgium. E-mail: ivan.raets@zol.be

to this age group nor to the female gender (4). Although SS has long been considered a monophasic and spontaneously remitting disease, recent reviews distinguish also episodic and chronic variants (1). Immoglobulins, immunosuppressants or rituximab are indicated if disease activity cannot be controlled with steroids alone (1). Although the diagnosis of SS remains essentially clinical, MRI is important for confirmation. Besides MRI characteristics allow differential diagnosis with

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into the deep white matter (2). Leptomeningeal enhancement is an important finding because it is often present in SS, but absent in MS and ADEM (1). Conclusion

Fig. 2. — Axial FLAIR (A) and T1 after Gadolinium (B) showing leptomeningeal enhancement.

multiple sclerosis (MS) and acute disseminated encephalomyelitis (ADEM), which can be confused with SS (1). The most striking MRI findings, especially in the encephalopathic form of SS, are microinfarcts presenting as small T2 and FLAIR hyperintensities in the central part of the CC, sparing the periphery and becoming T1 hypointense after the acute stage. Many of them are linear and radiating, so called “spokes”, and are best seen on sagittal

images (1, 4). “Snowballs” are larger centrally located CC lesions, evolving into “callosal holes”.They can be accompanied by microinfarcts in the capsula interna, visible on DWI and sometimes on axial FLAIR as a “string of pearls”.The combination of this central callosal lesions and the “string of pearls” is pathognomonic for SS (1). MS and ADEM on the contrary involve the undersurface of the CC and create ovoid or oblong plaques at the callososeptal interface with periventricular extensions

In patients with Susac’s syndrome, MRI is often useful in establishing the correct diagnosis, even before the classic triad is completed. The radiologist should be aware of SS and include it in the differential diagnosis when T2 and FLAIR weighted imaging show hyperintense ‘spokes’ or ‘snowballs’ in the central part of the CC, when DWI and FLAIR demonstrate capsular microinfarcts like a ‘string of pearls’, and in case of meningeal enhancement. References 1.

Saux A., Niango G., Charif M., et al.: Susac’s syndrome, a rare, potentially severe or lethal neurological disease. J Neurol Sci, 2010, 297: 71-73. 2. Demir M.K.: Case 142: Susac Syndrome. Radiology, 2009, 250: 598602. 3. Rennbohm R., Susac J.O., Egan R.A., et al.: Susac’s Syndrome – Update. J Neurol Sci, 2010, 299: 86-91. 4. Susac J.O., Murtagh F.R., Egan R.A., et al.: MRI findings in Susac’s syndrome. Neurology, 2003, 61: 17831787.

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AN UNUSUAL CAUSE OF SUBTALAR PAIN AND INSTABILITY: ACCESSORY CALCANEUS C. Boulet1, M. De Maeseneer1, H. Everaert2, M. Kichouh1, J. De Mey1, M. Shahabpour1 We report on a 45-yr-old male sports instructor with chronic pain and instability of the ankle. He was a recreational basketball player, but because of repeated ankle sprains and chronic subtalar pain this activity became impossible. The radiologic findings were compatible with the diagnosis of accessory calcaneus. In an initial therapeutic approach the patient was treated conservatively with taping and physical therapy, but this failed to relieve the symptoms. Next, a ligamentoplasty was performed. The instability improved, but the pain remained the same. Finally the accessory calcaneus was resected and short term follow-up was unremarkable. Accessory calcaneus is an uncommon anatomical variation that may cause subtalar pain and instability. Resection of the accessory bone may be necessary to provide relief of symptoms. Accessory calcaneus can be well demonstrated on CT, SPECT-CT, and MR. MR and nuclear medicine can indicate instability of the accessory bone by showing bone marrow edema on MR or uptake on fusion imaging. Key-word: Calcaneus.

Sesamoid bones and accessory ossicles about the foot and ankle are relatively common and represent developmental variants (1, 2). The most common accessory bones are os trigonum, accessory navicular , os peroneum, os supranaviculare, os vesalianum, and os intermetatarseum. Sesamoid bones arise within the tendon and are located adjacent to an articulation. Some sesamoid bones may have an articular surface, such as the sesamoid bone at the level of the first metatarsophalangeal joint. Accessory calcaneal ossicle is very rare. To the best of our our knowledge only a few case reports have been published (2-9). This anatomic variant should not be confused with an os calcaneum secundarium (or accessorium), which corresponds to a small ossicle located at the level of the anterior process of the calcaneus. This other variant may easily be confused with an avulsion fracture. Instability of the accessory os calcaneum may lead to bone marrow edema pattern on MR, or uptake on nuclear medicine studies. Case report A 45-year-old male sports instructor was seen at the orthopaedic clinic because of instability and pain along the lateral aspect of the ankle. His favorite sports activities were basketball and rock climbing, but these activities had become difficult. The patient’s past medical history

Fig. 1. — Lateral plain film. Note the corticalized accessory bone at the level of the sinus tarsi (arrow).

was positive for recurrent ankle sprains. Taping and physical therapy were unsuccessful in relieving symptoms. Physical exam revealed pain with pressure at the sinus tarsi. Weakness of the peroneal tendons was also evident. There was no evidence of a deformity of the foot arches. Radiography (Fig. 1) showed a bony structure in the sinus tarsi. A stress radiograph (Fig. 2) revealed lateral ligament laxity. MR imaging (Fig. 3) demonstrated a split tear of the peroneus brevis tendon. In addition, a large bony structure in the sinus tarsi was seen. Bone marrow edema was evident in the ossicle as well as in the adjacent talus, which suggested instability of the anatomical variant and impingement. Total body bone scan (Fig. 4) showed a hot spot area at the level of the right

Fig. 2. — AP stress radiograph. Note widening of the lateral tibio-talar joint space (arrow).

calcaneum. At SPECT-CT tracer uptake (Fig. 5) was seen in the calcaneus and the accessory bone. The patient was further treated conservatively, but his symptoms did not improve. Stress radiographs confirmed lateral ligament laxity and a Duquesnoy-Bostrom ligamentoplasty procedure was performed. The instability significantly improved. Nevertheless, chronic subtalar pain remained present. The next treatment step was resection of the accessory bone. The patient is doing well at short term follow-up. Discussion

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

Ossification of the os calcaneum occurs around the 6th gestational month from a central endochondral and a lateral intramembranous

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A B Fig. 3. — Sagittal T1-TSE weighted (A) and STIR weighted (B) MR. A. Note accessory bone inside the sinus tarsi (arrow). B. Note bone marrow edema pattern inside the accessory bone, as well as in the talus directly above the accessory bone, suggesting subtalar impingement (arrow).

focus (10). A secondary posterior apophyseal ossification center appears around the age of 610 years, and may cause Sever’s syndrome. The accessory calcaneus corresponds to a persistent apophysis at the level of the lateral calcaneal tuberosity (11). It is peculiar in that most case reports mention a previous history of ankle sprains and instability. Perhaps during childhood an accessory calcaneal apophysis could develop as a result of increased blood supply secondary to trauma. An accessory os calcaneus is located between the calcaneus, cuboid, talus, and navicular bone, and may have articulations with any of these bones. The accessory bone may be asymptomatic if small, or may limit normal range of motion of the hindfoot. This in turn may lead to early degenerative changes or subtalar conflict. Limitation of motion in the subtalar joint may lead to increased stress at the ankle joint. The ankle may then become more susceptible to sprains. Excision of the bone fragment is believed to relieve symptoms and prevent degenerative changes (6).

B Fig. 4. — Bone scan (total body). Note ‘hot spot’ at the level of the right calcaneum.

Diagnosis of an accessory calcaneus is sometimes possible on lateral radiographs. CT with multiplanar reconstructions is best able to show the relationship with adjacent bones. MR may reveal bone marrow oedema as a result of instability of the ossicle. In our patient T1 fat suppressed sequences following intravenous contrast administration were obtained, and revealed enhancement, a finding compatible with an inflammatory reaction. SPECT-CT is an excellent fusion technique in this

Fig. 5. — (A, B). SPECT-CT. A large irregular bone inside the sinus tarsi is shown, with tracer accumulation at the medial aspect (arrows).

setting. It shows the bony structure and relationship to adjacent bones. In addition, SPECT-CT provides an indication of the instability of the accessory calcaneum and conflict with adjacent bones. Either MR and radiography or SPECT-CT are valuable techniques to demonstrate the abnormality and the potentially associated instability of the fragment. Although ultrasound in experinced hands, may allow a limited assessment of the sinus tarsi, it is not possible to demonstrate bone

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marrow edema or osteoblastic reaction with this method, both findings which are important since they indicate instability of the accessory bone. Optimal treatment options in the setting of accessory calcaneus are unclear. In our patient, joint laxity was first addressed, but the performed ligamentoplasty was not effective for subtalar pain. Excision of the accessory bone may be the only option to provide relief of subtalar pain. In conclusion, we present a case of an unusual bony anatomical variant of the foot, the accessory os calcaneus. Although this variant can be detected on plain films, MR and SPECT-CT are valuable additional imaging methods that can show evidence of instability of the accessory bone.

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References 1. Coskun N., Yuksul M., Cevener M., et al.: Incidence of accessory ossicles and sesamoid bones in the feet: a radiographic study of the Turkish subjects. Surg Radiol Anat, 2009, 31: 1924. 2. Baghla D.P., Shariff S., Bashir W.A.: Acquired cavo-varus deformity caused by an accessory calcaneus: a case report and literature review. Skeletal Radiol, 2010, 39: 193-197. 3. Carlson D.H., Wilkinson R.H.: Variability of unilateral epiphyseal dysplasia (dysplasia epiphysealis hemimelica) Radiology, 1979, 133 : 369-373. 4. Wünschel M., Wülker N., Kluba T.: Progressive pes adductus caused by an accessory calcaneus: a case report. Foot Ankle Int, 2007, 28: 838840. 5. Ceroni D., De Coulon G., Spadola L., De Rosa V., Kaelin A.: Calcaneus

7. 8. 9. 10. 11.

secundarius presenting as calcaneonavicular coalition: a case report. J Foot Ankle Surg, 2006, 45: 25-27. Krause J.O., Rouse A.M.: Accessory calcaneus: a case report and literature review. Foot Ankle Int, 1995, 16: 646650. Uhrbrand B., Jenssen T.T.: A case of accessory calcaneus. Acta Orthop Scand, 1986, 57: 455. Heller A.G.: Accessory calcaneus; a case report. J Am Podiatry Assoc, 1961, 51:275-277. Kremser K.: Accessory supracalcaneum bone. Fortschr Rontgenstr, 1955, 82: 279. O’Rahilly R.: A survey of carpal and tarsal anomalies. J Bone Joint Surg, 1953, 35: 626-642. Freyschmidt J., Köhler A., Zimmer E.A., Brossman J., Sternberg A., Wiens J., Schmidt H.: Freyschmidt’s „Koehler/Zimmer“ borderlands of normal and early pathologic findings in skeletal radiography. 5th ed. Stuttgart: Thieme; 2003.

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SYNOVIAL CHONDROSARCOMA ARISING FROM SYNOVIAL CHONDROMATOSIS OF THE KNEE M.-S. Yao1, C.-M. Chang2, C.-L. Chen3, W.P. Chan1,2 We report the case of a 51-year-old woman who had suffered from right knee pain and stiffness for 40 years. Her symptoms had gradually worsened over the past 5 years. One year previously, when she first visited our clinic, plain radiographs and CT scan images had revealed synovial chondromatosis over the right knee. At the current admission, follow-up MRI showed synovial masses around the knee and worsening of endosteal cortical scalloping in the patella, femoral condyle, and tibial plateau. After diagnosis on the basis of frozen sections, the patient had total excision of the lesions and total knee athroplasty. Histological examination revealed synovial chondromatosis in the joint cavity and grade 1 chondrosarcoma invasion into the adjacent bone. In long-standing synovial chondromatosis, presentation with aggravated symptoms and deterioration on imaging findings should alert clinicians to the potential for malignant change. Key-words: Knee, neoplasms – Sarcoma.

Malignant transformation of synovial chondromatosis to chondrosarcoma is documented but rare (1, 2). The clinical features alone are not helpful for distinguishing them, and no definite imaging criteria can differentiate synovial chondromatosis from low-grade synovial chondrosarcoma (2-5). Synovial chondromatosis is very difficult to distinguish from secondary synovial chondrosarcoma solely on clinical, radiological or histological criteria. The diagnosis is usually made on the basis of a combination of clinical, imaging and histological criteria, as we did in our present case. Case report A 51-year-old woman had a 40year history of right knee pain and stiffness. She had injured her right knee and had been treated with surgery 27 years earlier. Her symptoms had gradually worsened over the past 5 years until she had become unable to walk. One year earlier, she had visited our outpatient clinic, when plain radiographs of the knee showed numerous intra-articular mineralized bodies of similar sizes over the right knee (Fig. 1). Computed tomography (CT) scan images revealed both calcified and ossified nodules (Figs. 2A, 2B). No evidence of degenerative osteoarthritis was noted. At this admission, physical examination revealed a large, hard, fixed

Fig. 1 — A. Anteroposterior and B. lateral projection of knee radiographs show extensive intra-articular synovial chondromatosis.

mass over the right knee, with a surgical scar. Her right knee was swollen, tender, and completely stiff at full extension. The knee had a zero-degree range of motion. Followup X-rays of the knee revealed no remarkable interval change of the synovial chondromatosis. Magnetic resonance imaging (MRI) showed deterioration in the distribution of intra-articular synovial masses

From: 1. Department of Radiology, Wan Fang Hospital, Taipei Medical University, Taipei, 2. Department of Radiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan, 3. Department of Pathology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan. Address for correspondence: Dr W.P. Chan, M.D., Department of Radiology, Wan Fang Hospital, Taipei Medical University, 111 Hsing-Long Road, Sec 3, Taipei 116, Taiwan. E-mail: wp.chan@msa.hinet.net

(Figs. 2C, 2D and 3). The synovial mass was lobulated, with fibrotic septa delineated by a small joint effusion, and largely involved the cruciate ligaments and the posterior capsule, with endosteal cortical scalloping in the patella, femoral condyle and tibial plateau. There were also lobular nonenhancing structures, with hyperintense signal on T2-weighted images, consistent with intra-articular cartilage. The calcified bodies were depicted as signal voids whereas ossified nodules were shown as high-signalintensity marrow surrounded by low-signal-intensity cortical bone. The chest X-ray was negative. A frozen biopsy section was examined three days later and

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Fig. 2 — A, B. Axial CT images confirm many calcified bodies (small arrow) and central lucent nodules (long arrow) in the suprapatellar bursa and some in the posterior capsule. C. Axial proton-density and D. postgadolinium MRI images 14 months later show multiple lobular cartilaginous masses (long arrow) (corresponding to central lucent nodules on CT images), with patellar erosions, and anterior and posterior extension signalvoid calcifications (small arrow).

Fig. 3 — A. Sagittal proton-density MRI image shows extensive synovial mass with multiple bone erosion (arrow). B. T1weighted MRI image, C. T2-weighted image, and D. postgadolinium image show numerous signal-void calcifications, both attached to and free from the synovium, with erosion about the adjacent bone (long arrow), and joint effusion (hyperintense signal on T2-weighted image but nonenhancing on postgadolinium image) and synovial thickening with obvious enhancement on postgadolinium image. There are some ossified bodies with MRI signal similar to that of bone marrow (short arrows). Note that the histologically proven intra-articular area of malignant transformation adjacent to the patellar erosion shows nonspecific minimal enhancement.

Discussion Fig. 4 — Photomicrograph shows nodular proliferation of chondroid tissues containing benign (short arrows) and malignant (long arrows) chondroid cells in the synovial tissue lined with synovial cells (arrowhead).

showed low-grade chondrosarcoma. Total excision of the lesion and total knee arthroplasty were then performed. The histological diagnosis was grade 1 chondrosarcoma arising from synovial chondromatosis (Fig. 4). There were multinodular cartilaginous islands and loose bodies

in the joint cavity. Stromal myxoid changes and atypical chondrocytes with loss of clustering and spindling were noted. The chondrosarcoma had low cellularity, mild nuclear atypia, chromatin clumping, little mitotic activity, and invasion into the patellar, femoral and tibial bone marrow.

Primary synovial chondromatosis is a benign, proliferative and metaplastic disease arising from the synovial membrane (6). It is characterised by the formation of multiple cartilaginous bodies of equal size, sometimes with calcification or ossification, in the synovium of joints, tendons, and bursae; similar findings were noted in our case. A useful differentiating feature is that the primary form is relatively uncommon and synovial masses are the predominant feature, whereas secondary synovial chondromatosis is rela-

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tively common and is typified by the presence of cartilaginous bodies against a background of degenerative joint disease (1, 2, 6). Primary synovial chondromatosis is preponderant in middle-aged and elderly male patients, with a mean age of 41 years (range, 17-76 years) and a male-to-female ratio of 1.5 to 1.0 (1, 2). The knee is the most common site of involvement (1). Clinically, symptoms include pain, limitation of the range of joint movement because of detached proliferating nodules, swelling due to synovial thickening or effusion, and palpable masses. All of the symptoms are nonspecific. One study reported that 50% of patients with synovial chondromatosis had radiographic evidence of marginal bone erosion (2). CT may show noncalcified bodies, and longstanding osteochondromatosis presents as an aggressive lesion attached to the adjacent bone, but plain X-ray cannot distinguish bone from overlapping ossified or calcified mass lesions. On MRI, the typical T1-weighted findings of synovial chondromatosis are multiple signal-void lesions in the joint caused by the calcification of the loose bodies. MRI reveals more erosion than radiography (80% compared with 50%) (2), and 45% of patients have joint effusion (1). MRI typically demonstrates lobulated lesions and is the best imaging tool to assess the intramedullary extent of the tumour. Kramer et al. reported three distinct MRI patterns of synovial osteochondromatosis (7). Pattern A was characterized by lobulated masses with multiple areas of hypointense septa due to fibrosis. Both plain Xray and CT scan showed no calcification, making diagnosis difficult. Pattern B, the most common pattern, was characterized by pattern A plus foci of signal void, corresponding to calcifications on plain film and CT scan. Pattern C had features of patterns A and B plus foci of peripheral low signal surrounding a central fatlike signal, corresponding to areas of ossification; a similar feature was noted in our case. Milgram classified loose bodies secondary to synovial osteochondromatosis on histology into three subgroups (8): (1) active

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intrasynovial disease with no loose bodies, similar to Kramer’s MRI pattern A; (2) intra-articular cartilaginous nodules with free loose bodies with nidi, consisting of the lobular type of cartilage; (3) multiple loose bodies with nidi, with no active intrasynovial disease, similar to Kramer’s pattern C, although this example may be controversial. Malignant transformation to chondrosarcoma arising from primary chondromatosis accounts for 5-10% of cases (1, 2). Malignant change should be suspected if the patient has a long clinical history or a rapidly enlarging mass or a recurring mass following excision, with evidence of deterioration on imaging (2, 9), as did our patient. A progressive or newly developed periosteal reaction, cortical destruction or erosion, or marrow invasion can indicate potential malignant transformation to chondrosarcoma (2, 9). In retrospect, MRI images showed minimal enhancement of the histologically proven area of malignant transformation adjacent to patellar erosion; this finding is nonspecific. Detection of lung metastases also is a clear imaging sign of malignancy (9). No definite histological criteria differentiate synovial chondromatosis from a low-grade synovial chondrosarcoma (1, 3, 4). Murphy et al. (6) reported that 28 patients with chondromatosis had histological evidence of atypical cells, and none subsequently developed malignancy. Both had similar features of hypercellular and atypical hyaline cartilage. Signs of malignancy were seen in necrosis within the tumor and permeation of trabecular bone. Anract et al. (10) proposed the following criteria to diagnose malignant transformation: 1) histological diagnosis of synovial chondromatosis established before diagnosis of chondrosarcoma; 2) histologic diagnosis of chondrosarcoma at the same anatomical site as the synovial chondromatosis; 3) diagnosis of chondrosarcoma and synovial chondromatosis in the same resection specimen. Our case was in accordance with the last two criteria. The treatment of suspected malignant transformation to chondrosarcoma must be a wide resec-

tion or an amputation (10). However, the preoperative risk still lies in the misinterpretation of the synovial chondromatosis as chondrosarcoma (10). Long-standing synovial chondromatosis presenting with aggravated symptoms and deterioration on imaging findings should alert clinicians to the potential for malignant change. The diagnosis is usually made on a combination of clinical, imaging and histological criteria. References 1. Davis R.I., Hamilton A., Biggart J.D.: Primary synovial chondromatosis: a clinicopathologic review and assessment of malignant potential. Human Pathol, 1998, 29: 683-688. 2. Wittkop B., Davies A.M., Mangham D.C.: Primary synovial chondromatosis and synovial chondrosarcoma: a pictorial review. Eur Radiol, 2002, 12: 2112-2119. 3. Hermann G., Klein M.J., Abdelwahab I.F., Kenan S.: Synovial chondrosarcoma arising in synovial chondromatosis of the right hip. Skeletal Radiol, 1997, 26, 366-369. 4. Anract P, Katabi M, Forest M, Benoit J, Witvoët J, Tomeno B.: Synovial chondromatosis and chondrosarcoma. A study of the relationship between these two diseases. Rev Chir Orthop Reparatrice Appar Mot, 1996, 82: 216224. 5. Wuisman P.I., Noorda R.J., Jutte P.C.: Chondrosarcoma secondary to synovial chondromatosis. Report of two cases and a review of the literature. Arch Orthop Trauma Surg, 1997, 116: 307-311. 6. Murphy F.P., Dahlin D.C., Sullivan C.R.: Articular synovial chondromatosis. J Bone Joint Surg (Am), 1962, 44: 77-86. 7. Kramer J, Recht M, Deely D.M., Schweitzer M, Pathria M.N., Gentili A., Greenway G., Resnick D.: MR appearance of idiopathic synovial osteochondromatosis. J Comput Assist Tomogr, 1993, 17: 772-776. 8. Milgram J.W.: The classification of loose bodies in human joints. Clin Orthop Relat Res, 1977, 124: 282-291. 9. McKenzie G., Raby N., Ritchie D.: A pictorial review of primary synovial osteochondromatosis. Eur Radiol, 2008, 18, 2662-2669. 10. Anract P., Katabi M., Forest M., Benoit J., Witvoët J., Tomeno B.. Synovial chondromatosis and chondrosarcoma. A study of the relationship between these two diseases. Rev Chir Orthop Reparatrice Appar Mot, 1996, 82, 216-224.

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SPONTANEOUS OTOGENIC PNEUMOCEPHALUS AND PNEUMATOCOELE O. Soenen1, J.W. Casselman1, B. Lerut2 We report the case of a 33-year old woman with an otogenic pneumocephalus associated with pneumatocoele. To our knowledge only 2 other cases have been documented. We discuss the imaging, treatment and causes of otogenic pneumocephalus. Key-word: Ear, diseases.

Case report A 33-year old woman, with no relevant medical history, presented with a retroauricular mass on the right side. The surgeon decided to puncture the mass and air was evacuated. One week later she was referred to an ENT surgeon for complaints of headache starting after puncture. Clinically there was polyposis nasi grade III. She had allergies (house dust mite) and had been sneezing for over 10 times a day, whereby she pinched her nose and thus induced a repetitive Valsalva manoeuvre. Lastly she also complained of a balance disorder she had been having for over a year. Subsequently an MR and CT study were performed to find the cause of this air-containing retroauricular mass. MR study is best suited for soft tissue examination due to its high contrast resolution. In this case MR was performed first to exclude underlying infection or tumor. Due to lack of signal, air and -though less likely-calcified bone were considered possible options (Fig. 1). CT is the method of choice when it comes to the bone or air visualisation. CT indeed visualized an epidural air collection with associated pneumatocoele (Fig. 2). Following radiological studies, the ENT surgeon placed a transtympanic drain inducing air evacuation and a shift of the brain. Because of the risk of recurrence and of otogenic meningitis an obliterative mastoidectomy with cartilage in the additus ad antrum and bone paté filling up the mastoid (variation of Mercke procedure) was performed. During surgery a large bony defect was seen at the level of the tegmen

Fig. 1. — Coronal T2-weighted image. Initially MR was performed to exclude underlying infection or tumor. Hypointense epidural air collection (pneumocephalus) with mass effect on the brain (white arrows). Hypointense air filled subcutaneous pneumocoele (black arrow).

and the sigmoid sinus. Follow up imaging was performed with a cone beam CT. Cone beam CT is ideal in situations where a young patient is repeatedly exposed to radiation, because it provides a higher resolution at a lower radiation dose. A clas-

From: 1. Department of Radiology and Medical Imaging, 2. Department of ENT, AZ Sint Jan Brugge-Oostende AV, Brugge, Belgium. Address for correspondence: Dr J.W. Casselman, M.D., Ph.D., Department of Radiology and Medical imaging, AZ Sint Jan Brugge-Oostende AV, Ruddershove 10, B-8000 Brugge, Belgium. E-mail: jan.casselman@azsintjan.be

sic CT study with a bigger Field of View (FOV) was needed at the beginning to examine the origin of the air and the amount of air that went intracranially etc. Cone beam CT with its smaller FOV was a better option after surgery because only the local post-operative status of the petrous bone and the bone paté filling had to be evalutated (Fig. 3). To date the patient is relieved from her symptoms, has normal middle ear pressures on a tympanogram and is still followed by her ENT surgeon in the context of her polyposis nasi.

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A Fig. 3. — Coronal Cone Beam CT image through the posterior mastoid. The surgeon used bone to obliterate the hyperpneumatised bone and to close the cortical defects (grey arrows).

Discussion

B Fig. 2. — Axial (A) and coronal (B) CT image with bone window setting through the upper and most posterior part of the mastoid. The hyperpneumatisation of the bone resulted in a defect of the inner and outer cortex of the bone (grey arrows) and an epidural pneumocephalus (white arrows) and subcutaneous pneumatocoele (black arrows).

Otogenic pneumocephalus is defined as the presence of air in the intracranial cavity entering through the temporal bone. Pneumocephalus was first described in 1714 by Lecat. The most common causes of pneumocephalus are trauma to the head, ear infection, tumors of the skull base and iatrogenic (e.g. skull base surgery) and in these cases the air is most frequently found in the subdural and subarachnoid space or in the brain parenchyma or ventricles. However, spontaneous otogenic pneumocephalus and epidural air collections are both very rare. A literature research revealed 18 cases of spontaneous pneumocephalus until today. Of these 18 cases 8 were reported in the last 10 years, probably due to better and easier access to imaging. These patients present with a variety of symptoms including headache, dizziness, aphasia, hemiparesis or hemiplegia, visual symptoms etc, some of which can be attributed to the presence of epidural air. Less frequent symptoms are tinnitus and otalgia (1). The presence of a subcutaneous pneumatocoele was only reported in

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two other cases and was the first and only complaint in these patients, which seems logic because the air is released which reduces the intra cranial pressure. In this new case the air probably also escaped subcutaneously through a defect in the outer cortex of the upper and posterior part of the mastoid. The pathogenesis of spontaneous otogenic pneumocephalus remains uncertain. The hypothesis is that a defect in the temporal bone and/or a pressure difference between the temporal bone or middle ear and the intracranial space are at the origin. Moreover pressure changes or repetitive Valsalva manoeuvres can

lead to hyperpneumatization of the mastoid. Pneumocephalus can also very rarely be caused by a barotrauma (2), however sometimes no underlying mechanism is detected. Furthermore, predisposing defects in the petrous bone are not uncommon in the general population. In this case, the repetitive Valsava manoeuvres probably led to the development of a pneumocephalus and pneumatocoele because of a pre-existing strong pneumatisation of the pretrous bone with thinned over and underlying cortical bone. Treatment of a spontaneous otogenic pneumocephalus is usually managed surgically with an attempt

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to relieve the intracranial pressure and a procedure to close the bone defect. References 1.

Krayenbühl N., Alkadhi H., Junh H.-H., et al.: Spontaneous otogenic intracerebral pneumocephalus: case report and review of the literature. Eur Arch Otorhinolaryngol, 2005, 262: 135-138. 2. Tucker A., Miyake H., Tsuji M., et al.: Spontaneous epidural pneumocephalus. Neurol Med Chir, 2008, 48: 474-478. 3. Pennings R.J.E., Liauw L., Cremers C.W.R.J.: A spontaneous otogenic extradural pneumocephalus. Otology Neurotol, 2009, 30: 864.

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TECHNICAL NOTE USEFULNESS OF PERCUTANEOUS CHOLANGIOGRAPHY COMBINED WITH CT IN POST-OPERATIVE PATIENTS WITH HEPATO-BILIARY SURGERY T. Kirchgesner1, C. Hubert2, E. Danse1

Hepato-biliary surgery for malignancies has a high mortality rate (7,3%) with also a high rate of readmitted patients within the first 30 days of discharge (14,315,5%) (1). After hepato-biliary surgery medical imaging is essential: computed tomography (CT) is required to detect collections, ultrasonography to assess dilatated biliary ducts and percutaneous cholangiography (PC) to ensure safe withdrawal of biliary drain or Kehr's drain. A recent paper published in the JBR-BTR depicted the interest of double contrast percutaneous transhepatic cholangiographic CT (DCPCT-CT) to explore bile duct obstruction, combining PC and CT with iodine injection (2). We would like to report on our experience with a recent procedure combining PC and CT without iodine injection, demonstrating anastomotic leak in jejunobiliary anastomosis. An 80-year-old female patient was diagnosed with intra-hepatic right cholangiocarcinoma (type IIIa of Bismuth-Corlette classification). There was no sign of left hepatic nor extra-hepatic dissemination. After multidisciplinary consultation, right portal embolization was performed before right enlarged hepatectomy with lymph nodes dissection, main biliary duct and gall bladder resection and jejuno-biliary anastomosis four months later. A biliary drain was placed in the anastomotic region. One week after procedure CT with iodine injection demonstrated a large hydroaeric collection in the site of the right hepatectomy. Two weeks after procedure we were asked to perform PC before drain withdrawal. PC showed jejunal and left biliary ducts opacification without any sign of leak. This exam was completed by CT without iodine injection, which

Fig. 1. — CT without iodine injection performed directly after the conventional percutaneous cholangiography (PC) demonstrating the anastomotic leak feeding the collection (arrowhead). The leak was not visible during PC.

demonstrated an important anastomotic leak feeding the collection seen one week earlier (Fig. 1). This result directly impacted on patient's care: the drain was kept in place with satisfying evolution under medical monitoring. CT after IV administration of a cholangiographic agent (iodipamide) was a very good method for biliary ducts exploration until contrast agent has been withdrawn from circulation because of higher risk of anaphylactic reaction (3). With new liver-specific contrast agent, MRI would be a great alternative in patients after hepato-biliary surgery, but unfortunately the availability of MRI in case of post-operative emergencies is not sufficient. Anastomotic leak diagnosis cannot be made without PC and biliary ducts opacification, but PC alone can easily be falsely negative. CT with or without iodine injection can demonstrate with precision fluid collections, but cannot show the origin of

From: Department of 1. Radiology, 2. Transplantation et Abdominal Surgery, Cliniques Universitaires Saint-Luc, Brussels, Belgium. Address for correspondence: Dr Th. Kirchgesner, M.D., Dept of Radiology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain. Avenue Hippocrate 10, B1200 Brussels, Belgium. E-mail: Thomas.Kirchgesner@gmail.com

the leak if there is no biliary opacification. With this case we would like to emphasize the interest of combining PC and CT with or without iodine injection in patients after hepatobiliary surgery, especially if complications such as fluid collection and/or anastomtic leak are suspected. References 1.

Schneider E.B., Hyder O., Wolfgang C.L., Hirose K., Choti M.A., Makary M.A., Herman J.M., Cameron J.L., Pawlik T.M.: Patient readmission and mortality after surgery for hepato-pancreato-biliary malignancies. J Am Coll Surg, 2012, 215: 607-615. 2. Wang C.L., Shi Q., Xiang X.J., Chen Z.Z., Yuan Z.D., Deng Q.H., Zhou H.Y., Ren X.X., Cheng L., Wang Y.X.J.: Double contrast percutaneous transhepatic cholangiographic CT in patients with obstructive jaundice: an initial experience of seven cases. JBR-BTR, 2012, 95: 251-256. 3. Van Beers B.E., Lacrosse M., Trigaux J.P., de Cannière L., De Ronde T., Pringot J.: Noninvasive imaging of the biliary tree before or after laparoscopic cholecystectomy: use of three-dimensional spiral CT cholangiography. AJR, 1994, 162: 1331-1335.

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IMAGES IN CLINICAL RADIOLOGY Gastroepiploic artery aneurysm M. Incedayi1, A.K. Sivrioglu2, M. Saglam1, G. Sonmez1, E. Ozturk1

A 61 year-old man was referred to our radiology departmant for abdominal multi dedector computed tomography (MDCT) evaluation because of undefined abdominal discomfort. Patients’s medical history was unremarkable. Contrast enhanced MDCT scans revealed a round mass of 5 cm axis in the mesentary fat plans, close to inferior portion of the gastric antrum including cresent shaped hypodens area and 2 × 3 cm sized hyperdense area (Fig. A). MIP and curved MPR scans revealed that, the mass is a true sacculary aneurysm at the midportion of the right gastroepiploic artery (Fig. B, C). The aneursym with true lumen of 2 × 3 cm size, includes crescent shaped thrombus formation. The patient was referred to surgery but follow-up failed. Comment

Splanchnic artery aneurysms are very rare and important to recognize because up to 25% may be complicated by rupture, and the mortality rate after rupture is between 25% and 70% (1). The distribution of aneurysms is as follows: splenic artery, 60%; hepatic artery, 20%; superior mesenteric artery, 5.5%; celiac artery, 4%; pancreaticodoudenal arteries, 2%; and gastroduodenal artery, 1.5% (1). Splanchnic artery aneurysms were traditionally diagnosed with catheter angiography. However, with increased use of noninvasive cross-sectional imaging with CT, both of which allow 3D imaging of the aorta and its branches, these aneurysms may be detected with greater frequency and in asymptomatic patients. Treatment is usually required even for asymptomatic patients if the diameter of the aneurysm is larger than 2 cm. Elective surgical repair is preferred. Percutaneus transcatheter embolization with a success rate of 85% may be preferred for aneurysms difficult to manage sugically and for high-risk surgical patiens. Gastroduodenal artery aneurysms are the least common of all the splanchnic artery aneurysms. Typically, these are pseudoaneurysms developing in patients with pancreatitis. We appreciated the case as a right gastroepiploic artery aneursym. We couldn’t find any similar case in the literature. Reference 1.

Pasha S.F., Gloviczki P., Stanson A.W., Kamath P.S.: Splanchnic artery aneurysms. Mayo Clin Proc, 2007, 82: 472-479.

1. Department of Radiology, GATA Haydarpasa Teaching Hospital, Istanbul, 2. Department of Radiology, Aksaz Military Hospital, Mugla, Turkey.

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IMAGES IN CLINICAL RADIOLOGY Recurrent sarcoidosis after lung transplantation K. Ramakers, W. De Wever, J. Coolen, J. Verschakelen1 A 43-year-old man had undergone bilateral lung transplantation 2 years previously for sarcoidosis stage 4 fibrocystic disease. The patient feels well, without significant symptoms, sputa, cough or fever. A control spirometry however showed a highly obstructive, mildly restrictive pulmonary function, with a very low diffusion capacity. Laboratory results revealed a CRP of 6.4 mg/l (nl <= 5 mg/l), ferritin of 669 µg/l (nl 200-400 µg/l) and otherwise normal results. Ferritin is also an acute phase reactant, and in this case a significant elevation indicates an inflammatory state. A high-resolution CT of the lungs was performed, which shows numerous centrilobular micronodules in a perilymphatic distribution pattern (subpleural, peribronchovascular), most pronounced in the upper lungs (axial images A, B and coronal image C). Additional pulmonary biopsy revealed recurrence of sarcoïdosis.

Comment Lung transplantation (LTX) is an appropriate therapeutic option for patients with severe, fibrocystic pulmonary sarcoidosis refractory to medical therapy. Survival rates following LTX for sarcoidosis are generally comparable to other indications as lymphangioleiomyomatosis (LAM), Langerhans cell histiocytosis (LCH), talc granulomatosis, diffuse panbronchiolitis and pulmonary alveolar proteinosis. Timing of transplantation for patients with sarcoidosis is challenging because mortality rates are high (27 to 53%) among sarcoid patients awaiting LTX. Recurrent sarcoidosis in the lung allografts can occur but does not affect survival or risk for complications. B In a review of the literature, Collins and al reported a frequency of recurrence among six centers of 35% (9 of 26 transplants), of which 2 patients presented with miliary nodules and 7 presented with a solitary pulmonary nodule. Recurrence of sarcoïdosis has been reported as early as 2 weeks after transplantation and as late as two years after transplantation. That this disease recurs is not surprising since it is characterized by an augmented immune response, with activated lymphocytes and mononuclear phagocytes at sites of disease activity. It has been hypothesized that acute allograft rejection and evolution of sarcoid granulomas may share common immunopathogenetic mechanisms. Although the incidence of acute rejection does not differ between patients with and those without sarcoidosis, histologic grades of rejection are substantially more severe among patients with sarcoidosis. Sarcoïdosis is the most commonly reported disease to recur. The other diseases that frequently recur are LAM, LCH, diffuse granulomatosis, diffuse panbronchiolitis and pulmonary alveolar proteinosis. C Diagnosis is usually made by high-resolution CT of the lungs, followed by (transbronchial) biopsy. The clinically significant post-transplant recurrences usually respond favorably to increased steroid therapy. In this patient the dose of cyclosporine was increased (to reach plasma levels of 200 µg/L), because cyclosporine seems to be effective in both rejection and sarcoïdosis. The daily dose of steroids was maintained (4 mg Medrol orally). Reference 1.

Collins J., Hartman M.J., Warner T.F., Müller N.L., Kazerooni E.A., McAdams H.P., Slone R.M., Parker L.A.: Frequency and CT findings of recurrent disease after lung transplantation. Radiology, 2001, 219: 503-509.

1. Department of Radiology, University Hospitals Leuven, Leuven, Belgium.

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IMAGES IN CLINICAL RADIOLOGY Proximal iliotibial band enthesopathy M. Posadzy-Dziedzic1, F.M. Vanhoenacker2,3,4 A 58-year-old female presented with sudden-onset pain and tenderness at the lateral aspect of the right pelvis occurring after long-distance walking. Physical examination showed a normal range of movements. Magnetic Resonance Imaging (MRI) was performed in order to exclude a stress fracture. Coronal fatsuppressed intermediate weighted images (WI) showed focal thickening and increased signal at the proximal insertion of the right iliotibial tract (ITT) at the iliac tubercle. There was also increased signal surrounding the deep and superficial layers of the ITT (Fig. A, arrows). Axial fatsuppressed T2-WI demonstrated also subtle muscular edema in the adjacent anterior part of the gluteus medius muscle (Fig. B, arrow). There was no evidence of tendon rupture. Based on the imaging findings, the diagnosis of proximal iliotibial band enthesopathy was made. The patient was treated with local infiltration of corticosteroids followed by kinesitherapy.

Comment Enthesopathy of the proximal ITT is an uncommon condition, often neglected in medical literature. It occurs most frequently in female athletes (runners, golfers, dancers) or older overweighted women. The pathogenesis is believed to be related to acute or repetitive microtraumatic injuries at the insertion of the ITT at the iliac tubercle of the iliac crest. The ITT is anatomically intimately related to the anterior part of the gluteus medius muscle. Although the tensor fasciae latae does not play a major role in hip movements, it acts as a supporting muscle in flexion and abduction. An imbalance between the system of agonist and antagonist hip muscles, their dynamic relations and postural factors such as increased anterior pelvic tilt may cause overloaded forces acting on tensor fasciae latae during any sport activity. Radiographs do usually not contribute to the diagnosis in the acute phase of the disease. Enthesophyte formation at the anterior aspect of the C iliac crest and adjacent calcifications are rarely specific. If the pain is localised at the iliac crest, ultrasound is the preferred examination, showing thickening of the ITT (Fig. C, arrow) and adjacent gluteus medius muscle, loss of normal fibrillar architecture and sometimes signs of hypervascularity on color Doppler in up to 50% of cases. As the complaints and clinical examination are often misleading, particularly in chronic overuse injuries, MRI is often performed as initial examination to exclude a stress fracture or other more common peri-articular hip pathology. MRI typically shows thickening and increased T2-signal in and around the ITT. Adjacent muscular edema in the anterior part of the gluteus medius muscle and subtle bone marrow edema in the iliac tubercle may be seen as well. To allow an appropriate diagnosis, it is of utmost importance that the Field of View (FOV) of the coronal images of the pelvis is large enough to visualise the iliac crest. The main differential diagnosis include partial or complete tear of the tendon, an avulsion fracture of the anterior superior iliac spine, injury of the sartorius muscle, bone or soft tissue neoplasm in this region, and neuropathy of the cutaneous femoris lateralis nerve. The treatment consists of local infiltration with corticosteroids, kinesitherapy, and recommendations on avoiding any improper loading forces during sport activities.

Reference 1.

Cohen M., Demondion X., Buby J., Coudreuse J.-M., Sbihi A.: Enthésopathies de la crête iliaque: tractus ilio-tibial ou tenseur du fascia lata? In: Bassin et hanche. Edited by Drapé J.L., et al. Printed by Sauramps médical, Montpellier, 2007, pp 157-167.

1. Department of Radiology, W. Degi Orthopaedic and Rehabilitation University Hospital, K. Marcinkowski University of Medical Sciences in Poznan, Poznan, Poland, 2. Department of Radiology, AZ Sint-Maarten Duffel-Mechelen, 3. Department of Radiology, Antwerp University Hospital, Edegem, 4. University of Ghent, Faculty of Medicine and Health sciences, Ghent, Belgium.

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IMAGES IN CLINICAL RADIOLOGY Tunnel enlargement and recurrent graft tear after ACL reconstruction K. Petrovic1, F.M. Vanhoenacker2,3,4, O. Nikolic1, P. Vandenberk5 A 24-year-old soccer player presented with right knee instability after a pivot shift trauma during soccer game. His past medical history included multiple Anterior Cruciate Ligament (ACL) reconstructions (three times). Last revision was one year previously using allografts. Meticulous analysis of the plain radiographs demonstrates widening of the tibial bone tunnel and less marked widening of the femoral tunnel (Fig. A). Magnetic Resonance Imaging (MRI) was performed for further evaluation. Coronal fatsuppressed T2Weighted Imaging (WI) (Fig. B) and sagittal T1-WI (Fig. C) confirmed tunnel enlargement, particularly of the tibial tunnel (black arrows). Furthermore, no residual intact graft fibers could be visualized, in keeping with graft tear. Based on the imaging findings, the diagnosis of tunnel expansion and recurrent ACL graft tear was made. The patient was treated with an Achillestendon bone allograft, in which the calcaneus bone plug was anchored into the tibial tunnel. The postoperative recovery was uneventful.

Comment Reconstruction of a torn anterior cruciate ligament (ACL) using allografts or autografts is a routine procedure in most orthopedic institutions. Although several possible donor site exist, the two most commonly used are bonepatellar tendon-bone and hamstring autografts. The rate of unsatisfactory results of ACL reconstruction ranges from 10%-25% depending on evaluation criteria used. Many factors responsible for graft failure, such as inappropriate tunnel placement, graft fixation, rehabilitation and timing of surgery, have been identified. Although conventional radiography offers an easy and costeffective way for the routine evaluation of the knee after ACL reconstruction, its role is limited and evaluation of the postoperative knee by MRI is standard of care. Tunnel enlargement is a specific postoperative complication of ACL reconstruction, characterized by widening of bone tunnels as seen on postoperative radiographs. It is measured as a distance between the two sclerotic margins of the bone tunnel at its widest dimension perpendicular to the longitudinal axis of the tunnel. The measurements are corrected for magnification and compared to the diameters drilled at surgery. On MRI, an increase in tunnel diameter is often associated with increased T2 signal within the tunnel due to fluid or granulation tissue. The etiology of bone tunnel enlargement is unclear, and probably multifactorial. Mechanical and immunological theories have been proposed. Tunnel expansion may result in an inadequate incorporation of the graft, which may cause graft failure. The presence of large tunnels often severely complicates revision ACL surgery, often requiring a two-stage revision with bone grafting of the tunnels followed by graft revision. If only the tibial or femoral tunnel is enlarged -like in our case- an Achilles-tendon bone allograft placement as a one stage procedure may suffice.

C Reference 1.

Wilson T.C., Kantaras A., Atay A., Johnson D.L.: Tunnel enlargement after anterior cruciate ligament surgery. Am J Sports Med, 2004, 32(2): 543-549.

1. Center of Radiology, Clinical Center of Vojvodina, Hajduk Veljkova 1-9, 21000 Novi Sad, Serbia, 2, Department of Radiology and 5. Orthopedic Surgery, AZ Sint-Maarten Duffel-Mechelen, Leopoldstraat, 2, B-2800 Mechelen, 3. Department of Radiology, Antwerp University Hospital, Wilrijkstraat 10, B-2650 Edegem, 4. University of Ghent, Faculty of Medicine and Health sciences, De Pintelaan 185, B-9000 Ghent.

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IMAGES IN CLINICAL RADIOLOGY Renal angiomyolipoma rupture C.H. Lee1, W.P. Chan1,2 A 63-year-old woman presented to our emergency department with an acute onset of severe right flank pain and tachycardia. Abdominal computed tomography (CT) revealed massive retroperitoneal extravasation (thin arrow, Fig. A) arising from right renal angiomyolipoma (AML) containing fat density (thick arrow, Fig. A) within a non-calcified soft tissue mass. Angiography revealed an aneurysm (arrow, Fig. B) arising from renal artery, and subsequent embolization was performed successfully. The patient recovered uneventfully. Follow-up CT scan obtained seven months after embolization shows well-defined renal contour and lipomatous components of the tumor (arrow). Comment

AML is a benign mesenchymal tumor containing mature adipose tissue, vessels, and smooth muscle. It is clinically important because of its propensity to life-threatening hemorrhage. As blood flow entering the tumor increases because of tumor growth, causing vessel dilatation and aneurysm formation resulted [1]. Acute rupture of an AML with extravasation of the contrast can be detected by enhanced CT [2]. Embolization as a treatment modality has been advocated for large tumors and symptomatic patients. Transarterial embolization for AML rupture has been advocated and is effective in treating and preventing hemorrhage [3]. References 1.

Chan C.K., Yu S., Yip S., Lee P.: The efficacy, safety and durability of selective renal arterial embolization in treating symptomatic and asymptomatic renal angiomyolipoma. Urology, 2011, 77: 642-648.

1. Department of Radiology, Wan Fang Hospital, Taipei Medical University, 2. Department of Radiology, School of Medicine, Taipei Medical University.

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IMAGES IN CLINICAL RADIOLOGY Collateral systems in superior vena cava occlusion C. Balliauw, M. Koolen, J. Verschakelen, W. De Wever1 A 48-year-old woman presents at the hospital with heavily developed subcutaneous collaterals over the chest. She suffers from slight discomfort, but no pain nor dyspnea. When bending forward, she feels her head swell. The patient has a history of right-sided breast cancer 5 years previously, treated with mastectomy and radiation therapy. Blood results show no increase of tumor markers (CA15-3 19 kU/L (reference < 30 kU/L)). The patient undergoes a CT of the chest and abdomen. Chest CT reveals subcutaneous collaterals (Fig. A, arrow), but also numerous densely opacified dilated bronchial and mediastinal veins (Fig. B, arrow). There is marked dilatation of the azygos and accessory hemiazygos vein, internal mammary veins and lateral thoracoepigastric veins. The CT images also demonstrate the presence of a long and narrow superior vena cava occlusion adjacent to the ascending aorta, just above the level of the right atrium (Fig. C, arrow).

Comment Superior vena cava (SVC) occlusion can be either due to benign or malignant causes. Most common benign etiologies include mediastinal or radiation fibrosis, infection or thrombosis. The most B frequent culprit is however metastatic pulmonary or mediastinal malignancy. In our case prior history of radiation therapy, the long and narrow SVC occlusion and absence of a mass on chest CT disclose the diagnosis of benign radiation fibrosis. SVC occlusion is associated with 4 major venous collateral systems: the azygos-hemiazygos pathway, which is the most dominant, the mammary-epigastric system, the lateral thoracic pathway, via the lateral thoracic and superficial circumflex veins and finally the vertebral plexuses. The first three pathways were dilated in our patient. A less frequent collateral route is a systemicto-pulmonary venous shunt. Anatomically the bronchial veins and pulmonary veins are interconnected through the bronchial venous plexuses, serving as nutritional channels for the bronchi. Bronchial veins predominantly drain into the right atrium and one third of the flow drains via the pulmonary veins into the left atrium. This balance can shift towards the left atrium when systemic pulmonary pressure rises. These collaterals may result in a right-to-left shunt, C subsequently causing a higher cardiac output state. The patient may suffer from dyspnea due to this shunt. The treatment of the SVC occlusion and the subsequent collaterals depends on the etiology. In malignancy, radiation or chemotherapy is used. Anticoagulants and thrombolytics are the treatment of choice for acute thrombosis. In fibrosis, endovascular angioplasty and stent placement may prove successful in 80% of the cases. However in advanced stenosis or complete occlusion, a surgical bypass may be necessary. Because of the supportable clinical status, our patient has not yet been yet treated. Reference 1.

Kapur S., Paik E., Vu D.: Where there is blood, there is a way: unusual collateral vessels in superior and inferior vena cava obstruction. Radiographics, 2010, 30: 67-78.

1. Department of radiology, University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium.

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JBR–BTR, 2012, 95: 373.

IMAGES IN CLINICAL RADIOLOGY Lymphoma of the sigmoid colon presenting with clinical signs of a diverticulitis J. Gossner1

A 56-year old man presented at the emergency department with a history fever and pain in the left lower abdomen. He was already treated with antibiotics for several weeks by his general practitioner because of suggested diverticulitis. Because of the prolonged course a computed tomography (CT) scan of the abdomen and the pelvis was performed. CT revealed a large mass of the sigma with marked narrowing of the lumen (Fig. A). The mass contained hypodense areas and air suggesting necrosis. In contact to the lesion one enlarged lymph node with a diameter of 3 cm could be found (Fig. B). Biopsy obtained during optical colonoscopy showed a high grade lymphoma. Staging with neck- and chest-CT revealed no further enlarged lymph nodes. There were three larger pulmonary nodules in accordance with a pulmonary manifestation of the patient’s lymphoma. As there were no signs of gastrointestinal obstruction no surgical intervention was performed and chemotherapy was started immediately after diagnosis. The patient just received the first cycles of his chemotherapy and is doing well. Comment

Most gastrointestinal lymphomas are located in the stomach. Lymphoma of the colon is a very rare tumour, only 0.5% of colonic malignancies are in fact lymphomas. In the colon most lymphomas arise from the cecum, a fact which is explained by the larger amount of lymphoid tissue in the proximal parts of the colon. It predominantly affects men around the age of 55 years. Most patients show weight loss, abdominal pain and change in bowel habits. But clinical symtoms are nonspecific and may also suggest inflammatory disease, like in our case. Especially in more acute presentations and for staging purposes CT plays a key role in primary imaging. The classic finding of gastrointestinal lymphoma is diffuse wall thickening with lymphadenopathy. More bulky disease is also common. Because of the low incidence there are no controlled trials for treatment. Chemotherapy is the key part of treatment regimes. The role of surgery is not established, but some authors advocate resection because of the reported relatively high incidence of perforation. Reference 1.

Stanojevic G.Z., Nestorovic M.D., Brankovic B.R., Stojancovic M.P., Jovanovic M.M., Radojkovic M.D.: Primary colorectal lymphoma: an overview. World J Gastrointest Oncol, 2011, 3: 14-18.

1. Department of Clinical Radiology, Evangelisches Krankenhaus GöttingenWeende, Göttingen, Germany.

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JBRâ&#x20AC;&#x201C;BTR, 2012, 95: 374.

IMAGES IN CLINICAL RADIOLOGY Calcific tendinopathy of the pectoralis major insertion with intracortical protrusion of calcification M.T. El-Essawy1, F.M. Vanhoenacker2,3,4

A 64-year-old male patient presented with pain at the right upper arm. His past medical history was unremarkable. Plain radiographs showed a focal radiolucency at the proximal humerus containing a faint central radio-opaque focus (Fig. A, small arrow). Computed Tomography (CT) demonstrated a focal ill-defined erosion of the anterior cortex of the proximal humerus (Fig. B, white arrow) with associated intracortical and soft tissue calcifications (Fig. B, black arrow)at the osseous insertion of the pectoralis major tendon. On Magnetic Resonance Imaging(MRI), the intracortical lesion appeared of high signal on T2-Weighted Images (WI) with subtle adjacent bone marrow edema as well as thickening and signal increase of the pectoralis major tendon (Fig. C, white arrow). Fatsuppressed T1-WI after administration of gadolinium contrast showed enhancement of the thickened tendon (Fig. D, white arrow). Based on the imaging findings, the diagnosis of calcific tendinopathy of the pectoralis major tendon was made. The patient was treated with nonsteroidal anti-inflammatory drugs and the symptoms resolved 4 weeks later. Comment

Calcific tendinopathy is a common self-limiting disorder of unknown etiology. It is characterized by deposition of calcium hydroxyapatite within or around the insertion of the tendon, potentially followed by spontaneous resorption and then subsequent tendon healing. The most common location is the supraspinatus tendon, but virtually any other tendon may be involved. Associated cortical erosion is unusual at the rotator cuff, but is particularly seen at areas of powerful traction, such as the osseous insertion of the gluteus maximus, vastus lateralis and pectoralis major tendons. Active inflammation with local increase of vascularization and the mechanical effect of traction may result in bone resorption and adjacent bone marrow and tendon edema. Plain radiographs may reveal tendon calcifications, but the osseous involvement is often underestimated. CT is more sensitive to depict the calcifications and for assessment of the intra-osseous and tendinous extent of the lesion. MRI is the imaging technique of choice for evaluation of marrow involvement and tendon inflammation, but calcification in the adjacent tendon may be far more difficult to appreciate. Therefore, MRI findings may mimic an aggressive lesion, such as neoplasm or an infection, particularly if the location near the anatomical tendon insertion is not considered. Absence of a significant soft tissue mass and bilateral involvement are other important clues in excluding neoplasm. Recognition of this unusual manifestation of this common disease may prevent unnecessary biopsy. After spontaneous resolution of the calcifications, an osseous defect may persist on plain radiograph and CT. Reference

1. Flemming D.J., Murphey M.D., Skektika K.M., Temple H.T., Jelinek J.J., Kransdorf M.J.: Osseous involvement in calcific tendinitis: a retrospective review of 50 cases. AJR, 2003, 181 (4): 965-972.

1. Department of Radiology, Damietta Oncology Institute, Damietta, Egypt, 2. Department of Radiology, AZ Sint-Maarten Duffel-Mechelen, 3. Department of Radiology, Antwerp University Hospital, Edegem, 4. University of Ghent, Faculty of Medicine and Health sciences, Ghent.

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JBR–BTR, 2012, 95: 375.

IMAGES IN CLINICAL RADIOLOGY Primary lymphoma of iliac bone M.T. El-Essawy1, F.M. Vanhoenacker2,3,4, H. Van Dijck5, M. Ferrante6 A 86-year-old male presented with weight loss of 7 kg and right groin pain of 2 months duration. Computed Tomography (CT) demonstrated an ill-defined osteolytic permeative lesion involving the right iliac bone with adjacent soft tissue mass (Fig. A, white arrow).Subsequent Magnetic Resonance Imaging (MRI) clearly showed the osseous origin of the lesion with huge surrounding soft tissue mass, wrapping around the right iliac bone. The lesion was of low signal intensity (SI) on T1-Weighted Images (WI) and of relatively low SI on T2-WI (Fig. B, white arrow). After intravenous administration of gadolinium contrast, there was significant enhancement of the bony lesion and surrounding soft tissue mass, with areas of central necrosis (Fig. C, asterisk). The differential diagnosis on imaging, according to the patient age, included metastasis, plasmacytoma and lymphoma. Further staging of the patient was negative for any primary malignancy. Biopsy of the iliac bone and subsequent histological examination revealed clusters of small to large lymphocytes, with a variable nucleocytoplasmic ratio, in keeping with a primary large cell Non-Hodgkin’s lymphoma of bone (Fig. D). The patient was scheduled for chemo-radiotherapy treatment.

Comment

Primary bone lymphoma (PBL) is an uncommon malignancy that accounts for less than 5% of all primary bone tumors. The diagnosis implies the exclusion of any evidence of nodal or disseminated disease. The vast majority consists of * non–Hodgkin’s lymphoma (NHL), whereas primary Hodgkin’s lymphoma (HL) of bone is extremely rare. Patients commonly present with local bone pain, soft tisC sue swelling or a pathological fracture. There is a slight male preponderance, and patients are usually over 45-50 years of age. Primary NHL of bone can arise in any part of the skeleton, but the long bones (femur, tibia, humerus) are the most common sites. Other osseous sites include the pelvis and spine. The radiographic and CT appearances of PBL are variable and often nonspecific ranging from a near-normal-appearing bone to a focal lytic lesion with geographic margins to a mixed sclerotic-lytic lesion to a diffusely permeative process with cortical destruction and soft-tissue involvement. There are – however – some peculiar imaging patterns that may help to suggest the potential diagnosis. When a solitary lytic lesion is encountered in a middle-aged or older patient near the end of a long bone with a permeative or moth-eaten pattern and aggressive periosteal reaction, PBL should be considered in the D differential diagnosis. The presumed imaging diagnosis is further strengthened in the presence of extensive soft-tissue and marrow involvement with surprisingly little cortical destruction. MRI is particularly recommended for more precise local staging of the lesion and evaluation of the exact size and extent of bone and soft tissue involvement. On T2-WI, PBL may be of relatively low SI due to the high cellularity of the lesion. [18F]Fluorodeoxyglucose positron emission tomography (FDG-PET)-CT is an excellent tool for detection of multifocality for staging purposes. Primary bone lymphoma has a better prognosis than many other malignant bone tumors. Therefore early detection is of utmost importance in order to allow appropriate treatment. The prognosis of PBL, depending on staging and histologic classification, is favorable following a combination of chemo-and radiation therapy, with an overall 5-year survival rate of 88%. Reference 1.

Heyning F.H., Kroon H.M., Hogendoorn P.C., Taminiau A.H., van der Woude H.J.: MR imaging characteristics in primary lymphoma of bone with emphasis on non-aggressive appearance. Skeletal Radiol, 2007, 36: 937-944.

1. Department of Radiology, Damietta Oncology Institute, Damietta, Egypt, 2. Department of Radiology, AZ Sint-Maarten Duffel-Mechelen, 3. Department of Radiology Antwerp University Hospital, Wilrijkstraat 10, B-2650 Edegem, 4. University of Ghent, Faculty of Medicine and Health sciences, De Pintelaan 185, B-9000 Ghent, 5. Department of Pathology, AZ Sint-Maarten Duffel-Mechelen, 6. Department of Gastro-enterology, AZ SintMaarten Duffel-Mechelen.

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JBR–BTR, 2012, 95: 376.

IMAGES IN CLINICAL RADIOLOGY Bone marrow involvement in sarcoidosis F. Van Den Bergh1,2, J. Wagemans3, A. Snoeckx4, K.L. Verstraete2, F.M. Vanhoenacker1,2,4 A 36-year-old woman presented with joint pain and swelling, not improving with nonsteroidal anti-inflammatory drugs. Plain radiographs of feet, ankles, pelvis and lumbar spine were unremarkable. To rule out seronegative spondylarthropathy, MRI of the sacro-iliac joints (SIJ) was performed. The SIJ were normal, but multiple, nodular zones of bone marrow replacement were seen within the iliac and ischial bones, sacrum and lumbar spine. The lesions were hypointense on T1-Weighted Images (WI) (Fig. A, arrows) and of intermediate to high signal intensity on T2-WI (Fig. B, arrows). Given the young age of the patient and relative minor complaints, sarcoidosis was suspected. Other differential diagnoses included metastatic disease, lymphoma, mastocytosis and widespread granulomatous infectious disease. Subsequent CT of the chest showed micronodular thickening of fissures, subpleural micronoduli and multiple enlarged hilar and mediastinal lymph nodes, in keeping with pulmonary sarcoidosis (not shown). On [18F]Fluorodeoxyglucose positron emission tomography (FDG-PET)-CT, multiple foci of increased FDG uptake in the pelvis, spine and mediastinum were seen (Fig. C, arrows). Transbronchial needle aspiration of the PET-positive infracarinal lymph nodes confirmed the presence of non-caseating granulomas. The patient’s symptoms resolved spontaneously.

Comment

Sarcoidosis is a granulomatous disease of unknown origin with a worldwide distribution. It can affect virtually every organ and typically affects young to middleaged adults. The highest prevalence is found amongst African-Americans, Swedes and Danes, with an incidence of sarcoidosis of 10,9-35,5 cases per 100.000. The typical histopathological appearance is that of non-caseating granulomas within the involved organs. Pulmonary involvement is the most common manifestation of sarcoidosis, but further discussion is beyond the scope of this short manuscript. Musculoskeletal (MSK) sarcoidosis was previously considered as uncommon, but due to the more widespread use of MRI and FDG-PET, bone marrow involvement is more commonly seen. Clinically, patients with musculoskeletal involvement present with weakness, unexplained local pain or joint swelling. Within the hands and feet, a typical lace-like pattern of osteolysis on plain radiographs is pathognomonic. Lesions may extend into the adjacent joints. MRI is the imaging modality of choice for detection of lesions within the bone marrow of the axial skeleton. Bone marrow involvement may either consist of multiple focal round (“cannonball”) lesions, diffuse confluent marrow infiltration or multiple ill-defined discrete lesions with “starry-sky” appearance. The signal intensity of the lesions may vary, but they are usually hypo-intense on T1-WI and hyperintense on T2-WI. Rarely, lesions may be hypointense on T2-WI. CT is normal in most cases. In rare cases, purely lytic, mixed or purely sclerotic lesions may be seen. Sarcoidal lesions are highly FDG avid on PET-CT. Bone marrow involvement may mimic metastatic disease both on MRI and PET. C The radiologist should consider the diagnosis of sarcoidosis in young patients with unexplained musculoskeletal symptoms particularly in the absence of known malignancy. As 90% of patients with MSK sarcoidosis have systemic involvement, particularly of the chest, additional chest imaging is mandatory for a more confident diagnosis. Biopsy may be needed to confirm the diagnosis. Reference 1.

Moore S.L., Teirstein A., Golimbu C.: MRI of sarcoidosis patients with musculoskeletal symptoms. AJR, 2005, 185: 154-159.

1. Department of Radiology, AZ Sint-Maarten, Duffel-Mechelen, 2. Department of Radiology, University Hospital Ghent (UZ Gent), 3. Department of Medical Oncology, AZ Sint-Maarten, Duffel-Mechelen, 4. Department of Radiology, University Hospital Antwerp (UZA), Belgium.

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JBR–BTR, 2012, 95: 377.

IMAGES IN CLINICAL RADIOLOGY Scurvy in a 3-year-old boy: MRI features J. De Cock1, M. Renard2, M. Smet1, L. Breysem1

A 3-year-old boy presented with painful knees (especially the right knee) and difficulty in walking for a few weeks. He complained of lower limb weakness. He was irritable and thinly built. At clinical examination movement of the knees and hips was painful. He had previously been diagnosed with autism. The mother reported that he didn’t eat well. Conventional imaging of the lower limbs revealed several abnormalities. Especially at the right femur, the cortex was thinned, and the medulla had a ground-glass appearance. The junction between diaphysis and growth cartilage showed a distinct zone of rarefaction just cranial of the epiphysis, with triangular defects on the side. The calcification zone was dense and wide (A). An MRI-scan of the right knee was performed. The medullar bone, surrounding soft tissues and growth cartilage of the distal femur showed a hyperintense signal on the T2-weighted images, compatible with oedema. There was a hyperintense signal underneath the periost, because of subperiosteal hemorrhage (C). A working diagnosis of scurvy was made. There was a broad differential diagnosis consisting primarily of non-accidental trauma and lymphoma. Rickets, copper deficiency, arthritis, syphilis, leukemia and Henoch-Schonlein purpura were also considered. The patient was treated with ascorbic acid and dietary modifications were prescribed. There was a significant improvement in the patient's health after a few days. A control radiograph of the lower limbs (B) after three months revealed the patient had recovered completely. Comment

Scurvy is the disease caused by deficiency of vitamin C and affects collagen-containing tissues. In developed countries, scurvy is rare and can be seen in children with severely restricted diets, related to psychiatric or developmental problems. Bone changes are typical for infantile scurvy and occur at the junction between the end of the diaphysis and growth cartilage. Patients with scurvy can easily be misdiagnosed but promptly helped with vitamin C treatment. Conventional radiologic findings in infantile scurvy can be diagnostic if the patient presents with the classic radiological features. These characteristic changes occur at the growth cartilage-shaft junction of bones with rapid growth. The knee joint, wrist, and sternal ends of the ribs are typical sites of involvement. In the early phase of scurvy, the cortex becomes thin and the trabecular structure of the medulla atrophies and develops a ground-glass appearance. The zone of provisional calcification becomes dense and widened, and this zone is referred to as the white line of Fränkel. The epiphysis also shows cortical thinning and a ground-glass appearance. As scurvy becomes more severe, a zone of rarefaction occurs at the metaphysis. This area of rarefaction typically involves the lateral sides, resulting in triangular defects called the corner sign of Park. This area has multiple microscopic fractures and may collapse with impaction. Magnetic resonance imaging shows areas of hemorrhage at the bony and subperiosteal level. Multiple focal areas of marrow oedema throughout the metaphyseal regions can be seen. The marrow appearances on MRI represent focal areas of haemorrhage or small infarcts. Subperiosteal fluid and displacement of the distal epiphysis are often visible as well. The MRI appearances completely resolve with vitamin C treatment. MRI should be recommended especially in the doubtful cases. Reference 1.

Umesh K., Shilpa K.: Scurvy presenting as pseudoparalysis without other classical clinical features: A case report. The Internet Journal of Pediatrics and Neonatology. 2009, Volume 10, Number 2.

Department of 1. Radiology, 2. Pediatrics, University Hospital Leuven, Leuven, Belgium.

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JBR–BTR, 2012, 95: 378.

IMAGES IN CLINICAL RADIOLOGY Ewing’s sarcoma of the rib in a child S. Van Petegem, L. Jans, V. Lambrecht, W. Huysse, K. Verstraete1

A 9-year-old boy was admitted to the emergency department with sudden onset of dyspnea without history of trauma or clinical signs of infection. Clinical examination revealed a painless, asymmetric swelling of the left anterolateral thoracic wall. Chest CT demonstrated expansile, mixed lytic-sclerotic lesions of the 5th rib and the 7th thoracic vertebral body. A large soft tissue mass was seen in the left hemithorax resulting in mediastinal shift and an extrathoracic component was present (Fig. A). MRI showed a large enhancing thoracic soft tissue mass (Fig. B) and a pathological fracture of the 7th thoracic vertebral body. Chest radiograph after central venous line placement illustrates the large size of the mass (Fig. C). The diagnosis of Ewing’s sarcoma of the rib was confirmed histologically. Comment

Ewing’s sarcoma is a rare malignant bone tumor, typically occurring in patients aged 10-25 years. In 7% of cases, the affected site is a rib. At the time of presentation 25% of patients have metastases to the lungs or bones. Radiography shows a small osteolytic bone lesion with a concomitant large soft tissue mass. CT provides information on the extent and pattern of bone destruction and periosteal reaction. The bone lesion is poorly defined and is associated with an aggressive periosteal response that has a lamellated ‘onion skin’ appearance. The extra-osseous soft tissue mass typically lacks ossification or calcification. MR imaging shows a marked decrease in size and perfusion in response to chemotherapy. In conclusion, a child presenting with a large thoracic soft tissue opacity concomitant with the presence of a small osteolytic rib lesion on chest radiography warrants dedicated CT and MRI examinations to exclude Ewing’s sarcoma of the rib. Reference 1.

Moser R.P. Jr., Davis M.J., Gilkey F.W., et al.: Primary Ewing sarcoma of Rib. Radiographics, 1990, 10: 899-914.

1. Department of Radiology and Medical Imaging, Ghent University Hospital, Gent, Belgium.

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JBR–BTR, 2012, 95: 379.

IMAGES IN CLINICAL RADIOLOGY WITH PATHOLOGICAL CORRELATION Suggestive MR features of Whartin’s tumor with correlation between diffusion-weighted imaging and pathology I.B. Aremu1, Ph. Grandjean2, M. Hamoir3, B. Weynand4, Th. Duprez2

A 54-year-old man without medical history presented with a right-sided tumor of the parotid gland. The consistency of the mass was soft. The patient was asymptomatic except for the self-palpation of the process. He had unremarkable clinical examination including neck nodal areas. The ‘conventional’ MRI examination gave significant clues for the diagnosis (Fig. A). The neoplasm displayed elevated signal intensity on unenhanced T1-weighted images (A) suggesting a colloid content and enhanced only slightly after paramagnetic contrast agent (CA) perfusion (B), which is a valuable criterion to distinguish it from other common benign (pleiomorphic adenoma) and malignant (carcinomas) neoplasms of the parotid gland which usually exhibit strong heterogeneous enhancement. Low contrast-enhancement was confirmed by subtracting pre- and post-contrast T1-weighted images (C). The T2-weighted images displayed a mosaic of hypo/ hyperintense sub-areas within the tumor which suggested coexistence of hydrated colloid areas and dense tissue made of tightly packed cells with high nucleocytoplasmic ratio. A worthy “histological-like” feature was given on diffusion-weighted images (Fig. E-G) which demonstrated alternating areas of very bright and very low signal intensity on DW trace images (E) corresponding to drastically decreased ADC values for the former and very increased ones for the latter (F). This constellation of features strongly suggested the diagnosis of cystadenolymphoma (Whartin’s tumor) which was confirmed by histopathological examination after surgical removal (G). Striking parallelism was observed between DW images (E,F) and histopathological aspect (G) with interleaving of hyperintense areas with decreased ADC values corresponding to tumoral ‘curls’, and hypointense areas with increased ADC values corresponding to colloid content. MRI therefore allows confident diagnosis of Whartin’s tumor which is clinically relevant because this tumor is almost the only neoplastic salivary disorder for which surgery can be suspended in tumors of limited size, in the absence of patient’s complaints, and in patients at risk for general anaesthesia.

1. Department of Medical Imaging, University of Ilorin, College of Health Sciences, Ilorin, Kwara State, Nigeria, 2. Department of medical Imaging, Université Catholique de Louvain, 3. Department of Head and Neck Surgery, Cancer Centre Cliniques Universitaires Saint-Luc, Brussels Belgium, 4. Department of Pathology, Université Catholique de Louvain, Cliniques Universitaires de Mont-Godinne, Yvoir, Belgium.

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JBR–BTR, 2012, 95: 380-396.

PROCEEDINGS OF THE MEETING “UPDATE IN ABDOMINAL AND UROGENITAL IMAGING”, BRUGES, 6-8 SEPTEMBER 2012 State of the art MRI and CT imaging of the liver: primary and metastatic neoplasms S. Thomas, P.R. Ros1 Recent advances in hepatic imaging techniques have drawn particular attention to detection and characterization of liver lesions. Optimal imaging diagnosis of hepatic lesions surely depends on the understanding of currently available modalities and its tailored application in consideration of clinical information. At present CT is the most frequently used modality for imaging the liver. The development of multi detector computed tomography (MDCT), which allows scanning the liver at multiple phases of contrast enhancement, may improve the diagnostic accuracy of hepatic lesions. Some of the recent advances in MDCT technology include three-dimensional (3D) imaging software and volumetric analysis. Dual energy technology

attempts to reduce radiation dose by eliminating the non-enhanced phase of imaging. The advantages of MRI as a preoperative imaging modality for liver masses are many fold. MRI with intravenous contrast can be used in patients with allergy to iodine based contrast. The emergence of liver specific MR contrast agents has added a new dimension by effectively discriminating between lesions of hepatocellular origin such as hepatocellular carcinoma (HCC) and focal nodular hyperplasia (FNH) from nonhepatocellular etiology such as metastases and cholangiocarcinoma. CT of the liver Non contrast CT imaging (NECT) alone is not routinely performed in clinical practice due to the low inherent attenuation difference between the normal liver parenchyma and lesions. Single phase imaging during the portal venous phase of enhancement is desirable,

because ~ 75% of hepatic blood flow is supplied by the portal venous system, and hence better delineation of common hypovascular hepatic focal lesions, such as majority of metastases and cysts against enhanced hepatic background is possible. A triple pass technique can be performed only on MDCT scanner (Fig. 1). The first imaging pass provides a true (or early) arterial phase and enhancement of hypervascular focal lesions. The second pass corresponds in timing to the initial opacification of the portal venous system and is called late arterial or ‘parenchyma phase’. For both primary and metastatic hypervascular neoplasms such as HCC, islet cell tumor, carcinoid and sarcoma, approximately 30% additional lesions are detectable on the late arterial dominant phase than in the delayed hepatic venous phase of enhancement. In the third imaging pass also known as hepatic venous phase, the hepatic veins are enhanced and the enhancement of background hepatic parenchyma is maximized. Acquisition timing corresponds to what has been conventionally labeled as the ‘portal venous phase’. Tumors, like HCC which are hyperattenuating on the arterial phase and parenchyma phase may become isoattenuating or hypoattenuating on the hepatic venous phase (1, 2). The appropriate scan delay for helical CT depends upon the contrast medium injection protocol used. The timing of peak aortic and hepatic contrast enhancement depends primarily on the injection duration. Rapid or low-volume (shorter duration) injections produce earlier peak enhancement, whereas slow or high-vol-

Fig. 1. — Early arterial (A), venous phase (B), and delayed phase (C) images demonstrate a right lobe HCC (arrow on A,B). An additional lesion is seen as a hypodense lesion against an enhanced hepatic background, consistent with multifocal HCC in a non-cirrhotic liver (arrow on C).

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PROCEEDINGS (BRUGES 2012)

381

Table I. — MDCT Protocol for liver in our practice. Protocol

Indications

oral

IV Delay rate/vol (sec)

Area

Collimation (mm)

Feed (mm)

Reconstruction (thk./int.)

Basic liver

Metastatic work up

C+

4/100

liver A/P

3.0

5/5

Hypervascular liver lesion

Hypervascular, metastasis, HCC, FNH, hemangioma

H2O

4/100

20 40 70

liver liver A/P

3.0

5/3

C+: 2.1% dilution of barium sulfate, H2O: water, A/P: abdomen to pelvis, thk: Thickness, int.: interval.

ume (longer duration) injections result in later peak enhancement (3-5). A typical MDCT protocol includes bolus injection for multipass imaging of 4cc/sec for 25 seconds of 60% nonionic contrast material (30 g iodine). Time to aortic peak is determined from the resultant time attenuation curve and is used as the injection to scan delay for multiphase imaging. Two passes during the arterial phase can be obtained; true arterial phase (10 to 20 seconds after contrast arrives in the abdominal aorta), and parenchyma arterial phase (30 to 40 seconds after the initiation of contrast). A third imaging pass beginning 60 to 70 seconds after the beginning of injection and employing a table speed of 15 mm per second corresponds in timing to the conventional "portal venous phase" to evaluate the remainder of the abdomen (Table I).

process virtual nonenhanced (VNE) images, by subtracting the iodine content of contrast-enhanced CT images using image post-processing techniques, may obviate the need for the nonenhanced imaging phase in multiphase studies. The benefits include shorter scan time and reduced radiation.VNE images can be useful in various clinical settings, such as CT urogram (7, 8).

Clinical utility

1) Torso coil (phased-array multicoil to improve signal-to-noise ratio (SNR)). 2) Image-intensity correction software to reduce image nonuniformity. 3) “Ghost” control techniques to reduce fat or respiratory motion artifact. 4) T1 and T2 weighted images and contrast imaging. 5) New techniques such as Diffusion weighted imaging (DWI), MR Elasto-

The shorter acquisition time of MDCT provides intense enhancement with intravascular contrast material and improved separation between the phases of contrast enhancement. There is less respiratory misregistration and improved z axis resolution. CT of the liver can be performed routinely with very thin collimation, yielding greater conspicuity of small lesions and improved lesion detection. Use of 2.5-mm-thick sections resulted in a 46% increase in detection rate versus use of 10.0-mm-thick sections and an 18% increase versus use of 5-mm-thick sections (6). Multiplanar reconstruction algorithm allows complete delineation of normal arterial anatomy and vascular variants, which can be seen in up to 45% of patients (Fig. 2). In addition, specific arterial etiology such as aneurysm and pseudoaneurysm of the hepatic artery and hepatic infarctions can also be evaluated. MDCT with dual energy capabilities have been introduced recently. The most current dual-energy technique is based on dual detector capability. There are two layers of detectors on the CT, the upper layer primarily absorbs the lower X-ray energy spectrum, and the lower detector layer absorbs the remainder of the spectrum, mainly in the higher energy range. Data from each layer, corresponding to lower- and higher energies, are independently reconstructed. The ability to

MRI MRI allows better detection and characterization of diffuse and focal hepatic parenchymal lesions and the biliary system. Newer contrast agents have provided a new dimension to imaging of the liver. Technique MRI of the liver consists of the following elements:

graphy, MR perfusion imaging, based on availability and clinical relevance. TI-weighted imaging 1) Conventional spin-echo pulse sequence (CSE) is used in patients incapable of holding their respiration for breath-hold gradient-echo pulse sequences. Due to prolonged acquisition time, motion artifacts are common. 2) Gradient-echo pulse sequence (GRE) is more common and multi-section spoiled gradient-echo pulse sequences image the entire liver in one or two breath-holds with higher contrast and SNR. 3) Chemical shift imaging uses two T1weighted gradient-echo pulse sequences with identical parameters except for TE, to produce in-phase and opposed-phase images, thereby aids in the diagnosis of steatosis and detection of microscopic in hepatic neoplasms. T2-weighted imaging 1) Conventional T2 spin-echo sequences have been practically abandoned due to their long acquisition times (up to 20 minutes) resulting in cardiac flow and particularly respiratory artifacts.

Fig. 2. — Coronal reformatted image demonstrates thrombosis of the right and left branches of portal vein (white arrows) with multiple rim enhancing abscesses (black arrows).

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Fig. 3. — MRI of the liver during arterial phase (20 sec) and delayed (15 min) after IV administration of Eovist. The enhancing lesion appears hypointense on the delayed phase, consistent with metastases from thyroid cancer. 2) Fast spin-echo (FSE) a. Rapid acquisition with relaxation enhancement (RARE) uses a single excitation pulse followed by a long train of spin-echoes with a different amplitude phase encoding gradient applied for each spin-echo. b. Hybrid RARE. Hybrid RARE uses multiple excitation pulses, with each excitation pulse followed by two or more 180° refocusing pulses. Fast recovery fast spin-echo (FRFSE) is a breath-hold pulse sequence that utilizes additional radiofrequency pulses after each echo-train to drive the recovery. Some breath-hold techniques such as FRFSE show lower lesion-liver contrast and low SNR, which may reduce the detection of solid liver masses requiring additional sequences. c. Single short hybrid RARE (SSHR) sequences are termed: 1) half Fourier acquisition single-shot turbo spin-echo (HASTE); and 2) singleshot fast spin-echo (SSFSE). SSHR allows sub second single-slice imaging, obviating motion artifact reduction measures. While producing high quality abdominal images, the limitations include reduced contrast between solid hepatic lesions and the surrounding parenchyma. However, increasing the sampling rate with enhanced gradient field strength, a higher soft tissue contrast resolution can be achieved (9). 3) Gradient echo pulses sequences have been replaced by SSFSE and FRFSE sequences. 4) Echo-planar Imaging (EPI) It uses ultra fast T2-weighting which requires enhanced gradients with high bandwidths and good fat suppression due to marked chemical shift artifacts. EPI allows diffusion images that can be used to characterize hepatic masses.

Contrast agents 1. Gadolinium based extracellular contrast (Magnevist, Optimark, Omniscan, ProHance). 2. Currently, in USA, there are two FDAapproved liver-specific MRI contrasts: gadoxetate (Eovist ) and gadobenate dimeglumine (MultiHance). Extracellular agents (Gadolinium DTPA) After intravenous injection, gadolinium chelate rapidly distribute in the interstitial spaces of the body. In the liver, this happens both in the normal parenchyma and in tumors, but at different rates, resulting in tumor-liver contrast which lasts for a short period of time. Clinically, this implies the use of rapid image acquisition techniques (gradient echo sequences) and a bolus injection. Some patients, who receive GBCAs, appear to be at an increased risk for developing a serious systemic fibrosing disease, Nephrogenic Systemic Fibrosis (NSF). The patients at risk are those with severe renal (kidney) insufficiency (glomerular filtration rate < 30 ml /min/1.73 m2). NSF causes fibrosis of the skin and connective tissues throughout the body that limits joint mobility. NSF can progress with time and can even cause death. In November 2009, the World Health Organization issued a restriction on use of some GBCA, stating that High-risk gadolinium-containing contrast agents (Optimark, Omniscan, Magnevist) are contraindicated in patients with severe kidney problems, in patients who are scheduled for or have recently received a liver transplant, and in newborn babies up to four weeks of age. Iron oxide based particles Superparamagnetic iron oxides (SPIO) and Ultra small super paramagnetic iron oxide (USPIO) are nanoparticles composed of a magnetically active crystalline iron core (magnetic) surrounded by a

dextran or starch coating. Because of its long residence in the vascular system, USPIO is considered a blood-pool agent. These reduce the T2 signals of absorbing tissue. Many of the agents, which were previously approved by the FDA including Ferumoxides (Feridex), Sinerem (Combidex), and Resovist (Cliavist), have been taken off the US market. Hepato-biliary agents There are two different types of hepato-biliary agents: gadolinium-based and manganese-based. The gadolinium based agents are often called bimodal contrast agents since they demonstrate both hepatocyte and perfusion imaging properties. These include gadoxetate (Eovist or Primovist, also known as Gd-EOB-DTPA, Bayer) and gadobenate dimeglumine (MultiHance, Bracco, formerly known as Gd-BOPTA). Following a rapid bolus, dynamic T1W GRE sequences are performed similar to those performed with non specific Gadolinium based agents. The enhancement of the liver on T1-weighted images peaks at about 20 minutes for Eovist and lasts for at least 2 hours after injection of the contrast agent. Tumors of hepatocellular origin show enhancement whereas non hepatocellular tumors such as metastases appear hypo-intense on delayed images (10) (Fig. 3). Magnafodipir trisodium (Tesla scan), withdrawn from US markets is predominantly a T1 shortening agent. The liver is enhanced onT1-weighted sequences from the end of the perfusion to 4 hours later. The free manganese released in the hepatocyte is excreted into the bile and the remnant ligand excreted through the kidneys. Diffusion Weighted Imaging (DWI) DWI can be easily added to the current MR I protocol. Some studies have shown higher sensitivity for hepatic lesion

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Fig. 4. — DWI demonstrates HCC in the right lobe, which appears bright against dark hepatic background.

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detection when compared to T2 –weighted imaging. The liver lesions are detected using low b values (below 100 sec/mm2), providing black-blood images, with high inherent tissue contrast and robust image quality. Higher b values (≥ 500 sec/mm2) can assess of lesion signal intensity qualitatively. Malignant lesions typically demonstrate impeded diffusion and appear bright against a dark hepatic background (11) (Fig. 4). MR elastography MR Elastography is a newer technique currently used for evaluating hepatic fibrosis in cirrhosis, based on the viscoelastic properties of the tissue. Determining the viscoelastic characteristics differentiate between dysplastic nodules and HCC may prove to be value in the future (12). MRI applications MRI is able to characterize with higher accuracy than CT the following: 1. Hemangioma: In addition to assessing morphology and enhancement pattern like CT, MRI also provides signal intensity characteristics (Fig. 5). 2. FNH: FNH is diagnosed with MRI based not only on the enhancement pattern (including delayed enhancement of the scar), but also on signal characteristics of the tumor and scar (bright in T2) (Fig. 6). 3. Fat containing tumors (hepatocellular adenoma, hepatocellular carcinoma): Using chemical shift imaging MR is able to prove fat in hepatocellular neoplasms with higher sensitivity than CT. 4. Cysts: Hepatic cysts are confidently diagnosed with MRI even if they are sub-centimeter in size, based upon its very high signal intensity and lack of enhancement. 5. Hemorrhage in tumors: The visualization of hemosiderin rings allows characterizing internal hemorrhage within neoplasms.

B Fig. 5. — MRI of the liver with a (arterial -15 sec) and b delayed (2 min) phases depicts early peripheral nodular enhancement of two Hemangioma with delayed centripetal filling in.

6. Benign versus Malignant Hepatocellular nodules: In the setting of cirrhosis, MR is able to characterize benign (macro regenerative and dysplastic) nodules from nodules of hepatocellular carcinoma. This is based both on enhancement criteria (arterial in malignant nodules and portal in benign nodules) as well as iron byproducts in benign nodules. 7. Metastases: detection of metastases with the use of gadolinium or specific contrast agents has been proven to be higher with MRI than with intravenously enhanced CT. MR with liver specific contrast agents is considered the imagery method of choice pre resection of liver metastases, having rendered CT arterial portography obsolete.

PET/CT and MRI/PET Positron emission tomography (PET)/CT is a functional imaging modality that has proven useful as a diagnostic tool for staging of a wide variety of cancers. Tumor cells demonstrate increased glucose uptake mediated by glucose transporters (GLUT) and accelerated glycolysis leading to tumor specific high intracellular accumulation of the glucose analog fluorodeoxyglucose ( 18F-FDG). While PET/CT has demonstrated immense benefit in staging extra hepatic disease in colorectal cancer staging, it role in initial staging and follow up of hepatic metastases is limited. Moreover, the sensitivity of PET in detecting metastases decreases considerably following neoadjuvant chemotherapy (13, 14).

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Fig. 6. — Post gadolinium fat suppressed arterial phase T1W I (A) demonstrates a intensely enhancing lesion in segment 5 which becomes isointense to hepatic parenchyma on portal venous phase (B), typical for FNH.

PET/CT has limited role in imaging HCC or other primary liver tumors except lymphoma, but our recent experience has demonstrated that PET maybe helpful in detecting extra hepatic spread of HCC. MRI/PET, with superior imaging MRI characterization of liver lesions, may prove to be beneficial in future in assessing tumor recurrence or residual tumor in posttherapy patients. Conclusion Both CT and MRI with continuously evolving technologies are effective in imaging of the liver. MRI allows better characterization of liver lesions, but is expensive as a screening tool. The choice of imaging study should be determined by the clinical indication, with consideration of availability, technical and clinical expertise, cost, and patient tolerance. References 1. Ros P.R., Ji H.: Special focus session: Multi-section (multi-detector) CT: Applications in the abdomen. Radiographics, 2002, 22: 697-700. 2. Sahani D., Saini S., Pena C., Nichols S., Prasad S.R., Hahn P.F., et al.: Using multidetector CT for preoperative vascular evaluation of liver neoplasms: Technique and results. AJR, 2002, 179: 53-59. 3. Bae K.T.: Intravenous contrast medium administration and scan timing at CT: Considerations and approaches. Radiology, 2010, 256: 32-61. 4. Chambers T.P., Baron R.L., Lush R.M.: Hepatic CT enhancement. Part II. Alterations in contrast material volume and rate of injection within the same patients. Radiology, 1994, 193: 518-522. 5. Silverman P.M., Roberts S.C., Ducic I., Tefft M.C., Olson M.C., Cooper C., et al.: Assessment of a technology that permits individualized scan delays on helical hepatic CT: A technique to improve efficiency in use of contrast material. AJR, 1996, 167: 79-84.

6. Weg N., Scheer M.R., Gabor M.P.: Liver lesions: Improved detection with dual-detector-array CT and routine 2.5-mm thin collimation. Radiology, 1998, 209: 417-426. 7. Graser A., Johnson T.R., Chandarana H., Macari M.: Dual energy CT: Preliminary observations and potential clinical applications in the abdomen. Eur Radiol, 2009, 19: 13-23. 8. Mahgerefteh S., Blachar A., Fraifeld S., Sosna J.: Dual-energy derived virtual nonenhanced computed tomography imaging: Current status and applications. Semin Ultrasound CT MR, 2010, 31: 321-327. 9. Hori M., Murakami T., Kim T., Kanematsu M., Tsuda K., Takahashi S., et al.: Single breath-hold T2-weighted MR imaging of the liver: Value of single-shot fast spin-echo and multishot spin-echo echoplanar imaging. AJR, 2000, 174: 1423-1431. 10. Goodwin M.D., Dobson J.E., Sirlin C.B., Lim B.G., Stella D.L.: Diagnostic challenges and pitfalls in MR imaging with hepatocyte-specific contrast agents. Radiographics, 2011, 31: 1547-1568. 11. Taouli B.: Diffusion-weighted MR imaging for liver lesion characterization: A critical look. Radiology, 2012, 262: 378-380. 12. Binkovitz L.A., El-Youssef M., Glaser K.J., Yin M., Binkovitz A.K., Ehman R.L.: Pediatric MR Elastography of hepatic fibrosis: Principles, technique and early clinical experience. Pediatr Radiol, 2012, 42: 402-409. 13. Lubezky N., Metser U., Geva R., Nakache R., Shmueli E., Klausner J.M., et al.: The role and limitations of 18-fluoro-2-deoxy-D-glucose positron emission tomography (FDG-PET) scan and computerized tomography (CT) in restaging patients with hepatic colorectal metastases following neoadjuvant chemotherapy: Comparison with operative and pathological findings.

J Gastrointest Surg, 2007, 11: 472-478. 14. Ramos E., Valls C., Martinez L., Llado L., Torras J., Ruiz S., et al.: Preoperative staging of patients with liver metastases of colorectal carcinoma. Does PET/CT really add something to multi-detector CT ? Ann Surg Oncol, 2011, 18: 2654-2661. 1. Department of Radiology, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, OH, USA. Hepatocellular carcinoma: the multistep process C. Bartolozzi1 The recent availability of different imaging modalities has improved the investigation of the processes taking place during the carcinogenetic pathway towards dysplasia and full malignancy, represented by the alteration of lesion vascular supply (progressive capillarization of the sinusoids and increasing number of muscularized, unpaired arterioles); and to the progressive histological changes (loss of biliary polarization of the hepatocytes and derangement of the microscopic secretory structure) (1). Imaging cirrhotic patients still remains a challenging issue, especially when a differential diagnosis between pre-neoplastic hepatocellular lesions, such as dysplastic nodules (DNs), and early neoplastic lesions, is requested. Actually, vascular supply to the lesion represents the key pathologic factors for differential diagnosis of nodules in cirrhosis, that can be evaluated by dynamic imaging studies; particularly, changes in lesions’ vascular supply, such as the development of new arterial vessels, termed nontriadal arteries, suggest lesions’ diagnosis. If ultrasound (US) examination still represents the first diagnostic approach in the follow-up of cirrhosis, nowadays nodules characterization is demanded to contrast enhanced Multidetector

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PROCEEDINGS (BRUGES 2012) Computed Tomography (CT) or Magnetic Resonance (MR) (2). At dynamic studies performed with both techniques, typical HCC shows a clear-cut enhancement on the arterial phase and rapid wash-out on subsequent phases (Fig. 1), while preneoplastic nodules usually have no specific features, because of different intranodular vascular supply. In doubtful cases, MR study, performed with hepatobiliary contrast agents, can furnish an insight on the so called “grey area”, in which significant histological changes are already present without an evident arterial supply of the nodule (Fig. 2) (3). Contrast behaviour of HCC after hepatobiliary agents is strictly related to tumor degree of differentiation: whereas moderately or poorly differentiated lesions fail to take up hepatobiliary agents, appearing as hypointense on T1w.i, well-differentiated tumor may appear

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Fig. 1. — On A, a clear cut enhancement of a small nodule within segment IV is appreciable, while on figure B, the nodule shows as hypodense. On the basis of these typical enhancement features, a diagnosis of HCC can be performed.

Fig. 2. — Man with HCV related cirrhosis. On segment VI, no nodules are clearly appreciable on the arterial phase (A), while on late dynamic and hepatobiliary phases (respectively B and C), a hypointense nodule is appreciable. A similar nodule is appreciable on segment III. Despite the lack of enhancement on arterial phase, the wash-out on the late phase and the hypointensity on hepatobiliary phase suggest premalignancy of nodules.

as hyperintense, as a result of the uptake and trapping of the agent within the lesion. References 1.

Bartolozzi C., et al.: Biliary and reticuloendothelial impairment in hepatocarcinogenesis: the diagnostic role of tissue-specific MR contrast media. Eur Radiol, 2007, 17: 2519-2530. 2. European Association For The Study Of The Liver; European Organisation For Research And Treatment Of Cancer. EASL-EORTC clinical practice guidelines: management of hepatocellular carcinoma. J Hepatol, 2012, 56: 908-943. 3. Inoue T., et al.: Assessment of GdEOB-DTPA-enhanced MRI for HCC and dysplastic nodules and comparison of detection sensitivity versus MDCT. J Gastroenterol, 2012, 17. 1. Diagnostic and Interventional Radiology, University of Pisa, Pisa, Italy.

Body MRI: fast, efficient, and comprehensive R.C. Semelka, B.S. Kim1,2 The use of fast scanning techniques allows for consistent high image quality and good conspicuity of disease with a decrease of imaging times. Examination time is critical because longer MRI studies may result in worsening of imaging quality due to motion that tends to progress through the course of the study from patient exhaustion. The inability of noncooperative patients to hold their breath impairs the image quality substantially on abdominal MRI. Therefore, it is useful to separate protocols are required for noncooperative patients from a standard cooperative protocol. Cooperative protocol T1-weighted sequences In-phase 2D spoiled gradient echo (SGE) has become a routine part of every

liver MR imaging for investigating disease of the abdomen. This sequence is primarily used to know abnormally increased fluid content, presence of subacute blood or concentrated protein, and presence of fat. Out-of-phase SGE sequence is very helpful for the recognization of diseased tissue in which fat and water protons are present within the same voxel. This sequence plays a important role in detecting the presence of fat within liver and lipid within adrenal adenoma. The value of magnetic susceptibility effects to assess the presence of iron using in- and out-of-phase image is also important. 3D GRE is suitable for dynamic contrast-enhanced MR because of thin section acquisition with larger volume coverage, and excellent inherent fat suppression and sensitivity to enhanced tissues. The hepatic arterial dominant phase (HADP) is the single most important data set. Hypervascular liver tumors, especially hepatocellular carcinomas, focal nodular hyperplasia and metastases, are well

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386 recognized as intensely enhancing lesions on HADP. The pancreas demonstrates uniform capillary blush on HADP, which render it markedly high in signal intensity. In general, pancreatic cancer usually appears as a focal hypovascular mass. In the early hepatic venous phase (1-1.5 minute postcontrast), the hepatic parenchyma is maximally enhanced so that hypovascular lesions are more clearly identified as regions of absent or diminished enhancement. Interstitial phase (2-4 minute postcontrast) are helpful to recognize critical late enhancement features such as washout and delayed capsular enhancement with hepatocellular carcinoma and progressive enhancement with mass-forming intrahepatic cholangiocarcinoma. T2-weighted sequences The important information that Single-Shot Echo-Train Spin-Echo (SSETSE) Sequence provide includes the presence of abnormal increased fluid content in diseased tissue and fluid containing tumors, the presence of chronic fibrotic tissue, the presence of low fluid content lesions, the presence of iron deposition, and the presence of lymph nodes in porta hepatis. Acquiring SS-ETSE sequences both without and with fat-suppression also permit evaluating for fat using T2-weighted sequences.

JBRâ&#x20AC;&#x201C;BTR, 2012, 95 (6) both in standard and motion resistant protocols. An additional advantage of this sequence is resistance to susceptibility artifact. As a result, the bowel wall can be clearly demonstrated and susceptibility artifact from metallic devices is minimal. In these settings it is however important to not use fat suppression. Conclusion Separation of protocols for cooperative and cooperation-challenged patients is necessary. Fast studies render MRI more cost effective in a progressively more cost contained environment. The clinical MRI study should be performed in a fast, efficient, and comprehensive fashion, and focus on the benefit to the patient and emphasize clinically essential strategies. References 1.

Motion-resistant protocol T1-weighted sequences 2D Magnetization-Prepared RapidAcquisition Gradient Echo (MP-RAGE) Sequence, for example Turbo-fast low angle shot (FLASH), which operates as a single shot technique, can generate T1weighted images that are resistant to deterioration from respiratory motion. This sequence can be used to obtain motion-free and moderate quality images with acquisition times as short as 1 second. The MP-RAGE in/out-of-phase images are able to demonstrate the presence of fat, which is necessary to evaluate the liver and adrenal masses in patients who cannot cooperate with 1020 second breath holds. Water excitation (WE) MP-RAGE should be used to provide fat-attenuated contrast-enhanced T1weighted images as excitation spoiling fat-attenuation does not work with MPRAGE due to the length of this preparatory scheme. WE-MP-RAGE at 3T can achieve better image quality and fatattenuation than 1.5T. Free-breathing T1 fat-suppressed 3D radial gradient echo sequences provide motion resistant data acquisition. In part this reflect that radial acquisition technique (projection reconstruction) has higher sampling density for central Kspace. This technique results in excellent motion control images in noncooperative patients, especially children. T2-weighted sequences The SS-ETSE sequence is a breathingindependent technique which is useful

3. 4.

Altun E., Semelka R.C., Dale B.M., Elias J., Jr.: Water excitation MPRAGE: an alternative sequence for postcontrast imaging of the abdomen in noncooperative patients at 1.5 Tesla and 3.0 Tesla MRI. J Magn Reson Imaging, 2008, 27: 1146-1154. Azevedo R.M., de Campos R.O., Ramalho M., Heredia V., Dale B.M., Semelka R.C.: Free-breathing 3D T1weighted gradient-echo sequence with radial data sampling in abdominal MRI: preliminary observations. AJR, 197: 650-657. Semelka R.C., Helmberger T.K.: Contrast agents for MR imaging of the liver. Radiology, 2001, 218: 27-38. Semelka R.C., Martin D.R., Balci N.C.: Magnetic resonance imaging of the liver: how I do it. J Gastroenterol Hepatol, 2006, 21: 632-637. Heredia V., Ramalho M., de Campos R.O., et al.: Comparison of a single shot T1-weighted in- and outof-phase magnetization prepared gradient recalled echo with a standard two-dimensional gradient recalled echo: preliminary findings. J Magn Reson Imaging, 2011, 33: 1482-1490.

1. Department of Radiology, University of North Carolina at Chapel Hill, Chapel Hill, USA, 2. Department of Diagnostic Radiology, Jeju National University School of Medicine, Jeju, Korea. Diffusion imaging of the liver F. Deckers1 Magnetic resonace imaging of the liver has been advocated as a highly accurate technique for diagnosing liver lesions since several years. Driven by technological advances, diffusion weighted (DW) sequences for the abdomen have become available on most commercial imagers in recent years. In higly cellular tissues (eg. neoplasm) the narrowing of interstitial space and the high density of cell membranes restrict the free motion of water molecules. This phenomenon generates the contrast

between tissues in DW imaging. Because it reflects underlying cellular density and integrity of cell membranes DW imaging of the liver opens up interesting opportunities for evaluating the effects of antitumoral treatment. DW imaging can be easily implemented in clinical setting as an added sequence in existing protocols. All these factors have contributed to the fast adoption of DW imaging of the liver in the radiologic community. Diffusion imaging provides both qualitative and quantitative assessment of lesions. ADC maps are automatically generated by most modern MR units and provide a quantitative insight in the degree of diffusion restriction. As most malignant lesions demonstrate impeded diffusion they will show up as areas of lower ADC values. Several authors have described cutoffs for detection of malignant liver lesions (1). However there is important overlap in ADC value between benign and malignant lesions. Furthermore, ADC measurements in the liver suffer a lower reproducibility. As opposed to benign lesions, most malignant lesions will manifest a high residual signal intensity compared with the background liver on images with high b values. By visually comparing the contrast between the liver and the lesion at different b-values a qualitative interpretation of lesions can be performed. Using this qualitative visual approach excellent specificity and sensitivity are obtained (2). Not all lesions that display restricted diffusion are malignant however and DW images should always be interpreted as part of a complete liver MR protocol, inluding conventional T1 and T2 images. For detecting liver lesions DW imaging generates very high sensitivity and specificity, particularly in detecting small metastasis (2, 3). In the investigation of liver metastasis DWI can be used as an alternative to gadolinium enhanced imaging in patients with impaired renal function or who have other contraindications for injection of gadolinium chelates. When applied to molecular-targeted therapies anatomic measurements can be misleading in the evaluation of response in oncologic patients. In these treatments response is often not reflected in a change in diameter. DW MR of the liver could be an interesting parameter for the follow up of these patients (4). Lower ADC values have been observed in cirrhotic liver compared with normal hepatic tissue. However, an important overlap exists between measured ADC values in different stages of fibrosis (5). Reflecting tissue cellularity, DW MR of the liver holds promise as a biomarker in oncologic imaging. Furthermore it has proven to be an excellent technique for the diagnosis of liver lesions. Therefore this attractive technique has become a part of routine liver imaging protocols. References 1.

Parikh T., Drew S.J., Lee V.S., et al.: Focal liver lesion detection and characterization with diffusion-

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PROCEEDINGS (BRUGES 2012) weighted MR imaging: comparison with standard breath-hold T2-weighted imaging. Radiology, 2008, 246: 812-822. 2. Kenis C., Deckers F., de Foer B., et al.: Diagnosis of liver metastasis: can diffusion-weighted imaging (DWI) be used as a stand alone sequence? Eur J Radiol, 2012, 81: 1016-1023 3. Löwenthal D., Zeile M., Lim W.Y., et al.: Detection and characterisation of focal liver lesions in colorectal carcinoma patients: comparison of diffusion-weighted and Gd-EOBDTPA enhanced MR imaging. Eur Radiol, 2011, 21: 832-840. 4. Cui Y., Zhang X.P., Sun Y.S., Tang L., Shen L.: Apparent diffusion coefficient: potential imaging biomarker for prediction and early detection of response to chemotherapy in hepatic metastases. Radiology, 2008, 248: 894-900.

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5. Wang Y., Ganger D.R., Levitsky J., et al.: Assessment of chronic hepatitis and fibrosis: comparison of MR elastography and diffusion-weighted imaging. AJR, 2011, 196: 553-561. 1. Department of Radiology, GZA SintAugustinus Hospital, Wilrijk, Belgium.

Hepatic tumor response after interventional treatment C. Bartolozzi1 Nonsurgical imaging-guided interventional therapies are actually largely applied for the treatment of hepatocellular carcinoma (HCC). Imaging techniques play a key role in all the subsequent steps of ablation treatments, from pre-treatment assessment, passing through the evaluation of technical success, up to the

assessment of tumor response to therapy (1). Complete or partial response, as well as progression of disease after interventional treatments have been re-defined depending on the percentage of enhancing areas appreciable within the treated lesions at the evaluation control (2). Regarding percutaneous ablation therapies, Contrast-enhanced US (CEUS) is routinely performed during peri-procedural evaluations, allowing both to target areas of residual viable tumor, as well as to monitor first tissue changes depending on the applied ablation modality (Fig. 1). Anyway, dynamic multidetector CT and MR imaging are still considered as the reference techniques to assess technical effectiveness of treatments (3). On both dynamic imaging studies, residual viable HCC is reliably depicted as it stands out in the arterial phase images against the unenhanced areas of coagu-

Fig. 1. — Periprocedural evaluation with CEUS a hour after laser ablation assesses the presence of neoplastic persistence within the target nodule (A). The evaluation after a second procedure of laser ablation, performed within two hours shows a complete ablation of the residual tumor (B). Complete response has been confirmed at CT examination after 1 month (C).

Fig. 2. — CT examination berore treatment did assess the presence of a small HCC within segment III (A). CT evaluation 1 month after microwave ablation did show a complete ablation area, larger that target lesion (B), suggesting complete response to treatment.

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388 lation necrosis, while in cases of complete response, no tumoral enhancement should be appreciable (Fig. 2). Moreover, MR performed with hepatospecific agents can furnish more information about post-ablation tissue components, revealing useful in doubtful cases, in differentiating periablation hyperemia or artero-venous shunts/thrombosis, from tumoral persistence or recurrence (3). MDCT and MR must be moreover considered as the reference methods for the evaluation of chemo and radio embolization treatments, usually performed in large, otherwise untreatable HCCs, as well as in patients on waiting list for transplantation as a down-staging approach. If MDCT can furnish an accurate evaluation of the homogenous distribution of Lipiodol as well as the progressive shrinkage of successfully treated lesions, dynamic MRI study has revealed very accurate in the assessment of residual enhancing viable tumor, thanks to the avoidance of iodinate oil artefacts that largely affect MDCT images (4). References 1.

de Lope C.R., et al.: Management of HCC. J Hepatol, 2012, 56 Suppl 1: S75-87. Review. 2. Gillmore R., et al.: EASL and mRECIST responses are independent prognostic factors for survival in hepatocellular cancer patients treated with transarterial embolization. J Hepatol, 2011, 55: 1309-16. Epub 2011 Apr 15. 3. Percutaneous ablation of liver malignancies: imaging evaluation of treatment response. Eur J Ultrasound, 2001, 13: 73-93. 4. Hepatocellular carcinoma treated with interventional procedures: CT and MRI follow-up. World J Gastroenterol, 2004, 10: 3543-3548.

JBR–BTR, 2012, 95 (6) 10 min) can sometimes be of help for characterizing hemangiomas. Detection and characterization with MRI is mainly based on intensity differences on T1- and T2-weighted imaging, DWI and ADC values, vascular enhanced imaging with extracellular gadolinium agents, and eventually reticulo-endothelial enhanced with SPIO or hepatocyte enhanced with Gd-BOPTA or Gd-EOB-DTPA. The use of US or CT-guided biopsy for characterizing benign liver lesions is in the last decade dramatically decreased due to the better non-invasive characterization of these lesions, especially with state-of-the-art MR imaging. In the group of benign hepatic masses we can distinguish primary benign liver lesions, secondary benign liver lesions, and hepatic pseudolesions. The primary benign hepatic neoplasms are of hepatocellular origin (hepatocellular hyperplasia, most commonly FNH, and hepatocellular adenoma), cholangiocellular origin (hepatic cysts), or mesenchymal origin (most commonly hemangioma). The secondary benign liver lesions are mostly abscesses, and in the group of hepatic pseudolesions we are most commonly dealing with focal steatosis, a focal spared area in a fatty liver or vascular disorders. Typical imaging findings of these benign hepatic masses will be discussed during the presentation. 1. Department of Radiology, Antwerp University Hospital, Edegem, Belgium. Imaging of focal splenic lesions F.M. Vanhoenacker1,2,3, A. Snoeckx2 The learning objectives of this presentation are to discuss the 10 most frequent encountered focal splenic lesions in Europe and to discuss the imaging characteristics of these lesions. The spleen is regarded as the forgotten and silent organ in the abdomen. Compared to the extensive literature on

liver and pancreatic imaging, little has been written on imaging of splenic lesions. However, splenic lesions may be encountered on imaging (ultrasound and computed tomography) done for other reasons. Characterization of splenic incidentalomas may be challenging for the radiologist. Imaging of focal splenic lesions Haemangioma A haemangioma is the most common benign splenic lesion. It is usually solitary, but multiple lesions may occur. The CT appearance is variable. Solid and cystic portions may be seen and the degree and pattern of enhancement may differ on CT and MRI. Rarely, central or curvilinear peripheral calcifications may be seen on CT. Calcifications The most frequent causes of splenic calcifications are healed postinfectious granulomas (tuberculosis or histoplasmosis) and phleboliths. Peripheral rimlike calcifications may be seen in cysts. Rare causes of calcifications include old infarcts, splenic hematoma, collagen-vascular diseases, amyloidosis, silicosis, Gamna-Gandy bodies,… Cystic lesions Two types of splenic cysts are distinguished along with the presence or absence of an epithelial lining, i.e. true cysts (20% of cases, true epithelial lining) and false cysts (80% of cases, with an absence of an epithelial lining usually due a posttraumatic etiology or old infarcts). The imaging appearance of both types is very similar. The clue to the correct diagnosis is the cystic content on US, CT and MRI. The signal intensity on T1-WI images may – however – be relatively high due to protein content. CT may show subtle wall calcifications (Fig. 1).

1. Diagnostic and Interventional Radiology, University of Pisa, Pisa, Italy. CT/MRI imaging of benign liver tumors B. Op de Beeck1 Today, most benign liver lesions are incidentally diagnosed using ultrasound (US), MDCT, and MRI. Most commonly, a liver tumor will be detected on US because this is the first line imaging examination for the liver. For characterization MDCT and/or MRI will be performed with a higher accuracy for MRI. Detection and characterization of liver lesions with MDCT is based on differences in density (attenuation), mainly during the different phases of dynamic imaging following a rapid bolus infusion of contrast material. Late arterial phase (35-40 sec) is the best for hypervascular tumors (FNH, HCA, small hemangiomas) and portal venous (parenchymal) phase (70 sec) for hypovascular lesions should be obtained in almost all abdominal CT scans. Equilibrium (delayed) phase (2-

Fig. 1. — Huge splenic cyst with typical wall calcification

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389 tion. Although imaging will not always provide a specific diagnosis, the combination of the clinical history, laboratory data and imaging is usually sufficient for characterization. In most clinical scenario’s, a wait-and-see policy is preferred. Bibliography 1. 2. 3. 4.

5. 6. 7.

8. Fig. 2. — Splenic infarcts. Wedge-shaped areas of non enhancement on a contrast enhanced CT (arrows).

Infarcts The etiology of splenic infarcts is highly variable and most infarcts are symptomatic in the acute stage. A typical wedgeshaped morphology is seen on contrast enhanced CT (Fig. 2.) and MRI. A diffuse pattern of infarction of the spleen may be encountered in systemic diseases (vasculitis). Sarcoidosis Splenic sarcoidosis should be considered in the differential diagnosis of multiple focal lesions on US or CT in asymptomatic patients. MRI typically shows multiple lesions with relatively low signal on T2-WI and a delayed enhancement pattern. Metastasis The spleen is a rare site of splenic metastasis due to lack of afferent lymphatics. Isolated splenic metastases are very rare. Even in the presence of a known primary malignancy, detection of splenic lesion is not necessarily related to malignant spread. Comparison with previous scans is helpful. Implant metastasis represents another pattern of metastatic spread to the spleen. Splenic lymphoma Splenic lymphoma is the most common splenic malignancy. Both Hodgkin and non-Hodgkin disease may involve the spleen. Usually, there is concomitant

widespread disease and associated adenopathy. Imaging features include splenomegaly, solitary or multiple focal lesions of variable size and splenic infarctions. Splenic infection Splenic infection is relatively rare in Western countries, but may be seen in immunocompromised patients, after chemotherapy and transplantation. Gamna-Gandy bodies Gamna-Gandy bodies consist of organized foci of hemorrhage and contain a mixture of hemosiderin, fibrous tissue and calcium. It is associated with long-standing portal hypertension. CT is insensitive for early detection and MRI is the preferred technique. The lesions are of low signal on both pulse sequences and may show blooming on gradient echo imaging. Miscellaneous Rare benign and malignant tumor and tumorlike conditions may involve the spleen (hamartoma, litteral cell angioma, Gaucher‘s disease,…). Conclusion Most focal splenic lesions are incidentally found on imaging and are benign. CT is the primary imaging modality for detection of these lesions. MRI may be of additional value in lesion characteriza-

Sameer A., et al.: Splenic Incidendalomas. Radiol Clin N Am, 2001, 49: 323-437. Rane S.R., et al.: Splenic tumoursautopsy study of ten years. Indian J Pathol Microbiol, 2005, 48: 186-189. Warshauer D.M., Hall H.L.: Solitary splenic lesions. Sem Ultrasound CT MR, 2006, 27: 370-88 Warshauer D.M., et al.: Nodular sarcoidosis of the liver and spleen: analysis of 32 cases. Radiology, 1995, 195: 757-762 Bernaerts A., et al.: Gamna-Gandy bodies. JBR-BTR, 2001, 84: 202. Vanhoenacker F.M., et al.: Vascular diseases of the spleen. Semin Ultrasound CT MR, 2007, 28: 35-51. De Schepper A.M., et al.: Vascular pathology of the spleen, part I and II . Abdom Imaging, 2005, 30:96-104 and 30: 228-238. Vanhoenacker F.M., et al.: Cystic angiomatosis with splenic involvement: unusual MRI findings. Eur Radiol Suppl, 2003, 6: L35-39. De Schepper A.M., Vanhoenacker F.: Medical Imaging of the Spleen. Springer-Verlag, Berlin Heidelberg New York, 2000.

1. Department of Radiology, AZ SintMaarten, Duffel-Mechelen, 2. Department of Radiology, Antwerp University Hospital, University of Antwerp, Edegem, 3. Faculty of Medicine and Health Sciences, University of Ghent. Update in abdominal ultrasound E. Danse, L. Annet, A. Dragean, I. Nica, P. Van Tiggelen, P. Trefois1 Ultrasound remains a current imaging procedure still required in many abdominal conditions. The advantages of sonography are a low cost technique, its repeatability, its bedside availability and the lack of radiation and side effects (1). The reason of the “sound” success story is based on permanent technical improvements and access to portable machines at a low cost. Improvements and innovations are constant in the sphere of B mode sonography, Color Doppler technique, Contrast ultrasound, elastography and volumetric approach, giving more confidence for the ultrasound practitioner. – the B mode improvements are based on efforts of the companies to increase the number of piezzo-electric elements and development of specific process to reduce artifacts. – Contrast ultrasound is permanently optimized. New indications are under

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390

JBR–BTR, 2012, 95 (6)

evaluation, particularly in the field of evaluation of response to therapy (2). – Volumetric ultrasound has moved from the obstetrical to the abdominal area, with applications for liver, kidney, bladder and bowel imaging. Volumetric ultrasound has been optimized with the development of matricial probes. Volume imaging is also incorporated in the interventional radiology room, allowing better guidance for difficult biopsies based on the “GPS” philosophy (3). – Elastography of the liver, initiated with the “Fibroscan” is integrated into our common probe, accelerating the access to liver stiffness evaluation and also new applications, including characterization of focal liver lesions. High quality portable devices are available, with high quality B Mode image, color Doppler and contrast ultrasound imaging in an easier way, particularly in the critical care and emergency medicine area, with a side effect : ultrasound can not be restricted to radiologists and the battle of “who has to perform ultrasound ?” is still alive (4, 5). These improvements (volumetric ultrasound and portable device) are an opportunity for a new approach for teaching medicine and radiology at the University: ultrasound is used to give a better anatomical understanding of the human body (6). References 1.

2. 3.

4. 5. 6.

Potthoff A., Gebel M.J., Rifai K.: Diagnostic and interventional abdominal ultrasonography. Internist, 2012, 53: 261-270. Nicolau C., Ripolles T.: CEUS in abdominal imaging. Abdom Imaging, 2012, 37: 1-19. Forsberg F., Berghella V., Merton D.A., Rychlak K., Meiers J., Goldberg B.B.: Comparing Image Processing Techniques for Improved 3-Dimensional Ultrasound Imaging. J Ultrasound Med, 2010, 29: 615-619. Puylaert J.B.: Abdominal ultrasound: a task for the radiologist. Ned Tijdschr Geneeskd, 2008, 152: 145. Roos J.C.: Abdominal ultrasound: a task for the internist. Ned Tijdschr Geneeskd, 2008, 152: 144. Afonso N., Amponsah D., Yang J., et al.: Adding New Tools to the Black Bag – Introduction of Ultrasound into the Physical Diagnosis Course. J Gen Intern Med, 2010, 25: 1248-1252.

images are not disturbed by gas and bone, while obesity is even an advantage; producing the CT images is not operator-dependent and CT can be reviewed at a later point in time and even from a distance by means of teleradiology. Finally, CT images are easier understood and accepted by clinicians than US images are. However, there are also specific advantages of US over CT: US has an image definition in the close range which is much higher. US is more interactive: patient’s history as well as painful area or palpable mass can be correlated with the US findings. US shows peristalsis, pulsations and blood flow. US shows the effects of respiration, Valsalva manoeuvre, gravity and compression with the probe, allowing to assess whether organs as bowel and gallbladder are soft or rigid. US allows easy puncture of intraperitoneal fluid and drainage of pus. US in acute abdomen is performed with graded compression. Compression is necessary to displace or compress bowel, eliminating the disturbing influence of bowel gas and to approach the pathological structure closely. This allows using a high frequency transducer with a better image quality. The compression should be graded to avoid unnecessary pain and to avoid pushing organs out of the US plane. US examination should be symptomdirected and requires communication with the patient. In patients with an acute abdomen the entire abdomen should be examined, i.e. from the axilla to the groin. The final US report should be integrated with the clinical findings, laboratory data, CT-scan and possible other radiological examinations.

The US images of appendicitis, diverticulitis, intussusception, acute biliary, urological and gynecological conditions, infectious ileocecitis, perforated peptic ulcer, small bowel obstruction, ruptured aneurysm, pancreatitis, Crohn's disease, epiploic appendagitis, omental infarction and perforating malignancy will be demonstrated using illustrative case histories, with emphasis on the specific advantages of US over CT. 1. Department of Radiology, MCH, The Hague. Cystic tumors of the pancreas: imaging and management K.J. Mortele1 Cystic tumors of the pancreas are a diverse group of lesions which vary from benign to pre-malignant to frankly malignant entities. There has been a 20-fold increase in detection of cystic pancreatic lesions over the last 15 years most notably by cross-sectional modalities such as computed tomography (CT) and magnetic resonance imaging (MRI). The true prevalence of pancreatic cystic lesions is unknown but has been previously reported to be around 2.4-16.0%, and they appear to be increasingly detected with increasing age. One study reported a prevalence of incidental pancreatic cystic lesions on MRI to be in the order of 13.5% and showed that the prevalence and cyst size also increased with age. These findings have been corrobated at autopsy with the prevalence of cystic lesions approaching 25%. Given the fact that the prevalence of pancreatic cystic lesions is increasing

Table I. — Our standardized in-house approach to cystic pancreatic lesions.

1. Department of Imaging, St Luc University Hospital, Université Catholique de Louvain, Brussels, Belgium.

US of the acute abdomen J.B. Puylaert1 CT has several advantages over US in the diagnosis of the acute abdomen: CT is extremely rapid, the true costs of CT are fairly low and probably lower than a time-consuming US examination, CT

Lesion size < 1 cm 1-2 cm

Recommended follow-up

Every 2 years (2x) for a total of 4 years; if still stable then STOP Every year for 2 years (2x), then once after 2 years; if still stable then STOP > 2 cm BUT < 3 cm Every 6 months for 1 years (2x), then every year for 3 years (3x); if still stable then STOP

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PROCEEDINGS (BRUGES 2012) due to increased detection by crosssectional imaging, and the fact that most cystic pancreatic lesions are neoplastic in nature, accurate diagnosis via clinical information, radiological images, +/- endoscopic ultrasound (EUS) with cyst fluid analysis plays an important role. The majority of these lesions, especially when large, have characteristic imaging features at radiology, and accurate differentiation between them is important to help guide future treatment and management. Nevertheless, smaller lesions may appear indeterminate and the management pathways of these may be confusing and variable. The aim of this lecture is to review the histopathologic features and common imaging findings for a vast array of cystic pancreatic neoplasms. These include the relatively common cystic tumors of the pancreas: serous microcystic adenoma, mucinous cystic tumor (MCT), intraductal papillary mucinous neoplasm (IPMN), and solid pseudopapillary tumor (SPT). Uncommon cystic tumors of the pancreas include cystic endocrine tumors, cystic metastases, cystic teratomas, and lymphangiomas. This lecture also aims to provide comprehensive algorithms on how to manage the individual lesions with recommendations on when to reimage patients (Table I).

plastic. Neoplastic lesions include cystic lymphangioma (Fig. 1), mucinous cystadenoma, cystic teratoma, cystic mesothelioma, MĂźllerian cyst, epidermoid cyst, tailgut cyst, bronchogenic cyst, etc. Nonneoplastic lesions include pancreatic pseudocyst, lymphocele, urinoma and hematoma. Non-cystic masses can be classified according to their origin. Lesions of vascular origin are hemangiopericytoma and retroperitoneal lesions associated with angiomatosis. Lesions of neurogenic origin are associated with NF-1 and include neurofibroma, schwannoma, malignant peripheral

391 nerve sheath tumor and duralectasia. Tumours of fibrous origin are desmoids and inflammatory pseudotumor. Liposarcoma (Fig. 2) and GIST are the most common malignant retroperitoneal tumours. Abscesses, iliopsoas bursitis, ischemic fasciitis, endometriosis and cisterna chyliare pseudotumoral lesions that may mimic a retroperitoneal or abdominal mass. Conclusion Although abdominal and retroperitoneal soft tissue tumours show many

Reference 1.

Dewhurst C.E., Mortele K.J.: Cystic tumors of the pancreas: imaging and management. Radiol Clin North Am, 2012, 50 (3): 467-86.

1. Associate Professor of Radiology, Harvard Medical School / Director, Division of Clinical MRI / Staff Radiologist, Abdominal Imaging and MRI, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Ansin 224, Boston, MA 02115, USA.

Fig. 1. â&#x20AC;&#x201D; Retroperitoneal lymphangioma. Diffuse infiltrating serpiginous lesion at the left flank and abdominal wall on fatsuppressed (FS) T2-Weighted image (WI).

Imaging of abdominal and retroperitoneal soft tissue tumours: a practical approach F.M. Vanhoenacker1,2,3, A. Snoeckx2, B. Op de Beeck2 The learning objectives of this presentation are to describe the imaging features of abdominal and retroperitoneal soft tissue tumours with emphasis on MRI and to define a practical approach for differential diagnosis. Abdominal and retroperitoneal soft tissue tumours are rare. Since clinical implications and therapeutic strategy vary depending the cause, imaging plays an important role. Imaging findings When approaching abdominal or retroperitoneal soft tissue tumours, the initial step in the evaluation is defining the precise localization of the lesion. The next step is to differentiate between cystic and non-cystic masses. Cystic lesions can be classified as neoplastic or nonneo-

Fig. 2. â&#x20AC;&#x201D; Retroperitoneal liposarcoma. Huge retroperitoneal mass containing fatty and nonlipomatous components on a FS T2-WI.

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392 overlapping characteristics, some imaging findings may suggest a specific diagnosis. Whereas CT is the initial imaging technique for detection, MRI can better characterize the tumour and define its extension. References 1.

Yang D.M., Jung D.H., KIM H., et al: Retroperitoneal cystic masses: CT, clinical and pathologic findings and literature review. Radiographics, 2004, 24: 1353-1365. 2. Rajiah P., Sinha R., Cuevas C., et al: Imaging of uncommon retroperitoneal masses. Radiographics, 2011, 31: 949-976. 3. Nishino M., Hayakawa K., Minami M., et al.: Primary retroperitoneal neoplasms: CT and MR imaging findings with anatomic and pathologic diagnostic clues. Radiographics, 2003, 23: 45-57. 4. Snoeckx A., Vanhoenacker F.M., Op de Beeck B., et al.: Imaging of abdominal and retroperitoneal soft tissue masses: a practical approach. E-Poster: P224 â&#x20AC;&#x201C; ESGAR, 2009.

1. Department of Radiology, AZ SintMaarten, Duffel-Mechelen, 2. Department of Radiology, Antwerp University Hospital, University of Antwerp, Edegem, 3. Faculty of Medicine and Health Sciences, University of Ghent. CT colonography: current status and pitfalls Ph. Lefere1 Current status Since its introduction as a revolutionary imaging technique for detecting tumoral lesions in the colon, CT colonography (CTC) has gained major interest from both the radiological and gastrointestinal community. After a rather long introductory period with variability of results, CTC is now more and more established as a useful and reliable technique to inspect the colon for colorectal cancer and its adenomatous precursors. Sustained efforts of the CTC community (ESGAR CTC faculty) resulted in the elaboration of a state-of-the-art technique focussing on the important aspects of patient preparation, colonic distension image acquisition and interpretation. The results of recently performed multicentre trials have proven these efforts to be worthwhile. State-of-the art CTC technique is based on 4 importants pillars: colonic preparation with fecal tagging, adequate colonic distension using an automated CO2 injector, acquisition with a multi-slice scanner (using (ultra-) low dose in asymptomatic patients), interpretation with dedicated colon software programs by an experienced CTC radiologist. Using this technique very good results of polyp detection have been obtained in several large trials with CTC obtaining a sensitivity of > 80% for adenomas and/or

JBRâ&#x20AC;&#x201C;BTR, 2012, 95 (6) advanced neoplasia 6-9 mm (some studies obtaining > 90%) and > 90% for adenomas â&#x2030;Ľ 1 cm. CTC is now an accepted indication after incomplete optical colonoscopy, in case of contra-indications and patient refusal of optical colonoscopy. While the use of CTC for population-based screening is a matter of debate because of an issue of cost-effectiveness, CTC is a good option for individual screening. CTC is a very good indication in the frail and elderly patients. CTC can be considered in patients with symptoms suggestive of colorectal cancer and patients with vague abdominal symptoms. CTC can be used for preoperative mapping of diverticular disease and colorectal cancer and in the posroperative patient for colorectal cancer surveillance. CTC is also an option in patients with endometriosis. CTC is very well accepted by the patient and currently techniques are developed to decrease the intensity the preparation in order to improve patient compliance. Furthermore CTC is a very safe examination with very few and mostly self-limiting complications. Radiation dose is very low with the development of better scanners and new acquisition and postprocessing methods. Pitfalls in imaging Pitfalls in imaging are related to the technical aspects of CTC, the anatomical aspect of the colon and two- and threedimensional imaging. Technique-related pitfalls are related to the preparation, colonic distension and CTC acquisition. Most problems are solved by preparing the patient with fecal tagging and obtaining optimal colonic distension. Some minor problems may be caused by noise related to the low dose technique and motion artefacts. Anatomy-related pitfalls are more difficult to handle. Some pitfalls occur in any colonic segment: segmental mobility, the flexural pseudotumor and extrinsic impressions. Some pitfalls are related to the colonic segments. As a closed structure the rectum is difficult to examine. The anal margin needs our particular attention because of possible internal hemorrhoids, hypertrophied anal papillae and true polyps. Futhermore the rectal catheter obscures this part of the rectum. The valves of Houston or rectal valves are 3 prominent folds that add more difficulties when inspecting the rectum. In the sigmoid most problems are caused by diverticular disease: diverticular fecaliths, polypoid mucosal prolapse and wall thickening with the issue of chronic diverticulitis vs cancer. The descending colon does not cause a lot of problems. Having a round aspect in the sigmoid, the colonic lumen becomes somewhat more triangular in the descending colon with a typical aspect in case of spasm. In the transverse and ascending colon the lumen becomes frankly triangular with deeper haustal folds. At both the splenic and hepatic flexures, flexural pseudotumors are frequently encountered. Finally the cecum is difficult to examine: first it is a closed

structure, second the ileo-cecal valve has several normal appearances mimicking tumors: lipomatous transformation, papillary transformation. Sometimes the ileo-cecal valve is difficult to localize or may be misinterpreted as a tumor. It is also necessary to examine the appendix to exclude a tumor or a mucocele. Conclusion CTC is a reliable tool for detecting tumoral lesions in the colon. To be succesful, a meticulous technique and interpretation by an experienced radiologist are mandatory. 1. Department of Radiology, Stedelijk Ziekenhuis Roeselare, Roeselare, Belgium. US of appendicitis and diverticulitis J. B. Puylaert1 Appendicitis US is the modality of choice to demonstrate appendicitis. In experienced hands in 90% of patients with appendicitis, the inflamed appendix can be demonstrated. It presents as a hypervascular, aperistaltic, sausage-like, blind-ending, concentrically layered structure, which is not or only moderately compressible. The inflamed appendix has an average diameter of 9 mms and is often surrounded by hyperechoic, noncompressible, inflamed fat. In contrast, the diameter of the normal appendix is usually < 7 mms, is wellcompressible, more mobile and never surrounded by inflamed fat. A possible pitfall is the demonstration of the normal proximal part of the appendix while the distal inflamed tip is overlooked because it is obscured by bowel gas. Also the diameter of the normal appendix at times may exceed 7 mms, in most cases because the lumen is dilated with fecal material. In children the hypoechoic deep mucosal layer may be very thick due to lymphoid hyperplasia and be responsible for a large diameter, while the appendix is not inflamed. In all of these cases the absence of inflamed fat and the absence of hypervascularity are the clue to the right diagnosis. A pitfall leading to a false-positive diagnosis is secondary enlargement of the appendix. This maybe due to conditions as cecal carcinoma, Crohn's disease, perforated peptic ulcer and sigmoid diverticulitis. If in these cases the underlying condition is not recognized, an incorrect diagnosis of appendicitis may lead to an unnecessary operation or, in case of a surgical condition, to an inappropriate incision. If, next to the inflamed appendix, fluid filled, dilated and aperistaltic bowel loops are seen in the right lower quadrant or throughout the abdomen, this indicates localized respectively generalized peritonitis. This means a high chance for perforation and usually it coincides with severe peritonitis, making surgery imperative.

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PROCEEDINGS (BRUGES 2012) Another pitfall is provided by the phenomenon of "spontaneously resolving appendicitis". These patients are admitted with suspected appendicitis, but after a variable period of time (12-36 hours) they experience rather sudden relief of pain and concomitant symptoms. If examined at that point US is still able to confirm an inflamed appendix which is however not anymore tender on pressure. Repeat US scans show gradual decrease of the appendix diameter over the following days. Conservative management in a large series showed a 40% recurrence rate, usually within one year. If appendicitis has been present for several days, and the erythrocyte sedimentation rate (ESR) is markedly elevated, while the patient's condition is relatively stable, US will usually denote large hyperechoic fatty masses surrounding the appendix as well as secondary wall thickening of ileum and cecum. These hyperechoic masses, often interspersed with irregular echolucent linear configurations, represent inflamed mesenterial fat and omentum, migrating towards the appendix in an attempt to wall-off the (imminent) perforation. These patients get the clinical diagnosis of “appendiceal mass”, which is commonly treated conservatively, because appendectomy is expected to be technically difficult or even impossible due to the large inflammatory mass . When these patients are followed with US, one observes a gradual decrease in size of the inflammatory periappendiceal mass). In case there is doubt whether to operate immediately or to remain conservative, the clinical impression and especially the duration of symptoms and the absence of peritonitis, has generally more weight than the US image. The diagnosis of appendiceal phlegmon can only be made in dialogue between radiologist and clinician, and never on the US or CT image alone. If there is a circumscribed fluid collection, this indicates the presence of an appendiceal abscess. Appendiceal abscess The treatment of choice for an appendiceal abscess is percutaneous drainage. However it is important to realize that many appendiceal abscesses disappear spontaneously. The smaller ones are resorbed, the larger ones evacuate itself into neighbouring bowel. If an abscess causes pain or recurrent fever, or if the patient recovers too slowly, percutaneous drainage is indicated. Preceding the drainage procedure, CT scan is mandatory to confirm the abscess, to delineate its extent and to establish a safe access route for the puncture. In general it is best to puncture from lateral, but all directions are possible, provided that vital structures as vessels and bowel are avoided. Puncture and insertion of the initial guidewire are best performed under direct US-guidance, subsequent dilatation and insertion of the final drainage catheter are performed using fluoroscopy.

In children, and in adults with frank peritonitis, surgical intervention is indicated. Diverticulitis Over all, the diagnosis of diverticulitis is more reliably made by CT than by US. However, since US is often used as a first modality in acute abdomen, it is important to be aware of the US signs of diverticulitis. Besides, in not too obese patients, US may be superior to CT. US is most useful in early, uncomplicated diverticulitis. Daily, repeated US examinations in patients with diverticulitis has taught us that diverticulitis, in the majority of cases, runs a predictable and benign course. Initially, there is local wall thickening of the colon with preservation of the US layer structure. Within the inflamed diverticulum a fecolith is present and the diverticulum is surrounded by hyperechoic, non-compressible tissue, which represents the inflamed mesentery and omentum “sealing-off” the imminent perforation. US follow-up shows evacuation of the fecolith to the colonic lumen, with or without the transient development of a small paracolic abscess, sometimes with disintegration of the fecolith . This process of spontaneous evacuation of pus and fecolith via local weakening of the colonic wall at the level of the original diverticular neck towards the colonic lumen, takes place within one or two days, rarely more. The residual inflammatory changes remain present for several days after the evacuation, and it is not uncommon to find an empty diverticulum at first presentation. If, in such cases, patients are specifically asked for their symptoms, they invariably declare that “the worst pain is over”… Whenever diverticulitis takes a complicated course, CT is superior to US, especially in the detection of free air, fecal peritonitis and deeply located abscesses, and in general in obese patients. Finally, US, if necessary followed by CT, has an important role in the diagnosis of alternative conditions: ureterolithiasis, pyelonephritis, perforated peptic ulcer, appendicitis, Crohn disease, epiploic appendagitis, gynecological conditions, colonic malignancy, pancreatitis, etc. Right sided colonic diverticulitis in many respects differs from its left sided cousin. Diverticula of the right colon are usually congenital, solitary, true diverticula containing all bowel wall layers. The fecoliths within these diverticula are larger and the diverticular neck is wider. There is no hypertrophy of the muscularis of the right colonic wall. My observations with US and CT in 110 patients with right colonic diverticulitis, clearly show that it invariably has a favorable course and never leads to free perforation or large abscesses. Although relatively rare (left: right = 15:1), it is crucial to make a correct diagnosis, since the clinical symptoms of acute RLQ pain may

393 lead to an unnecessary appendectomy or even right hemicolectomy. 1. Department of Radiology, MCH, The Hague. Inflammation and obstruction of the urinary tract J.R. Fielding1 What is the appropriate test for the evaluation of painless hematuria in the patient with high risk for TCC? High risk patients include those over the age of 60 with a smoking history. These patients routinely undergo cystoscopy to exclude a primary bladder cancer. Assessment of the upper tracts is performed to exclude a synchronous tumor or in the case of a negative cystoscopy, a primary site of disease. There are many methods to perform CTU, however, all involve a non-contrast enhanced image of the abdomen to exclude stones and identify renal cortical masses. A second pass through the abdomen and pelvis following injection of 100 cc of contrast material (350 mg I/ml) is performed at 75 seconds. Finally, a third pass performed at 5 to 10 minutes following injection is used to assess the intrarenal collecting systems and ureters. Coronal reformatted images of the delayed phase acquisition are essential and should be reviewed using both soft tissue and bone windows. The use of furosemide, a split bolus of contrast agent and compression bands all increase opacification of the ureters. What is the appropriate use of MR urography? MR urography can be a valuable substitute for patients who require evaluation of the kidneys and upper tracts but cannot receive IV contrast agents. Although it lacks the spatial resolution of CT, there is increased contrast resolution theoretically allowing for more accurate identification of soft tissue masses. In those patients who have undergone therapy for TCC, it may replace CTU for follow-up examinations. Despite the perceived complexity of MR urography, it can be performed in a simple fashion. The two most crucial components are the use of hydration (250 ml IV) and diuresis (furosemide 10 mg IV). Once these steps are completed, the acquisition of a thick slab fat saturated T2 weighted coronal image with a large field of view should yield high quality results. Parameters used for MRCP are satisfactory. Reference 1.

Silverman S.G., Leyendecker J.R., Amis E.S.: What is the current role of CT urography and MR urography in the evaluation of the urinary tract? Radiology, 2009, 250: 309-323.

1. University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.

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394 Imaging acute abdomen in the pediatric population F. E Avni1 Abdominal emergencies represent one of the largest parts of the workload in a Paediatric Radiology Department. Emergencies encompass a very wide spectrum of diseases and entities some life threatening while other more benign. The role of imaging is of utmost importance as in many patients, the origin of the acute symptoms is not obvious. Furthermore some specific entities such as non accidental trauma and child abuse have to be considered and will be suspected through imaging findings only. Considering abdominal emergencies, ultrasound (US) plays a central role in sorting between the differential diagnoses and therefore, a clinico-radiological triage has to be applied based on age, sex, symptoms, medical history, and sonographic findings. Imaging techniques As mentioned, among imaging techniques, ultrasound (US) occupies a central role. The technique is not irradiating, easy to perform (yet operator – dependant) and relatively low cost. The US examination has to be optimized and fitted to the size and age of the patient. Whatever the purpose of the examination, the entire abdomen should be checked. In many cases, color Doppler will provide additional information. In selected cases, a plain film of the abdomen will help to demonstrate calcifications or confirm intestinal (sub)obstruction. In some others, a CTscan would provide additional information useful for the proper management of the patient. Whenever performed, the CT technique should be optimized to deliver the lowest possible irradiation. MR Imaging is rarely performed as an emergency procedure, unless an abdominopelvic mass is detected. Finally, fluoroscopy has limited indications in emergency abdominal imaging. Acute abdominal conditions (trauma excluded) One way of defining the best optimal work up of an acute abdominal condition is to base the approach on the patient’s age: – The principal entities to consider around birth and up to 6 months are congenital anomalies, those related to premature birth and hypertrophic pyloric stenosis. Congenital anomalies are frequently detected during obstetrical US examination; yet, some do escape antenatal diagnosis and will be detected after birth only, secondary to symptoms of intestinal (sub)obstruction. Prematurely born babies are at risk for developing digestive complications such as necrotizing enterocolitis. At an early stage, US may demonstrate bowel wall thickening and a small amount of free fluid.

JBR–BTR, 2012, 95 (6) Thereafter, free air may dissect the bowel wall and reach the portal vein system. It will be demonstrated as hyperechoic dots within the liver parenchyma. In case with unfavourable evolution, a pneumoperitoneum may develop due to intestinal perforation. In a 6 week-old vomiting babyboy, a hypertrophic pyloric stenosis is the most probable diagnosis. US is confirmatory as it demonstrates the thickened pyloric muscle. The stomach is distended since food remains trapped for an abnormal long duration. – between 6 months and 2 years, the main diagnoses are intussusceptions, midgut volvulus and inguinal hernia. In classical cases, intussusception has a typical clinical and sonographic appearances. At US, a mass with a target pattern is visualized (above 3 cm diameter). Many small ganglions are usually included within the intussuception. Most AII are primary. Some (usually those before the age of 6 months or after 2 years) are secondary to leading lesions (e.g. intestinal duplications, Meckel’s diverticulum, lipoma, lymphoma) that can be visualized as persisting masses after the therapeutic reduction. A midgut volvulus is an acute condition that complicates intestinal malrotation and induces intestinal obstruction. In obvious cases of intestinal malrotation, the mesenteric vein lies to the right of the mesenteric artery; the condition can be complicated by a midgut volvulus where the bowel loops and the mesenteric vessels determine the so-called and characteristic Whirepool sign. Midgut volvulus is a surgical emergency. An Inguinal hernia corresponds to bowel loops entrapped within the patent inguinal canal. Peristalsis within the herniated loops can be observed. Secondary obstruction may develop. Note worthy, in baby girls, an ovary can be entrapped within the hernia. This condition should be operated rapidly. – Between 2 and 12 years, the spectrum of diseases occurring within this age group is wide and assessing the correct diagnosis is sometimes a real challenge. Still, by frequency, two conditions overpass all others. By far, constipation is the commonest cause for acute and chronic abdominal pain in children. This diagnosis can only be obtained through a careful interrogation of the child (if possible) and of his/her parents. If necessary, a plain film of the abdomen may confirm the condition. The second most common condition for acute abdominal pain is acute appendicitis which is actually the most commonly diagnosis suspected by the ER physician. A US diagnosis of acute appendicitis (AA) is based on the demonstration by US of a thickened, swollen, non depressible appendix (above 6 mm diameter). The inflamed appendix is painful under gentle US compression. On color Doppler, the peri-appendicular mesenteric fat appears hypervascularized. An echogenic appendicolith can be visualized. As the disease progresses, perfora-

tion may occur and peritonitis develop with abscess formation. The latter may be difficult to delineate and complementary CT may be necessary. Indications of CT include unusual clinical presentation (i.e. infants), clinico-imaging discrepancy and complicated cases (multiple abscesses). False negative diagnoses of acute appendicitis result from localized inflammation or abnormally located (retrocaecal or retrohepatic) appendix. False positive cases include other causes of appendicular infiltrations or thickening (e.g. carcinoïd tumor, cystic fibrosis, Crohn’s disease, …). Once acute appendicitis has been excluded, the list of diagnoses widens. For instance, the digestive tract can be involved infectious or inflammatory processes that lead to its thickening and hypervascularization. It can also be involved in auto-immune diseases (e.g Henoch-Schonlein Syndrome, Hemolytic and uremic syndrome...). Meckel’s diverticulum is surely a potential diagnosis and it may be complicated by torsion, abscess formation and rupture. Biliary lithiasis may occur under various favouring conditions (Sickle cell disease, infections, post-surgery, ….) and detected thanks to typical ultrasound features. Abdominal tumors may develop at any age and involve any organ. Neuroblastoma, Wilms’ tumor and lymphoma are the most frequent in children. Other classical tumors include cystic lymphangioma and teratoma. Both can be retro- or intraperitoneal. Cystic lymphangioma appears as large multiseptated fluid filled masses where as teratoma are usually more complex tumors including solid components and calcifications.In girls, the most common tumors in develop in the ovary. Teratoma (or dermoïd cyst) are the most classical histologic type encountered. Other entities that may lead to acute abdominal pain include acute pneumonia, acute pyelonephritis, testicular torsion, psoas abscesses or skeletal diseases. – Above 12 years, the list of diseases to be considered resembles the ones occurring in adults as for instance gastritis, gastro-duodenal ulcers or bowel inflammatory diseases and their complications may occur. In adolescent girls, gynaecological diseases have to be considered. Ovarian cysts may develop and torsion is a classical complication. At puberty, gynaecological malformations may become obvious due to hematocolpos. 1. Department of Pediatric Radiology, CHRU-Lille, France. MRI in fistulizing perianal disease D. Vanbeckevoort, D. Bielen, V. Vandecaveye, K. Op de beeck, R. Vanslembrouck, E. Mussen, S. Dymarkowski, M. Thijs1 Perianal fistulas are an uncommon but major cause of morbidity, occurring in 1/10000 predominantly male persons.

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PROCEEDINGS (BRUGES 2012)

ISS

Fig. 1. — Axial T2-weighted MR image shows the normal anatomy of the perianal region: ES = external sphincter, IS = internal sphincter, and ISS = intersphincteric space.

395 ber and location of the individual tumors (subserosal, intramural, transmural, submucosal) does not affect the approach, technique or outcome of UAE. MR guided high-intensity focused ultrasound (HIFUS) is a noninvasive treatment option for symptomatic leiomyomata. In contrast to UAE and surgery, it lacks the invasiveness of these procedures since the targeted leiomyoma are ablated by energy transmitted through the skin by focused ultrasound while exact delivery is monitored online by MR imaging. Size, location and number of fibroids are limiting factors for the application of HIFUS. Magnetic resonance imaging (MRI) is superior to ultrasound in delineating the extent of fibroid disease and excluding other pathologies or disease processes that may mimic fibroid-related complaints. 1. Department of Radiology, CharitéUniversitätsmedizin Berlin, Charité Campus Mitte, Berlin, Germany.

Normal anatomy The anatomy of the anal region is well demonstrated on MR images (Fig. 1): the involuntary internal sphincter, the intersphincteric space, and the voluntary external sphincter. Etiology and classification Perianal fistulas usually arise from infected anal glands, penetrating into the intersphincteric plane, spreading infection down to the skin. In patients with Crohn disease perianal fistulas arise from inflamed or infected anal glands and/or penetration of fissures or ulcers in the rectum or anal canal. Using the external sphincter as a reference point, Parks divided perianal fistulas in 5 types: intersphincteric, transsphincteric, suprasphincteric, extrasphincteric, and superficial (1). Diagnosis Standard assessment of perianal fistulas combines examination under anaesthesia and imaging with endoscopic ultrasound and/or pelvic MRI.

For medical treatment (measurement of fistula disease activity) Fistula inflammation and disease activity correspond well with the presence of T2 hyperintensity in fistula. Van Assche et al. have constructed a new MRI based score, taking into account both anatomical and inflammation criteria (3). This score correlates with clinical disease activity and with response to biological therapy. References 1.

Parks A.G., et al.: A classification of fistula-in-ano. Br J Surg, 1976, 63: 112. 2. Beets-Tan R.G., et al.: Preoperative MR imaging of anal fistulas: does it really help the surgeon? Radiology, 2001, 218: 75-84. 3. Van Assche G., et al.: Magnetic resonance imaging of the effects of infliximab on perianal fistulizing Crohn’s disease. Am J Gastroenterol, 2003, 98: 332-339. 1. Department of Radiology, University Hospitals, Catholic University of Leuven, Leuven, Belgium.

MRI protocol Coronal and axial MR images demonstrate fistula tracks in relation to the sphincter complex, ischiorectal fossa, and levator plate. Sagittal and oblique planes are helpful in anovaginal or presacral disease. Contrast enhanced and fat suppressed sequences are used to improve contrast and can distinguish inflamed tissue from normal perineal tissues. Accuracy and application of MR imaging For surgical treatment (preoperative assessment) Pelvic MRI may change surgical management in 10%-15% of cases (2).

Imaging and interventional treatment of benign uterine tumors Th.J. Kroencke, B. Hamm1 Uterine artery embolization (UAE) is a nonsurgical intervention for treating symptomatic uterine leiomyomas and represents an alternative to surgical removal (hysterectomy, moymectomy, hysteroscopic resection). The indication for uterine artery embolization crucially relies on the preinterventional assessment of symptomology and burden of disease. Especially the location, size, and number of leiomyomas are important to determine treatment options of patients. As a rule, both single and multiple fibroids can be treated by UAE. The num-

MR Imaging of cervical and endometrial cancer B. Hamm1 MR imaging is the method of first choice for staging uterine malignancies. The main criterion for staging endometrial cancer is the depth of myometrial invasion. The diagnostic accuracy can be improved by performing a dynamic contrast-enhanced study in addition to T2weighted imaging. Recently, it has been shown that DWI gives similar diagnostic information concerning myometrial invasion as dynamic contrast-enhanced imaging. The backbone of staging cervical cancer is T2-weighted imaging with a high spatial resolution performed in sagittal and transverse slice orientation. Invasion of the parametrium can thus be assessed with a high degree of accuracy. Especially in staging cervical cancer, MR imaging can replace numerous other diagnostic tests and thus improve pretherapeutic staging while at the same time reducing costs. In addition, MR imaging is used in planning radiotherapy and following up patients having undergone irradiation. MR imaging is a problem-solving method in patients with post-treatment complications such as assessment of fistulas and detection of recurrent cancer. 1. Department of Radiology, CharitéUniversitätsmedizin Berlin, Charité Campus Mitte, Berlin, Germany. MRI of the prostate J. Fütterer1 Prostate cancer is a major health issue in aging men. No treatment is required in less aggressive prostate cancer but there is consensus that radical treatment is needed in aggressive prostate cancer. Radical treatment has to start while the tumor is still confined to the gland and has

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396 not spread beyond. Potential side effects of radical treatment, such as impotence and incontinence, have a substantial impact on quality of life. This is of special importance because more than 25% of patients eligible for radical treatment are in the age range of 40 to 65 years. Conventional anatomical T2-weighted MRI is the mainstay in prostate cancer imaging. On T2-weighted images, normal prostate tissue displays an intermediate to high signal intensity while the transition-zone has lower signal intensity than the peripheral zone. Currently several MR imaging techniques are being explored. These include: 1H-MR spectroscopic imaging, dynamic contrast-enhanced MR imaging, and diffusion weighted imaging. Multiple studies have explored optimal parameter settings for the diagnostic MR-protocol, which allows accurate tumor localization. Although reported accuracies of the different separate and combined MP-MRI techniques vary for diverse clinical prostate cancer indications, MP-MRI has shown promising results and may be of additional value in prostate cancer localization and local staging. To increase MR imaging accuracy for the different clinical prostate cancer indications, one or more functional MR imaging techniques should be combined with T2-weighted MR imaging in a MP-MRI of the prostate. The optimal strength of MP-MRI is yielded by combining the information of the various techniques.

JBRâ&#x20AC;&#x201C;BTR, 2012, 95 (6)

Fig. 1. â&#x20AC;&#x201D; MR-guided prostate biopsy - transgluteal approach

1. Department of Radiology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands.

MR guided biopsies of the prostate, an update Th. Vogl1 Prostate cancer is the most frequently diagnosed malignancy in the western hemisphere in men aged 50 years and older. Early detection programs for prostate cancer with prostate-specific antigen level testing and an annual digital rectal examination should be performed in men over the age of 50. In this context the incidence of prostate carcinoma increased after the introduction of PSA testing.

Transrectal ultrasound-guided biopsy is recommended as the gold standard to confirm the diagnosis of prostate cancer. This systematic approach is characterized by low sensitivity and high specificity. A large number of patients with elevated and/or rising PSA levels have negative results on initial transrectal ultrasoundguided biopsy. Therefore, repeated biopsies have to be performed to confirm the diagnosis of prostate cancer. Missed prostate cancer at the first transrectal ultrasound-guided biopsy is described in about 25% of the patients. Magnetic resonance imaging has established itself as a useful diagnostic modality for accurate localization of prostate cancer. It is a complementary

reliable imaging technique after negative transrectal ultrasound-guided biopsy. MR-guided biopsy of the prostate is a promising technique which combines MR imaging and the possibility of a guided biopsy. Initial experience shows promising results using transgluteal, rectal and perineal approaches (Fig. 1). Manual MR guided-biopsy of the prostate gland with a transgluteal approach in a high-field MR system is feasible, safe and an advantage for prostate cancer detection. 1. Institute for Diagnostic and Interventional Radiology, Johann Wolfgang Goethe University Hospital, Frankfurt University, Frankfurt, Germany.

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JBR–BTR, 2012, 95: 397.

FORTHCOMING COURSES AND MEETINGS NATIONAL MEETINGS 10-12.01.13 5TH LEUVEN COURSE ON EAR IMAGING Leuven, Huis van Chièvres Information: Monika.Philips@uzleuven.be 28.02-02.03.13 BELGIAN WEEK OF GASTROENTEROLOGY Information: danse@uclouvain.be 26.01.13 RBRS ANNUAL SYMPOSIUM Interventional radiology in all radiological subdisciplines Information: jean-françois.dewispelaere@uclouvain.be 01.03.13 BELGIAN WEEK OF GASTROENTEROLOGY Research Meeting Imaging Section Information: danse@uclouvain.be

21-22.03.13 ATELIER DE COLONOSCOPIE VIRTUELLE Liège, Clinique St Joseph Information: anne-marie.mandic@chc.be 22.03.13 RBRS-Cardiovascular and Interventional Radiology Mons, Hôpital Ambroise Paré Information: Denis.henroteaux@skynet.be, sam.heye@uzleuven.be

12-13.09.13 ATELIER DE COLONOSCOPIE VIRTUELLE Liège, Clinique St Joseph Information: anne-marie.mandic@chc.be 10-12.10.13 HRCT OF THE LUNG Leuven Information: walter.dewever@uzleuven.be, Johny.verschakelen@uzleuven.be, www.everyoneweb.com/chestradiology

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INTERNATIONAL MEETINGS 18-19.01.13 13ÈMES MISES AU POINT EN IMAGERIE OSTEOARTICULAIRE France, Lille Information: filip.vanhoenacker@telenet.be

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