JBR 2013-4 by office

WETTEREN 1

P 702083

Volume 96 Page 189-272 July-August

Bimonthly

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2013

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-2013.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.

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JBR-BTR ♦ 96/4 ♦ 2013 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

ARTICLES The following section consists of short case reports published through the courtesy of the Editors of “Radiological Documents” and supported by Codali-Guerbet and Guerbet The edition – text and figures – is also available on RBRS website at http:www.rbrs.org Review article: Diagnosis and treatment of endoleaks after endovascular repair of thoracic and abdominal aortic aneurysms S. Heye . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189 Feasibility of an optimized MR enterography protocol in the evaluation of pediatric inflammatory bowel disease Th. Bosemani, A. Ozturk, A. Tekes, M.O. Hemker, Th. A. G. Huisman . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 196 Demographic changes in brain CT and MRI between 1990 and 2010 Th. Vancauwenberghe, Ph. Demaerel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203

SHORT REPORTS Intralobular pulmonary sequestration E. Alizadeh, H. Suliman . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 208 Perforation of the urinary bladder wall by foley catheter Z. Bozgeyik, E. Kocakoc, S. Aglamıs, E. Ogur . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 210 Benign lipoma of the inferior vena cava M. Cabri-Wiltzer, E. Danse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 212 Congenital hemangioma of the skull M. Coeman, N. Baelde, E. Matthys, N. Herregods, K. Verstraete . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 214 Goblet cell carcinoid tumor of the appendix B. De Keyzer, D. Crolla, P. Øvreeide, I. Crevits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 216 Bilateral branchial cleft fistula F.I. De Korte, R.R. van Rijn . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 218 Hepar lobatum carcinomatosum F.C. Deprez, E. Coche, B. Ghaye . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 220 Subacute intramural hematoma of the aorta P. Dewachter, F. Vandenbroucke, F. Van Tussenbroek, J. de Mey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 222 Parathyroid carcinoma A. Dilli, S.S. Gultekin, U.Y. Ayaz, S. Ayaz . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 224 Lyme neuroborreliosis M. Eyselbergs, B. Tillemans, P. Pals, D. De Vuyst, F.M. Vanhoenacker . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 226 Multifocal nodular steatosis T.A. Fassaert, E.R. Ranschaert, M.D.F. de Jong, I. Dubelaar . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 228 Osteoid osteoma M. Keupers, J. Vandevenne, E. Gielen, M. Horvath, Y. Palmers, M. Vandersteen . . . . . . . . . . . . . . . . . . . . . . . . . 230 Superior vena cava syndrome caused by behcet’s disease R. Kilicarslan, G. Burakgazi, S. Aglamis, E. Kocakoc . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 232 Spontaneous splenic rupture in infectious mononucleosis B. Koebrugge, D. Geertsema, M. de Jong, G. Jager, K. Bosscha . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 234 Bizarre parosteal osteochondromatous proliferations of the fingers S. Konijnendijk, A. Soepboer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 236 Chondroblastoma of calcaneus J. Liu, N. Xu, Y. Sun . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 238 Avulsion fracture of the anterior inferior iliac spine C. Mai, A. Michel, B. Claikens, P. Van Wettere . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 240

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Aortic coarctation A.S. Michel, C. Mai, L.V. Flore, B. Claikens . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 242 Gallstone ileus with a biliodigestive fistula L.J. Schijf, D. Van der Vlies, A.G. Aalbers, A. Bruining . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 244 Polyostotic fibrous dysplasia B.J. Schouten, H.M. Suliman . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 246 Small bowel diverticulosis O. Soenen, J. Capoen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 248 Rotator interval lesion M. Spaepe, A. De Schepper, M. Pouillon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 250 Intraosseous dissecting ganglion of the knee F. Van den Bergh, R. Van Rattinghe, K. Verstraete . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 252 Lipoma arborescens A. Van Landeghem, B. Arys, C. Heyse, N. Peters, W. Huysse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 254 Yolk sac tumor of the ovary T. Van Thielen, H. Degryse, D. Coeman . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 256 Neonatal cephalohematoma L. Willemot, P. Lagae, P. Jeannin, N. Baelde, K. Verstraete . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 258

IMAGES IN CLINICAL RADIOLOGY Orbital dermoid B. Denoiseux, J. Denekens, F. Van den Bergh, F.M. Vanhoenacker . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 260 Large occipital nerve (Arnold’s nerve) schwannoma M. Apaydin, M. Varer, O.T. Kalayci, F. Gelal, M.B. Koruyucu . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 261 Sprengel’s shoulder C. Ruivo, M.A. Hopper . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 262 Giant hydronephrosis in a 42-yr-old man revealed by low back pain S. Kouki, A. Fares, K. Akkari, S. Alard . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 263 Unusual cause of pelvic pain and polyuria in an adolescent: idiopathic megarectum S. Kouki, A. Fares, K. Akkari, S. Alard . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 264 Paradoxical reaction in non HIV-tuberculosis, a rare case with pancreatic involvement D. Denaeghel, L. Binet, P. Wackenier, P. Ravez, C. Winant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 265 Atypical obstructive submandibular sialoadenitis M. Sahan, N. Cullu, M. Deveer, A.K. Sivrioglu, H. Beydilli, L. Sözen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 266 Bilateral selective amygdala calcifications: lipoid proteinosis C. Yilaz, B. Gulek, E. Cenesizoglu, O. Kaya, G. Soker, A. Hursit Ispir . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 267

Abstract of papers for full membership at the Royal Belgian Society of Radiology . . . . . . . . . . . . . . . . . . . . . 268 In Memoriam: Prof. Sydney Wallace . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 269 Forthcoming Courses and Meetings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 270 Instructions to Authors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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

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

Editor: J. Pringot Assosiated Editor: H. Degryse

President: R. Hermans Consulting Co-Editor: M. Castillo (USA)

Vice-President: D. Henroteaux

Managing Editors: P. Seynaeve

Past-President: J.F. De Wispelaere

Editorial Board: F. Avni, L. Breysem, N. Buls, 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, P. Simoni, S. Sintzoff Jr, A. Snoeckx, J. Struyven, H. Thierens, P. Van Dyck, F. Vanhoenacker, Ph. Van Hover, J. Verschakelen, K. Verstraete.

General Secretaries: M. Lemort, J. Verschakelen Meeting Secretaries: M. Spinhoven, Y. Lefebvre Treasurers: D. Brisbois, A. Van Steen Coordinator of continuing education: 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

J.F. Nisolle, M. Shahabpour

Breast imaging

M. Mortier, S. Murgo

Cardiac imaging

R. Salgado, O. Ghekière

Cardiovascular and interventional radiology

S. Heye, D. Henroteaux

Chest radiology

B. Ghaye, W. De Wever

Head and neck radiology

J. Widelec, R. Hermans

Neuroradiology

M. Lemmerling, L. Tshibanda

Pediatric radiology

B. Desprechins, L. Breysem

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 Editorial 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

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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 next page)

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

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22/08/13 11:51

JBR–BTR, 2013, 96: 189-195.

REVIEW ARTICLE DIAGNOSIS AND TREATMENT OF ENDOLEAKS AFTER ENDOVASCULAR REPAIR OF THORACIC AND ABDOMINAL AORTIC ANEURYSMS S. Heye1 A common complication of endovascular repair of a thoracic or abdominal aortic aneurysm (TEVAR – EVAR) is an endoleak occurring in up to 30% of cases. Endoleak is defined as the persistence of blood flow outside the lumen of the endoprosthesis, but within the aneurysm sac and can be classified into 5 categories, depending on the blood flow into the aneurysm sac. Typical features of the different types of endoleaks are discussed as well as the imaging modalities to detect and classify an endoleak and the diverse (endovascular) treatment options. Key-words: Aneurysm, aortic – Aneurysm, therapy.

The goal of endovascular repair of a thoracic or abdominal aortic aneurysm (TEVAR – EVAR) is – as with open surgical repair – to prevent enlargement and rupture of the aneurysm (1). A common complication of TEVAR and EVAR is an endoleak and this is seen in up to 30% of cases (2). Endoleak is defined as the persistence of blood flow outside the lumen of the endoprosthesis, but with(3). A in the aneurysm sac classification system for endoleaks has been developed, organizing endoleaks into 5 categories, depending on the blood flow into the aneurysm sac (4). Endoleak categories Type I endoleak In type I endoleak the blood flow passes alongside the proximal (IA) or distal (IB) attachment sites of the endoprosthesis, as a result of poor or insufficient apposition between the attachment site and the arterial wall (4, 5) (Fig. 1A-C, Fig. 2A,B). An endoleak through a non-occluded iliac artery in a patient with an aortouni-iliac endoprosthesis and a femoral-femoral bypass is a type IC endoleak (2). In type I endoleaks there is a direct communication between the aneurysm sac and the systemic arterial circulation and therefore the aneurysm sac is at high risk for rupture (5). Type I endoleak is the most common type of endoleak in TEVAR (1).

A Fig. 1. — Contrast-enhanced CT-scan. Multiplanar reconstruction (MPR) images in (A) axial and (B) coronal plane showing a type IA endoleak in a patient with EVAR. There is contrast alongside the endoprosthesis, within thee aneurysm sac (arrow). C. DSA confirms the CT-findings of a type IA endoleak, with contrast in between the vessel wall and the endoprosthesis (arrows).

Type II endoleak Retrograde filling of the aneurysm sac through side branches, mainly from intercostal/lumbar arteries and/ or inferior mesenterica artery causes a type II endoleak (1, 2). A distinction is made between a type II endoleak involving a single side branch (IIA) (Fig. 3A-C) and a type II endoleak with more complex blood flow through 2 or more arteries (IIB). Type

* Paper presented at the Annual Symposium of the SRBR-KBVR, Tervuren, 26.01.2013. From: 1. Department of Imaging and Pathology, Radiology Division, University Hospitals Leuven, Leuven, Belgium. Address for correspondence: S. Heye, Department of Imaging and Pathology, Radiology Division, University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium. E-mail: sam.heye@uz.kuleuven.ac.be

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C II endoleak is the most common type of endoleak after EVAR (1). An association with aneurysmal expansion and rupture is possible, but the risk is lower in comparison to type I and type III endoleaks (0.5 vs 3.4%) (2).

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A A

B Fig. 2. — A. Contrast-enhanced CT-scan demonstrating a type IB endoleak, with contrast in the aneurysm sac, close to the right leg of the endoprosthesis (arrow). B. DSA in the same patient showing that there is poor apposition of the right leg of the endoprosthesis to the vessel wall, allowing leakage of contrast into the aneurysm sac alongside the right leg of the endoprosthesis (arrows).

Type III endoleak A type III endoleak occurs when there is a structural failure of the endoprosthesis, such as a hole in the fabric of the stent-graft (type IIIA) or a poor apposition or disconnection of different components of a modular endoprosthesis device (type IIIB) (Fig. 4A-C). These endoleaks are – as type I endoleaks – considered at high

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risk for rupture because of the aneurysm sac is subject to the arterial pressure (2, 5). Type IV endoleak Type IV endoleaks are caused by porosity of the endoprosthesis fabric and identified during implantation of the device, when the patient is fully anticoagulated. These endoleaks are

C Fig. 3. — Contrast-enhanced CT-scan. A. MPR images in axial plane showing contrast in the aneurysm sac after TEVAR (arrow). B. Maximum-intensity projection (MIP) images in right anterior oblique plane and (C,D) corresponding DSA images demonstrating the right superior intercostal artery as the inflow/outflow vessel to the endoleak (type IIA endoleak) (arrows). The connection between inflow/ outflow vessel (arrows) and the endoleak (arrowhead) can be seen on DSA.

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however not yet been determined (1). In the EUROSTAR registry imaging surveillance at 1, 6, 12, 18 and 24 month after TEVAR - EVAR and then yearly is suggested (7, 8). Other centers perform surveillance at 1 month, 6 months and 12 months and then annually (1). For endoleaks imaging surveillance is used for the detection and (if possible) the classification of endoleaks and for demonstration of any problems or deformities of the endoprosthesis. Several imaging techniques have been used for surveillance, but (multi-detector) CT angiography remains the most widely used.

MR angiography Gadolinium-enhanced MR angiography can be used to detect endoleaks, but only if the stents of the endoprosthesis are suitable for MR imaging. Stainless steel stents cause large susceptibility artifacts resulting in a nondiagnostic study. Elgiloy stents may obscure the vessel lumen. An endoprosthesis with nitinol stents will cause little or no artifacts and are therefore suitable for MR imaging (1). Time-resolved MR imaging can be used for characterization of the endoleak (1) and showed a 97% concordance with the findings of digital subtraction angiography (DSA) in one study (9).

B rarely seen in the devices that are used nowadays and will seal spontaneously when the coagulation profile is normalized (1). Type V endoleak

C Fig. 4. — Contrast-enhanced CT-scan. A,B. MPR images in axial plane revealing contrast in the aneurysm sac (asterisk) and an abrupt displacement of the anteriorly located leg of the endoprosthesis (medially located on (A) and at the lateral border of the aneurysm on B)). C. DSA in the same patient confirming the type IIIB endoleak (asterisk), caused by a disconnection of the left leg of the endoprosthesis from the short leg of the body of the endoprothesis (arrows).

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A continued expansion of the neurysm sac after TEVAR – EVAR, a without a radiological evidence of an endoleak is called type V endoleak or endotension (5, 6). The exact cause is unknown, but may be an undiagnosed or occult endoleak (because of very slow flow or suboptimal imaging) or ultrafiltration through the device fabric (4-6). Others suggested that in some patients the thrombus in the aneurysm sac provides an ineffective barrier to transmission of arterial pressure and that these significant forces continue to affect the sac (4). Surveillance Because of the potential complications after TEVAR – EVAR, such as an endoleak, a life-long imaging surveillance is necessary (1). The ideal frequency and imaging technique has

Ultrasound Ultrasound (US) has well known advantages over (MD)CTA (safe, inexpensive, no radiation, no use of iodine), but remains operator and patient dependent. Measurement of the aneurysm size with US correlates well with (MD)CT (1). Sensitivity for detecting an endoleak ranges between 67% and 86% in comparison to (MD)CT. Specificity varies between 67% and 100%. Positive predictive value (PPV) and negative predictive value (NPV) was between 29-100% and 90-100% respectively (10, 11). In 6 to 25% of cases US resulted in an inconclusive exam (10, 11). In the study of Uthoff and colleagues, the use of US as imaging surveillance technique increased during followup (26.6% at 6 months, 35.5% at 3 years), especially in experienced centers (12). Since US is not able to give sufficient information on the conformation of the stent-grafts, US is usually combined with plain radiographs of the endoprosthesis. US has also limited use in the surveillance after TEVAR (4).

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MDCT angiography MDCTA remains the most commonly used imaging modality for surveillance of TEVAR – EVAR. Sensitivity in depicting endoleaks is higher in comparison to DSA (92% versus 63%). Multiphasic MDCTA is recommended to increase sensitivity since endoleaks have variable flow rates and therefore they can be detected at variable time points after injection of contrast material (1). Images without contrast are used to differentiate between contrast in the aneurysm sac and calcifications, while delayed venous phase images are used to depict endoleaks that are not visible during arterial phase (such as some slow flow type II endoleaks). Multiphasic MDCTA can therefore also help to classify an endoleak, although classification – together with radiation dose – remains a problem. In order to reduce patient radiation dose from MDCTA exams, several possibilities has been sug gested. One way to reduce radiation dose is to replace the triple-phase MDCTA by a dual-phase MDCTA, by removing either the pre-contrast phase (except for the first examination at 1 month), or the arterial or venous phase. Removing the arterial phase was suggested in case of a stable or regressing aneurysm. Moreover since sensitivity for depicting endoleaks is higher with a delayed venous phase than with an arterial phase in some studies, it has been suggested to eliminate the arterial phase (1, 13). Others found that the decrease of sensitivity to detect endoleaks in the arterial phase was not significant, while specificity and PPV improved with the arterial phase. Therefore they proposed to eliminate the venous phase (13, 14). Dual-energy dual-source CT has been examined, comparing standard triple-phase examinations to either virtual non-enhanced + arterial + delayed phase or virtual non-enhanced images + delayed phase in 2 studies (15, 16). Examinations with virtual non-enhanced images + delayed phase resulted in a 61% reduction of radiation dose compared with triplephase imaging and a 41% reduction in radiation compared with dual phase imaging with a sensitivity, specificity, NPV and PPV of 100%, 97%, 100%, and 96% respectively (15, 16). To improve the classification of endoleaks with CT, Sommer and colleagues examined time-resolved CTA in 54 patients and compared the

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findings to contrast-enhanced US (17). They found a sensitivity, specificity, PPV and NPV of 94%, 93%, 89% and 96% respectively, with a mean effective radiation dose of 14.6 mSv (17). Digital subtraction angiography Although time-resolved imaging techniques may be promising, DSA remains the most specific modality for endoleak classification. Stavropoulos reported only an 86% agreement between CTA and DSA for the classification of endoleaks and DSA did change the choice of treatment in 11% of cases (18). In nearly all endoleaks contrast was seen in the inferior mesenteric artery and/or the lumbar arteries, but these findings reflect either inflow/outflow in a type II endoleak or – and probably more importantly – outflow from a type I or type III endoleak (1). Moreover in 2 studies on percutaneous interventions for suspected type II endoleaks (based on CTA findings), respectively 21% and 36% of the presumed type II endoleaks appeared to be occult type I or type III endoleaks (19, 20).

Endoleak treatment Type I and type III endoleaks Because of the high risk for rupture in type I and type III endoleaks (arterial systemic pressure on the aneurysm sac), immediate treatment is needed. This can be done by endovascular means such as angioplasty balloons and bare stent to improve the apposition of the stent-graft to the vessel wall (in type I endoleaks) or additional stent-graft to extend the covering of the aneurysm (type I) (Fig. 5 A,B) or to cover the hole in the fabric/the zone of the junctional disconnection (type III) (Fig. 6). In selective cases with a type I endoleak, embolization has been described (1). Surgical conversion is another option. Type II endoleak A lack of consensus exists concerning the treatment of type II endoleaks. Some groups believe that a type II endoleak that persists beyond 6 months should be treated (unless shrinkage of the aneurysm sac is documented) because the endoleak prevents thrombosis of the aneurysm sac and therefore a potential risk of aneurysm expansions and rupture exists (1). Others advocate a more conservative approach with close follow-up of the endoleak as

B Fig. 5. — A. DSA and (b) digital angio graphy (DA) image of the same patient as in fig. 2 with a type IB endoleak showing extension of the right leg of the endoprosthesis with a long stent-graft ending in the right external iliac artery (arrows) successfully treating this type IB endoleak. In order to prevent potential type II endoleak via retrograde flow in the right internal iliac artery, the internal iliac artery was embolized with coils (arrowheads) prior to the stent-graft placement.

long as the aneurysm does not show an increase in size. This is based upon the fact that 40% of the type II endoleaks will seal spontaneously. For this reason they believe that a

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B A Fig. 6. — DSA of the same patient as in Fig. 4 after placement of an additional stentgraft covering the location of the junctional disconnection at the left iliac axis. No residual type III endoleak is seen.

type II endoleak should only be treated if there is a combination with an expansion of the aneurysm sac greater than 5 mm, which is a rare (19, 21). phenomenon (1%-2.2%) Even though the debate is still going on, review of the evidence is in favor for the latter approach (22). The first treatment of choice for type II endoleaks is embolization. From a treatment point of view, type II endoleaks have been compared with an arteriovenous malformation, with the sac as the nidus and the side branches of the aorta as inflow and outflow vessels communicating with each other through a channel (that can be different from the endoleak). (6). Goal of the treatment is to disrupt the communications between the inflow and outflow vessels, thus occluding the vessels and the communicating channels (6). The approach for embolization can be either transarterial or direct via translumbar or transabdominal puncture (Fig. 7A-C, Fig. 8A-H). Both routes are equally effective if the endoleak cavity and the communicating vessels are embolized (23). The embolic agent used varies between the studies: most commonly used are coils and liquid embolic agents such as n-butyl cyanoacrylate (NBCA) and Ethylene-Vinyl-AlcoholCopolymer (EVOH, Onyx®), and often a combination of these materials is needed. Gelfoam slurry or throm-

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Fig. 7. — A. DA of the same patient as in Fig. 3 showing the cast of Onyx® in the right superior intercostal artery (arrows). Contrast-enhanced CT-scan. MPR images in B axial and C coronal plane demonstrating the cast of Onyx® extending in the type II endoleak (arrow).

bin are less frequently used in addition to coils (6). The outcome of type II endoleak embolization is variable for several reasons. First of all different inclusion criteria are used in the studies (all type II endoleaks versus all persistent endoleaks versus only type II endoleaks with enlarging aneurysms) and second different types of definitions and outcome parameters are used (19-21, 23-29). Some authors consider absence of a type II endoleak as successful, while others describe success as a stable or regressing aneurysm with or without a (residual) endoleak (19-21, 23-29). Some take aneurysm rupture or aneurysm-related death as clinical endpoint. Funaki and colleagues made a clear difference between technical success (absence of an endoleak on follow-up CT) and clinical success, defined as stabilization of the aneurysm sac (20), but in other studies this difference is not clearly made. In most studies different approaches and different embolic agents are used in the studied population, making it impossible to determine if the material used is a predictive factor for success or failure (19-21, 23-29). Moreover patient selection was sometimes done based only on CT, while others did perform a pre-intervention DSA study (19-21, 23-29). This may influence outcome as well, since some studies demonstrated an

C occult type I/III endoleak in about one third of patients. If this could be extrapolated to other studies, this may affect directly the outcome, because stabilization of the aneurysm is not to be expected (or at least to a lesser degree) in type I/III endoleaks. In general one could conclude from the available studies that a second percutaneous intervention is often needed and that technical success varies between 28% and 100%. There was also a wide range of clinical success between 44% and 100% if it was defined as stable or decreasing aneurysm diameter. No aneurysm rupture or aneurysm-related death was seen. Complication rate varied between 0% and 9.6%. Type IV endoleak As this is rare with the current evices and only seen during placed ment while the patient is fully anticoagulated, there is no specific treatment for this type of endoleak. Type IV endoleaks are self-limited and resolve spontaneously when the coagulation status of the patient is normalized (1). An endoleak demonstrated during follow-up is per definition not a type IV endoleak.

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C Type V endoleak Treatment options are limited in type V endoleaks. It is important however to confirm the diagnosis of endotension (and to exclude an underlying endoleak as cause of the aneurysm expansion). Endotension can be treated by relining (placing a new endoprosthesis within the old

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Fig. 8. — A. Contrast-enhanced CT-scan showing an endoleak anterior (arrow) and posterior (arrowhead) to the two legs of the endoprosthesis. (B,C). DSA shows that these are two independent type II endoleaks. The anteriorly located endoleak (asterisk) is opacified through retrograde flow in the inferior mesenteric artery (arrow) via the superior mesenteric artery. The inflow/outflow arteries of the posterior endoleak (white asterisk) are a common origin of the fourth lumbar artery on both sides and middle sacral artery and lumbar artery L3 at the left side (arrows). D. Percutaneous direct puncture of the posterior endoleak was done guided by a pre-planned trajectory on a conebeam CT-scan performed with a flat-panel detector system. E. DSA through the percutaneous needle showing the endoleak (white asterisk) and the inflow/ouflow vessels (arrows). F. DA after embolization of lumbar artery L4 on the left side with microcoils (arrows) and after embolization of the endoleak with glue (white asterisk). There is some spilling of glue in left lumbar artery L2 (arrowhead) and in the psoas muscle (white circle). G. DA showing superselective transarterial catheterization of the anterior endoleak (white asterisk) with a microcatheter. The outflow vessel of this endoleak is a right inferior polar artery (arrowheads). H. DSA after embolization of the endoleak (arrows) and the proximal segment of the inferior mesenteric artery (arrowhead) with microcoils. No more filling of the anterior endoleak through the inferior mesenteric artery is seen.

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one) or by conversion to surgery. The risk of rupture in patients treated conservatively is however very low (< 1%) in the first 4 years if patients were not treated with Vanguard stent-grafts and had aneurysm diameters < 70 mm (8). Conclusions Endoleak is a common complication of TEVAR and EVAR and therefore lifelong imaging surveillance is important. The ideal frequency and imaging technique have not yet been determined and the pros and cons of the different imaging modalities should be kept in mind. For the moment MDCTA is the most widely used technique for detection of endoleaks and classification is done by DSA. Type I and III endoleaks require immediate treatment because these endoleaks are prone to rupture. Available evidence support the conservative management of type II endoleaks, with treatment restricted to type II endoleaks with enlargement of the aneurysm sac >5 mm over a 6-month period or >10 mm in comparison with the diameter before TEVAR – EVAR. Before treating type II endoleaks one must exclude underlying occult type I/III endoleaks and the goal of the intervention should be to embolize the inflow and outflow vessels and the communicating channels in between. Treatment of type V endoleaks remains unclear and may be conservative, endovascular or surgical. References 1. Stavropoulos S.W., Charagundla S.R.: Imaging techniques for detection and management of endoleaks after endovascular aortic aneurysm repair. Radiology, 2007, 243: 641-655. 2. Golzarian J., Maes E.B., Sun S.: Endoleak: treatment options. Tech Vasc Interv Radiol, 2005, 8: 41-49. 3. Grande W., Stavropoulos S.W.: Treatment of complications following endovascular repair of abdominal aortic aneurysms. Semin Interv Radiol, 2006, 23: 156-164. 4. Stavropoulos S.W., Carpenter J.P.: Postoperative imaging surveillance and endoleak management after endovascular repair of thoracic aortic aneurysms. J Vasc Surg, 2006, 43 Suppl A: 89A-93A. 5. Bashir M.R., Ferral H., Jacobs C., McCarthy W., Goldin M.: Endoleaks after endovascular abdominal aortic aneurysm repair: management strate-

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gies according to CT findings. AJR Am J Roetgenol, 2009, 192: W178-W186. 6. Golzarian J., Valenti D.: Endoleakage after endovascular treatment of abdominal aortic aneurysms: diagnosis, significance and treatment. Eur Radiol, 2006, 16: 2849-2857. 7. Buth J., Harris P.L., van Marrewijk C., Fransen G.: The significance and management of different types of endoleak. Semin Vasc Surg, 2003, 16: 95-102. 8. Koole D., Moll F.L., Buth J., et al.: Annual rupture risk of abdominal aortic aneurysm enlargement without detectable endoleak after endovascular abdominal aortic repair. J Vasc Surg, 2011, 54: 1614-1622. 9. Cohen E.I., Weinreb D., Siegelbaum R., et al.: Time-resolved MR angiography for the classification of endoleaks after endovascular aneurysm repair. J Magn Reson Imaging, 2008, 27: 500503. 10. Gray C., Goodman P., Herron C.C., et al.: Use of color duplex ultrasound as a first line surveillance tool following EVAR is associated with a reduction in cost without compromising accuracy. Eur J Vasc Endovasc Surg, 2012, 44: 145-150. 11. Karthikesalingam A., Al-Junbi W., Jackson D., et al.: Systematic review and meta-analysis of duplex ultrasonography, contrast-enhanced ultrasonography or compted tomography for surveillance after endovascular aneurysm repair. Br J Surg, 2012, 99: 1514-1523. 12. Uthoff H., Peña C., Katzen B.T., et al.: Current clinical practice in postoperative endovascular aneurysm repair imaging surveillance. J Vasc Interv Radiol, 2012, 23: 1152-1159.e6. 13. Laks S., Macari M., Chandarana H.: Dual-energy computed tomography imaging of the aorta after endo vascular repair of abdominal aortic aneurysm. Semin Ultrasound CT MR, 2010, 31: 292-300. 14. Iezzi R., Cotroneo A.R., Filippone A., et al.: Multidetector CT in abdominal aortic aneurysm treated with endovascular repair: are unenhanced and delayed phase enhanced images effective for endoleak detection? Radiology, 2006, 241: 915-921. 15. Chandarana H., Godoy M.C.B., Vlahos I., et al.: Abdominal aorta: evaluation with dual-source dual-energy multidetector CT after endovascular repair of aneurysms – initial observations. Radiology, 2008, 249: 692-700. 16. Stolzmann P., Frauenfelder T., Pfammatter T., et al.: Endoleaks after endovascular abdominal aortic aneurysm repair: detection with dual-energy dual-source CT. Radiology, 2008, 249: 682-691. 17. Sommer W., Becker C.R., Haack M., et al.: Time-resolved CT angiography for

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the detection and classification of endoleaks. Radiology, 2012, 263: 917926. 18. Stavropoulos S.W., Clark T.W., Carpenter J.P., et al.: Use of CT angiography to classify endoleaks after endovascular repair of abdominal aortic aneurysms. J Vasc INterv Radiol, 2005, 16: 663-667. 19. Aziz A., Menias C.O., Sanchez L.A., et al.: Outcomes of percutaneous endovascular intervention for type II endoleak with aneurysm expansion. J Vasc Surg, 2012, 55: 1263-1267. 20. Funaki B., Birouti N., Zangan S.E., et al.: Evaluation and treatment of suspected type II endoleaks in patients with enlarging abdominal aortic aneurysms. J Vasc Interv Radiol, 2012, 23: 866-872. 21. Steinmetz E., Rubin B.G., Sanchez L.A., et al.: Type II endoleak after endovascular abdominal aortic repair: a conservative approach with selective intervention is safe and cost-effective. J Vasc Surg, 2004, 39: 306-313. 22. Patatas K., Ling L., Dunning J., Shrivastava V.: Statis sac size with a type II endoleak post-endovascular abdominal aortic aneurysm repair: surveillance or embolization? Interact Cardiovasc Thorac Surg, 2012, 15: 462-466. 23. Stavropoulos S.W., Park J., Fairman R., Carpenter J.: Type 2 endoleak embolization comparison: translumbar embolization versus modified transarterial embolization. J Vasc Interv Radiol, 2009, 20: 1299-1302. 24. Rosen R.J., Green R.M.: Endoleak management following endovascular aneurysm repair. J Vasc Interv Radiol, 2008, 19: S37-S43. 25. Nevala T., Biancari F., Manninen H., et al.: Type II endoleak after endovascular repair of abdominal aortic aneurysm: effectiveness of embolization. Cardiovasc Interv Radiol, 2010, 33: 278-284. 26. Abdularrage C.J., Patel V.I., Conrad M.F., Schneider E.B., Cambria R.P., Kwolek C.J.: Improved results using Onyx glue for the treatment of persistent type 2 endoleak after endovascular aneurysm repair. J Vasc Surg, 2012, 56: 630-636. 27. Uthoff H., Katzen B.T., Gandhi R., Peña C.S., Benenati J.F., Geisbüch P.: Direct percutaneous sac injection for postoperative endoleak treatment after endovascular aortic aneurysm repair. J Vasc Surg, 2012, 56: 965-972. 28. Massis K., Carson W.G. III, Rozas A., Patel V., Zwiebel B.: Treatment of type II endoleaks with Ethylene-VinylAlcohol-Copolymer (Onyx). Vasc Endovasc Surg, 2012, 46: 251-257. 29. Sarac T.P., Gibbons C., Vargas L., et al.: Long-term follow-up of type II endoleak embolization reveals the need for close surveillance. J Vasc Surg, 2012, 55: 33-40.

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Feasibility of an optimized MR Enterography Protocol in the evaluation of pediatric Inflammatory Bowel Disease T. Bosemani1, A. Ozturk1, A. Tekes1, M.O. Hemker2, T.A.G.M. Huisman1 Cross-sectional imaging forms an important alternative and complimentary tool to endoscopy in aiding the clinician with diagnosis and management of pediatric inflammatory bowel disease (IBD). The purpose of the study was to evaluate the feasibility of an optimized Magnetic Resonance Enterography (MRE) protocol in the evaluation of patients with suspected IBD. 31 children (18 boys and 13 girls) were evaluated by a pediatric gastroenterologist prior to MRE and given a grading for clinical severity of disease. Imaging was then performed with oral contrast and a tailored protocol using fast T1/T2 weighted pulse sequences. Additionally, contrast and glucagon were administered intravenously. Imaging findings were then correlated with the clinical data. Excellent distension was achieved in the small bowel. The majority of the studies were of diagnostic quality with no motion artifacts. Imaging findings showed statistically significant correlation with disease activity. An optimized pediatric MRE protocol is feasible and correlates well with clinical disease activity. This in turn aids the clinician in the management of children with this chronic debilitating disease. Key-words: Crohn disease – Children, gastrointestinal system – MR Enterography.

Cross-sectional imaging forms an important alternative and complimentary tool to endoscopy in aiding the clinician with diagnosis and management of pediatric inflammatory bowel disease (IBD). Inflammatory bowel disease including Crohn’s disease (CD) and Ulcerative colitis (UC) are chronic inflammatory diseases of the gastrointestinal tract which may be accompanied by extra-intestinal manifestations (1-3). Pediatric IBD has been reported to have an overall prevalence of 16.6 cases per 100,000 children and 5.3 cases per 100,000 children younger than 16 years old. CD is twice as common as UC (1). It has a complex disease course with frequent relapses. Next to endoscopy, computed tomography (CT) is frequently used to study IBD. Because IBD often affects young patients who are known to be more sensitive to the deleterious effects of radiation than adults (4), alternative radiation-free diagnostic tests should be explored. The lifetime cancer mortality risk is significantly higher for children than for adults for a given radiation dose (5). This is of additional importance, considering that IBD frequently requires multiple follow up studies, often spanning decades. Endoscopy frequently fails to evaluate the exact extent of disease because it provides limited access to

the small bowel and does not visualize extra luminal complications. Low patient compliance, especially in the pediatric population also remains a concern with endoscopy. Hence, the need for a non- or minimally-invasive, radiation-free and reproducible alternative imaging test. The test should allow to confirm diagnosis, identify complications early and allow monitoring disease activity and response to therapy (6). Ultrasonography (US) is radiation-free and renders high resolution cross sectional images that can be performed bedside with wide availability. It is relatively cheap, but also has its own limitations. A systematic evaluation of the entire small and large bowel is rather difficult and image quality is typically degraded by endoluminal air. US also remains heavily operator dependent and are not widely accepted by the referring physicians. Based upon the physical properties, such as lack of radiation, multiplanar capabilities, multiple anatomical and functional image contrasts that can be generated, magnetic resonance imaging (MRI) is a straightforward alternative for crosssectional imaging of the pediatric gastro-intestinal tract (7-10). Previous studies have shown that MRI allows to assess both inflammatory changes of the bowel wall and

From: 1. Division of Pediatric Radiology, Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins Hospital, Baltimore, MD, USA, 2. Division of Pediatric Gastroenterology and Nutrition, Johns Hopkins Hospital, Baltimore, MD, USA. Address for correspondence: Dr T.A.G.M. Huisman, M.D., EQNR, FICIS, Professor of Radiology and Radiological Science, Medical Director, Division of Pediatric Radiology, Russell H. Morgan Department of Radiology and Radiological Science, 600 North Wolfe Street, Nelson, B-173, Baltimore, MD 21287-0842, USA. E-mail: thuisma1@jhmi.edu

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extramural complications in IBD (11). MRI of the bowel also known as MR enterography (MRE) has the potential to impact three important aspects of patient care: diagnosis, management, and treatment monitoring (10, 12, 13). These studies have used a variety of imaging protocols. To facilitate the diagnostic value of MRE, a standard, optimized protocol should be used (12, 13). The goal of our study is to evaluate a carefully designed imaging protocol which a) takes advantage of all recent MRI developments including fast, high-resolution T1 and T2weighted sequences, b) uses a biphasic oral, hyperosmolar contrast agent for optimal and complete bowel distension, and c) uses intravenous glucagon to suppress bowel motion. For the purpose of the study, MRE findings were systematically analyzed and correlated with clinical findings. Material and methods Thirty one consecutive patients were included in this retrospective study. All patients were referred by the division of pediatric gastroenterology because of clinically suspected IBD. MR Enterography was requested to confirm the clinical diagnosis, to assess the exact extent of disease activity, to look for evidence of recurrence, to identify stenosis, and to exclude extra-intestinal complications. Two patients had multiple follow up studies. Each patient was seen by a pediatric gastroenterologist with special expertise in the diagnosis and management of IBD. For the purpose of the study, the electronic medical records were again systematically

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reviewed by a pediatric gastroenterologist (MOH). The gastroenterologist was asked to determine if the clinical data confirmed the final diagnosis of IBD; categorize disease as CD, UC, indeterminate colitis or functional symptoms, and differentiate between active and inactive disease. If the clinical data suggested active disease, patients were further subdivided for the degree of disease into mild, moderate or severe symptoms on the basis of a physician global assessment scale. The gastroenterologist was blinded for the MRI findings. MR Enterography took advantage of an optimized protocol incorporating all recent developments in MR imaging of the small and large bowel. The majority of studies were performed on a 1.5 Tesla (Avanto, Siemens Medical Systems, Erlangen, Germany) or a 3 Tesla MR scanner (Trio, Siemens Medical Systems, Erlangen, Germany). Two patients were examined on a 3 Tesla Philips MR unit (Phillips Medical Systems, Best, The Netherlands). All patients were examined with multichannel torso phase-array coils. Care was given to ensure that the entire abdomen was imaged reaching from the diaphragm to the lowest point of the pelvic floor. Patients were imaged in the prone position in order to have the majority of the small bowel loops as close as possible to the imaging coils, to increase separation of the small bowel loops and to move residual intraluminal air as far away as possible from the coils. In addition, the prone position typically reduces respiration related intra-abdominal organ motion. Optimal bowel distension was achieved by oral application of a biphasic (T1-hypointense, T2-hyper intense) hyper-osmolar contrast agent (VoLumen®). The hyperosmolarity enhances distension of the distal ileum. Patients were instructed to drink VoLumen 60 minutes prior to the MR Enterography examination (10 mL/kg of bodyweight). No rectal contrast was administered. Combinations of fast axial and coronal T1- and T2-weighted sequences were used to cover the entire gastrointestinal tract. Typically, fat saturated thin-sliced T2-weighted true fast imaging with steady-state precession (FISP) sequences (slice thickness: 3-4 mm; interslice gap: 10%; field-of-view (FOV): 420 x 340 – 280 x 250 mm; matrix: 448 x 364 – 320 x 280; TR range: 4.46-4.88 ms; TE: shortest) and 3D T1-weighted fast saturated unenhanced and contrast enhanced (gadolinium based

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intravenous contrast agents, 0.1 gradient-echo semmol/kg) quences (slice thickness: 2.5-3 mm; FOV: 420 x 340 – 280 x 250 mm; matrix: 448 x 364 – 256 x 202) were acquired. The FOV and matrix were adapted for each individual patient on the basis of the body size. Postprocessing included calculation of subtraction images based upon the matching pre- and post-contrast T1weighted sequences. In addition, glucagon was intra venously injected prior to the T1weighted sequences to suppress bowel motion. In children < 20 kg, 0.5 mg glucagon was injected intravenously; in children > 20 kg, 1 mg glucagon was injected. No parasympatholytic agent was administered to further decrease bowel motion. Contraindications for the use of glucagon included known hypersensitivity to the commercial preparation and known or suspected pheochromocytoma or insulinoma. Image analysis All MRE studies were systematically reviewed by two experienced pediatric radiologists in consensus. A standardized evaluation protocol was used for all readings. To facilitate systematical interpretation of images, the bowel was subdivided into the following segments: duodenum, jejunum, proximal ileum, terminal ileum, colon, rectum and anal canal. The terminal ileum was defined as the distal segment of ileum nearest to the ileocecal valve. Distinction among segments of the bowel was based on the readers’ visual assessment of their location, the folding pattern, and the estimated distances from the duodenojejunal junction and ileocecal valve. The overall diagnostic quality and presence of motion artifacts were assessed using a three point scale: 0: non diagnostic, extensive motion artifacts; 1: diagnostic, moderate motion artifacts; 2: highly diagnostic, no motion. The degree of distension of the different bowel segments were evaluated using a four-point qualitative scale: 0: poor distension; 1: mild distension; 2: moderate distension; 3: excellent distension. In addition, it was recorded if contrast was noted within the lumen of the studied bowel segments. Five “direct” imaging findings of IBD were studied for each bowel segment. They are as follows: Bowel wall thickening without obvious edema (wall thickness > 3 mm with

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matching T1 and T2-isointensity); bowel wall edema (wall thickness > 3 mm with matching T2-hyperintensity and T1-hypointensity); bowel wall hyperemia characterized by increased contrast enhancement; focal stricture/stenosis (lumen < 3 mm, simultaneously identified on two timely separated imaging planes); and pre-stenotic dilatation. Bowel wall inflammation was also studied for multifocality or presence of so called “skip lesions”. Each “direct” sign was assigned a score of 1, and if present in multiple segments was then multiplied by 2 in order to obtain a total direct score with a possible maximum of 10. In addition, four “indirect” signs of inflammation were studied: “comb sign” or mesenteric stranding; fibrofatty proliferation; mesenteric lymph nodes; and presence of abscess and/ or fistulae. The “comb sign” relates to an increased mesenteric vascularity as a result of bowel wall inflammation extending beyond the serosa of the bowel. Fibrofatty proliferation, also known as “creeping fat” refers to a fatty deposition along the mesenteric border of inflamed bowel segments, characterized by an increased amount of fat separating adjacent bowel loops. Mesenteric lymph nodes are considered to indicate inflammation if larger than 5 mm in diameter, especially if clustered and contrast enhancing. Finally, presence of intra-abdominal abscesses as well as entero-enteric, entero-colic, entero-cutaneous, entero-vesical or perianal fistulae was studied. Findings were graded as absent or present for each imaging sequences. Each “indirect” sign was assigned a score of 2, with a possible maximum score of 8. A total radiological score was obtained from the sum of the “direct” and “indirect” sign scores. The maximum total score theoretically achievable was 18. The radiological scores for each patient examination were then correlated with the clinical severity of disease activity to further define and determine the specificity of MRE in disease stratification. The clinical severity of disease activity was obtained on the basis of the physician global assessment scale. Statistical Analysis Agreement between clinical and radiological findings of disease, as well as agreement between clinical and radiological determination of involved bowel segments were calculated using the Kappa statistic.

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Table I. — Clinical data with distribution of patients and grading of disease.

Clinical diagnosis Crohn’s disease Ulcerative colitis Indeterminate colitis Functional symptoms

N (%)

Active disease

Mild

Moderate

Severe

Inactivity

24 3 1 3

24 3 1 0

4 1 0 0

15 2 1 0

5 0 0 1

0 0 0 2

Complete agreement corresponds to k = 1, and lack of agreement (i.e. purely random coincidences of rates) corresponds to k = 0. k < 0.20 correlates with a poor agreement; k <0.20 - 0.40>: fair agreement; k <0.40-0.60>: moderate agreement; k < 0.60-0.80>: good agreement; k <0.80 to 1.00>: very good agreement. A negative kappa value is a sign that the two observers agreed less than would be expected, just by chance and implies that there is no effective agreement. Pearson’s Chi square test was used to determine the association between radiological findings and the degree of disease. This study was approved by our Institutional Review Board. The study was compliant with the Health Insurance Portability and Accountability Act. Results 13 boys and 18 girls were included in the study, and their median age was 14 years, with a standard deviation of 4.01 years. The age range was between 1-18 years. In total 34 MRE studies were available for evaluation. Two patients with CD were examined multiple times. Twenty-five patients were imaged in the prone position. The other six patients had to be scanned in the supine position because of intolerance to being in the prone position for the duration of the study.

Of the 31 patients, the final clinical diagnosis was CD in 24 patients, UC in 3, indeterminate colitis in one and the remaining three were deemed to be negative for IBD. All patients with IBD, i.e., 28 of them (100%) presented with active disease based upon clinical presentation and findings during the time of the study. The three patients who were negative for IBD were most likely presenting with functional symptoms on the basis of a clinical diagnosis. Amongst the 24 CD patients, on the basis of the physician global assessment scale; four, had mild, 15 moderate and four with severe disease grading. Within the three UC patients, one was mild and the other two had moderate disease. One child of the functional group had severe disease and the other two children were clinically inactive. The distribution of patients amongst the groups and clinical grading of disease is summarized (Table I). Image analysis The overall diagnostic quality and presence of motion artifacts were assessed. 26/34 (76.5%) of the studies, the majority were graded as “highly diagnostic without motion artifacts”. In 7/34 (20.6%), they were “diagnostic with moderate motion artifacts” and “non-diagnostic with extensive motion artifacts” in 1/34 (2.9%).

Excellent distension of the duo denum was present in 29 (85.3%) studies, with contrast in the lumen seen in 32 (94.1%) of the studies (Table II). Distension of the jejunum was graded excellent in 29 (85.3%) studies, with contrast in the lumen in 33 (97%) of the studies. The ileum and terminal ileum showed excellent distension in 31 (91.2%) and 21 (61.8%) of studies, with contrast in the lumen in 32 (94.1%) and 31 (91.2%) respectively. The colon showed excellent distension in 17 (77.3%) of studies with contrast in the lumen in 11 (32.3%) of studies. The cecum and rectum showed excellent distension in 12 (44.4%) and 7 (36.8%) studies, with contrast in the lumen in 20 (58.8%) and 6 (17.6%) respectively. The direct and indirect imaging findings with visibility on the various pulse sequences were evaluated for the different inflamed bowel segments (Table III). Amongst the direct signs, bowel wall thickening was seen as the leading imaging finding (82.4%), followed closely by bowel wall edema (79.4%) and bowel wall hyperemia (79.4%). Bowel wall thickening was equally well visualized in T1 and T2 weighted images (82.4%) and closely followed by post contrast imaging (79.4%). Bowel wall edema as expected was best appreciated in the T2 weighted images (79.4%). Focal strictures were present in 20/34 (58.8%) examinations

Table II. — Degree of bowel distension with VoLumen. Bowel Segment

No distension N (%)

Mild distension N (%)

Moderate distension N (%)

Excellent distension N (%)

Duodenum Jejunum Ileum Terminal ileum Cecum Colon Rectum

2 (5.9%) 1 (2.9%) 2 (5.9%) 5 (14.7%) 6 (22.2%) 5 (22.7%) 10 (52.6%)

2 (5.9%) 0 (0%) 0 (0%) 1 (2.9%) 0 (0%) 0 (0%) 0 (0%)

1 (2.9%) 4 (11.8%) 1 (2.9%) 7 (20.6%) 9 (33.3%) 0 (0%) 2 (5.9%)

29 (85.3%) 29 (85.3%) 31 (91.2%) 21 (61.8%) 12 (44.4%) 17 (77.3%) 7 (36.8%)

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Table III. — Visibilty of direct and indirect imaging findings on various pulse sequences in the inflamed bowel segments. Total visibilty N (%)

T2-W visibility

T1-W visibility

T1-W Post Gad visibility

Direct imaging signs Bowel wall thickening

28/34 (82.4%)

Bowel wall edema

27/34 (79.4%)

28/34 (82.4%) 27/34 (79.4%)

Bowel wall hyperemia (contrast enhancement) Focal stricture

27/34 (79.4%)

N/A

27/34 (79.4%) 22/34 (64.7%) 27/34 (79.4%)

20/34 (58.8%)

Prestenotic dilatation

9/34 (26.5%)

20/34 (58.8%) 9/34 (26.5%)

Indirect imaging signs Comb sign Fibrofatty proliferation Mesenteric lymph nodes

21/34 (61.8%) 22/34 (64.7%) 27/34 (79.4%)

Abscesses and/or fistula

0/34 (0%)

and were nearly equally visible on all sequences. Of the “indirect imaging signs”, mesenteric lymph nodes are most frequently seen (79.4%) followed by the fibrofatty proliferation (64.7%) and the “comb sign” (61.8%). Also, all indirect imaging signs were nearly equally well visible amongst all the sequences. The ileum was predominantly involved as determined by imaging, with 22 of the 34 studies (64.7%), followed by the colon in 17 (50%) and the rectum with 5 (14.7%). Correlation between clinical and radiological findings Kappa values were separately calculated for each bowel segment to determine correlation. Involvement of ileum is seen in 64.7% of radiological examinations in contrast to 61.8% clinically. The k value of 0.557 for ileum shows moderate correlation (Table IV). The correlation

23/34 (67.6%) N/A

9/34 (26.5%)

for colon was fair with a k value of 0.294. Clinical evaluation for colon showed considerably higher positivity with 67.6% and only 50% with MRE. The upper GI tract and anal canal showed no correlation. The upper GI tract did not show any involvement on MRE, however was noted in 20.6% of the examinations to be positive clinically. The overall correlation between clinical and radiological findings for diagnosis of IBD showed good agreement (k = 0.61) for CD, moderate agreement for UC (k = 0.52) and again moderate in IBD (both UC and CD together) with a k value of 0.42. The various direct and indirect radiological findings were correlated with the clinical degree/ severity (mild, moderate and severe) of disease on the basis of the physician’s global assessment scale. A PearsonChi square test (Table V) shows significant association for most signs, except multiple segment and

19/34 (55.9%) 8/34 (23.5%) 20/34 (58.8%) 21/34 (61.8%) 26/34 (76.5%)

mesenteric stranding (comb sign) with a p value of 0.215 and 0.182 respectively. Table VI is a summary of the 31 examinations with specific mention of the radiological scores and the clinical disease severity grading. Also, mean values of the direct, indirect and total radiological scores were obtained for each degree of clinical disease severity. The mean total radiological scores for moderate and severe disease measured 10.2 and 11.9 respectively (Table VII) out of a possible maximum of 18. In the mild grade of disease, the mean total score was 1.75. Discussion IBD is a chronic disease with a relapsing and remitting course. In our study, we have evaluated the utilization of an optimized Pediatric MR Enterography protocol. MR Entero graphy as a technique has been

Table IV. — Bowel segment involvement with clinical and radiological findings and correlation. Clinical Ileum Colon Upper GI tract Anal canal

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Radiology Yes (n) 21 23 7 2

No (n) 13 11 27 32

% 61.8 67.6 20.6 5.9

Kappa Yes (n) 22 17 0 2

No (n) 12 17 34 32

% 64.7 50 0 5.9

0.557 0.294 0 -0.062

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escribed in the literature with referd ence to its ability in diagnosing IBD. However, to our knowledge, the feasibility and practicality of a welldesigned protocol has not been studied enough to consolidate the evidence base, in order to bolster confidence in daily practice. Our patient group, although a relative small number of 31; they were all initially evaluated by a pediatric gastroenterologist for suspicion of IBD. The patient group had comprehensive clinical assessments which included labs, endoscopy and appropriate ancillary tests. The gastroenterologists who were blinded to the MRI findings provided a clinical grading of disease severity on the basis of a

Table V. — Association between clinical degree of disease and presence of imaging signs. Imaging signs Direct Bowel wall thickening Bowel wall edema Bowel wall hyperemia Bowel stricture Multiple segment Indirect Lymphadenopathy Mesenteric stranding Fatty proliferation

Pearson Chi square X2

P value

20.62 14.54 11.73 9.57 5.79

< 0.001 0.006 0.019 0.048 0.215

17.01 6.24 10.12

0.002 0.182 0.038

Table VI. — Summary of radiological and clinical scoring. Patient

Clinical grading

Direct radiological score (Max=10)

Indirect radiological score (Max=8)

Total radiological score (Max=18)

IBD class and activity

1 2 3 4 5 6 7 8 9 10 11 12 13 14.1 14.2 14.3 15 16 17 18 19 20 21 22.1 22.2 23 24 25 26 27 28 29 30 31

Severe Moderate Inactive Mild Moderate Moderate Severe Inactive Severe Moderate Moderate Moderate Moderate Severe Severe Severe Moderate Moderate Moderate Mild Mild Moderate Mild Moderate Severe Moderate Moderate Moderate Moderate Moderate Moderate Severe Severe Moderate

3 4 0 0 6 2 4 0 6 0 8 4 3 8 8 6 4 8 8 3 0 8 0 8 8 8 8 6 6 6 2 4 8 8

6 4 0 0 6 2 6 0 2 0 6 6 2 6 6 4 6 2 6 4 0 4 0 6 6 6 6 6 6 6 4 6 6 2

9 8 0 0 12 4 10 0 8 0 14 10 5 14 14 14 10 10 14 7 0 12 0 14 14 14 14 12 12 12 6 10 14 10

CD/ active CD/ active Functional UC/ active CD/ active CD/ active CD/ active Functional Functional CD/ active CD/ active CD/ active CD/ active CD/ active CD/ active CD/ active CD/ active CD/ active CD/ active CD/ active CD/ active CD/ active CD/ active CD/ active CD/ active UC/ active CD/ active UC/ active IDC/ active CD/ active CD/ active CD/ active CD/ active CD/ active

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Table VII. — Correlation between mean radiological scores and clinical severity of disease. Clinical disease severity

Direct score – Mean value

Indirect score – Mean value

Total score – Mean value

Severe Moderate Mild

55/9 = 6.1 107/19 = 5.6 3/4 = 0.75

48/9 = 5.3 86/19 = 4.5 4/4 = 1

107/9 = 11.9 193/19 =10.1 7/4 = 1.75

physician global assessment scale; with a compendium of all clinical symptoms, signs and other supportive data. This comprehensive assessment proved invaluable in the correlation of our MRI findings. The vast majority (25/31) of the patients were scanned in the ideal prone position. In children, intolerance to the prone position is of particular concern. The benefits of the prone position; with enhanced separation of small bowel loops, displacing intraluminal air and decreasing respiratory motion was achieved in the vast majority, with 26/34 (76.5%) examinations being highly diagnostic without motion artifacts. Only one examination in our study group was non-diagnostic. Our patient age group had a median age of 14 years with 13 boys and 18 girls. Bowel distension with oral contrast is critical for a high-quality diagnostic examination because collapsed bowel can obscure lesions or create the false appearance of wall thickening (11). In addition, good distension typically suppresses bowel motion. Furthermore, endoluminal contrast material also reduces air in the bowel and consequently minimizes susceptibility artifacts. An ideal oral contrast agent should be absorbed minimally or not at all and should be evacuated completely. VoLumen (E-Z-EM Inc., New York, NY), a lowconcentration barium solution (0.1% weight/volume) that contains sorbitol is a hyperosmolar biphasic contrast agent that is minimally absorbed, attracts additional fluid into the bowel lumen and is consequently well suited for optimal distension of the bowel. Our 60 minute interval between start of drinking the contrast agent and imaging achieved excellent distension in 91.2% and 61.8%, in the ileum and terminal ileum respectively. Moderate distension was 20.6% in the terminal ileum. A previous study that used oral mannitol reached very good or excellent distension in 77.3% and 79.2% of respectively the ileum and terminal ileum (14). Putting our moderate and excellent distension

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groups together for correlation with the aforementioned study, our results for the terminal ileum would remarkably reach 82.4%. Crohn’s disease primarily affects the ileum, and hence benefits from the adequate distension of in particular this region of the ileum. Also, the avoidance of nasojejunal tube passage and bowel preparation was of benefit to our patients with no compromise of the diagnostic quality of the examination. The image quality was further enhanced by taking advantage of several other “imaging optimizing tricks”. An antiperistaltic drug was used to transiently reduce peristaltic motion artifacts in MR Enterography. Glucagon was the drug of choice in our study. 26/34 (76.4%) of our examinations were graded as “highly diagnostic without motion artifacts”. Moreover, fast sequences that are able to acquire T1- and T2-weighted images within a single breath-hold are essential requisites for high end MRI evaluation of the small bowel. Fat saturation causes an increase in contrast between bowel wall and the surrounding fat tissue. This enhances assessment of bowel wall inflammation and facilitates identification of the inflammatory changes in peritoneal fat tissue. True-FISP (true fast imaging with steady-state precession) is particularly useful in children, as breath holding is generally not required for satisfactory imaging. Our dedicated method of using direct and indirect imaging findings for the purpose of the study to correlate with clinical disease activity was based on extensive personal experience. This was crucial to obtain a valid dataset in an objective manner for further scrutiny. To our knowledge, there are few studies in the literature on MR imaging of the small bowel in the pediatric population (1519). Laghi et al. (15) correlated clinical disease activity with contrast enhancement and wall thickening on MRI, whereas, the Alexopoulou group (16) only used contrast enhancement. The clinical activity in our group of patients was deter-

mined by the physician global assessment scale. Our total and split radiological score was more comprehensive with 9 factors or entities studied. This in turn was used to obtain a comprehensive dataset for correlation of disease activity. Bowel wall thickening was the most frequent direct imaging finding seen in 82.4%. Bowel wall edema and bowel wall contrast enhancement were both seen in 79.4% of the examinations (Table III). Focal strictures were present in 20/34 (58.8%). Mesenteric lymphadenopathy was the most frequent indirect imaging finding present in 79.4% of the examinations. Fibrofatty proliferation with 64.7% and Comb sign with 61.8% closely followed suit. A Pearson Chi Square test was per formed to determine the association between the clinical severity of disease and the various imaging findings (Table V). Bowel wall thickening, bowel wall edema, bowel wall hyperemia and focal stricture, amongst the direct findings were statistically significant, with p values < 0.05. Mesenteric lymphadenopathy and fibrofatty proliferation were statistically significant amongst the indirect findings. Hence, we have shown that the systematic analysis of various direct and indirect imaging findings, specific for inflammation has a high yield in predicting disease activity or severity. Correlation between bowel segment involvement on the basis of the MRI and clinical findings showed moderate agreement for ileum (k = 0.557), the most significant area for concern in Crohn’s disease (Table V). However, the upper GI tract and anal canal showed virtually no agreement, which is a limitation, in spite of excellent distension with oral contrast. This could be partly attributable to the smaller patient group. On further scrutiny, there were seven patient examinations with clinical evidence of disease in the upper GI tract that were not picked up by MRE. Only one of the seven had isolated duodenal disease. The others had ileal or colonic

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disease in addition to the upper GI tract. Only fair agreement was noticed with regards to colonic disease (k = 0.2941) in our study group. The majority of our patient group had Crohn’s disease affecting the ileum (61.8%). A total radiological score was obtained by the sum of the direct and indirect scores for each patient examination as summarized in Table VI. A maximum total score possible was 18. Mean direct radiological scores of 6.1 and 5.6 for severe and moderate disease was noted. The total scores of 11.9 and 10.1 were present for severe and moderate disease respectively (Table VII). The mild disease group had considerably lower scores of 0.75 (direct) and 1.75 (total). Therefore, imaging findings were helpful in distinguishing between the mild disease group and the others. However, distinction between the moderate and severe clinical grading was not achieved. Our MR Enterography protocol has been put to the test to fulfill our goal of evaluating a robust, reproducible and child friendly examination. The prudent selection of appropriate pulse sequences, ideal patient preparation, adequate bowel distension and use of glucagon has been validated against clinical findings. Although a relative small group of patients, we have elucidated the methods for evaluation of disease activity. In contrast to earlier studies, the use of a comprehensive set of imaging findings for clinical correlation demonstrated the advantages and less favorable points. Distinction of the mild disease group from others was a unique finding. Also, this was further reiterated by the fact that most imaging findings, apart from mesenteric stranding and multifocality showed significant statistical association. The upper GI tract fared poorly in our relative small group of

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patients, perhaps an area to focus upon in the future. Imaging of the ileum, the cornerstone of Crohn’s disease remains a very strong point for MR Enterography. Conclusion The MR Enterography protocol that we have proposed is a robust, feasible, well-tolerated imaging technique in children permitting assessment of disease activity, particularly in the ileum, free of ionizing radiation. References 1. Hyams J.S.: Inflammatory bowel disease. Pediatr Rev, 2000, 21: 291-295. 2. Sawczenko A., Sandhu B.K., L ogan R.F., et al.: Prospective survey of childhood inflammatory bowel disease in the British Isles. Lancet, 2001, 357: 1093-1094. 3. Mann E.H.: Inflammatory bowel disease: imaging of the pediatric patient. Semin Roentgenol, 2008, 43: 29-38. 4. Brenner D.J.: Estimating cancer risks from pediatric CT: going from the qualitative to the quantitative. Pediatr Radiol, 2002; 32: 228-223; discussion 242-224. 5. Shenoy-Bhangle A., Nimkin K., Gee M.S.: Pediatric imaging: current and emerging techniques. J Postgrad Med, 2010, 56: 98-102. 6. Paolantonio P., Ferrari R., Vecchietti F., Cucchiara S., Laghi A.: Current status of MR imaging in the evaluation of IBD in a pediatric population of patients. Eur J Radiol, 2009, 69: 418-424. 7. Adamek H.E., Breer H., Karschkes T., Albert J., Riemann J.F.: Magnetic resonance imaging in gastroenterology: time to say good-bye to all that endoscopy? Endoscopy, 2000, 32: 406410. 8. Wong S.H., Wong V.W., Sung J.J.: Virtual colonoscopy-induced perforation in a patient with Crohn’s disease. World J Gastroenterol, 2007, 13: 978979. 9. Saibeni S., Rondonotti E., Lozzelli A., et al.: Imaging of the small bowel in Crohn’s disease: a review of old and

new techniques. World J Gastro enterol, 2007, 13: 3279-3287. 10. Zhu J., Xu J.R., Gong H.X., Zhou Y.: Updating magnetic resonance imaging of small bowel: imaging protocols and clinical indications. World J Gastro enterol, 2008, 14: 3403-3409. 11. Darge K., Anupindi S.A., Jaramillo D.: MR imaging of the bowel: pediatric applications. Magn Reson Imaging Clin N Am, 2008, 16: 467-478. 12. Leyendecker J.R., Bloomfeld R.S., DiSantis D.J., Waters G.S., Mott R., Bechtold R.E.: MR enterography in the management of patients with Crohn disease. Radiographics, 2009, 29: 1827-1846. 13. Korman U., Kurugoglu S., Ogut G.: Conventional enteroclysis with complementary MR enteroclysis: a combination of small bowel imaging. Abdominal imaging, 2005, 30: 564575. 14. Borthne A.S., Abdelnoor M., Rugtveit J., Perminow G., Reiseter T., Kløw N.E.: Bowel magnetic resonance imaging of pediatric patients with oral mannitol MRI compared to endoscopy and intestinal ultrasound. Eur Radiol, 2006, 16: 207-214. 15. Laghi A., Borrelli O., Paolantonio P., et al.: Contrast enhanced magnetic resonance imaging of the terminal ileum in children with Crohn’s disease. Gut, 2003, 52: 393-397. 16. Alexopoulou E., Roma E., Loggitsi D., et al.: Magnetic resonance imaging of the small bowel in children with idiopathic inflammatory bowel disease: evaluation of disease activity. Pediatr Radiol, 2009, 39: 791-797. 17. Magnano G., Granata C., Barabino A., et al.: Polyethylene glycol and contrast-enhanced MRI of Crohn’s disease in children: preliminary experience. Pediatr Radiol, 2003, 33: 385391. 18. Toma P., Granata C., Magnano G., Barabino A.: CT and MRI of paediatric Crohn disease. Pediatr Radiol, 2007, 37: 1083-1092. 19. Darbari A., Sena L., Argani P., Oliva-Hemker J.M., Thompson R., Cuffari C.: Gadolinium-enhanced magnetic resonance imaging: a useful radiological tool in diagnosing p ediatric IBD. Inflamm Bowel Dis, 2004, 10: 67-72.

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DEMOGRAPHIC CHANGES IN BRAIN CT AND MR IMAGING BETWEEN 1990 AND 2010 Th. Vancauwenberghe1, Ph. Demaerel1 Study objective: During the last decades, computed tomography and magnetic resonance imaging have revolutionized neuro-imaging. Nowadays these techniques are routinely used, but the extent and variation of use has been investigated poorly. Our purposes were to retrospectively determine the evolution in demographic variables and indications of cranial CT and MRI scanning in 1993, 2000 and 2009, at our hospital. Methods: We retrospectively studied medical and neurologic in- and outpatients, who underwent CT- or MR imaging of the head for several demographic and patient characteristics. Results: We observed a modest increase in mean age and a marked increase in total number of cranial CT examinations, MR confirmation studies and repeat examinations. Metastatic disease, head injury and headache were indications associated with more rapid growth in CT use than were others. Conclusion: Among the 5 patient and hospital factors considered (total number of examinations, age, indication, MR confirmation study and repeat examinations), all had a significant variation during the past 16 years. Strict regulations with compelling guidelines for the rational use of brain CT and MRI are inevitable in order to control expenditure and radiation exposure. Key-words: Brain, CT – Brain, MR - Epidemiology.

Radiological imaging was and still is a fast growing sector of health care industry. Neuro-imaging has experienced major and significant changes, this in almost exclusively high-cost imaging modalities like computed tomography (CT) and magnetic resonance (MR) imaging (1). Since these imaging modalities have proven themselves sensitive in appropriate applications, they have become essential tools in evaluating several neurological conditions (2). Despite these developments, use patterns of these procedures remain unknown. We determined in this study the extent of use and trends for CT and MR imaging in our hospital, as well as possible reasons for the changes, by comparing the use rates of neuroimaging procedures performed in 1993, 2000 and 2009. Materials and methods Study population Our study population consisted of medical and neurologic in- and outpatients, who underwent brain CT or MR imaging at our hospital, in order to maximize the generalization of our results. Data collection and processing Data were retrospectively collected from a database of all radiology examinations at our institution.

utomated classification of radioloA gy reports identified 2214 head computed tomographic and 1486 brain magnetic resonance imaging examinations, performed during a one-month period (October) in 1993, 2000 and 2009. Finalized radiology reports in our radiology information system (RIS) are archived by patient medical record number and examination accession number in the database (PACS System). Not all examinations that were performed during the study period were included. For example, patients undergoing CT-scanning more than once in the defined study period were excluded. After this exclusion for each year, a study cohort of 2159 cranial CT examinations remained. First, data were subcategorized according to age, into eleven age groups, each of ten years. Second, patients were classified according to clinical information and radiological questioning. Here we only used those patients who underwent cranial CT scanning during the first two weeks of October, supposing this would be a representative study population. Seizure was defined as a suspected or witnessed seizure. Bleeding was defined as control of known intracranial hemorrhage. Metastasis was defined as screening for this malignancy. Headache was defined as any head pain, whether diffuse or local. Head injury was defined as any trauma above

the clavicles, including contusions, abrasions, lacerations and deformities. Third, we determined repeat examination rate, which is defined as a CT examination performed in a patient, who did have a previous CT scan/MR scan for the same indication, in the period of 1 month before the actual study. This specific time interval was chosen in trying to exclude examinations performed for another episode of illness or for annual screening. Finally we considered patients who underwent additional MRI study of the head, within 20 days after the CT scan was performed. Results were subdivided into MRI studies at less than 48 hours, between 2 and 5 days, between 5 and 10 days, and between 10 and 20 days. These four time intervals were chosen to approximate various patient care episodes. Zero to forty-eight hours encompasses emergency department care and 20 days encompasses most hospital admissions. Methodology A MEDLINE search of English language publications was conducted for the period from January 1990 through February 2011 using the following medical subject heading (MeSH) search terms: tomography, x-ray computed, head, epidemiology and magnetic resonance imaging. These terms were searched in all fields of publication. Results

From: 1. Department of Radiology, K.U. Leuven, Leuven, Belgium. Address for correspondence: Dr Th. Vancauwenberghe, IJzerenmolenstraat 154 app. 74, B-3001 Heverlee, Belgium.

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During the last 16 years significant variation was found among most of

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Table I. — Absolute number of CT studies and previous cranial CT and MR examinations for the 9 most common cranial CT indications in 1993, 2000 and 2009. 1993

2000

2009

Indication

Total No. CT study MRI study Total No. CT study MRI Total No. CT study MRI study of CT before** before*** of CT before** study of CT before** before*** studies* studies* before*** studies*

Stroke

Post operative 35

Head injury

Headache

Bleeding

Mental deterioration

Dizziness

Seizure

Metastasis

Total:

188

246

363

102

*Absolute number of CT-examinations performed during the first two weeks of October. **Number of patients, with previous cranial CT study(-ies), performed in September. ***Number of patients, with previous cranial MRI study(-ies), performed in September.

the 5 patient and hospital factors considered in our study. Frequency From 1993 to 2009, the number of CT examinations increased from 491 to 1041, constituting a 2-fold increase. When compared to the 1993 data, the incidence rate in 2000 had increased by 41%. Indication The 10 most commonly asked radiological questions/clinical information associated with CT scanning were identified for each year, and listed in Table I. During the 16-year period studied, stroke was the most common indication. The absolute number of CT investigations increas ed substantially for all questions during the survey period. Still, metastatic disease (3.3 times more investigations), head injury (2.7 times higher) and headache (2.2 times higher) were indications associated with more rapid growth in CT use than were others. Repeat examinations Repeat examinations account for nearly 20% of total number of CT examinations in 1993, 12% in 2000 and 20% in 2009, representing a constant

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proportion (Table I). Patients with known intracranial hemorrhage and those who had undergone cranial surgery comprise the major group of commonly repeated examinations. Taken together, they account for more than 70%, 57% and 57% of the CT repeat examinations in 1993, 2000 and 2009 respectively. Age The mean age of the 2159 patients studied, increased from 45 years in 1993, to 53 years in 2000 (+ 20%) and 57 years in 2009 (+26%). As shown in Fig. 1, the number of patients undergoing cranial CT scanning varied by age. MR confirmation In October 1993, 280 cranial MR scans were performed in our hospital. In 2000 and 2009, the use rate of brain MR was 515 and 691 procedures respectively. This change represents a 247% increase in the use rate of MR neuro-imaging procedures in our study population in 2009 compared with 1993. From 1993 to 2009, the number of MR-confirmation studies increased from 13 to 82, constituting a 6.3-fold increase (Table II). Less than 10 percent of patients had confirmation with MR scanning of the head (3% in

1993, 7% in 2000 and 8% in 2009). Of these, stroke and seizure have been associated with the most MR- confirmation studies. Limitations Some limitations of the study need to be considered. A first limitation is that our study suffers from a lack of generalization, because it relies on data from a single institution. We could be under- or overestimating, as examinations performed outside our institution would not have been captured. Secondly, our retrospective data are influenced by nonmedical factors, i.e. governmental policy in limiting the total number of MRI units. Finally, we included no information on the diagnosis. Therefore, it was impossible to compare changes in use for different diagnostic groups. Discussion In the first years after the introduction of computed tomography (CT) in 1972, the technique was a scarce resource reserved for severely disabled patients. As CT scanners became more widely available, they were seen as an accurate method in diagnosing structural brain diseases. Even after the discovery of magnetic

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resonance imaging in the late 1980s, CT remained the investigation method for the diagnosis and management of many central nervous system diseases (2). Frequency

*Prevalence in absolute number of CT examinations for each age group. Fig. 1. — Distribution pattern of cranial CT examinations, according to patient’s age

Our study revealed a doubling in total number of cranial CT examinations, between 1993 and 2009. In Belgium, between 2000 and 2007, the number of CT examinations grew up to 51.44% (3). This increased CT utilization was expected. But surprising is the sustained high rate of this growth. The increase is influenced by population aging, upgrading imaging modalities, expanding knowledge throughout the medical community about the capabilities of CT in the study of neurologic disorders, the patient expectations, increasing availability of CT scanners, the national health care planning policies

Table II. — Time interval between CT examination and MR confirmation. Indication 1993

2000

2009

Total No. of CT -examinations

< 48h*

2-5d*

5-10d*

10-20d*

Stroke

Seizure

Postoperative control

Stroke

Seizure

Metastasis

Head injury

Postoperative control

Headache

Dizziness

Mental deterioration

Stroke

Seizure

Metastasis

Head injury

Postoperative control

Headache

Dizziness

Mental deterioration

Total: 13

Total: 47

Total: 82

*Number of examinations confirmed by MR scanning in the indicated period (h = hours/d = days).

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and also some physicians are still not willing to accept the risk of missing an abnormality (1) (4-5). Also the contribution of radiologist self referral has repeatedly come under scrutiny. Lee et al. were able to counter this hypothesis in their study published in 2007 (6). In contrast, limiting factors include caution regarding to radiation and interventions to improve evidence-based guideline adherence (7). This rapid increase is a measure of the increasing power of radiology in medical care, but even so a measure for the radiology workload, since the number of radiologists is not increasing at the same pace. Possible solutions can be found in technologic advances. The increasing use of CT has also become a subject of concern for national health authorities. In 2000, Belgian expenditures on CT and MR examinations were 122 million euro (this is 14% of the total expenditures on medical imaging). In 2009, these expenditures increased to 214 million euro, representing 19% of the total expenditures on medical imaging (3). Indication In our study, stroke was the indication most commonly associated with cranial CT scanning. Computed tomography still plays a central role in the evaluation of patients with acute cerebral ischemia. It is used to differentiate ischemic from hemorrhagic stroke and even may demonstrate evidence of early ischemic changes (8). According to our findings, head injury was commonly associated to the use of CT and remained essentially stable during the study period. Cranial CT scanning is considered to be the imaging modality of choice for the rapid and reliable diagnosis of traumatic head injuries (9). Several retrospective studies conclude that CT is indicated in all patients with minor head injury (10-11). Finally, headache was a frequently asked radiological question. A study by Frischberg et al. has shown that headache, is one of the most common complaints encountered by general practitioners and neurologists (12). Neuro-imaging is in most of cases not indicated (13). Still, in our study it was listed as one of the most frequently asked questions associated with CT scanning. Repeat examinations As expected, a modest percentage of patients had undergone previous neurologic imaging. Patients who

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had undergone cranial surgery comprise the major group of commonly repeated examinations. This reflects the reliance on cross-sectional imaging in surgery follow-up. Another reason performing repeat imaging is the economic pressure within the health care system. An American analysis of inpatient hospital costs demonstrated that, for every $100 spent on diagnostic imaging, hospitalization was reduced by about 6 hours (14). Age Our finding is that CT was and still is more frequently used in middle aged and elderly. This is similar to the findings of other authors (15-16). Still, we found a relatively high rate and alarming growth in CT use among children and adults, knowing that this age group is more vulnerable to harmful effects of radiation. We suggest further investigation to confirm this finding, as we do not have enough information to identify the causing mechanisms. MR-confirmation MR scanning is especially helpful for patients in whom the CT examination revealed an abnormality that cannot sufficiently be characterized. The complementary roles of CT and MRI offer a powerful tool for the diagnosis and management of benign and malignant conditions. According to our findings, MRI may have a greater role in the evaluation, as it becomes more widely available. MRI is superior to CT but the cost of MRI remains higher (17). Therefore it is important to avoid the simultaneous use of both techniques and to encourage the substitution of CT by MR imaging. In contrast with CT, the total number of MRI units in Belgium is restricted and determined by government. Besides accredited MRI units, a number of non-accredited units are operational in Belgium. These are not entitled to the reimbursement of MRI services, but need to be taken into account, in order to have a complete view on all operational units. Though, data on the non-accredited units is not easy to obtain, therefore estimates were made. In 2000 the number of accredited and estimated non-accredited MRI units in Belgium was 59, in 2008 the total number of MR units was 96. As there is no data available of 1993, the total number was estimated on 9 units (3, 18). Still, our study was not aimed at measuring under- or overuse of this imaging technique.

Conclusion In summary, we found substantial temporal changes in almost all of the patient and hospital factors from 1993 through 2009. There is a paucity of literature that discusses epidemiologic information about utilization of radiology services. Still they can elucidate future needs and help to ensure that necessary services are available for patients. These studies are not only important for radiologists in making financial decisions and evaluating their hospital practice, they are of great value for policy makers and health insurance parties as these techniques are quite expensive. A more rational use of brain CT and MRI examinations enforced by guidelines seems inevitable in the near future in order to control expenditures as well as radiation exposure to patients. References 1. Rao V.M., Parker L., Levin D.C., Sunshine J., Bushee G.: Use Trends and Geographic Variation in Neuroimaging: Nationwide Medicare Data for 1993 and 1998. AJNR, 2001, 22: 1643-1649. 2. Franz J.: Wippold II. Head and Neck Imaging: The Role of CT and MRI. J Magn Reson Imaging, 2007, 25: 453465. 3. Obyn C., Cleemput I., Léonard C., Closon J.-P.: Magnetische Resonantie Beeldvorming: kostenstudie. Health Technology Assesment (HTA). Brussel: Federaal Kenniscentrum voor de Gezondheidszorg (KCE): 2009. KCE reports 106A (D/2009/10.273/14). 4. Levin D.C., Rao V.M.: Turf wars in radiology: other causes of over utilization and what can be done about it. J Am Coll Radiol, 2004, 1: 317-321. 5. Larson D.B., Johnson L.W., Schnell B.M., Salisbury S.R., Forman H.P.: National trends in CT use in the emergency department: 1995-2007. Radiology, 2011, 258: 164173. 6. Lee S.I., Saokar A., Dreyer K.J., et al.: Radiologist Recommendation for Follow-up with the Same Imaging Modality Contribute Substantially to High-Cost Imaging Volume? Radiology, 2007, 242: 857-864. 7. Baker L.C., Atlas S.W., Afendulis C.C.: Expanded use of imaging technology and the challenge of measuring value. Health Aff (Millwood), 2008, 27: 14671478. 8. Lövblad K.O., Baird A.E.: Computed tomography in acute ischemic stroke. Neuroradiology, 2010, 52: 175-187. 9. Glauser J.: Head injury: which patients need imaging? Which test is best? Cleve Clin J Med, 2004, 71: 353357.

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10. Borg J., Holm L., Cassidy J.D., et al.: Diagnostic procedures in mild traumatic brain injury: results of the WHO Collaborating Centre Task Force on Mild Traumatic Brain Injury. J Rehabil Med, 2004, 43: 61-75. 11. Reinus W.R., Wippold F.J. II, Erickson K.K.: Practical selection criteria for noncontrast cranial computed tomography in patients with head trauma. Ann Emerg Med, 1993, 22: 1148-1155. 12. Silberstein S.D.: Practice parameter: Evidence-based guidelines for migraine headache (an evidence-based review). Neurology, 2000, 55: 754-762.

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13. Demaerel P., Boelaert I., Wilms G., Baert A.L.: The role of cranial computed tomography in the diagnostic work-up of headache. Headache, 1996, 36: 347-348. 14. Beinfeld M.T., Gazelle G.S.: Diagnostic imaging costs: are they driving up the costs of hospital care? Radiology, 2005, 235: 934-939. 15. Blackwell C.D., Gorelick M., Holmes J.F., Bandyopadhyay S., Kuppermann N.: Pediatric head trauma: changes in use of computed tomography in emergency departments in the United States over time. Ann Emerg Med, 2007, 49: 320-324.

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16. Mettler F.A. Jr., Huda W., Yoshizumi T.T., Mahesh M.: Effective doses in radiology and diagnostic nuclear medicine: a catalog. Radiology, 2008, 248: 254-263. 17. Demaerel P., Béatse E., Roels K., Thijs V.: Intermediate short-term outcomes after brain computed tomo graphy and magnetic resonance imaging in neurology outpatients. Med Decis Making, 2001, 21: 444450. 18. Obyn C., Cleemput I.: The capital cost and productivity of mri in a Belgian setting. JBR-BTR, 2010, 93: 92-96.

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INTRALOBULAR PULMONARY SEQUESTRATION E. Alizadeh, H. Suliman1 Key-word: Lung, abnormalities

Background: A 59-year-old non-smoking woman, with a history of gall stones, type 2 diabetes mellitus and hypertension, was referred to our hospital because of persistent coughing, night sweats, headaches and weight loss. Clinical examination revealed no abnormalities. The laboratory findings on admission were as follows: erythrocyte sedimentation rate was 39 mm/h, C-reactive protein level was 62 mg/mL and leukocyte count was 8.0 x 109/L. Bronchoscopic examination showed a normal bronchial tree.

1. Department of Radiology, Sint Lucas Andreas Hospital, Amsterdam, The Netherlands

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1A 1B

Fig. 2A 2B

2C 2D

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Based on the radiological findings, the diagnosis of pulmonary sequestration was made. Since, on CT scan the lesion was embedded in the lung tissue, sharing with it a common pleural investment, and had an abnormal vascular supply, the diagnosis was further refined to pulmonary sequestration of the ILS (intralobular) type.

< 20 years of age. In most cases, the lower lobes are involved, typically the left lobes (in 55-60%), always above the diaphragm. The sequestration is usually supplied by an artery arising from the thoracic aorta, whereas the venous drainage is typically performed by the pulmonary veins. In rare cases, ILS is associated with congenital malformations. There is no gender predominance in the occurrence of ILS. ELS is considered a congenital disease. It results from an accessory lung bud that in some cases maintains the original connection with the intestine, allowing communication between the sequestration and the gastrointestinal tract. Typically, it is a single, asymptomatic lesion, ovoid or pyramidal shaped and measuring from 3 to 6 cm. The diagnosis of ELS is usually a result of incidental findings on routine chest radiographs or at the occasion of laparotomy or thoracotomy. Traditionally, angiography was required for a definite diagnosis of pulmonary sequestration. R ecent advances in diagnostic accuracy of CT-angio graphy have resulted in the use of this imaging modality as a non-invasive alternative diagnostic method for pulmonary sequestration. In particular, 3-D CT provides accurate information on the aberrant vascular supply and can replace angiography. The treatment for pulmonary sequestration is surgery. The identification and control of the aberrant artery branch, above or below the diaphragm, are essential for preventing hemorrhage. Post operative results have been reported to be excellent.

Discussion

Bibliography

The term sequestration, which is derived from the Latin verb ‘sequestrare’, meaning “to set apart”, was first used by Pryce in 1946. Pulmonary sequestration is a development lung disease, defined as nonfunctioning pulmonary tissue lacking normal communication with the bronchial tree and supplied by a systemic artery. Two forms of sequestration are recognized: extralobar (ELS), which is separated from the lung tissue by a separate lining of pleura, and intralobar (ILS), which is embedded in the normal lung, sharing with it a common pleural investment. ILS accounts for about 75% of pulmonary sequestration findings. It is considered an acquired disease, with recurrent episodes of pulmonary infection affecting approximately 50% of the patients

1. Bolca N., Topal U., Bayram S.: Bronchopulmonary sequestration: radiologic findings. Eur J R adiol, 2004, 52: 185-191. 2. Garstin W.I., Potts S.R., Boston V.E.: Extra-lobar pulmonary sequestration. A report of three cases and a review of the literature with special reference to the embryogenesis. Z Kinderchir, 1985, 40: 104-105. 3. Hirai S., Hamanaka Y., Mitsui N., et al.: Surgical treatment of infected intralobar pulmonary sequestration: a collective review of patients older than 50 years reported in the literature. Ann Thorac Cardiovasc Surg, 2007, 13: 331-334. 4. O’Mara C.S., Baker R.R., Jeyasingham K.: Pulmonary sequestration. Surg Gynecol Obstet, 1978, 147: 609-616.

Work-up Conventional radiograph of the thorax (A: postero-anterior view, B: lateral view) shows a sharply circumscribed oval density of about 4 cm in diameter is visible in the posterior right lower lobe of the lung (arrows). Contrast-enhanced CT scan of the thorax (Fig. 2) (A: reformatted image in the coronal plane, B: reformatted image in the sagittal plane) shows a lesion located in the paravertebral and basal region of the right lung (arrows). A prominent vessel is seen within the lesion. On axial section (C), there are several vessels inside the lesion, of which the main one is originating from the aorta (arrow). None of the vessels seem to be compromised. Venous drainage is via the pulmonary vein. Furthermore, in the liver multiple well-circumscribed low density areas, matching cysts, are visible. On axial image, lung window setting (D), the lesion is embedded in the lung tissue, sharing with it a common pleural investment. Radiological diagnosis

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JBR–BTR, 2013, 96: 210-211.

perforation of the urinary bladder wall by Foley catheter Z. Bozgeyik, E. Kocakoc, S. Aglamıs, E. Ogur1 Key-word: Catheters and catheterization, complications

Background: A 45-year-old male patient was admitted to the urology department with hematuria. Patient was known with bladder cancer and refused surgery four years ago. Two years ago patient was admitted also with hematuria. Presence of an intravesical mass, with invasion of right ureter, right seminal vesicle, and infiltration of perivesical fat was diagnosed. Based on these findings the condition was considered as inoperable and the patient underwent four-cure chemotherapy. In addition, ten-day radiotherapy was given on the pelvic region one year ago. At the occasion of the most recent admission MRI was performed for further diagnostic work-up.

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1. Department of Radiology, Firat University, School of Medicine, Elazig, Turkey

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FOLEY CATHETER â&#x20AC;&#x201D; BOZGEYIK et al

Work-up MRI of the pelvis (Fig. 1) shows on sagittal T2weighted image (A) perforation on anterior-superior wall of the bladder. Foley catheter extends to outside of bladder lumen. There is also a focal subserosal fl uid collection around the tip of the Foley catheter. Gadolinium-enhanced axial T1-weighted image (B) demonstrates diffuse homogeneous enhancement, except for the perforation area and right anterior wall of the bladder (arrow). Perfusion weighted image (C) shows a perfusion defect at a ruptured segment of the bladder wall and decreased perfusion on right anterior bladder wall (arrow). Radiological diagnosis MRI images of the pelvis clearly demonstrate perforation of the urinary bladder wall by Foley catheter. Discussion Perforation of the urinary bladder is a lethal condition when early diagnosis is not made and subsequent treatment is not installed. An important cause of bladder perforation is spontaneous rupture. Fujikawa et al evaluated 143 patients with carcinoma of the cervix following radiation therapy, of which 6 patients out of them developed spontaneous rupture of urinary bladder. Therefore, one must consider the possibility of urinary bladder perforation after pelvic radiation therapy for gynecological and urological malignancies. It is presumed that radiation therapy induces structural weakness in all layers of the bladder, which may facilitate spontaneous perforation. Urinary bladder carcinoma may, however, spontaneously result in bladder rupture. A few cases are reported on Foley catheter induced bladder perforation. Most of these reports are related to incorrect positioning of the catheter.

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Bladder perforation related to Foley catheter positioning was reported due to balloon inflation in a bladder diverticulum. In the presented case, MRI clearly showed the level and extent of perforation by the Foley catheter with perivesical fluid collection. MRI may be used alternatively instead of cystography as a non-Â invasive method for demonstration of bladder perforation and associated perivesical fluid collection. In the presented case, it remained unclear certain whether the perforation was related to the placement of Foley catheter or occurred spontaneously. But the location of the tip of the catheter outside the bladder lumen at the site of the perforation may suggest perforation related to placement of the Foley catheter. Weakness of bladder wall due to radiotherapy may have contributed to this perforation. In conclusion the risk of bladder perforation should be considered in bladder cancer patients, especially if patient underwent radiotherapy. Catheter position should be monitored radiologically in these patients, since they are prone to perforation. MRI may be used as an alternative to detect bladder rupture in high-risk patients. Bibliography 1. Abadi S., Brook O.R., Solomonov E., et al.: Misleading positioning of a Foley catheter balloon. Br J Radiol, 2006, 79: 175-176. 2. Atalay A.C., Karaman M.I.: Spontaneous rupture of a bladder with invasive bladder carcinoma. Int Urol Nephrol, 1998, 30: 723-734. 3. Baseman A.G., Snodgrass W.T.: Repeat spontaneous bladder rupture following radiation therapy. J Urol, 2003, 170: 2417. 4. Fujikawa K., Yamamichi F., Nonomura M., et al.: Spontaneous rupture of the urinary bladder is not a rare complication of radiotherapy for cervical cancer: report of six cases. Gynecol Oncol, 1999, 73: 439-442.

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JBRâ&#x20AC;&#x201C;BTR, 2013, 96: 212-213.

BENIGN LIPOMA OF THE INFERIOR VENA CAVA M. Cabri-Wiltzer, E. Danse1 Key-word: Venae cavae

Background: A 72-year-old woman with personal history of metastatic renal adenocarcinoma, considered as under remission was referred for CT scan of thorax and abdomen.

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1. Department of Imaging, St Luc University Hospital, Avenue Hippocrate 10, 1200 Brussels, Belgium

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BENIGN LIPOMA OF THE INFERIOR VENA CAVA — CABRI-WILTZER et al

Work-up On contrast-enhanced CT scan of the thoracoabdominal junction (portal venous phase) (Fig. 1, A and B: adjacent axial sections) a fatty lesion (mean density value – 74 HU) surrounded by a ring of iodine contrast medium is observed at the supra hepatic portion of the inferior vena cava. The lesion appears to be intraluminal (arrow). On reformatted image in the coronal plane (C), the lesion has a plate-like shape. Continuity of the fatty lesion with the fat adjacent to the esophagus is observed (arrow). On MRI of the thoraco-abdominal junction, T2weighted image in the coronal plane. On this sequence the fatty tissue lesion close to the vena cava is confirmed. Radiological diagnosis Based on the CT findings, and after review of a previously performed MRI with fat specific sequences, the diagnosis of benign lipoma of the inferior vena cava was concluded. Comment Lipoma of the inferior vena cava (IVC) is a very rare anomaly, observed in less than 0.5% of abdominal CT scans in adults. It is a well delimited, round or oval fatty lesion, almost always smaller than 23 mm. In more than 90% of cases the lipoma develops in the medial wall of the IVC at the level or above the suprahepatic veins. The lipoma of the IVC is a benign and asymptomatic condition that does not require treatment or follow up. In the presented case the differential diagnosis includes (in descending order of frequency): “pseudolipoma”, lipoma of the IVC and an intravascular fatty lesion. A “pseudo-lipoma“ is due to an artifact resulting from the mix of iodine contrast with non-enhanced blood. A “true” lipoma of the IVC is nearly always secondary to fat accumulation close to the supra hepatic part of the IVC. During inspiration, an angle is created between the IVC and the crus of the diaphragm allowing a small amount of fat to move into a scalloping of the IVC. A partial volume artifact then creates the image of endovascular fat. Three factors have an influence on this phenomenon: the degree of vessel filling, the blood pressure and the depth of the Valsalva manoeuvre. Intravascular fatty lesions are even rarer than lipoma of the IVC and comprise: fatty component of a hepatocellular carcinoma, posttraumatic fat hernia through a

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suprahepatic vein, massive fat embolism, and fatty diseases of the vessel wall (such as hemangioma, angiosarcoma, leiomyosarcoma and leiomyoma). Knowledge of the clinical context is essential for a correct diagnosis: a lipoma is asymptomatic in contrast to a posttraumatic fat embolism, a hepatocellular carcinoma, a posttraumatic fat herniation through a suprahepatic vein or massive fat embolism. Lipoma of the vena cava is detected easily with CT or MRI. Ultrasonography has only a limited diagnostic value. The CT appearance is that of a fat nodule or an elongated fatty lesion, close to and/or extending into the IVC. Multiplanar reconstructions contribute in demonstrating the extent of the lipoma into the vessel and/or close to the distal and right part of the esophagus. The difference between lipoma and intravascular fatty lesion can be established with coronal reconstructions which show the continuity of the lipoma with the paravascular fat. A second proof for an extravascular lesion can be obtained with a later CT scan: due to the variability of the influencing factors creating the partial volume artifact, the lipoma will change or totally disappear. MRI by using fat specific sequences, allows to rule out an angiomatous or a solid tissue component of the lesion, and helps to confirm its benign origin. On ultrasonography the lesion may appear either slightly hypo- or hyperechoic relatively to the liver with reduction of the lumen of the vein. Color Doppler reveals a minor turbulent flow to stenosis with hemodynamic repercussions. However, due to the location of the lesion, the contribution of sonography is limited both for detection and characterization of the lesion. References 1. Hines J., Katz D.S., Goffner L.D., et al.: Fat collection related to the intrahepatic inferior vena cava on CT. AJR, 1999, 172: 409-411. 2. Miyake H., Suzuki K., Ueda S., et al.: Localized fat collection adjacent to the intrahepatic portion of the inferior vena cava: a normal variant on CT. AJR, 1992, 158: 423-425. 3. Raju N.L., Austin J.H.M.: Case 37: Juxtacaval fat collection – mimic of lipoma in the subdiaphragmatic inferior vena cava. Radiology, 2001, 220: 471-474. 4. Grassi R.J., Di Mizio R., Barberi A., et al.: Ultrasound and CT findings in lipoma of the inferior vena cava. BJR, 2002, 75: 69-71.

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JBRâ&#x20AC;&#x201C;BTR, 2013, 96: 214-215.

CONGENITAL HEMANGIOMA OF THE SKULL M. Coeman1, N. Baelde2, E. Matthys3, N. Herregods1, K. Verstraete1 Key-word: Angioma

Background: A newborn (male, 6 hour-old) was referred to the radiology department for imaging of a solid tumor-like nodular lesion on the vertex of the skull. The treating pediatrician wanted to exclude a (meningo)-encephalocele or other dysraphism-like lesions.

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Department of Radiology and Medical Imaging, 1. Ghent University Hospital, Belgium, 2. AZ Jan-Palfijn Ghent, Belgium, 3. Department of Pediatrics, AZ Jan-Palfijn Ghent, Belgium

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CONGENITAL HEMANGIOMA OF THE SKULL — COEMAN et al

Work-up At clinical presentation a solid raised red lesion is seen on the vertex of the skull (Fig. 1 A,B). On CT scan of the skull (Fig. 2, A: coronal reconstruction in bone window and B: sagittal reconstruction in bone window), no bone defects nor bony abnormalities are found. A cutaneous, sharply demarcated soft-tissue mass is seen. On ultrasonography (Fig. 3A) the cutaneous lesion measures 11 x 11 x 4 mm and has a lobulated surface without keratinisation of the skin. The findings were compatible with a cyst or mass. Dopplerultrasonography of the lesion (Fig. 3B) shows a vascularised lesion with fast flow, suggestive for hemangioma or arteriovenous malformation. MRI of the brain (Fig. 4, A: contrast-enhanced MPRAGE coronal image and B: contrast-enhanced MPRAGE sagittal image), after gadolinium administration, an intense enhancement of the lesion is seen. Communication with intracranial vessels is formed by small vessels in the diploë. On MRI, the lesion is mildly hyperintense on T2-WI with small intern flow voids. There are no signs of encephalocele. Radiological diagnosis Based on the clinical presentation and imaging findings, a rapidly involuting congenital hemangioma was suspected. Resolution of the lesion during the first weeks of life confirmed the diagnosis. Discussion While infantile hemangiomas are the most common soft-tissue tumors of childhood, congenital hemangiomas are much more rare. Unlike infantile hemangiomas, they are mature at birth and don’t have accelerated postnatal growth. Two major types of congenital hemangiomas have been described: rapidly involuting congenital hemangiomas (RICH) and the less common noninvoluting congenital hemangiomas (NICH). Both can appear as bossed plaques or tumors. Most common locations for RICH are the limb, head, or neck. Three variants of RICH have been described: (1) a lesion with a characteristic red-purple color, often with telangiectasias on its surface or at the periphery, (2) a flat infiltrative tumor with violaceous color, or (3) a raised grayish tumor with tiny telangiectasias surrounded by a pale halo. RICH may involute rapidly resulting in difficult to heal central fissuring and ulceration. In the nuchal area, RICH lesions may be seen on second-trimester ultrasonography and be suggestive for lymphatic malformation, encephalocele, or other forms of cranial dysraphism.

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RICH exhibit fast flow at ultrasonography and may show flow voids on MRI. Angiography of RICH shows large and irregular feeding arteries in a disorganized pattern with arterial aneurysms, arteriovenous shunts, and intravascular thrombi. Rapidly involuting congenital hemangioma lesions stain negative with GLUT1, a marker which is positive in infantile hemangiomas. In the majority, involution starts within the first weeks of life and is complete after 6 to 14 months of life. In a patient with typical clinical presentation and features on ultrasound or MRI, observation is usually the first line of treatment. Firm lesions that show no tendency to involute are difficult to differentiate, even after imaging, and require biopsy to exclude more serious tumors such as fibrosarcoma or rhabdomyosarcoma. Some cases of apparent RICH cease to involute, persisting with clinical characteristics identical to NICH. NICH are much less common and will never disappear or involute, they undergo proportional growth. NICH are more plaque-like with a pink or purple color and prominent overlying coarse telangiectasias. Doppler-ultrasonography shows fast flow, and magnetic resonance imaging shows hyperintensity on T2-weighted sequences with flow voids similar to infantile hemangioma. Arteriography shows arterial-like feeders and a tumorlike capillary blush with small arterial channels. Early venous draining is not seen, which differentiates these lesions from arteriovenous malformations or arteriovenous fistulas. NICH lesions stain also negative with GLUT1 and excision is the recommended treatment. Most hemangiomas are diagnosed clinically and require no imaging. Ultrasonography and contrastenhanced MRI are the modalities of choice for assessment of extension, relationship with adjacent structures and atypical features. Bibliography 1. Acebo E., Gardeazábal J., et al.: Congenital hemangioma: a report of evolution from rapidly involuting to noninvoluting congenital hemangioma with aberrant Mongolian spots. Pediatr Dermatol 2009; 2: 225-226. 2. Krol A., MacArthur C.: Congenital Hemangiomas. Rapidly involuting and noninvoluting congenital hemangiomas. Arch Facial Plast Surg. 2005; 7: 307-311. 3. Restrepo R., Palani R., et al.: Hemangiomas revisited: the useful, the unusual and the new. Part 1: overview and clinical and imaging characteristics. Pediatr Radiol, 2011, 41: 895-904. 4. Roncero M., Martinez de Salinas A., et al.: Rapid involuting congenital hemangioma. Clinical and Experimental Dermatology, 2009, 34: 937-938.

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JBRâ&#x20AC;&#x201C;BTR, 2013, 96: 216-217.

Goblet cell carcinoid tumor of the appendix B. De Keyzer, D. Crolla, P. Ă&#x2DC;vreeide, I. Crevits1 Key-word: Appendix, neoplasms

Background: A 70-year-old male patient presented at the emergency department with heavy abdominal pain and fever since one day. Physical examination revealed a supple abdomen, but heavy pain and rebound tenderness in the right fossa.

1A Fig. 1B

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

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GOBLET CELL CARCINOID TUMOR — DE KEYZER et al

Work-up Contrast-enhanced CT scan of the abdomen (Fig. 1, transverse image at the level of the cecum (A)) shows the presence of diffuse infiltration of the pericecal fatty tissue. The appendix is retrocecally located with thickened wall (arrow). The appendix has a maximal outer diameter of 1,5 cm. On reformatted image in the coronal plane (slice thickness of 22,5 mm) (B), the appendix is seen, surrounded by diffusely infiltrated fatty tissue. An appendicolith is observed at the base of the appendix (arrow). Radiological diagnosis The CT images are suggestive for acute appendicitis. An appendectomy was performed. Pathology showed a Goblet cell carcinoid tumor of the appendix. Reintervention with right hemicolectomy was performed. There was no further evidence of malignancy. Discussion The goblet cell carcinoid was first described in 1969, and almost exclusively seen in the appendix. Most patients present with signs and symptoms of acute appendicitis due to obstruction of the lumen of the appendix. The initial imaging manifestations may reflect inflammatory disease, caused by the tumor obstructing the base or a portion of the appendix. In these cases the tumor may not be readily evident at sonography or CT scan.

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Cross-sectional imaging will typically reflect the infiltrative nature of the tumor, with mild but diffuse mural thickening. At pathology, goblet cell carcinoid tumors are usually located near the tip of the appendix. Macroscopically, there is no well-defined mass in most of the cases. Areas of mural indurations or diffuse fibrous thickening of the appendix may provide clues to the tumor at surgery. Metastasis occurs in nearly 20% of the cases. The most common routes of metastatic spread are lymphatic and intraperitoneal invasion. Ovarian and peritoneal metastatic diseases are often diagnosed before lymph node enlargement is seen. Diagnosis of cecal involvement is important since with this involvement a more radical surgical approach Goblet cell carcinoid should be considered as a low-grade malignancy, so most patients undergo a right hemicolectomy, followed by adjuvant chemotherapy in some selected cases. Bibliography 1. Levy A.D., Sobin L.H.: Gastrointestinal Carcinoids: Imaging Features with Clinicopathologic Comparison. Radiographics, 2007, 27: 237-257. 2. Pahlavan P., Rani K.: Goblet cell carcinoid of the appendix. W J Surg Oncol, 2005, 3: 36. 3. Pickhardt P.J., Levy A.D., Rohrmann C.A. Jr., et al.: Primary neoplasms of the appendix: radiologic spectrum of disease with pathologic correlation. Radiographics, 2003, 23: 645-662. 4. Roy P., Chetty R.: Goblet cell carcinoid tumors of the appendix: an overview. World J Gastrointest Oncol, 2010, 15: 251-258.

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JBR–BTR, 2013, 96: 218-219.

BILATERAL BRANCHIAL CLEFT FISTULA F.I. De Korte1, R.R. van Rijn2 Key-word: Branchial cleft

Background: An 8-year-old boy was admitted to the pediatric department with two small lumps a few centimeters above the clavicles, medial from the mid-clavicular line, in a symmetrical arrangement (Fig. 1). Sometimes fluid was leaking out of the lump on the right side. During physical examination the lumps were suspected to be part of a branchial cleft abnormality. Medical history revealed microcephaly without a cause and bilateral hearing loss. The parents were consanguineous. Diagnostic tests for a genetic cause, in particular the branchio-oto-renal syndrome, were negative.

Fig. 1A 1B

1. Department of Radiology, Kennemer Gasthuis, Haarlem, The Netherlands, 2. Department of Radiology, Academic Medical Center, Amsterdam, The Netherlands

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BILATERAL BRANCHIAL CLEFT FISTULA — DE KORTE et al

Work-up On clinical photograph of the neck (not shown), two small lumps a few centimeters above the clavicles, medial from the mid-clavicular line, in a symmetrical arrangement are demonstrated. On X-ray fistulography during administration of contrast medium through the opening in the lump on the right side (Fig. 1) (A: posterior-anterior view, B: lateral view during the same procedure), contrast extends to the submandibular space. On MRI of the neck (Fig. 2) (A: axial T2-weighted image at the level of the thyroid), small, rounded hyperintense structure at the periphery or next to the anterior border of the right sternocleidomastoid muscle is seen (arrow). On axial T2-weighted image at the level of the submandibulary glands (B), the same hyperintense structure is seen dorsal to the right submandibular gland (arrow). On axial T2weighted image a the level of the oropharynx (C), a punctiform hyperintense structure is observed in the pharyngeal mucosa (arrow). This could correspond to the cranial opening of the tract ventral to the right middle pharyngeal constrictor muscle. Radiological diagnosis Based on physical examination and the typical radiological findings, a bilateral branchial cleft sinus/ fistula was diagnosed. The boy is scheduled for surgical excision. Discussion Branchial cleft abnormalities are cysts, sinuses or fistulas that arise because of incomplete obliteration of the branchial clefts. Cysts have no connection with surrounding tissue, while sinuses connect with skin, and fistulas connect with both skin and pharyngeal mucosa. Anomalies of the second branchial cleft are more common than anomalies from the first, third or fourth cleft.

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Branchial cleft abnormalities are congenital in origin. However, patients present at any age with complaints of swelling, painful when infected. Bilateral abnormalities are present in 2‑3%, and often familial, in particular in case of the branchiooto-renal syndrome. Conventional neck radiographs (fistulography) can be performed if there is a connection with the skin. Following injection of contrast in the opening, the extension and course of the tract can be visualized. On ultrasonography, especially second branchial cleft cysts are suitable for examination, due to their location anterior to the sternocleidomastoid muscle. They manifest as a sharply marginated, anechoic to hypoechoic, thin-walled lesion, with no Doppler signal in it. CT shows a low attenuation lesion or tract with a thin wall. On MRI it manifests as a low to intermediate signal intensity lesion on T1, high signal intensity on T2. In our hospital, MRI is the imaging method of choice for depicting the anatomic relationships in children. When infected, the wall of the cyst usually becomes thick and irregular, and may enhance after administration of contrast medium. Treatment of branchial cleft anomalies consists of complete surgical excision. Bibliography 1. Benson M.T., Dalen K., Mancuso A.A., et al.: Congenital anomalies of the branchial apparatus: embryology and pathologic anatomy. Radio Graphics, 1992, 12: 943-960. 2. Koeller K.K., Alamo L., Adair C.F., et al.: From the archives of the AFIP: congenital cystic masses of the neck: radiologic-pathologic correlation. Radio Graphics, 1999, 19: 121-146. 3. Lowe L.H., Stokes L.S., Johnson J.E., et al.: Swelling at the angle of the mandible: imaging of the pediatric parotid gland and periparotid region. RadioGraphics, 2001, 21: 1211-1227.

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JBR–BTR, 2013, 96: 220-221.

HEPAR LOBATUM CARCINOMATOSUM F.C. Deprez, E. Coche, B. Ghaye1 Key-word: Lung neoplasms, secondary

Background: A 59-year-old woman was admitted for rapid health degradation, with abdominal pain, icterus and ascites. She was known for a two years long-standing breast cancer aggravated progressively by multi-organ metastases. The patient was treated by hormonal therapy (Tamoxifen followed by Exemestane) and chemotherapy (5-Fluorouracil – Epirubucin – Cyclophosphamide then Cisplatine – 5-Fluorouracil).

Fig. 2A

1. Department of Radiology, Cliniques Universitaires St-Luc, Catholic University of Louvain, Brussels, Belgium

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HEPAR LOBATUM CARCINOMATOSUM — DEPREZ et al

Work-up Axial contrast-enhanced CT scan, section at the level of the liver (January 2011) (Fig. 1), showed a normal sized and smooth liver. Small metastases are already observed in the right hepatic lobe. No ascites or portal hypertension is present. Axial contrast-enhanced CT scan of upper abdomen (August 2011) (Fig. 2) shows on section at the level of the liver (A) a highly dysmorphic and heterogeneous liver with capsular retractions, lobulated pattern and multiples hypodense lesions, complicated by ascites. On section at mid-abdominal level (B), features of portal hypertension are demonstrated with ascites, enlarged mesenteric veins and congested wall of the right colon. Notice also the presence of multiple bone metastases. Radiological diagnosis Based on the radiological findings and the clinical history, the diagnosis of hepar lobatum carcinomatosum was made. Discussion Hepar lobatum carcinomatosum (HLC) is an cquired non-cirrhotic liver dysmorphy associated a with liver metastases of carcinoma, most often breast carcinoma. Hepar lobatum, characterized by a coarsely nodular lobulated liver parenchyma by deeply grooved scars, was first described in association with tertiary syphilis. Since 1924, this entity was occasionally reported in association with carcinomatous liver metastases and thus renamed hepar lobatum carcinomatosum. At pathology, diffuse metastatic involvement of the liver is observed in HLC, characterized by the presence of fibrous septa originating from the organ surface and running deep into the parenchyma. These septa contain scattered metastatic cells. HLC can be observed independently of neoplasic progression or apparent regression, and independently of chemotherapy of the metastatic carcinoma. On imaging, HLC must be suggested in case of rapid (months) dysmorphic transformation of a previously smooth and normal sized liver into a liver with capsular retractions and lobulated pattern, in the absence of etiologic factor for cirrhosis (hepatitis B or C, alcohol or drug consumption, hemochromatosis,...).

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Metastatic liver lesions can be observed or not. MRI demonstrates scarring and progressive fibrosis of the liver, demonstrated by late parenchymal enhancement after IV Gadolinium injection. The oncologic history is usually already known, but HLC can occasionally be the initial manifestation of an occult metastatic carcinoma. The physiopathology of HLC remains contro versial. First authors hypothesized a desmoplastic stromal response in reaction of metastatic cells invasion. Later, it has been proposed that HCL could be a certain form of healing and scarring after tumor regression, since several cases have been reported following chemotherapy. More recently, it has been suggested that vascular injuries could play a major role in HCL development: firstly, direct diffuse invasion and obstruction of intra-hepatic portal and/or hepatic venous branches has been reported in most of cases. This peripheral vascular invasion can be responsible for a congestive effect on liver, leading to its gradual shrinkage with t ypical venocentric distribution of fibrosis and development of portal hypertension. Secondly, chemotherapy could be an additional factor due to toxic vascular lesions. In summary, HLC could result from the combination between an important stromal reaction to carcinomatous cells associated to intrahepatic vascular tumoral obstruction, potentially aggravated by chemotherapy vascular toxicity. HLC has a poor prognosis, even in case of apparent tumoral regression after chemotherapy. Bibliography 1. Cervoni J.P., Dobrin A., Sailley N., et al.: Hepar lobatum carcinomatosum: A rare cause of portal hypertension complicating hepatic metastases in breast cancer. Gastroenterol Clin Biol, 2008, 32: 740-744. 2. Graber I., Dumortier J., Poncet G., et al.: Hepar lobatum carcinomatosum revealing an occult metastatic lobular carcinoma of the breast. Ann Diagn Pathol, 2010, 14: 438-442. 3. Honma K.: Hepar lobatum carcinomatosum due to metastatic breast carcinoma. Virchows Arch A Pathol Anat Histopathol, 1987, 410: 465-469. 4. Teke Z., Nessar G., Kiremitci S., et al.: Hepar lobatum carcinomatosum associated with metastatic rectal carcinoma: an unusual cause of liver dysmorphy. Med Princ Pract, 2011, 20: 93-96.

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JBRâ&#x20AC;&#x201C;BTR, 2013, 96: 222-223.

subacute intramural hematoma of the aorta P. Dewachter, F. Vandenbroucke, F. Van Tussenbroek, J. de Mey1 Key-word: Hemorrhage

Background: An 82-year-old male was admitted to the emergency department with nausea and severe peri-umbilical and lumbar pain. On physical examination the right peri-umbilical region and right iliac fossa were tender. There was an increased blood pressure of 232/91 mm Hg.

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Fig. 2B 2C

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1. Department of Radiology, UZ Brussel, Jette, Belgium.

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SUBACUTE INTRAMURAL HEMATOMA OF THE AORTA — DEWACHTER et al

Work-up On unenhanced CT scan at the level of the abdominal aorta (Fig. 1), hyperdense crescentic thickening along the aortic wall with inward displacement of calcifications is seen. The aortic wall was normal on CT scan of the lumbar spine 2 months prior (not shown). Contrast-enhanced CT scan (Fig. 2) shows on A (axial slice at the level of Fig. 1) typical crescentic density along the aortic wall. Curved MPR image along the aorta (B) confirms the hyperdense crescentic thickening along the aortic wall (arrow). On axial image at the level of the renal arteries (C), the ostium of the left renal artery is seen, but no enhancement is observed in the renal artery and kidney. MRI at the level of the abdominal aorta (Fig. 3) shows on A (axial T1-weighted image) hyperintense crescent along the aortic wall, and on B (axial T2weighted image) the crescent along the aortic wall has an intermediate density. Radiological diagnosis Based on the CT and MRI findings the diagnosis of a subacute intramural hematoma of the aorta was made. It is our hypothesis that the aortic intramural hematoma was due to hypertension secondary to an embolus in the left renal artery. Discussion Intramural hematoma (IMH) is a relatively rare but potentially fatal entity. Rupture of the vasa vasorum into the media of the aortic wall is the most cited mechanism. The evidence for this theory is thin. IMH cannot be clinically distinguished from aortic dissection. Arterial hypertension is the most frequent predisposing factor for IMH, followed by Marfan and Turner’s syndrome and is associated with blunt or iatrogenic trauma. In contrast to aortic dissection there is no intimal tear flap visible on imaging. IMH presents more commonly in the descending aorta (50-80%) and is more frequently found in the elderly. There is an equal male-to-female ratio. IMH can progress to aortic dissection, saccular or fusiform aneurysm or rupture. The clinical presentation is usually severe back pain. Since intramural hematomas are generally found more superficially (nearer to the adventitia),

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rupture is more common in IMH than in aortic dissection and occurs in up to 35% of the cases. Patients with uncomplicated IMH are generally treated like patients with uncomplicated aortic dissection in the same aortic location. The Stanford system, classifies dissections that involve the ascending aorta as type A, regardless of the site of the primary intimal tear, and all other dissections as type B. Patients with type A (40%) IMH should undergo immediate surgery and those with type B (60%) IMH may receive initial medical management. On unenhanced axial CT-images, a crescentic eccentric hyperattenuating region of thickening of the aortic wall is considered pathognomonic of acute intramural hematoma. Intimal calcifications may be displaced inward and are best seen on images with narrow window setting. On contrast-enhanced axial CT-images the intramural fluid collection appears as a circumferential or crescentic low density along the aortic wall. No intimal flap is seen. The absence of contrast enhancement within the aortic wall helps to differentiate IMH from classic aortic dissection, penetrating aortic ulcers and other aortic wall pathologies. On MRI, as on CT, IMH presents as a focal, crescent-shaped wall thickening with smooth luminal surface. The advantage of MRI over CT is the ability to discriminate between acute (< 7 days) and subacute (> 7 days) IMH. On gradient-echo T2-weighted images, an acute intramural hematoma is hyper intense, whereas a subacute or chronic intramural hematoma has an intermediate signal intensity on these sequences. On T1-weighted spin-echo images, an acute intramural hematoma appears isointense because of the presence of oxyhemoglobin; however, as the hematoma ages, it becomes hyperintense on T1-weigthed images, due to the formation of methemoglobin. Bibliography 1. Batra P., et al.: Pitfalls in the diagnosis of thoracic aortic dissection at CT angiography. Radiographics, 2000, 20: 309-320. 2. Chao C.P., et al.: Natural history and CT appearances of aortic intramural hematoma. Radiographics, 2009, 29: 791-804. 3. Maraj R., et al.: Meta-analysis of 143 reported cases of aortic intramural hematoma. Am J Cardiol, 2000, 86: 664-668. 4. Song J.K.: Diagnosis of aortic intramural haematoma. Heart, 2004, 90: 368-371.

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JBR–BTR, 2013, 96: 224-225.

PARATHYROID CARCINOMA A. Dilli1, S.S. Gultekin2, U.Y. Ayaz3, S. Ayaz4 Key-word: Parathyroid, neoplasms

Background: A 32-year-old woman with palpable neck mass and clinical presentation of hypercalcemic crisis and primary hyperparathyroidism was referred to radiology and nuclear medicine departments for imaging studies. The patient’s medical history didn’t reveal any findings related to neck irradiation, family history of parathyroid or calcium problems, nor any organ cancers. The laboratory tests showed severe hypercalcemia, a 7-fold increase in serum PTH concentration, high creatinine and normal phospate serum levels.

1A 1B 2

Fig. 3A 3B

Departments of 1. Radiology and 2. Nuclear Medicine Ministry of Health, Dıs¸kapı Yıldırım Beyazıt Training and Research Hospital, Ankara, Turkey, 3. Department of Radiology, Ministry of Health, Mersin Women’s and Children’s Hospital, Mersin, Turkey, 4. Department of Nuclear Medicine, Ministry of Health, Mersin State Hospital, Mersin, Turkey

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PARATHYROID CARCINOMA — DILLI et al

Work-up Ultrasonography and color Doppler ultrasono graphy of the neck (Fig. 1) shows a large (4.1 x 2.6 x 2.8 cm) hypo-echogenic solitary nodular lesion with slightly irregular borders localised in the right side of the neck is seen. On B, the mass shows increased peripheral blood flow. On double-phase parathyroid scintigraphy (Fig. 2) two hours after intravenous injection of 20 mCi 99mTc-sestamibi, a persistent sestamibi uptake in the lesion of the right thyroid lobe is observed. MRI of the neck area (Fig. 3, A: transverse T1weighted image and B: T2-weighted image) demonstrates a mass localised in the right lobe of the thyroid gland presenting with low intensity on T1weighted (A) and high-intensity on T2-weighted (B) images. On Gd-enhanced transverse T1-weighted axial image (C) , moderate heterogeneous enhancement of the lesion is seen. On coronal STIR sequence image (D) and axial diffusion-weighted image (E), the mass shows high-intensity signal on the STIR sequence coronal image (D) and diffusion weighted sequence axial image (E). Radiological diagnosis Based on clinical and multimodality imaging findings obtained with ultrasonography, parathyroid scintigraphy and MRI of the neck, diagnosis of parathyroid carcinoma was proposed. This diagnosis was confirmed histopathologically after surgical resection of the lesion. Discussion Parathyroid carcinoma is a rare endocrine tumor and represents less than 1% of all cases with hyperparathyroidism. The etiology of the disorder is unclear but a genetic predisposition (jaw tumor syndrome-germ line mutations in the gene CDC73) and a close relationship with some familial syndromes (familial isolated hyperparathyroidism, multiple endocrine neoplasia type 1 and type 2A) or irradiation of the neck have been reported. An increased risk of atypia and carcinoma is reported for large (median size: 3.3 cm) hyperfunctioning parathyroid glands. A palpable neck mass can be shown in 22% up to 76% of patients with parathyroid carcinoma. In most cases, the dominant clinical picture is severe hypercalcemia. Severe nephrolithiasis, nephrocalcinosis, impaired renal function and bone disease are frequently seen. Surgery is the primary treatment of choice of parathyroid carcinoma. Although preoperative definitive diagnosis of parathyroid carcinoma is not

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possible, preoperative and intraoperative decisions are very important to determine the extent of the surgical intervention and to achieve reasonable results. Long-term survival rates due to frozen section workup are not helpful. The various imaging methods provide valuable information and contribute to the patient management by detecting, showing exact location and extent of the tumor, and by disclosing recurrence or metastases of the disease during preoperative or postoperative periods. The same imaging modalities are used to show both benign parathyroid tumors and parathyroid carcinomas. A combination of 99mTc sestamibi parathyroid scintigraphy and high-resolution ultrasonography offers high sensitivity and specificity (85% to 95%) for detecting of parathyroid pathologies. The most common cause for false-positive results is the presence of concomitant nodular thyroid disease. Parathyroid scintigraphy is used to define the primary lesion and to detect sites of recurrent and metastatic disease in functional parathyroid cancer, but it does not allow differentiation between benign and malignant tumors. Ultrasonography may show signs such as marginal irregularity, direct extention into adjacent structures and lymph node involvement, which are suggestive for malignant behaviour, but not always not specific. CT scan and MRI have initially been popular to show localisation of the primary parathyroid carcinoma. Hovewer, they may be more useful for detection of persistent, recurrent or metastatic foci in a wide range of regional or distant locations, including neck, lungs, bone and liver. These methods provide valuable information based on detailed anatomic information and perfusion characteristics. Finally, positron emission tomography (PET) has successfully been utilized to detect recurrent and metastatic parathyroid carcinoma. Although hybrid imaging modalities seem to be helpful in the evaluation of the metastatic disease from parathyroid cancer, it has been noted that brown tumors may sometimes lead to an incorrect interpretation on PET scan. Bibliography 1. Fang S.H., Lal G.: Parathyroid cancer. Endocr Pract, 2011, 17: 36-43. 2. Hindié E., Ugur O., Fuster D., et al.: Parathyroid Task Group of the EANM. 2009 EANM parathyroid guidelines. Eur J Nucl Med Mol Imaging, 2009, 36: 1201-1216. 3. Palestro C.J., Tomas M.B., Tronco G.G.: Radio nuclide Imaging of the Parathyroid Glands. Semin Nucl Med, 2005, 35: 266-276. 4. Rodgers S.E., Perrier N.D.: Parathyroid carcinoma. Curr Opin Oncol, 2006, 18: 16-22.

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JBR–BTR, 2013, 96: 226-227.

Lyme neuroborreliosis M. Eyselbergs1,2, B. Tillemans3, P. Pals3, D. De Vuyst1, F.M. Vanhoenacker1,2,4 Key-word: Lyme disease

Background: A 24-year-old woman presented to the emergency department with headache, apathy, aphasia and mild paresis of the right leg. Routine laboratory results revealed slightly raised infectious parameters. CT scan of the brain was requested. Non-enhanced CT scan of the brain demonstrated a large low density lesion with irregular borders in the left thalamus. There was no enhancement of the lesion after iodine contrast administration (not shown). CT findings prompted immediate MRI.Repeated anamnesis revealed that the patient had been in contact with ticks three years previously. There was no recollection of skin manifestations such as erythema chronicum migrans at that time.

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Fig. 1C 1D

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1. Department of Radiology AZ Sint-Maarten, campus Rooienberg Duffel, Belgium, 2. Department of Radiology Antwerp University Hospital, Edegem, Belgium, 3. Department of Neurology, AZ Sint-Maarten, campus Zwartzustersvest, Mechelen, Belgium and 4. University of Ghent, Faculty of Medicine and Health Sciences, Belgium

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LYME NEUROBORRELIOSIS â&#x20AC;&#x201D; EYSELBERGS et al

Work-up On MRI of the brain on admission (Fig. 1), axial T1-weighted image (A), a slightly hypointense lesion compared to the white matter is seen within the left thalamus (double arrows). A second hypointense lesion in the splenium of the corpus callosum is also demonstrated (arrow). On axial FLAIR image (B), both lesions are hyperintense compared to the surrounding perilesional white matter.On Gd-enhanced axial T1-weighted image (C), none of the lesions show enhancement. On diffusion weighted image (DWI) (D) and corresponding apparent diffusion coefficient (ADC) map (E), the lesion within the splenic portion of the corpus callosum shows diffusion restriction (arrow) but the thalamic lesion does not. MRI of the brain, axial FLAIR image after treatment (Fig. 2), resolution of both thalamic and corpus callosum lesions is noted. Radiological diagnosis Because of the anamnestic finding of contact with ticks three years ago, analysis of serum and cerebrospinal fluid (CSF) was performed and revealed raised IgM and IgG Borrelia-antibodies. Subsequent enzyme linked immunosorbent assay (ELISA) and Western blot analysis were also positive. Based on the combination of clinical, laboratory and imaging findings, the diagnosis of Lyme neuroborreliosis was made and the patient was treated with intravenous antibiotics. Follow-up MRI six weeks later after antibiotic treatment showed complete resolution of the lesions (Fig. 2). Discussion Lyme borreliosis is an insidious multisystem inflammatory disease caused by the spirochete Borrelia garinii and Borrelia afzelli in Europe transmitted to humans through the bite of infected ticks. There are three different clinical stages which are classically described as early localized, early disseminated and late. In the early stage fever, myalgias, a petechial rash and neurological symptoms such as headache are the main features. The early disseminated stage comprises erythema chronicum migrans, arthralgias and adenopaÂthies. Arthritis, carditis, scleroderma-like lesions, central and peripheral nervous system abnormalities including

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cranial nerve palsies, white matter and spinal cord involvement are typical for the late stage. Typical CT findings of Lyme neuroborreliosis are small hypodense periventricular lesions. There is no or only faint enhancement after intravenous iodine administration. On MRI, these lesions are typically less than 3 mm, hypointense on T1-WI and hyperintense on T2-WI and FLAIR. T1-WI after intravenous gadolinium contrast administration variably shows faint enhancement of white matter lesions or the meninges. Third, fifth and seventh cranial nerve enhancement has been reported but the seventh cranial nerve is affected most frequently. Less frequent imaging characteristics are the presence of larger lesions, corpus callosum involvement and diffusion restriction of some lesions, as demonstrated in our case. The diffusion restriction in the corpus callosum lesions can be explained by the presence of intramyelinic and/or cytotoxic edema. Follow-up MRI is essential for therapy monitoring. If the correct treatment is implemented, resolution of the lesions on T2-WI, FLAIR and DWI can be demonstrated. The main differential diagnoses of intra-axial hyperintense lesions on T2-WI and FLAIR include a tumoral process, multiple sclerosis and neurosarcoidosis. A solitary peripheral enhancing white matter mass with central necrosis, mass effect and edema would be more typical for a tumor. Multiple sclerosis shows predilection of the lesions for the callososeptal region and enhancement after contrast administration in case of active inflammation. In neurosarcoidosis the lesions are typically located in the perivascular space and show more prominent enhancement. Excluding tumoral pathology is essential to avoid unnecessary biopsy procedures. The combination of initial and follow-up imaging studies, clinical data together with laboratory findings is essential and guides therapy. Bibliography 1. Agarwal R., Sze G.: Neuro-lyme disease: MR Imaging findings. Radiology, 1999, 253: 167-173. 2. Agosta F., Rocca M.A., Benedetti B., et al.: MRimaging assessement of brain and cervical cord damage in patients with neuroborreliosis. Am J Neuroradiol, 2006, 27: 892-894. 3. Singh P., Gogoi D., Vyas S., et al.: Transient splenial lesions: further experience with two cases. Indian J Radiol Imaging, 2010, 20: 254-257.

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JBR–BTR, 2013, 96: 228-229.

multifocal nodular steatosis T.A. Fassaert, E.R. Ranschaert, M.D.F. de Jong, I. Dubelaar1 Key-word: Liver, diseases

Background: A 62-year-old male with no medical history underwent an ultrasonography of the abdomen because of changed bowel habits and abdominal pain. CT-scan of the abdomen was performed, which initially suggested liver metastases. However, no primary tumor could be identified. Further work-up comprised optical colonoscopy which showed diverticulosis but no evidence of malignancy. Tumor markers were within normal limits. US-guided biopsy revealed normal liver parenchyma but the representativity of the biopsy was questioned. PET-CT scan was planned and a new biopsy was requested, but after interdisciplinary discussion it was decided to perform MRI of the liver first.

Fig.

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1. Department of Radiology, Jeroen Bosch Hospital, Postbus 90153, 5200 ME ‘s-Hertogenbosch, The Netherlands

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MULTIFOCAL NODULAR STEATOSIS — FASSAERT et al

Work-up Ultrasonography of the liver (Fig. 1) shows ultiple hyperechoic nodules throughout the liver m parenchyma, some surrounded by a subtle hypoechoic rim. Contrast-enhanced CT of the abdomen (70 seconds delay after IV injection) (Fig. 2) shows multiple hypodense nodular lesions in left and right liver lobe. MRI of the liver (Fig. 3) includes axial T1-weighted images, in-phase (A) and opposite phase (B). The liver lesions are hyperintense on in phase and hypointense on opposite phase images. Diffusion-MRI DWI images (Fig. 3), with B-values 10 (C) and 400 (D) show no diffusion restriction at the lesions. Dynamic MRI after Gd-EOB-DTPA, shows in the arterial phase (E) (portal phase and venous phase not shown) no abnormal enhancement is seen. In the liver specific phase (20 min after injection of contrast medium) the liver parenchyma enhances homogeneously (F). Radiological diagnosis Based on the MRI characteristics and in concordance with the US and CT-findings, the diagnosis of a multifocal nodular steatosis was established. Reassessment of the histology that was obtained earlier confirmed hepatic steatosis with a low-grade inflammatory component. At 1 year follow-up, MRI remained unchanged and clinically, the patient did not have any complaints. Discussion Multifocal nodular steatosis (MFNS) is a rare subtype of hepatic steatosis of unknown epidemiology and etiology. As with other types of steatosis, the accumulation of triglycerides within hepatocytes can be accompanied with a low grade inflammation. The fatty changes can remain or resolve. There is no difference in cellularity or vascularity compared to normal liver tissue. Steatotic nodules may vary in size from a few millimetres to several centimetres. As was shown in this case, unfamiliarity with this benign entity might result in unnecessary invasive workup and therefore in unwanted risks and anxiety for the patient. On ultrasonography, the typical findings of MFNS are homogeneous more or less sharply delineated hyperechoic foci, usually with some acoustic s hadowing. On CT, the lesions are round or oval with sharp margins, and are hypodense compared the surrounding liver parenchyma – typically between 2045 HU- but a large variety in density values is seen. Enhancement patterns follow the normal liver parenchyma. The abnormalities are considered

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pseudo-lesions, which therefore typically lack mass ffect. Frequently however, MFNS lesions are too e small to rely on this feature. While US and CT might fail to differentiate between this benign entity and malignancy, MRI of the liver is highly specific to obtain a correct diagnosis. Phase-shift sequences are very useful in depicting the presence of microscopic fat. On the in-phase images, lesions are iso- or hyper-intense relative to the surrounding tissue. On the opposite phase images, signal intensity drops in fat-containing lesions which therefore appear hypo-intense. Contrast-enhanced MRI using the liver-specific contrast agent Gd-EOB-DTPA, is reported to have a higher accuracy in the detection of liver metastases, especially for smaller lesions (< 1 cm). In case of MFNS, the liver enhances normally as with an extracellular chelate. In the liver specific phase (20 min after contrast injection) the liver enhances homogeneously because of contrast uptake in the hepatocytes, which are present in both normal parenchyma and steatotic nodules. This enhancement pattern renders malignancy unlikely. Diffusion-MRI techniques rely on the differences in the motility of water molecules. This is largely influenced by cellular density in tissues: most neoplasms have higher cellularity than liver parenchyma and thus a relatively higher amount of intracellular and lower amount of extracellular water molecules. Diffusion rates are ten times lower intracellularly. So, in comparison to normal liver tissue malignant lesions have restricted diffusion. Diffusion restriction results in high signal intensity with increasing B-values. Because cellularity is normal in MFNS, no restricted diffusion is shown. Diffusion-MRI has shown to be equally effective to contrast-MRI and PET-CT scan in detecting pathologic liver lesions > 20 mm lesions and superior in detecting lesions < 20 mm. Bibliography 1. Coenegrachts K., Geeter F. de, ter Beek L., et al.: Comparison of MRI (including SS SE-EPI and SPIOenhanced MRI) and FGD_PET/CT for the detection of colorectal liver metastases. Eur Radiol, 2009, 19: 370-379. 2. Hamer O.W., Aguirre D.A., Casola G., et al.: Fatty Liver: Imaging patterns and pitfalls. Radiographics, 2006, 26: 1637-1653. 3. Kroncke T.J., Taupitz M., Kivelitz D., et al.: Multifocal nodular fatty infiltration of the liver mimicking metastatic disease on CT: imaging findings and diagnosis using MR imaging. Eur Radiol, 2000, 10: 1095-1100. 4. Zech C.J., Herrmann K.A., Reiser M.F., et al.: MR Imaging in patients with suspected liver metastases: value of liver-specific contrast agent GdEOB-DTPA. Magn Reson Med Sci, 2007, 1: 43-52.

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OSTEOID OSTEOMA M. Keupers1, J. Vandevenne1,2, E. Gielen1, M. Horvath1,2, Y. Palmers1,2, M. Vandersteen2 Key-word: Osteoma

Background: A 12-year-old boy presented with complaints of intermittent left hip pain for over one and a half year. The pain was worse at night and was relieved by taking non-steroidal antiinflammatory drugs (NSAIDs), such as Aspegic. There was no history of previous trauma. Being a refugee, the patient was lost to follow-up. However, we managed to contact him and arranged a surgical treatment.

1. Department of Radiology, Ziekenhuizen Oost-Limburg, Genk, Belgium, 2. Department of Morphology, Hasselt University, Campus Diepenbeek, Diepenbeek, Belgium

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1 2A

Fig. 2B 3A

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19/08/13 10:34

OSTEOID OSTEOMA — KEUPERS et al

Work-up On conventional radiography of the left hip (AP view) (Fig. 1), cortical thickening and sclerosis near the lesser trochanter of the femur is observed. CT scan of the left femur (Fig. 2, A: axial section, B: Reformatted image in the coronal plane) demonstrates a round radiolucent focus within the sclerotic area. This focus was connected to the bony surface by hypodense grooves (arrow). MRI of the left hip was performed. Coronal proton density (PD) weighted-image with fat saturation (FS) (A) shows a round focus of intermediate signal intensity surrounded by hypo-intense sclerotic bony rim is seen. Diffuse bone marrow edema at the proximal femur is seen. Transverse Gadolinium-enhanced T1-weighted image (B) demonstrates contrast enhancement at the soft tissue surrounding the lesser trochanter. Pronounced enhancement is seen at a round focus, that is connected to an enhancing groove (arrow) traversing the hypointense sclerotic bone. MR angiography (C) shows a rapidly enhancing nodule in the arterial phase corresponding with the round focus (arrow). Radiological diagnosis Based on imaging findings the diagnosis of osteoid osteoma was made. The radiolucent contrastenhancing round focus represents the nidus of the osteoid osteoma. Note the vascular grooves traversing the sclerotic bone, representing the feeding arterioles of the nidus. Discussion Osteoid osteoma is a benign osteoblastic neoplasm composed of osteoid and woven bone that is most commonly located in the cortex of long bones. It occurs most frequently in young boys. Osteoid osteoma is a painful lesion and the pain gets worse at night. NSAIDs, such as Aspirin often give drastic relief of the pain and can be used for conservative treatment. Osteoid osteoma can be successfully treated with surgical excision or CT-guided percutaneous radiofrequency ablation. Radiographically, an osteoid osteoma classically appears as a sclerotic cortical thickening in the shaft of a long bone with usually a small radio lucent area within the center of the sclerosis. This radiolucent area is called the nidus of the osteoid osteoma and causes the pain. The nidus is often

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obscured on plain radiographs by the surrounding sclerosis. CT scan and MR angiography, however, can provide a more precise anatomic location of the nidus to the surgeon. On CT scan, the nidus of an osteoid osteoma appears as s a round hypolucent area surrounded by curvilinear hypolucent grooves that appear to radiate through the thickened sclerotic surrounding bone. These lucent grooves represent feeding arterioles that have become encased by the sclerotic bone reaction around the nidus. These vascular grooves on CT scan can help to distinguish osteoid osteomas from other bone neoplasms or inflammatory processes. Because the osteoid osteoma nidus is hypervascular, gadolinium-enhanced MRI can be used to differentiate osteoid osteoma from other bone lesions. On the T1-weighted images with fat saturation after intravenous gadolinium injection, a contrastenhancing nidus with enhancing grooves through hypointense sclerotic bone can be seen, representing the hypervascularity of the nidus. This was already demonstrated on digital subtraction angio graphy with arterial injection of contrast material for diagnosis and preoperative localisation of this benign tumor. MR angiography may equally well show the rapid enhancing nodule in the arterial phase corresponding with the nidus. The patient underwent surgery and the nidus of the osteoid osteoma was successfully curetted. H istopathological examination confirmed the diagnosis of an osteoid osteoma. The osteosclerosis often regresses after surgical removal of the osteoid osteoma. Bibliography 1. Liu P.T., Chivers F.S., Roberts C.C., et al.: Imaging of osteoid osteoma with dynamic gadoliniumenhanced MR imaging. Radiology, 2003, 227: 691-700. 2. Liu P.T., Kujak J.L., Roberts C.C., et al.: The vascular groove sign: A new CT finding associated with osteoid osteomas. AJR, 2011, 196: 168-173. 3. Kransdorf M.J., Stull M.A., Gilkey F.W., et al.: From the Archives of the AFIP Osteoid Osteoma. RadioGraphics, 1991, 11: 671-696. 4. Van Rompaey W., Vereycken H., De Schepper A.: Diagnosis of osteoid osteoma by digital subtraction angiography. Fortschr Röntgenstr, 1986, 145: 578-581.

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JBR–BTR, 2013, 96: 232-233.

SUPERIOR VENA CAVA SYNDROME CAUSED BY BEHCET’S DISEASE R. Kilicarslan1, G. Burakgazi2, S. Aglamis2, E. Kocakoc1 Key-word: Behçet disease

Background: A-36-year-old man presented with a six-year history of Behçet’s disease and superior vena cava (SVC) syndrome. He said his symptoms related with Behçet disease (recurrent genital and oral ulcers, joint tenderness) did start 20 years ago. He has dyspnea and generalized joint tenderness. Physical examination was normal except for generalized joint tenderness. Laboratory findings were unremarkable.

Fig.

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1. Department of Radiology Bezmialem Vakif University, Faculty of Medicine, Istanbul, Turkey and 2. Department of Radiology, Faculty of Medicine, Firat University, Elazig, Turkey

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BEHCET’S DISEASE — KILICARSLAN et al

Work-up On 3D-volume rendered MDCT angiography (Fig. 1), extensive superficial collateral blood vessels located at the chest wall and abdominal wall are demonstrated. On coronal maximum intensity projection (MIP) image of the thorax, obtained during the arterial phase after administration of contrast medium (Fig. 2), narrowing of superior vena cava without thrombus is noticed (arrow). There is no evidence for lymphadenopathy nor associated mediastinal mass. Radiological diagnosis Based on clinical history and imaging features, the diagnosis was superior vena cava syndrome caused by Behçet’s disease was made. Corticosteroids, cyclophosphamide and warfarin were given for treatment. After treatment, partial improvement of the symptoms of the syndrome has been observed. Discussion The superior vena cava (SVC) syndrome is a clinical presentation caused by obstruction of the SVC or its major tributaries by intraluminal occlusion or by extrinsic compression and/or invasion from malignant and benign diseases. As a result the venous return of the head, neck and upper extremities is critically diminished.

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The main causes of SVC syndrome are malignant intrathoracic tumors (such as bronchogenic carcinoma and lymphoma), iatrogenic factors (placement of central catheter, insertion of a pacemaker, etc.), and vasculitic syndromes such as Behçet’s disease. Behçet’s disease is multisystemic vasculitis of unknown etiology. Its diagnosis is based on clinical criteria. The disease is characterized by recurrent urogenital ulceration, cutaneous eruptions, ocular manifestations, arthritis and vasculitis. Although SVC thrombosis is a rare but well- recognized manifestation of Behçet’s disease, SVC syndrome due to vasculopathy, without evidence of thrombosis is very rare. In the presented case, the SVC syndrome developed without evidence of thrombosis. Behçet’s disease should be considered in the differential diagnosis of SVC syndrome. Bibliography 1. Kantarci M., Fil F., Bayraktutan U.: Superior vena cava syndrome in a child and venous collateral pathways: MDCT imaging. J Thorac Oncol, 2008, 3: 915-916. 2. de Paiva T.F. Jr, Ribeiro H.B., Campanholo C.B., et al.: Behçet’s disease associated with superior vena cava syndrome without thrombosis. Clin Rheumatol, 2007, 26: 804-806.

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JBR–BTR, 2013, 96: 234-235.

SPONTANEOUS SPLENIC RUPTURE IN INFECTIOUS MONONUCLEOSIS B. Koebrugge1, D. Geertsema1, M. de Jong2, G. Jager2, K. Bosscha1 Key-word: Mononucleosis, infectious

Background: Two cases are presented: A 16-year-old female (patient A), presented at the emergency department with a continuously stabbing abdominal pain in the upper left abdomen. Since 1 month, she suffered from a sore throat, fatigue and weight loss. Physical examination revealed a sick girl with clear conscious‑ ness and no paleness. Her heart rate was 100 beats per minute (bpm) and blood pressure was 110/60 mmHg. Blood analysis showed a decreased hemoglobin level of 5.3 mmol/L. Another, before healthy, 22-year-old female (patient B), presented at her family doctor, com‑ plaining of abdominal pain, fever and fatigue. At physical examination a clear conscious, pale, young women with a heart frequency of 110 bpm and a blood pressure of 90/49 mmHg was seen. Laboratory investigation showed a decreased hemoglobin level of 4.8 mmol/L.

Fig.

1A 1B 2 3A 3B

Departments of 1. Surgery and 2. Radiology, Jeroen Bosch Ziekenhuis, ’s‑Hertogenbosch, The Netherlands

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raised pressure, increases the risk of spleen rup‑ ture. On ultrasonography of the spleen in patient A The exact etiology of spontaneous splenic rup‑ (Fig. 1, A: on admission), an inhomogeneous and ture due to EBV infection remains unclear. Several irregular enlarged spleen with an obvious rupture hypotheses are described: vascular congestion and free fluid surrounding the spleen is seen. Fol‑ with acute increase of portal venous pressure (e.g. low-up examination (B) demonstrates a hematoma Valsalva), sudden compression of the enlarged surrounding the spleen, combined with a thin sub‑ spleen due to contraction of the diaphragm, ab‑ capsular hematoma. The spleen appears homoge‑ dominal wall trauma or another, small, unnoticed neous. The splenic rupture cannot be visualised. trauma. Ultrasonography of the spleen in patient B (Fig. 2) The treatment of a spontaneous splenic rupture shows an enlarged spleen, without signs of splenic is still subject to discussion. In the past, the stan‑ rupture nor subcapsular hematoma. Contrast- dard treatment was splenectomy. This resulted in a enhanced CT scan of the upper abdomen in patient life-long increased morbidity and mortality, caused B (Fig. 3, A: transverse section) visualizes the hema‑ by an increased risk of infections with encapsulated toma surrounding the enlarged spleen, with free bacteria such as Streptococcus pneumonia, Hae‑ intra-abdominal fluid in the Douglas pouch. The va‑ mophilus influenzae and Neisseria meningitidis. riety of densities in the hematoma and interruption For this reason all patients are vaccinated against of the splenic parenchyma indicate the occurrence these bacteria 2 weeks after splenectomy. Other of multiple splenic hemorrhages. On reformatted possible complications of splenectomy are pancre‑ image in the coronal plane (B), caudal splenic atitis, pneumonia and the risk of wound infections. capsule interruption is diagnosed. In recent literature, a number of case reports de‑ scribe spleen-conserving surgery or even a conser‑ vative approach. The authors recommend conser‑ Radiological diagnosis vative treatment in hemodynamically stable patients and monitoring of the patient at the inten‑ Upon serological examination Epstein-Barr virus sive care unit with strict bed rest and pain treat‑ (EBV) was detected in both patients. ment. If the patient becomes hemodynamically The images plus the serological evidence of EBV unstable, splenectomy is a legitimate option, infection led to the diagnosis of spontaneous splen although spleen-conserving surgery sometimes ic rupture as a complication of infectious mono remains possible. nucleosis. Work-up

Discussion An Epstein-Barr Virus (EBV) infection rarely causes a spontaneous splenic rupture, the inci‑ dence being 1‑2 per 1000 patients per year. If splen‑ ic rupture occurs, it usually occurs 4 to 21 days after the diagnosis of EBV infection. The majority of these spontaneous splenic ruptures affect males without previous trauma. EBV infection causes infiltration of the spleen with lymphocytes and atypical lymphoid cells that lead to change of the structure in the splenic paren‑ chyma. The invasion of these cells induces com‑ pression of the supporting splenic tissue and increases the pressure on the splenic capsule. The capsule becomes thinner, which, together with the

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Bibliography 1. Asgari M.M., Begos D.G.: Spontaneous splenic rupture in infectious mononucleosis: a review. Yale J Biol Med, 1997, 70: 175-182. 2. Gayer G., Zandman-Goddard G., et al.: Sponta‑ neous rupture of the spleen detected on CT as the initial manifestation of infectious mononucle‑ osis. Emergency Radiol, 2003, 10: 51-52. 3. Pasternack M.: Clinical features, management and prevention of sepsis in the splenectomized patient. Uptodate, 2008. 4. Stephenson J.T., Du Bois J.J.: Nonoperative management of spontaneous splenic rupture in infectious mononucleosis: A Case Report and Review of the Literature. Pediatrics, 2007, 120: 432-435.

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Bizarre parosteal osteochondromatous proliferations of the FINGERS S. Konijnendijk, A. Soepboer1 Key-word: Osteochondroma

Background: A 22-year-old patient with no medical history presented with a swollen index finger without previous trauma. Physical examination revealed a mildly tender swelling of the middle phalanx of the second digit.

1. Department of Radiology, Sint Elisabeth Ziekenhuis Tilburg, The Netherlands

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BIZARRE PAROSTEAL OSTEOCHONDROMATOUS PROLIFERATIONS — KONIJNENDIJK et al

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As this kind of lesion also was described by dr. Nora in 1983, it is hence sometimes called Nora’s Plain radiograph of the second digit of the right disease or Nora’s lesion. hand (Fig. 1) shows amorphous calcified lesion BPOP involves the small bones of the hand and with some cortical irregularity. There is also some feet in the majority of cases, especially at the level accompanying soft tissue swelling. of the phalanges. The location is most often meMRI of the right hand (index), images in the taphyseal. There is no evident sexual predilection. coronal plane (Fig. 2) shows on unenhanced T1The importance of recognizing BPOP lies in the weighted image (A) a fairly sharp defined lesion at fact that it constitutes in fact a benign entity with a the radial side of the second digit is seen. The le- high tendency of recurrence if excised. Immediate sion has a low signal intensity on this pulse se- excision is not required, neither has the lesion to be quence. Coronal fat-suppression STIR image (B) biopsied. Instead, a 6 months radiological followdemonstrates focal high signal intensity is observed, up will suffice, unless the natural course of the lesion especially in the center of the lesion, indicating a is not clear. Natural evolution of the lesion takes relatively high water content. C: on gadolinium- place within 6 months, in which the lesion comenhanced T1-weighted image, the lesion enhances pletely calcifies. moderately. BPOP often presents as a painless mass or swellCT image through the second digit (Fig. 3) includes ing without previous history of trauma. Radiologian axial slice through the middle phalanx of the cal hallmarks of the lesion are the relatively normal second digit (A) and a reformatted MPR-image in appearance of the underlying bone and the absence the coronal plane (B). Locally, discontinuity of the of contact between the lesion and the medullary cortex is observed. Fine trabecular bone can be bone. This distinguishes BPOP from osteochondroseen within the lesion. There is a thin surrounding ma, in which contact between the lesion and the cortical rim and a subtle periosteal reaction is medullary bone is always present. Differential diagnoticed. nosis includes both benign and malignant conditions: chondroma, parosteal osteosarcoma and, as previously noticed, parosteal osteochondroma. Radiological diagnosis Bibliography The combination of imaging findings is consistent with a Nora’s Lesion or bizarre parosteal osteo- 1. Dhondt E., Oudenhoven L., Khan S., et al.: Nora’s chondromatous proliferation (BPOP) lesion. lesion, a distinct radiological entity? Skeletal Radiol, 2006, 35: 497-502. 2. Gruber G., Giessauf C., Leithner A., et al.: Bizarre Discussion parosteal osteochondromatous proliferation (Nora’s lesion): a report of 3 cases and a review The above described properties of the lesion best of the literature. Can J Surg, 2008, 51: 486-489. match a bizarre parosteal osteochondromatous 3. Nora F.E., Dahlin D.C., Beabout J.W.: Bizarre parproliferation (BPOP). osteal osteochondromatous proliferations of the Although the lesion is known among patholohands and feet. Am J Surg Pathol, 1983, 7: 245gists, it is relatively unknown among radiologists. 250. Work-up

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Chondroblastoma of calcaneus J. Liu1,2, N. Xu2, Y. Sun1 Key-word: Chondroblastoma

Background: A 19-year-old male complaining of pain on left foot for one month presented to our hospital. Pain was insidious in onset and gradually progressive with difficulty in walking. He had aggressive pain for 5 days before enrolled in our hospital. On examination, the patient had tenderness on left foot in calcaneus region. Percussion tenderness was obvious.

1. Department of Radiology, the Second Hospital of Kunming Medical University, Kunming, P. R. China, 2. Department of Radiology, the Second Hospital of Jilin University, Changchun, P. R. China

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CHONDROBLASTOMA OF CALCANEUS — LIU et al

Work-up Radiological features are characteristic. X-Ray of left foot (Fig. 1A,B) shows round radiolucent area within left calcaneum bone, the lesion was more clearly depicted in lateral view than anteroposterior view, the lateral view showed the septum in the lesion and osteosclerosis. The density of the lesion was heterogenous. No fractures or dislocation of the calcaneum was seen. 256-slice multidetector computed tomography (Fig. 2 A,B) showed 4.1 cm x 6.1 cm x 4.3 cm cystic lesions on the left calcaneum. There was septum in the eccentric lesion with a thin cortical bone, and the margin of the lesion was smooth. The internal calcifications can be seen from the axial section. Both axial section and sagittal section showed the osteosclerosis within left calcaneus bone. The solid periosteal reaction was not seen in this case. The space between each bone appeared normal. Radiological diagnosis A radiological diagnosis of chondroblastoma was made and proved with pathologic examination. Histopathology showed proliferation of round cells with eccentric nuclei within eosinophilic cytoplasm and chondroid matrix proliferation with “chicken-wire or lace” calcification (Fig. 3). The differential diagnosis includes giant cell tumor. Compared with chondroblastoma, the radiographic features of giant cell tumor include no matrix calcification and no surrounding sclerosis. Discussion Chondroblastoma is rare benign cartilaginous tumor. It occurs in the epiphyses and secondary ossification centers of long bones most commonly in humerus, femur and tibia. Chondroblastoma represents less than 1% of all primary bone tumors. Chondroblastoma is rare in calcaneus bone of foot. Few cases showed aggressive soft tissue invasion, sarcomatous change or metastasis. Chondroblas-

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toma occurs predominantly in male than female in 3:2 ratios. The concept of this tumor as benign chondroblastoma was clearly established by Jaffe and Lichtenstein after they reported several cases in 1942. One study showed that benign calcaneal tumors are very rare in which only 12 cases are found during 12-year period (1.9% of bone tumors seen) without any case of chondroblastoma of calcaneus. Patients may present with insidious onset of pain in heel region, morning stiffness and limitation of motion at ankle. The site of location of tumor can effect on functionality of patient. Radiographic imaging shows chondroblastoma as centrally or eccentrically located osteolytic lesion which involves epiphysis or secondary ossification centers. Chondroblastoma is round or oval lesion which is radiolucent with well-defined margins on radiograph. Some calcified or bony fragments can be present. It has well defined margins and sclerotic border. CT scan shows mineralization of matrix with soft tissue extension and cortical erosion. On MRI, chondroblastoma shows low signal on T1 weighted images and high or variable signal on T2 weighted images which denote prominent cellular stroma of tumor. In treatment, curettage with usage of high speed burr and bone grafting can be done. Heavy irradiation with or without curettage is inadvisable in young patients due to possible damage of active epiphyseal tissue with later deformity. Bibliography 1. Jaffe H.L., Lichtenstein L.: Benign Chondroblastoma of Bone: A Reinterpretation of the So-Called Calcifying or Chondromatous Giant Cell Tumor. Am J Pathol, 1942, 18: 969-991. 2. Kurt A.M., Unni K.K., Sim F.H., McLeod R.A.: Chondroblastoma of bone. Hum Pathol, 1989, 20: 965-976. 3. Oommen A.T., Madhuri V., Walter N.M.: Benign tumors and tumor-like lesions of the calcaneum: A study of 12 cases. Indian J Cancer, 2009, 46: 234-236.

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avulsion fracture of the anterior inferior iliac spine C. Mai, A. Michel, B. Claikens, P. Van Wettere1 Key-word: Spine, fractures

Background: A 15-year-old boy complained of pain in the right groin after kicking against a heavy ball. He could still walk, but every time he put weight on his right leg he felt a stabbing pain in his groin area. The pain was very localised, he situated it just above the hip joint.

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

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ANTERIOR INFERIOR ILIAC SPINE — MAI et al

Work-up Conventional radiographs of the right hip (Fig. 1), AP-view (A) and lateral view (B) show an avulsed bony fragment in the region of the anterior inferior iliac spine. Ultrasonography of the groin region (Fig. 2) consists of a view of the right groin region (A) and a left groin region (shown for comparison) (B) on which no abnormalities are observed. On a sagittal view cranial to the hip joint, an additional hyperechoic structure with retro-acoustic shadow is seen adjacent to the anterior inferior iliac spine (arrow). Unenhanced CT scan of the pelvis (bone window setting) (Fig. 3) includes a transverse section (A), a reformatted image in the coronal plane (B) and a reformatted image of the right groin in the sagittal plane (C). These images show the inferiorly displaced avulsed fragment from the right anterior inferior iliac spine. Radiological diagnosis Based on conventional radiography and ultra sonography, the diagnosis of avulsion fracture of the anterior inferior iliac spine was made, which was confirmed after CT. Discussion In the literature several cases of anterior inferior iliac spine (AIIS) fractures have been reported. However, these fractures are much less common then avulsion fractures of the anterior superior iliac spine. Just like all avulsion fractures, fractures of the AIIS usually occur in either young people with unfused apophysis, either in older people with weak osteopenic bone. The injury is the result of one single violent contraction or repeated, chronic contractions. The AIIS is the origin of the straight head of the rectus femoris muscle. The rectus femoris is a bicarticular muscle, that plays a role in extension of the knee and flexion of the hip. It’s easy to understand that forceful hip extension with the knee in flexion is the cause of this type of avulsion fracture. The condition is therefore commonly seen in soccer players, hockey players, runners and h urdlers. Patients typically report a sudden severe pain during physical activity, followed by a loss of mus-

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cular function. Sometimes a “pop” or “snap” is heard. On physical examination, local swelling and tenderness can be observed. Sometimes the avulsed fragment can be palpated. Walking is still possible, but leaning upon the pathological side can evoke severe pain. Diagnosis is based on the typical clinical history and radiographic appearance. Radiography is mostly sufficient for diagnosis and shows a bone fragment at the anterior inferior iliac spine. The avulsion has to be differentiated from a ‘tug lesion’ (metaphyseal fibrous defect, cortical irregularity syndrome) which is a reactive fibrous reaction at the insertion of major muscles, is asymptomatic and shows no correlation with acute trauma. A tug lesion presents radiographically as a irregularity of AIIS with alternating radiolucent and sclerotic areas, on CT scan as cortical thinning and thickening with small cystic areas which are surrounded by sclerotic bone. CT is only needed when there is no clear traumatic event in the clinical history, in the case of subacute or chronic avulsion fractures, where posttraumatic bone changes can mimic osteomyelitis or even a neoplastic process, and to differentiate from an avulsion fracture of the anterior superior iliac spine. The latter can, if retracted inferior, simulate an avulsion fracture of the AIIS. MRI is useful to differentiate from injuries of the muscles, tendons and ligaments, but is mostly not necessary for diagnosis. Avulsion of the AIIS is treated with bed rest, with the hips and knees flexed, and analgesia in the acute stage, followed by progressive weight bearing. Recovery time is usually short and varies from 3 weeks to 4 months. Bibliography 1. Atalar H., Kayaoglu E., Yavuz O.Y., et al.: Avulsion fracture of the anterior inferior iliac spine. Ulus Travma Acil Cerrahi Derg, 2007, 13: 322325. 2. Stevens M., El-Khoury G., Kathol M., et al.: Imaging features of avulsion injuries. RadioGraphics, 1999, 19: 655-672. 3. Tehranzadeh J.: The spectrum of avulsion and avulsion-like injuries of the musculoskeletal system. RadioGraphics, 1987, 7: 945-974.

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aortic coarctation A.S. Michel1, C. Mai1, L.V. Flore2, B. Claikens1 Key-word: Aorta, stenosis or obstruction

Background: During elbow surgery on a 20-year-old competition level volleyball player, seriously elevated arterial pressures were found. Systolic pressures were as high as 200 mmHg and diastolic pressures as high as 120 mmHg. At clinical examination there was a discrepancy between these systolic pressures measured at the arteria brachialis and the palpation of the lower limbs: at the arteria femoralis and tibialis posterior only faint pulsations could be felt and the arteria dorsalis pedis could not be palpated at all. Electro- and echocardiographic examination withheld left chamber hypertrophy. Magnetic resonance angiography (MRA) was performed to evaluate the thoracic vessels.

C 1A 1B Fig. 1C 2

1. Department of Radiology, AZ Damiaan OostendeOostende, and 2. Department of Cardiology, University Hospitals Leuven, Leuven, Belgium

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AORTIC COARCTATION — MICHEL et al

Work-up MR Angiography (MRA) of the thoracic vessels (Fig. 1) consists of Multiplanar Reconstruction (MPR) MRA (A), three-dimensional MRA (B), and curved coronal MPR MRA (C). MRA shows a severe narrowing of the thoracic aorta just distal to the left subclavian artery. As a result, the descending aorta and its branches are perfused by collateral vessels from the axillary and internal thoracic arteries through the intercostal arteries. Chest radiography (Fig. 2) shows typical notching of the posterior third of ribs 6 till 8 due to impression by large collateral arteries and subtle indentation of the aortic wall at the site of coarctation, which produces a ‘3 sign’. Radiological diagnosis Based on clinical and imaging findings the diagnosis of aortic coarctation was made. Discussion Aortic coarctation is a narrowing of the thoracic aorta most commonly located immediately distal to the left subclavian artery. It is a common malformation accounting for 5 to 8% of all congenital heart disorders and it occurs 2 to 5 times more often in males than females. Its clinical manifestation varies in different age groups. In previously undiagnosed adults, as in our case, the classic presentation sign is hypertension, possibly leading to headache, epistaxis, heart failure and aortic dissection. Classic clinical findings are hypertension in upper extremities, diminished or delayed femoral pulses (brachialfemoral delay) and low arterial blood pressure in the lower extremities. The cardiac examination may be normal except for continuous murmurs from collateral vessels or systolic murmurs from coexisting defects. Electrocardiographic (ECG) abnormalities vary with age and severity of the coarctation. In older

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children and adults the ECG may show left ventricle hypertrophy. The diagnosis of coarctation is typically established with MR (or CT-) angiography or with TTE. MR-angiography clearly defines the location and severity of the coarctation as well as the collateral vessels. The presented case report shows that chest radiograph also can contain vital clues for the diagnosis. Timely diagnosis of the disorder is important. When untreated, mean survival is 35 years and mortality reaches 75% by the age of 46. Most frequent related causes of death are heart failure, aortic rupture and dissection, endocarditis and intracranial aneurysm with subsequent subarachnoidal or intracerebral hemorrhage. Reminding the latter, it is also strongly advised to perform MR of the brain at diagnostic work-up. Treatment depends upon the severity of the coarctation, the patient’s age and the clinical presentation. In adults the ACC/AHA recommend intervention when the peak-to-peak coarctation gradient is greater than or equal to 20 mmHg. In general, if the coarctation escapes early detection, repair should be performed at the time of actual diagnosis by surgery or balloon angioplasty and stenting. Bibliography 1. Brickner M.E., Hillis L.D., Lange R.A.: Congenital heart disease in adults. First of two parts. N Engl Med, 2000, 342: 256-263. 2. Connolly H.M., Huston J., Brown R.D., et al.: Intracranial aneurysms in patients with coarctation of the aorta: a prospective magnetic resonance angiographic study of 100 patients. Mayo Clin Proc, 2003, 78: 1491-1499. 3. Warner C.A., Williams R.G., Bashmore T.M., et al.: ACC/AHA 2008 guidelines for the management of adults with congenital heart disease: a report of the American College of Cardiology/ American Heart Association Task Force on practice guidelines. Circulation, 2008, 118: e714.

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gallstone ileus with a biliodigestive fistula L.J. Schijf1, D. Van der Vlies2, A.G. Aalbers3, A. Bruining4 Key-word: Gallbladder, calculi

Background: A 34-year-old woman with breast cancer, metastasized to bone and brain, was admitted to our hospital with abdominal discomfort, nausea and constipation. Physical examination revealed a diffuse tender abdomen without bowel sounds. On laboratory examination, slightly elevated gamma-GT levels were found; gastroscopy showed 2 liter of bilious fluid. A nasogastric tube was placed.

Fig.

1A 1B 1C 2

1. Department of Radiology, Academic Medical Center Amsterdam, Amsterdam, The Netherlands, 2. Department of Radiology, Gelre ziekenhuizen, Apeldoorn, The Netherlands, 3. Department of Surgery and 4. Department of Radiology, Nederlands Kanker Instituut – Antoni van Leeuwenhoek Ziekenhuis, Amsterdam, The Netherlands

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GALLSTONE ILEUS WITH A BILIODIGESTIVE FISTULA — SCHIJF et al

Work-up On contrast-enhanced CT scan of the abdomen (Fig. 1), reformatted image in the sagittal plane (A), some slightly dilated small bowel loops are visible, with multiple air-fluid levels (white arrowhead) and a duodenal tube (dark arrowhead). On reformatted image in the sagittal plane (B), a fistulous communication between gallbladder and duodenum (dark arrow) is visible, with the presence of gas in the gallbladder (white arrow). Obstruction at the level of the terminal ileum by a slightly calcified structure (dark arrowhead), consistent with ectopic gallstone. On axial images at different levels (C), the aerobilia (white arrow), bilio-digestive fistula (dark arrow) and obstructing gallstone (dark arrowhead) are demonstrated. Figure 2 shows the impacted stone after enterolithotomy. Radiological diagnosis Based on the CT findings, the diagnosis of gallstone ileus with a biliodigestive fistula was made. The patient underwent a laparoscopic enterolithotomy, a calcified gallstone measuring more than 3 cm was removed. Discussion Cholelithiasis is a common disease with a 10% prevalence in the United States and Western Europe. Gallstone ileus is an unusual complication of cholelithiasis, occurring in less than 0.5% of the patients. It is responsible for approximately 1-3% of all mechanical intestinal obstructions. Nevertheless, it is a quite important disease, especially in elderly patients, as the disease causes 25% of nonstrangulated small bowel obstructions in patients older than 65 years. The pathogenesis of gallstone ileus is based on acute or chronic cholecystitis associated with chole-

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lithiasis, spreading inflammation leading to adhesions with the alimentary tract and developing biliary-enteric fistula. Symptoms are commonly insidious at onset, with alternate phases of im provement and relapse, corresponding to the progression of the stone along the digestive tract. The diagnosis is often delayed since symptoms may be intermittent and investigations fail to identify the cause of the obstruction. The radiographic criteria for the diagnosis of gallstone ileus were first described in 1941 by the Rigler’s triad: pneumobilia, mechanical bowel obstruction and an ectopic gallstone. Plain abdominal radiographs remain the single most important diagnostic test, but less than 15% of gallstones are visible on these radiographs. Ultrasonography can reveal fistulas, impacted stones, and residual cholelithiasis. Abdominal CT scan, though, demonstrates the biliary status, the cause and degree of intestinal obstruction (frequently the complete Rigler’s triad) and often also the bilio-digestive fistula. Surgical enterolithotomy is the traditional treatment and this allows for relief of the obstruction in the short term. Whether treatment of existing fistula is necessary remains unclear. Bibliography 1. Abou-Saif A., Al-Kawas F.H.: Complications of gallstone disease: Mirizzi syndrome, cholecystocholedochal fistula, and gallstone ileus. Am J Gastroenterol, 2002, 97: 249-254. 2. Ayantunde A.A., Agrawal A.: Gallstone ileus: diagnosis and management. World J Surg, 2007, 31: 1292-1297. 3. Lassandro F., Gagliardi N., Scuderi M., et al.: Gallstone ileus analysis of radiological findings in 27 patients. Eur J Radiol, 2004, 50: 23. 4. Reisner R.M., Cohen J.R.: Gallstone ileus: a review of 1001 reported cases. Am Surg, 1994, 60: 441-446.

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POLYOSTOTIC FIBROUS DYSPLASIA B.J. Schouten, H.M. Suliman1 Key-word: Bones, fibrous dysplasia

Background: A 51-year-old male was referred to the hospital with pain on the right side of the thorax, without any apparent trauma. There was no medical history. He had a nonproductive cough and smoked 15 cigarettes a day. The patient did not have fever or weight loss and was not feeling ill. There was no history of asbestos contact. Laboratory results showed no signs of infection or liver disease.

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Department of Radiology, Sint-Lucas Andreas Hospital, Amsterdam, The Netherlands

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POLYOSTOTIC FIBROUS DYSPLASIA — SCHOUTEN et al

Work-up On chest radiography (PA-view) (Fig. 1), an enlarged, ground-glass aspect of the entire 4th right rib is seen, as well as peripheral wall thickening at the level of the right upper lobe. On contrast-enhanced CT scan of the thorax and upper abdomen (soft tissue window setting) (Fig. 2), an enlarged 4th right rib is seen (A), with peripheral zone of sclerosis and no internal matrix formation. There is a fracture of the lateral side of the 4th rib. There are similar findings in the 12th right rib on the dorsal side (B), with a fracture on the dorsal side. Large cortical kidney cysts are visible on the right side. A morphologically similar lytic lesion with a sclerotic edge is seen in the body of the 2nd lumbar vertebra (C). Radiological diagnosis Based on the image findings the diagnosis polyostotic fibrous dysplasia was made. The pain was most likely caused by the rib fractures. For a complete overview of the locations of the lesions, further imaging by means of a PET-CT is planned.

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nopathies manifesting as precocious puberty, hyperthyroidism or acromegaly. Patients with polyostotic FD often have renal phosphate wasting. The disease, however, has a wide clinical spectrum, so many patients are asymptomatic. Diagnosis relies on radiographs and pathology. There is no gender prevalence for FD. The monostotic form is more common and affects the 20‑ 30 years age group. Polyostotic FD has its onset mainly in children younger than 10 years of age. The lesions grow with the child, stabilize after puberty, and most commonly involve craniofacial bones, ribs, and metaphysis or diaphysis of the proximal femur or tibia. The occurrence ratio of polyostotic to monostotic FD is 3:7. Signs and symptoms of FD include bone pain, pathological fractures and bone deformities. Serum alkaline phosphatase is occasionally elevated, but calcium, parathyroid hormone, 25‑hydroxyvitamin D and 1,25-dihydroxyvitamin D levels are normal in most cases of FD. Persons with extensive poly ^ostotic FD may have hypophosphatemia, hyperphosphaturia and osteomalacy. Malignant transformation is rare and is usually precipitated by radiation therapy.

Discussion

Bibliography

Fibrous dysplasia (FD) is a sporadic benign skeletal disorder that can affect one bone (monostotic form) or multiple bones (polyostotic form). The latter may form part of the McCune-Albright syndrome (MAS) or of the Jaffe-Lichtenstein syndrome (JLS). JLS is characterized by polyostotic FD and café-au-lait pigmented skin lesions, while MAS has the additional features of hyperfunctional endocri-

1. Chapurlat R.D., Orcel P.: Fibrous dysplasia of bone and McCune-Albright syndrome. Best Pract Res Clin Rheumatol, 2008, 22: 55-69. 2. Feller L., Wood N.H., Khammissa R.A., et al.: The nature of fibrous dysplasia. Head Face Med, 2009, 4: 22. 3. http://rad.desk.nl/en/4bc9b15f76a78#p4bc9b4421 c3d1 (as seen on 13 january 2011).

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SMALL BOWEL DIVERTICULOSIS O. Soenen, J. Capoen1 Key-word: Intestines, diverticula

Background: A 60-year-old male patient presented with upper abdominal pain, which started as a epigastric cramp at night. He had no fever, nor changes in stool habits and he didn’t had to vomit. Physical examination of the abdomen revealed rebound tenderness in the left hypochondric region and left lumbar region. Laboratory results showed increased inflammatory parameters (leukocytosis 10200/μl and CRP 7,6 mg/l).

1. Department of Medical Imaging, AZ Jan Yperman, Ieper, Belgium

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SMALL BOWEL DIVERTICULOSIS — SOENEN et al

Work-up Dual energy CT scan of the abdomen was performed (Fig. 1) on admission. Coronal reformatted (A) and axial (B) image of the abdomen show a cyst-like, expansile mass in the left mesogastrium with enclosed air densities (black and white arrows). The lesion has a diameter of 4.7 cm. Diffuse thickened and enhancing wall of the lesion and infiltration of the surrounding fat tissue is noticed. Low dose CT scan was used during follow-up (Fig. 2). On coronal reformatted (A) and axial (B) images of the abdomen the cystic mass in the left mesogastrium is no longer observed after treatment (asterix). Conventional small bowel follow through was carried out to confirm the diagnosis (Fig. 3). At jejunal level (A,B), multiple diverticula of various size (big lesions: asterix, smaller ones: arrow) are diagnosed. Radiological diagnosis Based on the imaging findings the patient was diagnosed with colon diverticulosis, small bowel diverticulosis and diverticulitis. The patient was treated with antibiotics and, as shown, responded well to the treatment. Discussion Small bowel diverticulosis is a disorder with special characteristics as it usually remains silent. The site of protrusion is found at the entry points of the bowel vascular supply through the mesentery. This anatomical preference often makes them difficult to detect as they are located in the mesenteric leaves. Small intestinal diverticula are far less common than colonic diverticula: the prevalence of jejunoileal diverticula on autopsy ranges from 0.06% to 1.3%. Coexistent diverticula are found in the colon (20%-70%), duodenum (10%-40%), and esophagus and stomach (2%). The prevalence increases with age, peaking at the sixth and seventh decades.

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As stated above small intestinal diverticulosis usually remains silent until it presents itself with complications. Symptoms are vague and chronic abdominal pain of varying intensity, epigastric or periumbilical in location, with a bloating sensation after food intake. This may be one of the first symptoms. Acute complications include intestinal obstruction, bleeding, inflammation and perforation. In general the clinical presentation of small bowel diverticulitis is that of an acute abdomen. Upper gastrointestinal contrast series with small bowel follow-through examination and mainly enteroclysis are the two main diagnostic methods. In selected cases (mainly complicated jejuno-ileal diverticular disease (JID)), other diagnostic tech niques, such as ultrasonography, CT scan, endoscopy, intraoperative endoscopy, laparoscopy, radiotagged erythrocyte bleeding scans, and selective mesenteric arteriography are helpful. Laparotomy remains the gold standard for definite diagnosis of asymptomatic and complicated diverticula. Small bowel diverticula do not require surgical treatment unless refractory symptoms or compli cations occur. When complications occur, partial enterectomy and primary anastomosis should be performed. It is reasonable to conclude that asymptomatic diverticula incidentally discovered on routine contrast studies or at laparotomy do not need resection. Bibliography 1. Kassahun W.T., Fangmann J., Harms J., et al.: Complicated small-bowel diverticulosis: A case report and review of the literature. World J Gastroenterol, 2007, 13: 2240-2242. 2. Kumar M.J., Vallence K. Small intestinal diverticulosis (SID). The Internet Journal of Gastro enterology, 2005, 3: 2. 3. Makris K., Tsiotos G.G., Stafyla V., et al.: Small intestinal nonmeckelian diverticulosis. J Clin Gastroenterol, 2009, 43: 201-207. 4. Mantas D., Kykalos S., Patsouras D., et al.: Small intestine diverticula: Is there anything new? World J Gastrointest Surg, 2011, 27: 49-53.

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ROTATOR INTERVAL LESION M. Spaepe, A. De Schepper, M. Pouillon1 Key-word: Shoulder

Background: A 58-year-old male patient felt right anterior shoulder pain of sudden onset during work. The patient is a painter. The patient presented at the emergency department with persistent right shoulder pain. He mentioned a sensation of a ‘snap’ in the shoulder.

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1. Department of Radiology, GZA St. Augustinus Hospital, Antwerp, Belgium

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ROTATOR INTERVAL LESION — SPAEPE et al

Work-up Ultrasonography of the right and left shoulder (Fig. 1) shows normal left subscapularis tendon in comparison with an abnormal right subscapularis tendon. There is a luxation of the biceps tendon (arrows) out of the bicipital groove. Arthrography of the right shoulder with the arm in endorotation (Fig. 2) reports normal findings. Direct MR arthrography of the right shoulder after intra-articular injection of diluted gadolinium contrast medium (Fig. 3, A, B: Axial T1-weighted images with fat saturation) shows marked luxation of the biceps tendon (arrows) out of the bicipital groove. There is a partial subscapularis tendon rupture with the biceps tendon lying between the subscapularis tendon fibers. Coronal T1-weighted image with fat saturation (C) demonsrates partial rupture of the supraspinatus tendon at the articular side (arrow) with filling of the defect with contrast medium. Radiological diagnosis The imaging findings are diagnostic for rotator interval lesion (biceps-pulley lesion), type 5 according to the Bennett classification. Discussion The rotator interval (RI) is the portion of the shoulder joint reinforced by the coracohumeral ligament (CHL) and internally by the superior glenohumeral ligament (SGHL) and transversed by the intra-articular portion of the biceps tendon. The rotator interval is a triangular anatomic area defined superiorly by the anterior edge of the supraspinatus tendon and inferiorly by the superior edge of the subscapularis tendon. The base of this triangle is at the base of the coracoid process, and its apex is at the transverse ligament over the bicipital groove. The CHL and SGHL form a slinglike band surrounding the biceps brachii tendon proximal to the bicipital groove. The medial portion of the CHL, the SGHL and the superior fibers of the subscapularis tendon are believed to act as a pulley, which is critical in preventing the biceps tendon from subluxation or dislocation. Diagnosis of abnormality of the RI is often difficult because of its complex anatomy and the difficulty in visualizing the structures within it both on imaging studies and arthroscopy. Therefore it is called the «hidden lesion». Bennett was the first to classify biceps subluxation-instability in 2001 and has since modified his classification on the basis of subsequent experience with arthroscopic diagnosis and treatment.

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The classification summarizes the possible injury patterns of the RI: Type 1 lesions are isolated tears of superior fibers of subscapularis tendon, resulting in medial subluxation of the biceps tendon within the groove. Type 2 represents tear of the medial sheath (CHL–SGHL complex), allowing medial subluxation of biceps tendon. Type 3 represents lesions of both medial sheath and subscapularis tendon, allowing medial dislocation of biceps tendon from out of the bicipital groove. Type 4 involves tears CHL and most-anterior fibers of supraspinatus tendon, allowing biceps tendon to dislocate anteriorly to the subscapularis and coracohumeral ligament. Type 5 combines lesions of all structures (subscapularis tendon, medial sheath, CHL, and supraspinatus tendon), which allows the biceps tendon to dislocate either anteriorly or medially. The typical clinical presentation of a rotator interval lesion is persistent anterior shoulder pain. It can have an acute onset after trauma or a more chronic onset with underlying chronic anterior shoulder impingement. Imaging is mandatory for further differentiation and to exclude chronic shoulder disease or rotator cuff tears which need surgery. The first step in evaluating the rotator cuff is an ultrasound examination. Imaging the components of the rotator interval is challenging. The small size of the structures requires high spatial resolution imaging. The imaging modality of choice however is direct MR arthrography. Intraarticular contrast material separates the folds of tissue in the RI and allows better structure delineation. (Sub)luxation of the biceps tendon out of the bicipital groove is an important clue to the diagnosis since it will always be associated with a RI injury. Therapy of rotator interval lesions with biceps luxation is controversial and consists of biceps tenodesis or biceps tenotomy. Bibliography 1. Bennett W.F.: Correlation of the SLAP lesion with lesions of the medial sheath of the biceps tendon and intra-articular subscapularis tendon. Indian J Orthop, 2009, 43: 342-346. 2. Bennett W.F.: Subscapularis, medial and lateral head coracohumeral ligament insertion anatomy: arthroscopic appearance and incidence of “hidden” rotator interval lesions. Arthroscopy, 2001, 17: 173-180. 3. Petchprapa C.N.: The Rotator Interval: A review of anatomy, function, and normal and abnormal MRI Appearance. AJR, 2010, 195: 567-576.

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JBR–BTR, 2013, 96: 252-253.

intraosseous dissecting ganglion of the knee F. Van den Bergh1, R. Van Rattinghe2, K. Verstraete1 Key-word: Knee, cysts

Background: A 66-year-old man consulted the orthopedic surgeon for persisting pain in the right knee after moving flower pots one month previously. There was no history of trauma and clinical findings were consistent with meniscal problems. At the time of the examination there was no joint effusion and the knee was stable.

1A 1B

Fig. 2A 2B

1. Department of Radiology, UZ Gent, Ghent, 2. Department of Radiology, AZ Maria

2C 2D

Middelares, Ghent, Belgium

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INTRAOSSEOUS DISSECTING GANGLION — VAN DEN BERGH et al

Work-up On radiographies of the right knee (Fig. 1, A: AP and B: lateral views) two fairly visible osteolytic lesions in the proximal part of the tibial diaphysis are seen. These are unsharply delineated, located side by side, the largest lesion more distally. The knee joint is normal. MRI of the right (Fig. 2) knee consisted of sagittal T2-weighted STIR images (A-C). A shows an unsharply delineated,high-intensity lesion located posteromedially in the tibial plateau, suggestive of bone marrow edema. On B and C, a serpiginous, multilocular, high-intensity lesion extending from the posteromedial side of the tibial plateau up to the diaphysis. Remark the smaller hyperintense cysts along its course, ending in a large cyst in the tibial diaphysis. On the gadolinium-enhanced axial T1-weighted image (D), peripheral contrast enhancement is seen, proving the cystic nature of the lesion in the tibia. Radiological diagnosis The diagnosis of intraosseous dissecting ganglion was made. The serpiginous trajectory in the proximal tibia corresponds to synovial fluid creating multiple cysts that are filled with synovial fluid. Discussion Intraosseous ganglion cysts (IOGC) are quite common and often published as case reports in orthopedic, plastic surgical and radiological literature. Different names have been given since the first description of a ‘subchondral synovial cyst’ as a separate entity by Hicks in 1956. In 1966 Crabbe was the first to use the name ‘intraosseous ganglion’. The clinical features are aspecific. The most common presentation is pain, aggravated by activity. The lesions may remain asymptomatic for several years. Pathological fractures may occur. Most frequent sites for IOGCare long tubular bones (subchondral region, especially femoral head and tibia), the acetabulum and the carpal bones (especially the lunate). Most investigators regard IOGC as distinctive entities, other than posttraumatic or degenerative bone cysts. Histologically IOGC are identical with cutaneous myxoid cysts and soft tissue ganglion

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cysts, which consist of a capsule-like wall surrounding an acellular gelatinous fluid. Calcification, periosteal reaction or remodelling has not been described in IOGC. The pathogenesis remains uncertain. We believe that a meniscal tear might cause recurrent joint effusions. The abundant synovial fluid might then follow the line of the least resistance through a small cartilaginous fissure into the subchondral bone, or through a small cortical interruption of the joint (bare area). In the presented case the ‘entrance area’ of the cyst is visible in the proximal part of the tibia (Fig. 2a). More distally the smaller cysts fuse into a larger intraosseous ganglion. Radiologically the differential diagnosis includes simple bone cyst (should have sharp borders and a sclerous rim), giant cell tumor (should be located in the epiphysis) and fibrous dysplasia (the cystic form should have a groundglass appearance), multiple myeloma and metastasis. MRI shows multiple communicating lesions extending from the joint onwards, and branching in the epiphyseal and metaphyseal regions. The lesions have the same signal intensity as joint fluid on all sequences. Increasing window level and window width to very high values only showed remaining high signal intensity of both synovial fluid and the cystic content. This pleads for a synovial fluid filled structure and against a tumor. On T1weighted images there is low signal intensity, with peripheral rim enhancement following Gadolinium administration. Bibliography 1. McCarthy C.L., McNally E.G.: The MRI appearance of cystic lesions around the knee. Skeletal Radiol, 2004, 33: 187-209. 2. Pope T.L. Jr., Fechner R.E., Keats T.E.: Intra-osseous ganglion: report of four cases and review of the literature. Skeletal Radiol, 1989, 18: 185-187. 3. Resnick D., Kransdorf M.J.: Bone and joint imaging, Elsevier Saunders 2005, Philadelphia, Pennsylvania, section VII Degenerative Diseases, chapter 29 Degenerative Diseases of Extraspinal Locations, Radiographic-Pathologic Correlation, Cyst Formation p. 361-364. 4. Schajowicz F., Clavel Sainz M., Slullitel J.A.: Juxta-articular bone cysts (intra-osseous ganglia), a clinicopathological study of 88 cases. J Bone Joint Surg Br, 1979, 61: 107-116.

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lipoma arborescens A. Van Landeghem, B. Arys, C. Heyse, N. Peters, W. Huysse1 Key-word: Lipoma and lipomatosis

Background: A 34-year-old man presented with recurrent and intermittent painful hydrops of the knee. This has started 13 years ago, after he underwent a reconstruction of the anterior cruciate ligament (ACL) and a partial resection of the lateral meniscus. Clinical examination revealed marked swelling due to the hydrops.

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

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LIPOMA ARBORESCENS — VAN LANDEGHEM et al

Work-up On lateral radiograph of the knee (Fig. 1) hydrops of the suprapatellar recess and degenerative changes are seen. Orthopedic hardware is present in the lateral aspect of the distal femur and proximal tibia after extraarticular ACL repair. Notice the hypodense area cranial to the patella in the suprapatellar recess. MRI of the knee (Fig. 2), sagittal proton densityweighted image (A) confirm effusion in the knee joint. Numerous and large synovial proliferations with signal intensity equal to that of fat are observed. Chemical-shift artifacts are seen at the inferface of the proliferations with the effusion. Sagittal gradient echo image with water excitation (B) shows complete loss of signal at the proliferations. Radiological diagnosis Based on the MRI findings the diagnosis of lipoma arborescens was made. Discussion Lipoma arborescens is a rare intra-articular mass in which hypertrophic synovial villi are seen, that are distended by fat, due to infiltration of the subsynovial tissue by mature adipocytes. The lesion is of unknown origin, but is frequently associated with degenerative joint disease, diabetes mellitus, chronic rheumatoid arthritis or prior trauma. The condition is mainly found in adults, there is a male predominance.

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It occurs most frequently in the knee, particularly in the suprapatellar pouch. Patients usually report a long-standing, painless, slowly progressive swelling of the joint with recurrent effusions. The clinical course is typically marked by intermittent exacerbations. Radiographs typically show soft tissue swelling, rarely with radiolucent areas, joint fulness and frequently osteoarthritic changes. The diagnosis of lipoma arborescens can be suspected only when radio-lucent areas suggestive of fat are seen in a joint space. Sonography is useful for documenting the joint effusion as well as the villous nature of the mass. Precise diagnosis with MR imaging is possible, especially when T1-weighted and fat-suppressed sequences are used, since the villous proliferations in lipoma arborescens display fat signal intensity on all pulse sequences and a chemical shift-artifact at the interface with the effusion. Synovectomy is the definitive treatment. Bibliography 1. Murphey M.D., Carroll J.F., Flemming D.J., et al.: From the archives of the AFIP. Benign musculoskeletal lipomatous lesions. Radiographics, 2004, 24: 1433-1466. 2. Sheldon P.J., Forrester D.M., Learch T.J.: Imaging of intra-articular masses. Radiographics, 2005, 25: 105-119. 3. Vanhoenacker F.M., Marques M.C., Garcia H.: Lipomatous tumors. In: De Schepper A.M., Vanhoenacker F.M., Gielen J., Parizel P.M., eds. rd Imaging of soft tissue tumors. 3 ed. Berlin, Heidelberg, Springer, 2006, pp 227-261.

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JBRâ&#x20AC;&#x201C;BTR, 2013, 96: 256-257.

YOLK SAC TUMOR OF THE OVARY T. Van Thielen1, H. Degryse1, D. Coeman2 Key-word: Ovary, neoplasms

Background: A 10-year-old girl presented to the emergency department with acute abdominal pain in the right fossa. There was no known previous medical history. She had a fever up to 38,4Â°C without any complaints of nausea, vomiting or diarrhea. Clinical investigation showed a swelling of the lower abdomen, present since 4 months, a positive McBurney sign and muscular defence. Laboratory findings showed an elevated C-reactive protein of 11,4 mg/dL (normal value 0-0,5 mg/dL) and leukocytosis.

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Department of 1. Medical Imaging and 2. Gynecology, AZ Klina, Brasschaat, Brasschaat, Belgium

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YOLK SAC TUMOR — VAN THIELEN et al

Work-up Ultrasonography of the abdomen (Fig. 1) shows on A (sagittal section on the midline) a large mass with a cystic as well as a solid components. On color–Doppler image (B), increased vascularisation, especially on the edges of the lesion, is observed. On sagittal section through the lower part of the mass (C), a clear separation between the mass and the uterus is shown. Hence the mass is presumed to have on ovarian origin. Contrast-enhanced CT scan of the abdomen (Fig. 2, A: axial section, B: reformatted image in the coronal plane, C: reformatted image in the sagittal plane) demonstrates a complex ovarian mass with displacement of the uterus to the left fossa. The tumor is predominantly cystic but also contains a solid component, which shows contrast enhancement in the solid tumor component. In between the cysts are large vessels visible (best seen on the axial section (A)). Radiological diagnosis Based on the imaging findings, the diagnosis of yolk sac tumor of the ovary was suggested. This diagnosis was confirmed by histopathological examination following surgery. Discussion The yolk sac tumor (YST), also known as an endodermal sinus tumor is a rare malignant germ cell tumor. Tumors from germ cell origin represent 1520% of all ovarian masses, and are malignant in less than 5% of the cases. A YST is the second most common malignant germ cell tumor and counts for only 1% of the malignant ovarian masses. YST mostly occur in the 2nd and 3rd decades of life and are only rarely seen in patients over 40 years of age. In about 50% the tumor is limited to one ovary, stage II shows pelvic spread (10%) and in 40% of cases metastases are present. In most cases there are no clinical symptoms. Abdominal swelling may be present in case of rapid growth and can be very pronounced at the time of diagnosis. If complications, such as hydronephrosis or ovarian torsion are present, more acute symptoms can occur as seen in the presented case. The imaging findings of YST may vary between entirely solid to a predominantly cystic mass. There are also reports of a mixed type tumor with solid as well as cystic components. The cystic components of this tumor are often due to necrosis or cystic degeneration. This composition determines the ultrasonographic appearance, in the presented case due to the mixed composition, as a large ovarian mass with solid as well as cystic components. The solid components are often seen in the periphery of the mass. As an endodermal sinus tumor is highly vascularized color Doppler flow can show many small

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arterioles with a low RI value. The cystic components of the tumor have the same echogenicity as the urine in the urinary bladder. Contrast-enhanced CT examination shows a large mass with well-enhancing solid components and also a cystic or necrotic portion. Large vessels are present in almost all cases of a yolk sac tumor. This phenomenon is described as the ‘bright dot sign’. Because large areas of hemorrhage and necrosis are common findings in yolk sac tumors and by its high capability in demonstration of hemorrhage, MRI might be useful in the diagnosis. T1-weighted images may show several high intensity spots within the solid portion indicating small hemorrhages. As these hemorrhages can be subtle, they can be missed on ultrasonography. Microscopic studies reveal stromal edema, which might explain the high signal intensity on T2-weighted images and the prominent enhancement after administration of Gadolinium. A third finding on MR-images may be the presence of signal voids as the tumor has a rich vascular supply. Microscopic examination of a YST reveal multiple patterns, with a predominance of reticular honeycombed structure of communicating spaces lined by primitive cells. Shiller-Duval bodies, resembling the endodermal sinus of rodent placenta, are also present. The stroma of the tumor is often edematous with zones of necrosis and hemorrhage. In imaging studies it is important to distinguish the yolk sac tumor from a sclerosing stromal tumor. A sclerosing tumor shows a strong enhancement compared to the uterine myometrium. The rim of hypo-intensity on T2-weighted images and the presence of low intensity nodules set against high-intensity stroma on T2-weighted images may help to distinguish a sclerosing stromal tumor from a yolk sac tumor. The key diagnosis of a yolk sac tumor is seen in the laboratory results with an elevated alfa-fetoprotein (AFP) level. In the presented case the AFP level was initially 36300 μg/l (normal value 0-12 μg/l) and rapidly decreased to 20667 μg/l after surgery. The recommended treatment is initially surgical with unilateral salpingo-oophorectomy, with limited debulking of extra ovarian tumor, followed by chemotherapy. Bibliography 1. Hyuck J.C., Min H.M., Seung H.K., et al.: Yolk sac tumor of the ovary: CT findings. Abdom Imaging, 2008, 33: 736-739. 2. Seung E.F., Fae M.L., Sung E.R., et al.: CT and MR Imaging of ovarian tumors with emphasis on d ifferential diagnosis. Radiographics, 2002, 22: 1305-1325. 3. Toshihide Y., Kaori T., Takashi K., et al.: Yolk Sac Tumor of the ovary: radiologic-pathologic correlation in four cases. J Comput Assist Tomography, 2010, 24: 605-609.

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JBR–BTR, 2013, 96: 258-259.

NEONATAL CEPHALOHEMATOMA L. Willemot1, P. Lagae1, P. Jeannin2, N. Baelde1, K. Verstraete3 Key-word: Infants, newborn, injuries

Background: A few hours after birth a newborn baby developed two soft well-defined bumps situated bilaterally on the posterior part of the parietal regions of the skull. The swellings were separated by the sagittal suture and do not cross the lambdoid suture. The infant was delivered vaginally in a head-first position after a full term pregnancy (G2A1P0) without complications. There was no prolonged labour nor use of forceps, vacuum extractor or other techniques of assisted delivery. The newborn weighted 2.8 kg (P10) and measured 47 cm (P10) with a head circumference of 32.5 cm (P6). The APGAR scores after 1 and 5 minutes were respectively 6 and 9. Ultrasound examination showed crescentic hypoechoic fluid collection along the periosteum of the parietal bone bilaterally.

C 1A 1B Fig. 1C 2

Departments of 1. Radiology and 2. Pediatrics, AZ Jan Palfijn Gent, Ghent, and 3. Department of Radiology, University Hospital Ghent, 9000 Ghent, Belgium

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NEONATAL CEPHALOHEMATOMA — WILLEMOT et al

Work-up Plain digital radiography of the skull (Fig. 1) shows on lateral view (A) a subtle soft tissue swelling and subperiosteal calcification at the superoposterior margin of the parietal bone. Postero-anterior view (B) demonstrates bilateral soft tissue swelling with subperiosteal curvilinear calcification at the posterior margin of the parietal bone. The bumps are divided by the sagittal suture. There is no evidence of skull fracture. On Townes view (C) the parietal bumps are shown even more clearly. Also on this incidence, there is no evidence of fracture. Figure 2 is the clinical photograph of the infant’s head. Radiological diagnosis Based on the clinical findings of parietal scalp swellings confined to the parietal bone vault in a newborn, the subperiosteal fluid on ultrasound examination, and the characteristic radiographic appearance of soft tissue swelling with an elevated rim of curvilinear bone, the diagnosis of cephalo hematoma was made. The diagnosis was confirmed three weeks later on digital radiography of the skull. Discussion A cephalohematoma is a posttraumatic subperiosteal accumulation of blood. It is the most frequent cranial injury in the neonates, occurring in approximately 2.5% of all births. The hemorrhage is caused by traumatic passage through the birth canal and is associated with instrumental delivery (particularly vacuum extraction and forceps delivery), prolonged labour and primiparae. Clinically this condition presents as a soft fluctuant mass, typically located over the middle and posterior parts of the parietal bone, sometimes bilaterally. The second most common site is over the occiput. Anatomically the normal scalp consists of 5 layers: (1) the skin, (2) the subcutaneous tissue, (3) the galeal apnoneurosis: a thin but dense layer of fi brous tissue continuous with the frontal, temporal and occipital muscles, (4) the subgaleal space, consisting of loose connective tissue allowing movement between the scalp and the skull, and (5) the periosteum or pericranium: a layer of fi brous tissue connected loosely through the subperiostal layer to the cranial bone, but firmly attached to the sutures through which it is continuous with the dura mater. Traumatic disruption of veins communicating between the cranial diploic space and the pericra-

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nium causes subperiosteal hemorrhage. Because of a strong adherence of the pericranium to the sutures, cephalohematomas do not cross the suture lines. This characteristic facilitates differentiation with other posttraumatic scalp swellings in the neonate such as, the caput succedaneum, subgaleal hematoma and subgaleal hygroma. The caput succedaneum is a localized edema (often with hemorrhage) of the subcutaneous tissue due to injury to the presenting head after difficult or instrumental delivery. It is typically located on the vertex and is not restricted by suture lines. The swelling usually subsides within a few days. Subgaleal hemorrhage occurs in the subgaleal space which extends from the supraorbital ridges to the neck and laterally to the ears. Although rare, massive subgaleal hemorrhage can be fatal in neonates. Subgaleal hygroma is caused by skull fracture, usually after forceps delivery, whereby cerebral spinal fluid is allowed to flow through the fracture into the subgaleal space. Infection of the cephalohematoma is rare and usually associated with (unnecessary) needle aspiration or scalp electrode application. Other complications are hyperbilirubinemia and anemia. Accompanying skull fractures or subdural hemorrhages should be excluded. Small cephalohematomas spontaneously disappear after a few weeks, others tend to increase in size. By the end of the first 2 or 3 weeks calcifi cations/ossifications produced by the elevated pericranium start to develop and the mass becomes firmer. In most cases subperiosteal hematomas resolve after 2 to 3 months, in some cases they persist through life. Ultrasound and radiographic investigations usually suffice to diagnose birth trauma in newborns. However, when findings are unclear and/or further investigations are necessary to exclude more serious injuries, the use of other techniques like CT or magnetic resonance imaging is to be considered. Bibliography 1. Currarino G.: Neonatal subperiosteal cephalohematoma crossing a synostosed sagittal suture. Pediatr Radiol, 2007, 37: 1283-1285. 2. King S.J., Bootroyd A.E.: Cranial trauma following birth in term infants. BJR, 1998, 71: 233-238. 3. Moron F.E., Morriss M.C., Jones J.J., et al.: Lumps and bumps on the head in children: use of CT and MR Imaging in solving the clinical diagnostic dilemma. Radiographics, 2004, 24: 16551674. 4. Watchko J.F.: Identification of neonates at risk for hazardous hyperbilirubinemia: emerging clinical insight. Pediatric Clin North Am, 2009, 56: 671687.

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IMAGES IN CLINICAL RADIOLOGY Orbital dermoid B. Denoiseux1, J. Denekens1, F. Van den Bergh2,4, F.M. Vanhoenacker2,3,4

A 40-year-old woman presented with a slowly growing and painless mass located at the superolateral aspect of the right orbit. On clinical examination, the lesion was easily palpable and of firm consistency with smooth borders. Computed Tomography (CT) showed a small ovoid mass, with a well-defined wall and an intralesional fat-fluid level (Fig. A, soft tissue window, arrow). The lesion was intimately related to the zygomatico-frontal suture (Fig. B, bone window, asterisk). Magnetic Resonance Imaging (MRI) confirmed the fat-fluid level on the T1-weighted images (WI) (Fig. C, arrow). There were no erosive changes in the adjacent bone, nor any intra-orbital extension. Based on the combination of characteristic clinical and imaging findings, the diagnosis of orbital dermoid was made. For cosmetic reasons, the patient was referred for a surgical excision of the lesion. Comment

A dermoid is a congenital benign neoplasm, derived from ectoderm and esoderm. It is considered as a choristoma, comprising histologically normal m cells in an abnormal location. Although dermoids may occur in any subcutaneous location, more than 80% are found in the head and neck area, predominantly in the orbital and peri-orbital B area. It is one of the most common non-inflammatory and space-occupying orbital lesions in children, accounting for about 2-9% of all orbital masses. However, dermoids are slowly growing and therefore may appear at any age. They develop most commonly adjacent to suture lines, especially at the zygomaticofrontal suture and less frequently adjacent to the nasofrontal suture. It is believed that during embryogenesis, ectoderm may get entrapped at the site of the suture. Histologically, the lesion is lined by a keratinized squamous epithelium with intralesional dermal appendages such as hair follicles, smooth muscle, sweat and sebaceous glands and fibroadipose tissue. The presence of dermal derivates distinguish dermoids from epidermal cysts. Intralesional accumulation of keratin debris, sebaceous fluid and calcium is typically present in the cavity and can be noted on the imaging. Superficially located lesions are more frequent than deeply located lesions. C On clinical examination, superficial orbital dermoids have well-definable margins, while deep lesions may extend beyond the orbital rim and therefore have incomplete palpable margins. Deep lesions may have dumbbell morphology, with extra- and intra-orbital components. Depending on the size and extension, they can cause ptosis, proptosis and even diplopia. In rare cases the orbital dermoid can rupture, which may cause a marked inflammatory response. On CT, an orbital dermoid presents usually as a round or ovoid mass at the superolateral orbital rim near the zygomatico-frontal suture. The majority of the lesions have a well-defined wall. The contents of the lesion depends on the amount of lipid and keratin within it. Intralesional fat or a fat-fluid level may enhance the specificity of the diagnosis. Calcifications are rare. CT is the preferred technique to demonstrate the intimate relationship with adjacent sutures and any associated erosive bone changes. MRI may confirm the T1-hyperintense fat component and the fat-fluid levels. Hypointense components may be due to intralesional keratin debris or calcifications. After administration of gadolinium contrast, there is subtle rim enhancement of the lesion wall but lack of any central enhancement. It is important to determine whether the cyst is superficially or deeply located, because of the different therapeutic approach. In this regard, imaging plays a pivotal role for precise assessment of intra-orbital or even intracranial extension. Although superficially located asymptomatic lesions can be left alone, they often cause cosmetic problems and therefore surgical excision is preferred. Deep lesions require a more complex orbital dissection and recurrence rate is considerably higher due to partial excision of the lesion wall. Reference 1. Cavazza S., Laffi G.L., Lodi L., Gasparrini E., Tassinari G.: Orbital dermoid cyst of childhood: clinical pathologic findings, classification and management. Int Ophthalmol, 2011, 31: 93-97.

1. Faculty of Medicine en Health Sciences, University of Antwerp, 2. Department of Radiology, AZ Sint-Maarten, Duffel-Mechelen, 3. Department of Radiology, University Hospital Antwerp (UZA), 4. Department of Radiology, University Hospital Ghent (UZ Gent).

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IMAGES IN CLINICAL RADIOLOGY Large occipital nerve (Arnold’s nerve) schwannoma M. Apaydın, M. Varer, O.T. Kalayci, F. Gelal, M.B. Koruyucu1 A 37 year-old man who had a ten years history of remitting and intermittently severe neck pain with a suboccipital mass is presented. On initial neurological examination there was no abnormal finding except little mass in the posterior neck. Following physical examination radiological evaluation was requested. In sagittal pre (A) and postcontrast (B) T1W images the lesion in between cervical 2 and 3 spinal process (arrow). The lesion was well defined, encapsulated, heterogeneously enhanced in 2.5 x 2 cm size. There was no bony destruction but remodeling. On axial image the configuration and the location in the semispinalis capitis muscle was easily identified easily (C). The patient underwent operation and final pathologic and radiologic diagnosis was schwannoma with Antoni A cells which was originated from the greater occipital nerve.

Comment Schwannoma is a capsulated, benign and slow growing tumor which arises in myelinated nerve. It can occur in peripheral, spinal and cranial nerves. While these lesions are frequently seen in head and neck region (25-45%) but it is rare in suboccipital region (1). The cervical sympathetic chain is located posterio-medially to carotid vessels and passes through posterio-medially longus capitis to the prevertebral fascia (1). Schwannomas are frequently solitary lesions. Also another condition called familial schwannomatosis is genetically distinct disease from NF-1. In the radiologic findings, well defined soft tissue mass on X-ray, hypo or/ and isodense lesions to muscle on CT, T1 WI hypo, T2 WI hyperintensity on MR can be seen. On T1WI the fat around the tumor called split fat sign, in T2 WI hypointensity in the mass is called target sign (50%). The capsule is seen 70 %, like our case. Also cystic degeneration causes heterogeneous signal. Muscular or lipoid tumors, metastatic and reactive lymphadenopathies should be in differential diagnosis. But characteristic MR signals help to make definite diagnosis. Big occipital nerve (Arnold’s nerve) which originates from C2 cervical nerve posterior fibers, takes some nerve fibers from C1 and C2. This nerve cutaneously innervates mostly semispinalis capitis muscles via posterior cervical plexus. Schwannoma in this nerve mostly and makes local irritation and pain (1). In our case there was a mass neighboring to the right semi spinalis capitis muscle in the right big occipital nerve track. In spite of the frequency of schwannomas, big occipital nerve (Arnold’s nerve) schwannoma is rare entity in the cervical region. Reference 1. Ballesteros-Del Rio B., Ares-Luque A., Tejada-Garcia J., Muela-Molinero A.: Occipital (Arnold) neuralgia secondary to greater occipital nerve schwannoma. Headache, 2003, 43: 804-807.

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1. Izmir Ataturk Education and Training Hospital, Izmir, Turkey.

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IMAGES IN CLINICAL RADIOLOGY Sprengel’s shoulder C. Ruivo1, M.A. Hopper2

An otherwise healthy 5-year-old boy was referred for shoulder asymmetry and limited range of motion on the left. According to the boy’s mother, he hardly ever complained about it, and was a good swimmer. Physical examination revealed left scapular elevation; glenohumeral function was good, apart from forward elevation (150 degrees). Frontal chest radiograph (Fig. A) and left shoulder plain film (Fig. B) showed elevation of the left scapula with medial rotation of its inferior angle, pointing towards the spine (arrow). This was connected to the posterior elements of the sixth cervical vertebra by a bony bar (arrowheads), which was better appreciated on a lateral radiograph of the cervical spine (Fig. C). The right shoulder girdle was normal (Fig. A, dotted arrow). No other abnormali ty was seen.

Comment Sprengel’s deformity, named after one of the doctors who drew attention to the condition in 1891, is a rare skeletal abnormality. It is, nevertheless, the most common congenital malformation of the shoulder girdle, resulting from failure of the scapula to descend from its position in the neck to its normal position in the posterior thorax during embryological development. This complex anomaly consists of scapular malposition and dysplasia: the affected scapula appears not only elevated with its inferior part medially rotated, but is also smaller and more cephalad than the normal contralateral one. Regional muscle hypoplasia or atrophy is usually present, which adds to the disfigurement and limitation of shoulder movement. The deformity can be unilateral, with the left side being more commonly affected than the right, or bilateral, which is cosmetically more acceptable but functionally more disabling. It may occur in isolation or associated with other anomalies, including KlippelFeil syndrome (the most frequent one, characterized by the congenital fusion of any two of the seven cervical vertebrae), spinal dysraphism, vertebral and rib segmentation or fusion abnormalities. An omovertebral bone – a rhomboid- or trapezoid-shaped fibrous/cartilagineous or osseous bar connecting the superomedial border of the affected scapula to the spinous processes, lamina or transverse processes of the cervical spine (most commonly the 4th to 7th vertebrae) – is present in 30% of patients, which is best visualized on a lateral or oblique radiograph of the cervical spine. Cavendish classified the deformity into four grades, based on its severity: grade 1 – very mild deformity, with the shoulders almost at the same level, not noticed with the clothes on; grade 2 – mild deformity, but the superomedial portion of the high scapula is visible as a lump; grade 3 – moderate and visible deformity, with the affected shoulder 2-5 cm higher than the opposite shoulder; grade 4 – severe deformity, the scapula is very high, with the superomedial angle at the occiput, with neck webbing and brevicollis. Surgical correction of the deformity should be considered in patients with moderate or severe cosmetic and functional compromise, and it should be performed between 3 and 8 years of age. Techniques described in literature involve a combination of scapular lowering with shift of the origin or the insertion of the scapular muscles on the spine/scapula, resection of the superomedial border, and omovertebral bar resection. Although multiple procedures have been described, the Green and the Woodward procedures remain the gold standards for correction of the condition, and their modified forms (with strategies to reduce complications, including morcelisation of the middle third of the clavicle) are most popular presently. The Green procedure detaches the muscles from the scapula whereas the Woodward procedure detaches the origins of the trapezius and rhomboids from the spinous processes. Postoperative complications include winging of the scapula, prominent scars, and neurovascular injury (which is minimized by clavicle osteotomy). In this case, the Sprengel’s deformity was moderate (grade 3 on the Cavendish grading system). Nevertheless, the glenohumeral function was relatively preserved, with restriction of motion only on forward elevation of the arm, and apparently causing no significant impact in the boy’s routine. The mother’s main worry was cosmesis/functional compromise in the future, but she was reluctant to proceed directly to surgery. Therefore, a conservative approach was adopted for the time being, and contact between the mother and people who had/had not surgery was arranged.

Reference 1. Kadavkolan A.S., Bhatia D.N., Dasgupta B., Bhosale P.B.: Sprengel’s deformity of the shoulder: Current perspectives in management. Int J Shoulder Surg, 2011, 5: 1-8. 1. Department of Radiology, Hospitais da Universidade de Coimbra – Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal, 2. Department of Radiology, Addenbrooke’s Hospital, Cambridge, United Kingdom.

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IMAGES IN CLINICAL RADIOLOGY Giant hydronephrosis in a 42-year-old man revealed by low back pain S. Kouki1, A. Fares2, K. Akkari1, S. Alard1

A 42-year-old man with no medical history complaining of back pain for several months with bilateral sciatica poorly systematized. Radiographs of the lumbar spine show a narrowing of the L4/L5 disc space. A lumbar spine Computed Tomography (CT) was requested to explore these low back pain. It revealed a medial disc herniation at the L4-L5 level and discovers a large cystic swelling with thin septations occupying whole of the abdomen (Fig. A). Contrast- enhanced abdominal CT scan confirmed left giant hydronephrosis secondary to pelviureteric junction obstruction (Fig. B) with thin renal parenchyma (white arrowheads) (Fig. 3). It’s shifting all the bowel loops to the right side. Non left ureteral stone, never mass syndrome has been highlighted. Left nephrectomy was performed and approximately 8 liters of clear urine was drained. The patient had an uneventful recovery postoperatively. Comment

Giant hydronephrosis is a rare condition, defined as the presence of massive dilatation of renal collecting system containing more than a liter of fluid. Approximately 200 cases have been reported in the world literature since it was first described in 1746. It’s mainly caused by congenital obstruction of the ureteropelvic junction, followed by stones, trauma, and tumors. Other less common causes include obstructive megaureter, ureteric atresia, polar or aberrant vessels, flap-like mucosal folds and impacted ureteric stone. Giant hydronephrosis is a slowly progressive disease, and a huge abdominal mass or distended abdomen may be the only sign. Occasionally patients present with flank pain, hematuria, recurrent urinary tract infection or low back pain like in our patient. The most common and efficient diagnostic modalities are CT and ultrasound. Magnetic resonance imaging can help to establish diagnosis in allergic for iodine patients or sometimes in pregnant women. The differential diagnosis of giant hydronephrosis arises with intra-abdominal cystic masses and ascites. Giant hydronephrosis can lead to complications like renal failure, infection, malignancy and rupture of the kidney. Treatment depends upon anatomical configuration and functional status of renal units. Usually, nephrectomy is the treatment of choice as the affected kidney is often very poorly functioning. However percutaneous nephrostomy may be performed in the compromised patient to relieve secondary. Reference 1. Rajaini S., Kekre N.S.: Giant hydronephrosis mimicking massive ascites. ANZ J Surg, 2012, 82: 468-469.

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1. Radiology Department, CHU Sint-Pieter, Brussels, 2. Radiology Department, Hospital ZNA-Middelheim, Antwerp, Belgium.

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IMAGES IN CLINICAL RADIOLOGY Unusual cause of pelvis pain and polyuria in an adolescent: idiopathic megarectum S. Kouki1, A. Fares2, K. Akkari1, S. Alard1 A 16-year-old girl presented to the emergency department with subacute pelvic pain, painful micturition and polyuria for 3 days. She had a past history of dysmenorrhea and chronic constipation for many years without any relevant surgical history. Patient had no fever or vomiting. On examination the patient had a soft abdomen with non-tender pelvic mass. The abdominal plain film revealed a lower abdominal opacity (Fig. A) without any air-fluid levels or pneumoperitoneum. Abdominopelvic CT revealed fecal impaction in a megarectum (Fig. B) without significant colonic dilatation (Fig. C). Enemas failed to relieve the impaction. The surgical treatment was the only choice with resection of the rectum and coloanal anastomosis without any reported postoperative complications with improvement of the patient’s complains. Comment

The definition of megarectum is variable. Such author suggests that megarectum is defined as an enlarged rectum with a recto pelvic ratio greater than 0.61 associated with significant abnormalities in the anorectal manometry, pressure-volume curves, or rectal compliance. The aetiology and pathology are unknown. Diagnosis is often easier for children who are presenting constipation or encopresis with a large rectum. The megarectum is rarely diagnosed in adults. Clinical presentation may be sometimes unusual when other symptoms are in the foreground such as urinary symptoms like in our patient. Secondary forms of megacolon may be related to an alteration of the rectal innervations such as in spinal dysraphism or in Parkinson’s disease. Colonic perforation is the most dangerous reported complication. Medical treatment is often based on laxatives. Surgical treatment, often a rectal resection with coloanal anastomosis, is reserved for severe forms with a very large rectum as in our case. Reference 1. Van der Plas R.N., Benninga M.A., Staalman C.R., et al.: Megarectum in constipation. Arch Dis Child, 2000, 83: 52-58.

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1. Radiology Department, CHU Sint-Pieter, Brussels, 2. Radiology Department, Hospital ZNA-Middelheim, Antwerp, Belgium.

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IMAGES IN CLINICAL RADIOLOGY Paradoxical reaction in non HIV-tuberculosis, a rare case with pancreatic involvement D. Denaeghel¹, L. Binet², P. Wackenier², P. Ravez², C. Winant¹

A 24-year-old young man presents a sudden hepatic cytolysis and cholestasis after two months of isoniazid, rifampin and pyrazinamide therapy for severe lung tuberculosis. Initial data included heroin consumption history, HIV-negative serology, drug sensitivity and a normal abdominal CT. The ultrasound showed a dilatation of intra hepatic biliary ducts, as well as of a dilatation of the main biliary duct, this dilatation was caused by an extrinsic mass developing from the head of the pancreas (Fig. A). This mass presents a heterogeneous echostructure pattern and measured 36 x 31 mm. A computer tomography scan of the abdomen was performed. All images were loaded on a clinical workstation with 3D functionalities and revealed a hypoattenuated, heterogeneous mass, with irregular outlines at the head of the pancreas (Fig. B and C), causing a dilatation of the biliary duct upstream. There is no dilatation of pancreatic duct associated. After contrast injection, this mass enhanced in the periphery (arrows), leaving the central necrotic part unenhanced. The possibility of pancreatic tuberculosis is suspected. This diagnosis is then confirmed by an ultrasound guided trans-duodenal biopsy of the lesion. The results demonstrate the presence of a granulomatous reaction associated with the caseous necrosis within this mass confirming a tuberculosis of the head of the pancreas. The patient was treated with sphincterotomy and biliary prosthesis. The liver function test showed that the transaminases back to normal within two days, and the GGT normalized after thirteen days post intervention. The antibuberculous treatment was maintained. Comment

Pancreatic tuberculosis is rare; a paradoxical pancreatic tuberculous r eaction has been reported only in one case of abdominal tuberculosis but never, to our knowledge, in pulmonary tuberculosis with no initial abdominal involvement. Paradoxical tuberculosis reaction is defined by clinical or radiological worsening of previous lesions or new ones in patients receiving adequate anti-tuberculosis therapy that initially improved on treatment. Paradoxical reaction is mostly seen in human immunodeficiency virus (HIV) positive patients. The dissemination of abdominal tuberculosis are first to lymph nodes, then liver, spleen, bone marrow and pancreas in C rare case. The most common differential diagnosis of a hypoattenuated, heterogeneous mass, developing from the head of the pancreas can be an adenocarcinoma, hypervascular mass, with or without pancreatic ducts obstruction. Other differentials can be a metastasis, usually from kidney and melanoma, or lymphoma but they rarely cause any billiary duct obstruction and finally, the Langerhans cell tumor, which consists of a hypervascular pancreatic mass, with liver metastases. In conclusion, the possibility of a pancreatic tuberculosis must be thought in cases of a pancreatic mass at a young man treated for lung tuberculosis, although this event remains very rare. Reference 1. Lee Y.J., Jung S.H., Hyun W.J., Kim S.H., Lee Hle, Yang H.W., Kim A., Cha S.W.: A case of Obstructive Jaundice Caused by Paradoxical Reaction during Antituberculous Chemotherapy for Abdominal Tuberculosis. Gut and Liver, 2009, 3: 338-342.

1. Department of Radiology, 2. Department of Pneumology, CHU Ambroise Paré, Mons, Belgium.

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IMAGES IN CLINICAL RADIOLOGY Atypical obstructive submandibular sialoadenitis M. Sahan1, N. Çullu2, M. Deveer2, A. K. Sivrioglu3, H. Beydilli4, H. Sözen5

The patient is a 52-year-old female who had undergone medical treatment for right acute suppurative submandibular sialoadenitis three times in the last two months. The patient was referred to our clinic due to persistance of complaints and presence of a mass in the submandibular region. On physical examination, the right submandibular gland was diffusely enlarged and adherent. Also, seropurulent decreased salivation was observed pressing on the Wharton’s channel. Evidence of stone in the channel was not detected at palpation. On USG examination, right submandibular gland enlargement, two reactive lymph nodes (dimention, 19 x 12 mm ve 19 x 8 mm) in submandibular area and hypoecoic noduler lesion which was difficult to discriminate from the surrounding tissue measuring 5 x 3 mm in diameter were detected. Also dilatation at duct of salivary gland (mean 2 mm) was present. For further evaluation MRI examination was recommended. MRI examination revealed a slight increase in the right submandibular gland dimensions. No significant pathologic enhancement was present (Fig. A, B). Under general anesthesia, right submandibular gland excision was performed with lymph node dissection. During operation, it was observed that the gland was middle hard and attached to the anterior belly of the digastric muscle due to probably passed infection. After removal of gland, a foreign body (grass seed) was found to be in the Wharton’s duct during the macroscopic examination. After taking the photographs (Fig. C, D), the foreign body was sent to Ankara University, faculty of Agriculture for further analysis. Since the patient was a farmer by occupation, it was thought that the grass seed might had been inserted accidentally into Wharton’s duct. Due to their linear extensions They move easily in a space freely. Comment

Sialoadenitis is inflammation of the salivary glands. The most common etiologic factors are viral or bacterial disease, radiation, obstructive pathologies, Kuttner tumor, Sjögren’s syndrome, and Heerford’s syndrome. Obstructive sialoadenitis is generally due to canal stenosis secondary to sialolithiasis (%80-90), mucous plugs and a variety of causes (1). Rarely, sialithiasis may be due to a foreign body like fish bones. The imaging features depend on the foreign body. Fish bone is seen in most cases of foreign bodies and reveals high- echo image by ultrasonography. Wharton’s duct tumors, granulation polyps and chronic sclerosing sialoadenitis (Kuttner tumor) can be seen as rare causes (1). Sialoendoscopy has been used for both diagnosis and treatment over the last 5-10 years (1). Sialoendoscopy which was unavailable in our institution could have been contributive in this patient. Reference

1. Yu, C., et al.: Endoscopic observation and strategic management of obstructive submandibular sialadenitis. J Oral Maxillofac Surg, 2010, 68: 1770-1775.

1. Department of Otolaryngology, 2. Department of Radiology, Mugla Sitki Kocman University Faculty of Medicine, Mugla, 3. Department of Radiology, Aksaz Military Hospital, Mugla, 4. Department of Emergency, Mugla Sitki Kocman University Faculty of Medicine, Mugla, 5. Department of Clinical Microbiology and Infectious Disease, Mugla Sitki Kocman University Faculty of Medicine, Mugla, Turkey.

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IMAGES IN CLINICAL RADIOLOGY Bilateral selective amygdala calcifications: lipoid proteinosis . C. Yılmaz¹, B. Gulek¹, E. Çenesizoğlu², Ö. Kaya¹, G. Söker1, A. Hurs¸ it Ispir²

A 14-year-old boy presented with progressive skin and mucous embrane changes including multipl papules on the eyelid margins. His m parents also noted hoarseness since early childhood. His rashes emerged first when he was 1-month-old and healed by leaving scars. Voice distorsion appeared at the age of 1. At the age of 5, he developed bilateral multiple papules on the eyelids. His sister also developed similar cutaneus and eyelid lesions as well as voice hoarseness. On physical examination, bilateral beaded papules were present on the margins of eyelids (arrows in Fig. A). Also noted were widespread facial acneiform scars, thickening of the tongue associated with restricted tongue movement. Comment

Lipoid proteinosis was firstly defined as “lipoidosis cutis et mucosae” by Urbach and Wiethe in 1929. The disorder has recently been shown to result from loss-of-function mutations in the extracellular matrix protein 1 gene on chromosome 1q21. It is rare autosomal recessive disorder that presents in early childhood with hoarseness, skin infiltration and thickening with beaded papules on eyelid margins, and facial acneiform or poxlike scars. Histological examination reveals widespread deposition of hyaline like material and disruption of basement membrane around vessels and at the dermal-epidermal junctions. The first symptom of the disease is hoarseness, which is attributed to laryngeal infiltration. It occurs in the majority of patients soon after birth. Congenital dystoni, congenital hypothyroidism and lipoid proteinosis should be included in differential diagnosis when hoarseness is seen in early childhoodd. The other clinical manifestations of LP may vary considerably between affected individuals. Multiple systemic involvement may occur at some individuals. Moniliform blepharosis is a pathognomonic finding and is seen in 50% of patients. LP involves the central nervous system (CNS) infrequently. The amygdalae, hippocampus, parahippocampal gyrus and the striatum are the most commonly affected sites.CNS involvement mostly occurs as a result of accumulation of hippocampal perivascular calcium deposits. Patients with involvement of the amygdalae may experience symptoms related to limbic system dysfunction such as alteration in fear recognition, modulation of attention, perception, learning and memory. Dystonia is seen in some cases with striatral calcifications. The essential imaging findings in LP are atypical intracranial calcifications which are mostly seen in medial temporal lobes, amygdala, hippocampus and parahippocampal gyrus. Bilateral horn or comma – shaped amygdala calcifications are almost pathognomonic (arrows in Fig. B, C) occurring in approximately 50% of cases. Despite the progressive nature of the disease, the prognosis of LP patients is rather good. Laser microlaryngoscopy and dissection of the vocal cords may be performed to improve voice quality. Although intralesional heparin and oral dimethylsulphoxide and steroid therapies have been reported in the literature, there is currently no effective treatment. Only symptomatologic therapeutic approaches are available.

Reference 1. Gonçalves F.G., Melo M.B., Matos V.L., Barra F.R., Figueroa R.E.: Amygdalae and Striatum Calcification in Lipoid Proteinosis. AJNR, 2010, 31: 88-90. 1. Department of Radiology, 2. Department of Dermatology, Numune Teaching and Research Hospital, Adana, Turkey.

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ABSTRACT OF PAPER FOR FULL MEMBERSHIP AT THE ROYAL BELGIAN SOCIETY OF RADIOLOGY NEURORADIOLOGY High resolution surface coil imaging in patients with refractory epilepsy S. Dekeyzer, S. Lapeire, E. Achten, K. Deblaere1 Introduction: In up to 30% of patients with epilepsy, the disease becomes refractory to antiepileptic drugs or the side effects of the medications are intolerable. These patients may be referred for surgical resection. Patients with refractory epilepsy in whom the epileptogenic zone cannot be precisely identified using the currently available presurgical evaluation tools are not likely to undergo resective surgery and remain prone to uncontrolled seizures. The aim of this study is to assess the added value of surface coil imaging at 3-Tesla (3T SCI) with regard to their potential to locate the epiloptogenic zone in order to increase the number of patients eligible for resective surgery. Methods: So far, 17 patients with medically refractory epilepsy who were included in a presurgical epilepsy evaluation protocol underwent a surface coil MRI exam at 3 Tesla. Patients were scanned on a Siemens Trio system using a 4-channel Bitemporal Phased Arry surface coil (NMSC-003, Nova Medical). 3D MPRAGE (0.9 mm3, TR 2530 ms, TE 2.3 ms) images were acquired as well as axial and coronal TSE T2-weighted images (slice thickness 3 mm, in plane

0.37 mm3, TR 6000 ms, TE 74 ms). In patients in whom a previous MEG-examination was available (n = 14), the surface coil position was determined by the location of the MEG dipole cluster. In the remaining patients, the position of the surface coils was based on seizure semiology (n = 2) and ictal-SPECT results (n = 2). On a previous epilepsy optimized MRI at 3T, the majority of patients had a negative MRI (n = 16). One patient had right hippocampal sclerosis (n = 1), but was included in the study as ictal-SPECT suggested an extratemporal epileptogenic focus. Results: In 7 out of 17 patients (45%) 3T SCI showed a previously undiagnosed lesion. These lesions demonstrated the imaging characteristics of small cortical migration anomalies, consisting of blurring of the gray matter-white matter transition area, with or without increased signal intensity in the subcortical white matter, and thickening of the cortex. In one patient, the lesion could retrospectively be identified on standard epilepsy optimized 3T MRI. The remaining patients showed no structural anomalies on standard 3T MRI. Discussion: In patients with refractory epilepsy, surface coil imaging at 3T has shown added value in the detection of subtle cortical lesions that were previously not visible or missed on 3T MRI. The location of the identified lesions correlated with the location of the MEG-

dipole cluster in all patients in whom MEGdata was available (n = 4). So far, only one patient has been operated and pathological examination confirmed the presence of focal cortical dysplasia in this patient. The remaining patients either achieved acceptable seizure frequencies following anti-epileptic drug changes (n = 3), are undergoing additional presurgical testing (n = 2) or are lost to follow-up (n = 1). Further follow-up of our current patient group and additional research in larger patient groups is needed to e valuate the exact value of the technique, especially in patients with a negative standard epilepsy optimized MRI in whom other examinations such as MEG suggest an extratemporal epileptogenic focus. References 1. Deblaere K., Achten E.: Structural magnetic resonance imaging in epilepsy. Eur Radiol, 2008, 18: 119-129. 2. Moore K.R., Funke M.E., Constantino T., Katzman G.L., Lewine J.D.: Magnetoencephalographically directed review of highspatial-resolution surface-coil MR images improves lesion detection in patients with extratemporal epilepsy. Radiology, 2002, 225: 880-887. 1. Department of Radiologie en Medische Beeldvorming, UZ Gent, Ghent, Belgium.

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IN MEMORIAM: PROFESSOR SIDNEY WALLACE, MD (1929-2013) THE INTERVENTIONAL RADIOLOGICAL COMMUNITY MOURNS A LEGENDARY PIONEER: A SHORT GLANCE AT HISTORY Sidney Wallace, a legend of his time in Interventional Radiology, passed away on May 25, 2013, at the age of 84. Sid was born in Philadelphia in 1929 and grew up in his father’s kosher meat market «a natural transition into surgery», Sid commented. He obtained his MD degree at Temple University School of Medicine in 1950 and entered a one year residency in surgery at Philadelphia General Hospital. Sid spent two years as a surgeon in the US Army, from 1956 to 1958, stationed in Korea and Japan. Thereafter, Sid became attracted by «the light or darkness however you want to look at it» of radiology and started residency training at Jefferson Medical College Hospital in Philadelphia. In 1963, like most of the radiologists interested in angiography, he spent a one year fellowship at the Department of Radiology of the University Hospital of Lund, Sweden, headed by Olle Ollson. Lund at that time was the «Mecca» of diagnostic angiography. Sid was sent to the barium section for a couple of months before being finally assigned to angiography, where he met with Erik Boijsen and Anders Lunderquist, with whom he continued to cooperate until retirement. In 1969, Sid was appointed Professor of Radiology at the Department of Diagnostic Radiology of MD Anderson Cancer Center, Houston, Texas, where he spent his entire medical career. In 1989, he became Division Head of Diagnostic Imaging and Department Chairman of Diagnostic Radiology and in retirement Professor Emeritus. Sidney Wallace was a one of the most fertile creators and inventors in interventional radiology. Those of us, who have practised lymphangiography, remember his groundbreaking series of publications on the diagnostic and therapeutic potential of the procedure and introduction of ultrafluid Lipiodol as a lymphatic contrast medium. Sid described cannulation of the lymphatic channels as «giving an enema to a flea». He also popularized percutaneous lymph node biopsy under lymphangiographic guidance. Furthermore, Sid performed percutaneous biliary drainage for the first time in the USA in 1962-1963 and promoted percutaneous hepatic abscess drainage as an alternative to surgery, before the advent of cross-section imaging. Most of his work however was devoted to cancer treatment. Sid had a determinant influence on the introduction and development of arterial tumor embolization, chemo-embolization and chemo-infusion. He had submitted himself to preoperative renal cancer embolization. Sid had started micro-encapsulation work as early as 1975 and continued working on Tamoxifen after retirement. The collaboration at MD Anderson, of Sid Wallace and Cesare Gianturco, another giant in the field of radiological intervention, was extremely beneficial. The creative imagination of both had given birth to a great variety of original devices and techniques, all nowadays in daily practive. They advocated systematic heparinization during diagnostic angiography, did the preliminary work on percutaneously placed vena cava filters and experimented on the first wooly tail arterial embolization spring coils. After vessel occlusion, they thought about permanent vessel opening. Gianturco had designed the first angioplasty balloon catheter that was used only in one patient. Around 1980, Sid inspired Cesare to devise the first stainless steel selfexpanding vascular zig-zag stents, which came up five years later. The Radiology Department at MD Anderson has been working on vascular and non vascular stent development ever since. Bill Cook, another early entrepreneur in intervention, recognized the potential of the newly conceived devices and was highly instrumental in their spread among the medical community through his company. Although Sidney Wallace had focused his pioneer work on the development of devices, techniques and pharmaceuticals, patients remained always his primary concern. From the beginning, Sid believed strongly in the advantages of a multidisciplinary approach in the treatment of cancer patients, which he put into practice at MD Anderson. The Department of Radiology grew up under his leadership to tremendous dimensions while MD Anderson Cancer Center was recognized the best Tumor Institute in the USA. Sid was an accomplished radiologist, clinician and researcher and in addition a remarkable teacher. Sid put during all his life great energy and verve in teaching the next generations, lecturing tiressly throughout the world on the radiological contribution to management of cancer patients. His loud and plain convincing voice captured immediately the attention of the audience until the end of his talk. Sid spoke on several occasions at combined meetings of the Belgian Surgical, Gastro-enterological and Radiological Societies. Together with Anders Lunderquist and others, he conceived a special hands-on, one week teaching programme in intervention in the animal lab. These courses run regularly at MD Anderson in Houston, in Malmö and in Liège and were taken over later in other places. Sid was a gentle and cultured man, full of humor, always in good mood and much devoted to friendship. He placed utmost importance in his faith. Beside being a talented interventional radiologist, Sid was a gifted artist, cantor, song writer, cartoonist, painter and sculptor. The center of Sid’s life was his family. He is survived by his beloved wife Marsha, without whom he never travelled abroad and three children who carry on their parents’ talents: Stewart is a music composer, Andrea a movie costume designer and Michael an interventional radiologist at MD Anderson. Hon Prof Dr Robert F. Dondelinger, Hon FRCR University of Liège

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