JBR 2013-6 by office

WETTEREN 1

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Volume 96 Page 333-432

November-December

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.

Single issue 38 € 44 €

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

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

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

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

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Editor: J. Pringot

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

Consulting Co-Editor: M. Castillo (USA)

President: R. Hermans 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

–

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 JBR-BTR 2013, 96-5: p. II)

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JBR-BTR ♦ 96/6 ♦ 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

LETTER OF THE BOARD The Belgian society of radiology: the future has (finally) begun G. Villeirs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

REVIEW ARTICLE Cone beam CT: non-dental applications J.W. Casselman, K. Gieraerts, D. Volders, J. Delanote, K. Mermuys, B. De Foer, G. Swennen . . . . . . . . . . . . . 333

ARTICLES A rare cause of intraabdominal hematoma: rupture of mesenteric artery branch aneurysm Y. Gunduz, S. Sipahi, R. Kara, A. Tamer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 354 Hemangiomatosis of the spleen in a patient with Klippel-Trénaunay syndrome S. Dekeyzer, B. Houthoofd, A. De Potter, M. Van Bockstal, P. Smeets, D. Vogelaers . . . . . . . . . . . . . . . . . . . . . . . 357 MRI whirpool sign in midgut volvulus with malrotation in pregnancy S. Kouki, A. Fares, S. Alard . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 360 Hypothalamic hamartoma L. Topff, G. Gelin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 362 CT features of groove pancreatitis subtypes S. Dekeyzer, S. Traen, P. Smeets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 365 Sylvius aqueduct septum T. Coolen, L. Médart, M. Tebache, L. Collignon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 369 radIologIcal aspect of fungus ball wIthIn a mucocele of the sphenoId sInus M.F. Inci, F. Özkan, A. Aksoy, M. Kelles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 372 Giant retroperitoneal liposarcomas: Diagnostic approach with multidetector computed tomography and magnetic resonance imaging K. Hekimoglu . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 375 Ground-glass pattern fibrous dysplasia of frontal sinus D. Chourmouzi, E. Psoma, A. Drevelegas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 378 Primary bone lymphoma in a 10-year-old boy J. Kreutz, J. Khamis, E. Bauduin, N. Francotte, T. Khuc . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 381 Post EVAR endovascular revision of late onset stent graft collapse due to Type 1 endoleak in a complicated case with left limb occlusion and solitary kidney S. Akpinar, M. Parildar, B. Alicioglu . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 383 Unusual presentation of osteopoikilosis P. Simoni, J. Denut, S. Ben Mustapha, E. Bianchi, E. Mutijima, V. Alvarez-Miezentseva, O. Malaise . . . . . . . . . 386

SPECIAL ARTICLE Optimizing communication between the radiologist and the general practitioner L.B.O. Jans, J.M.L. Bosmans, K.L. Verstraete, R. Achten . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 388

IMAGES IN CLINICAL RADIOLOGY Transfusional iron overload presenting as choroid plexus hemosiderosis D.E. Sossa, F. Chiang, A.R. Verde, D.G. Sossa, M. Castillo . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 391 Macrocephaly in an 8-month-old infant K. Ramakers, W. Siemons, L. Meylaerts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 392

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Pituitary stalk interruption syndrome S. Dekeyzer, N. Herregods, V. Meersschaut, J. De Schepper . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 393 Sister Mary Joseph nodule I. De Kock, S. Dekeyzer, B.S. Smet, L. Delrue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 394 Aqueductal stenosis secondary to Whipple’s disease F. Chiang, A.R. Verde, D.E. Sossa, D.G. Sossa, M. Castillo . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 395 Marked increase of breast density due to a levonorgestrel-releasing intrauterine device J. Gossner . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 396 The hypodense artery sign in acute cerebral infarction J. Bogdan, D. Rommel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 397 Extruded disc herniation in the posterior epidural space P. Tritschler, P. Mailleux, B. Devyver . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 398 Pulmonary hematoma presenting as pseudotumor S. Dekeyzer, I. De Kock, B. Smet, S. Van Meerbeeck . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 399 Cubonavicular coalition B. De Keyzer, P. Øvreeide, I. Crevits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 400 Proceedings of the cardiac – CT course held in Brussels on 16.11.2013 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 401 Report on the symposium organized in Antwerp on 23.05.2013: new milestones in vascular interventions M.H. Voormolen, O. d’Archambeau, T. van der Zijden, F. De Belder, J. Maes, F. Delrue, H. Fransen, P.M. Parizel . . 413 Annual General Assembly of the Royal Belgian Society of Radiology (RBRS), Leuven, 26.11.2013 Abstract of papers presented at the RBRS Annual Symposium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 417 Presidential Address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 428 2013 Honorary Membership Nominees: Prof. R. Maroldi, Dr H. Tanghe, Prof. G. Marchal and Prof. J. Pringot . 428 Forthcoming Courses and Meetings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 432 News from the Museum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 380 Instructions to Authors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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

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

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Erasmus Course MRI Head & Neck 3-7 February 2014, Brugge Preliminary program Monday, February 3, 2014 08:30-09:00 Registration. 09:00-09:15 Welcome address. Introduction, course & workshop organization. J.W. Casselman (Brugge). 09:15-09:45 MRI of the Head and Neck: basic technical requirements (coils, sequences, technique). J.W. Casselman ( Brugge). 09:45-10:30 Cranial nerves, from intra- to extracranial compartments: anatomy and MRI anatomy. T. Yousry (London). 10:45-11:30 Pathology of the cranial nerves, emphazising the extracranial course. J.W. Casselman (Brugge). 11:30-12:15 MRI of the eye and orbit. T. Ferreira (Leiden). 13:30-14:15 Skull base lesions. A. Borges (Lisbon). 14:15-15:15 Workshop 1: Cranial nerves. Workshop 2: Eye and orbit. Workshop 3: Skull base. 15:30-17:30 Workshop 1,2,3. 17:30-18:00 MRI of the temporo-mandibular joint. A. Borges (Lisbon). 20:00 Guided visit to the old city of Bruges. Lobby Hotel Acacia Tuesday, February 4, 2014 09:00-09:45 09:45-10:30 10:45-11:30 11:30-12:15 13:30-14:15 14:15-15:15 15:30-17:30 17:30-18:00

The nasopharynx and related deep spaces: compartimental anatomy and MR anatomy. M. Lemort (Brussels). The nasopharynx and related deep spaces: pathology. J.W. Casselman (Brugge). The nose and paranasal sinuses: functional anatomy and sectional radio-anatomy. C. Czerny (Vienna). The nose and paranasal sinuses: pathology. T. Beale (London). MRI of the salivary glands. N. Freling (Amsterdam). Workshop 4: Nasopharynx and related deep spaces. Workshop 5: Nose and paranasal sinuses. Workshop 6: Salivary glands. Workshop 4,5,6. Thyroid and parathyroids. H. Imhof (Vienna).

Wednesday, February 5, 2014 09:00-09:45 09:45-10:30 10:45-11:30 11:30-12:15 13:30-14:15 14:15-15:15 15:30-17:30 17:30-18:30

Oral cavity, sectional MR anatomy. B. De Foer (Antwerpen). Oral cavity and oropharynx. S. Golding (Oxford). The larynx and hypopharynx: anatomy and MR sectional anatomy. M. Lemmerling (Gent). Larynx and hypopharynx: pathology. M. Becker (Geneva). MRI of the thoracic outlet. W. Van Es (Nieuwegein). Workshop 7: Oral cavity and oropharynx. Workshop 8: Larynx and hypopharynx. Workshop 9: Thoracic outlet. Workshop 7,8,9. Imaging of post-treatment changes and value of PET/CT-MR in head & neck tumors. M. Becker (Geneva).

Thursday, February 6, 2014 09:00-09:45 09:45-10:30 10:45-11:30 11:30-12:00 13:15-15:15 15:30-16:30 16:30-17:00 17:00-17:45

MRI of the inner ear. J.W. Casselman (Brugge). MRI of the petrous apex, external auditory canal and facial nerve. F. Veillon (Strasbourg). MRI of the middle ear. B. De Foer (Antwerpen). MRI or CT for head and neck pathology, when? why? S. Golding (Oxford). Workshop 10: Inner ear. Workshop 11: Petrous apex, facial nerve. Workshop 12: Middle ear. Workshop 10, 11, 12. Head & neck MR-angiography. M. Mack (München). MR diffusion/perfusion, head & neck applications. V. Vandecaveye (Leuven).

Friday, February 7, 2014 09:00-09:30 MRI for assessment of lymph nodes in the head & neck. R. Maroldi (Brescia). 09:30-10:15 Pediatric head & neck MRI. J.W. Casselman (Brugge). 10:30-11:15 MRI of soft tissue lesions (lumps & bumps) of the neck. R. Maroldi (Brescia). 11:15-12:15 Examination 13:30-15:30 Workshop 13: Soft tissue lesions of the neck, lymph nodes. Workshop 14: Pediatric MRI. 15:45-16:15 Examination answers. 16:15-16:30 Certificates and closing remarks.

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JBR–BTR, 2013, 96: XI.

LETTER FROM THE BOARD THE BELGIAN SOCIETY OF RADIOLOGY: THE FUTURE HAS (FINALLY) BEGUN On the occasion of the last Royal Belgian Radiological Society Annual Meeting, on November 16th, 2013, the Belgianradiological community has lived a historical moment. The Belgian Society of Radiology(BSR) was founded as a merger of the National Union of Radiologists (NUR), the Consilium Radiologicum Belgicum and the Royal Belgian Radiological Society (RBRS). This merger was the successful culmination of a long process in which diverse opinions were reconciled, common objectives were formulated, converging statutes were approved and legal barriers overcome. Sixteen new Board Members have been elected on the same occasion for a mandate of three years. The Belgian Society of Radiology is a professional organization according to the Belgian Law on Professional Organizations of March 31, 1898. Its goals are to defend, to study, to protect and to foster both the scientific and professionalinterests of all Belgian radiologists. Accordingly, the statutesof the BSR are an efficient synthesis of those of the former RBRS and the former NUR. The merger of both societies has several advantages: it combines a better integration of scientific and professional interests, a better visibility and accessibility of the radiological executives for all stakeholders, and a more efficient and influential representation at the governmental level. The BSR is meant to be a forum for the elaboration of all issues that influence or impend on the radiologicalfunctioning. For this, several Councils and Working Groups have been established, among which the Scientific Council, which will cover all scientific activities of the former RBRS and will host all former RBRS Scientific Sections, and a PublicRelations Council, which will professionalize the external relations of the Society. Furthermore, Working Groups have been created for several issues such as the potential impact of a fixed rate reimbursement system on radiological services, the role of extramural radiology, the current and future indications of CBCT and its budgetary impact, the health insurance reimbursement of current and future radiological techniques, and the integration of eHealth and electronic data transmission in radiological services. With this, the long-awaited unique radiological society has now become reality and the first steps in this new era have been taken. The BSR Board meanwhile wants to sincerely thank all Belgian radiologistsfor their patience, sympathy and support. Long live the Belgian Society of Radiology! Geert Villeirs President BSR The BSR-Board (2013-2016) (*) President Geert Villeirs Vice-President Denis Henroteaux Secretary Christian Delcour Treasurer Piet Vanhoenacker (co-opted) BVAS/ABSYM-Representative Olivier Ghekiere

Board Members Patrick Aerts Bert De Foer Jean-François De Wispelaere Martijn Grieten (co-opted) Hans Jaspers Jean-Paul Joris Raymond Oyen Patrick Seynaeve Geert Souverijns Denis Tack Bruno Vandeberg Ghislain Vandenbosch Charles Van de Velde

(*) Elected by General Assembly on the 16th of November 2013.

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JBR–BTR, 2013, 96: 333-353.

REVIEW ARTICLE CONE BEAM CT: NON-DENTAL APPLICATIONS J.W. Casselman1,3,4, K. Gieraerts1, D. Volders1, J. Delanote1, K. Mermuys1, B. De Foer3, G. Swennen2 Initially Cone Beam CT was almost exclusively used to perform dental radiology. However, the first generation CBCT systems were later increasingly used to study sinuses, facial and nose fractures, temporomandibular joints etc. 3D-cephalometric head and neck studies became possible once CBCT systems were available that allowed scanning of the complete head. For this purpose a double rotation technique with stitching of the resulting two data sets was needed. CBCT systems on which the rotation could be stopped were needed to perform dynamic swallow or pharyngography studies. The advent of more powerful high-end CBCT systems led the way to temporal bone and skull base imaging. Finally, high-end “supine” CBCT systems using a “gantry” made small joint musculoskeletal imaging possible. These non-dental CBCT studies gradually replaced conventional X-rays and CT/MDCT studies because they allowed imaging with higher resolution, lower radiation dose and less metal artifacts. In this paper the most important non-dental CBCT indications will be discussed. Key-words: Computed tomography (CT), cone beam – Temporal bone, CT – Paranasal sinuses, CT.

Initially, Cone Beam CT was almost exclusively used to perform dental radiology. The first major application was presurgical planning of implant placement (1). In these patients cross-sectional imaging provided additional information and especially avoided damage to the inferior alveolar nerve during implantation. The second major indication was the evaluation of the relation between impacted wisdom teeth and the inferior alveolar canal prior to extraction. Many other applications followed: tooth impaction, supplementary and surnumerary teeth, tooth agenesis, cleft lip and palate, preoperative evaluation in maxillofacial surgery, dental- jaw trauma, cysts and benign lesions of the jaws, and finally also orthodontic and endodontic prob(2). Before 3D introduction, lems dental plain films and panoramic radiographswere mostly used for the above indications. However, conventional CT and multidetector CT (MDCT) gradually replaced these imaging modalities. The major drawbacks of these conventional CT systems were the moderate spatial resolution of 500 micrometer (µm) or higher and the higher radiation burden which withheld the clinicians to ask for CT studies especially in younger patients. The advent of Cone Beam CT systems using 10100 microsievert (µSv) and resolutions down to 200 µm took away most restraints. This was not always justified as some of the early Cone

Table I. — Most frequent dental indications (based on 899 CBCT studies performed during 2 consecutive months in 2012). Presurgical implant planning Endodontics – periodontology Pre-operative screening (cardiac surgery etc.) Pre-operative wisdom teeth removal Trauma

Beam CT systems used an effective radiation dose of up to 1200 µSv which is an equivalent of 240 panoramic radiographs (3). Nevertheless newer CBCT systems in general use a lower radiation dose than conventional CT’s (4-6) and reach a spatial resolution of 100 µm or less. This latter characteristic gave CBCT the status of a valuable “endodontic” diagnostic technique. It was obvious that the strongest trumps of CBCT, lower radiation dose, higher spatial resolution and less metal artifacts also applied in other head and neck regions (7). The major drawback remains the long acquisition time of 10 to 40 seconds. It is not possible to perfectly immobilize young children and less cooperative especially edentulous elderly people for such a long time and therefore these patients are better studied with fast MDCT. Extensive literature on the CBCT technique and dental CBCT indications (Table I), today accounting for 27% of the studies in our hospital (Table II), is already available (8). Be-

From: Department of 1. Radiology and Medical Imaging and 2. Maxillo-Facial Surgery, AZ St. Jan Brugge AV, Brugge, Belgium, 3. Department of Radiology, AZ St. Augustinus, Wilrijk, Belgium, 4. University of Gent, Gent, Belgium. Address for correspondence: Pr J.W. Casselman, M.D., Ph.D., Department of Radiology, AZ St. Jan Brugge AV, Ruddershove 10, 8000 Brugge, Belgium.

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64% 19,5% 10% 4,5% 2%

low the most established and new non-dental applications will be discussed. CBCT 3D-cephalometric analysis Conventional lateral cephalograms were used for many years for ortho dontic assessment, treatment and follow-up. On these 2D projection images both the bony structures and the overlying soft tissues could be evaluated and measured prior to surgery or non-surgical orthodontic treatment. Maxillofacial surgeons however dreamed of 3D-data which would allow them to make 3D-cephalograms and to achieve more exact presurgical assessment and planning (Fig. 1). This became possible on conventional CT and MDCT but the much higher radiation dose and low spatial resolution hampered further use of this technique at that stage. These inconveniences were overcome with CBCT. CBCT 3D-cephalography became the second major CBCT application as dentists and maxillofacial surgeons were the first to have access to CBCT (9, 10). This was however not possible before a major technical problem was tackled: the small size of the flat panel detectors. Most CBCT detectors have

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Table II. — Most frequent cone beam CT indications (based on 899 CBCT studies performed during 2 consecutive months in 2012). Sinus Dental MSK 3D-Cephalogram Maxillofacial Temporal bone Vertex TMJ Miscellaneous

a height of 13 cm and a width of 23 cm and therefore it is impossible to image the facial structures from the upper larynx to the forehead and to include both external auditory canals as well. To achieve this the “double rotation” technique was introduced. A first CBCT acquisition (full rotation) centered on the lower half of the facial structures is followed by a second CBCT acquisition centered on the upper half of the facial structures. A considerable overlap is used to avoid artifacts at the interface and a final “extended field-of-view (FOV)” image of 17 cm high x 23 cm wide can be achieved by software “stitching” of the two 13 x 23 cm data sets (Fig. 1a). Patient immobilization is crucial as the X-ray

38% 26,5% 14% 10% 5% 4,5% 1% 0,5% 0,5%

tube and flat panel detector must be displaced during this double rotation acquisition. Another solution uses vertical rotation of the flat panel detector. This solves the problem of the image height but reduces the image size in the transverse plane making it often difficult to include the nasion and both external auditory canals and overlying soft tissues. Initially these images were predominantly used in young patients for pre-surgical assessment, planning and followup of patients requiring orthodontic (11) (Fig. 2), cleft lip and palate (12, 13) and major congenital facial malformation/deformity corrective surgery (Fig. 3). In these young patients repetitive imaging is often needed and therefore CBCT’s using a low ra-

diation dose are preferred. Another requirement is that these patients must be scanned in the sitting position in order to evaluate the soft tissues in their natural upright position and therefore CBCT’s with a trolley designed to scan patients in the supine position can’t be used for this application. It also became gradually possible to superimpose 3D laser acquired data of the soft tissues of the face on top of the bony skull image generated by the CBCT. This was at first only possible with the development and use of dedicated “imagematching” software (Fig. 2). Fully integrated facial scanning only became possible with newer CBCT systems that enable concomitant 3D laser acquisitionof the soft tissues of the face during the CBCT acquisition (1), potentially providing more accurate 3D information as both data sets are acquired at the same time with the patient immobilized in the same position. The same CBCT technique can of course also be applied in other patients like those requiring jaw bone or facial bone reconstruction following destruction by a malignant tumor (Fig. 4) etc. Today 3D-cephalometric CBCT studies are the fourth most frequent CBCT indication and account for 10% of all CBCT studies in our department although this is probably somewhat biased by the

Fig. 1. — Extended field of view (FOV) CBCT acquired with the double rotation technique covering all the necessary structures from the larynx to the forehead. Stitched extended FOV CBCT image, one of the 360 (lateral) views used to reconstruct the 3D CBCT images (A). These 3D CBCT images can provide more accurate measurements than the 2D projection conventional cephalograms. Both the 3D CBCT images and 2D projections (cephalograms) made from these 3D CBCT images can be made from the CBCT data set (B).

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Fig. 2. — Three-dimensional analysis of maxillary protraction with intermaxillary elastics to miniplates. A,B: Three-dimensional CBCT reconstruction of the face pre-treatment (A) and after protraction (B) showing the retrognathia (black arrow) and correction after treatment (grey arrow). C,D: Clinical image of pre-treatment maxillary retrognathia (C) (black arrow) and correction after protraction (D) (grey arrow). E: Superimposed 3D laser acquired data on the CBCT acquired 3D reconstruction of the teeth (white arrows).

specific high referral pattern of these patients in our hospital (Table I). CBCT of the sinuses The first real CBCT application outside the dental and maxilla-facial field was sinus imaging. Several years ago low dose MDCT of the sinuses replaced the conventional Xrays of the sinuses and became the golden standard and it took a couple years again before it was challenged by CBCT. Nevertheless the first experiences were dental again and concerned odontogenic sinusitis and evaluation of the osteomeatal unit

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(OMU) in oral implant candidates (14-16). Many studies demonstrated that similar low dose scanning can be achieved with MDCT and CBCT. Low dose imaging is crucial as inflammatory sinus disease is often recurring and results in repetitive imaging requests. However, at such a low dose MDCT images become very “noisy”, are degraded by metal artifacts and still have a moderate spatial resolution in comparison with CBCT. Hence, although the radiation dose can be similar the MDCT image quality is no longer comparable with the quality provided by good and/or high-end CBCT’s. It is also important

to know that the use of a small FOV is one of the easiest ways to further reduce the radiation dose. Good collimation and planning allows imaging of the sinuses using a 8 cm (h) x 8cm (d) FOV instead of a 12 cm (h) x 12 cm (d) FOV which results in a 70% dose reduction. A major advantage of CBCT is that images have the same quality in all possible planes. This allows the ENT surgeon to evaluate the OMU and frontal sinus drainage anatomy in detail prior to acute or chronic sinusitis surgery (Fig. 5, 6). For this indication CBCT with the lowest possible radiation dose can be used and provides all

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F: Post-treatment AP image with only visualization of the teeth and the bone anchored miniplates (white arrows). G: Lateral view with superimposed pre- and post-treatment CBCT image of the teeth. Red color indicates displacement upper teeth by the treatment (grey arrows), green indicates that the structures were not displaced during the treatment. H,I: Superimposed pre- and post-treatment 3D CBCT soft tissue surface reconstructions showing that the treatment selectively corrected the retrognathia and overlying soft tissues (red color)(black arrows) while the other structures remained uninvolved (green color). Follow-up studies in young patients can only be justified when the radiation is very low and this became possible with the advent of CBCT. Courtesy: Prof. De Clerck H, St-Luc Hospital, UCL, Brussels, Belgium and Prof. Lucia Cevidanes, Chapel Hill, North Carolina, USA.

necessary information. Follow-up CBCT can also be justified then as the radiation dose is very low (Fig. 7). Other indications are diagnosis and follow-up of benign sinus and nasal cavity lesions (Fig. 8). The weakness of CBCT is that its “contrast resolution” is bad and that consequently the soft tissues cannot be evaluated. That is why a CBCT should be avoided in patients with a suspect lesion or proven malignant tumor (Fig. 9) or in patients presenting with neurological signs and/or deficits. In these patients the imaging modality of choice is MR. A large population has sinusitis and they of-

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ten require repetitive imaging. This explains the fast increase in the number of CBCT “sinus” studies accounting today for almost 38% of all the CBCT studies in our hospital. These CBCT sinus studies substitute the sinus studies on MDCT which increases the availability of these more expensive MDCT systems for more complex CT examinations. CBCT of the temporomandibular joint For many years conventional Xray’s were used to get a view on the temporomandibular joints (TMJ’s).

Lateral oblique transcranial (Schuller’s), posteroanterior (Towne’s) and caudocranial (Hirtz) views were very popular but were not always easy to acquire because of superposition of different structures on these 2D projection images. This explains why condylar fractures were one of the most missed fractures at that time. This problem was solved when CT and later MDCT were used to study the TMJ’s. On these 3D-images superposition of bony structures was of course no longer a problem but this was achieved at the cost of a higher radiation dose. With the advent of CBCT this radiation dose

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Fig. 3. — Patient with Gardner’s syndrome Three dimensional CBCT with reconstruction of the face and anterior skull showing the multiple osteomas which are typically found in patients with Gardner’s syndrome. These patients require repetitive imaging and hence low radiation dose CBCT is the perfect tool to keep the radiation dose low while providing 3D anatomical information.

↓ Fig. 4. — Oral cavity squamous cell carcinoma with mandibular destruction, pre-operative planning. A: Pre-operative diagnostic CBCT showing the mandibular destruction (arrow). B: Selection of the region which should be resected and reconstructed (red) (arrows). C: Computer simulation of the mandibular reconstruction, using bone grafts (arrows). D: Computer simulation of the fibular graft donor site on 3D MDCT images of the lower leg (arrows).

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Fig. 5. — Status after bilateral FESS in patient with chronic s inusitis. A-C: Coronal (A), axial (B) and sagittal (C) CBCT of the sinuses using a 8 x 8 cm FOV and a spatial resolution of 125 µm. Bilateral removal of the inferior turbinate, uncinate process, part of the medial wall of the maxillary sinus and major part of the ethmoid sinus. Bilateral remaining mucosal thickening and thickened appearance of the maxillary sinus walls confirming the “chronic sinusitis”.

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Fig. 6. — Anatomy of the frontal sinus drainage – preoperative assessment. A: Coronal 8 x 8 cm FOV CBCT with a spatial resolution of 125 µm. The uncinate process (white arrows) is attaching medially. Computer identification of the drainage pathway (green surface) shows that the frontal sinus drainage passes lateral to the uncinate process. If the frontal recess opens laterally to the uncinate process then an attempt to find the recess medial to the ethmoidal process would potentially lead to the olfactory fossa or the frontal lobe! Concha bullosa (grey arrow). Haller cell (white arrowhead). B: Axial CBCT image made at the level of the horizontal line on image Fig. 6A. Uncinate process (white arrow), frontal sinus drainage pathway (green surface).

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Fig. 7. — Repetitive imaging of the sinuses illustrating the need of “low dose” sinus imaging. A: Presurgical CBCT dentascan for planning of implant placement showing an insufficient height of the alveolar ridge on both sides (white arrows). The sinuses are incompletely visualized and the OMU cannot be assessed. B: CBCT of the sinuses performed 6 weeks later after a sinus lifting procedure was performed on both sides. On the left side the procedure is complicated by infection (black arrow) and the complete sinus is inflamed and now the OMU can be evaluated but a clear opening to the middle meatus cannot be recognized (grey arrow). C: Follow-up CBCT of the sinuses after 8 weeks showing that the inflammation cannot be controlled conservatively (black arrow). D: Follow-up CBCT of the sinuses after 26 weeks. The infected material used for the sinus lifting was removed and a bilateral FESS procedure was performed (white arrowheads). There is healing of the left alveolar ridge (white arrow) but there is still partial obliteration of both sinuses which needs treatment before a new attempt of sinus lifting is possible.

could be further reduced. This made CBCT the technique of choice to study bony pathology of the TMJ (17). The most frequent indications today to perform a CBCT of the TMJ are: osteoarthritis (Fig. 10), inflammatory arthritis, synovial chondromatosis, fractures (Fig. 11), ankylosis, developmental abnormalities, benign neoplasms etc. (18). The low radiation dose also made CBCT suited to perform follow-up studies for the evaluation of disease progression or treatment results. CBCT with a 15 cm FOV in the axial plane allows visualization of both TMJ’s (19) . However, TMJ pain and internal derangement is most often caused by a disc problem. The soft tissues of the TMJ and the disc cannot be visualized by CBCT and hence internal derangement problems should be studied using (pseudo)dynamic MR. Maxillofacial and nose trauma CBCT is well suited to detect maxillofacial and orbital fractures and its

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very high resolution and low radiation dose make it a better adapted imaging technique than MDCT. Moreover CBCT images have the same high quality in all possible planes, while the quality of the reformatted MDCT images is lower than the quality of the original in-plane axial MDCT images. This advantage of CBCT is best seen in patients with fractures at the level of the cribriform plate, orbita roof (Fig. 12) and orbital floor (Fig. 13) (20) which are easier to detect on coronal and sagittal CBCT images. This also explains why CBCT is very helpful in patients with CSF rhinorrhea where small fracture lines or breaches in the anterior or middle fossa must be detected. On the other hand CBCT has a very bad contrast resolution and therefore blood or soft tissue damage can hardly be evaluated. This explains why CBCT should no longer be used when clinical examination reveals potential intracranial, skull base or cranial nerve damage. Epidural and subdural hematomas, cerebral concussion and

bleeding, cranial nerve damage, intraorbital or globe lesions etc. can all be overlooked on CBCT and therefore these patients should immediately be referred for a MDCT or MR examination. Another CBCT indication is the evaluation of nose fractures. It is known that nasal fracture lines are missed on lateral and anteroposterior conventional X-ray’s in up to 50% of the cases. False positive diagnoses are caused by nasal fissures, false negative diagnoses by lateral wall (Fig. 14) and cartilage fractures which cannot be distinguished on these images. The latter have however consequences as patients with nasal septum damage need an open reduction procedure. The most frequent reason to use imaging in patients with nose fractures are the medico-legal context (52%), the “diagnostic” reason for the referral (29%), the detection of trauma related foreign bodies etc. But, as mentioned, 2D X-ray’s are often false negative and fractures or lesions of the septum and lateral nasal walls

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Fig. 8. — Maxillary sinus disease of odontogenic origin – keratocyst. A: Axial CBCT of the sinuses showing that the left maxillary sinus is completely opacified. The cortical lining of the lesion inside the walls of the maxillary sinus reveals that the lesion is of odontogenic origin (white arrows). B: Sagittal CBCT images through the left maxillairy sinus showing the cortical wall of the keratocyst (white arrows) and the upward displacement of the molar tooth, squeezed against the orbital floor (black arrow). C: Coronal CBCT images confirming the displacement of the molar tooth (black arrow).

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Fig. 10. — Osteoarthritis of the left TMJ. A: Sagittal CBCT of the right TMJ showing a normal joint space (white arrow) and condyle. B: Sagittal CBCT of the left TMJ with sclerosis of the condyle and an anterior osteophyte (grey arrow) and narrowing of the joint space (black arrow). C: Coronal CBCT of both TMJs. Normal joint space on the right side (white arrow), narrowed joint space (black arrow) and anteromedial condylar osteophyte on the affected left side (grey arrow).

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Fig. 9. — Inability of CBCT to visualize soft tissue lesions – squamous cell carcinoma of the ethmoid sinus invading the frontal lobes. A: Low dose (32µSv) coronal CBCT of the sinuses with a spatial resolution of 400µm. The destruction of the ethmoid cells, medial orbital walls (white arrows), and floor of the anterior fossa is obvious, however the extension of the tumor in the anterior fossa (black arrow) and nasal cavity (white arrowhead) cannot be assessed. B: Coronal gadolinium-enhanced T1-weighted MR image through the sinuses and anterior fossa showing the tumor extension in the anterior fossa (grey arrow), in the extraconal space of the left orbit (black arrow) and the extension down to the inferior meatus on the left side (white arrow).

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Fig. 11. — Undisplaced fracture of the left condyle. A-D: Axial CBCT image at the level of the upper (A) and lower (B) part of the condyles and coronal (C) and sagittal (D) CBCT image through the left condyle showing the intact condyle on the right and the fractures through the cortex of the left condyle (arrows) without any displacement of the latter.

Fig. 12. — Fracture through the anterior wall of the frontal sinus with extension in the orbital roof. A-B: Sagittal (A) and axial (B) CBCT image showing an impression fracture of the anterior wall of the frontal sinus (white arrows). C: Three-dimensional virtual reality CBCT reconstruction of the face showing the complex impression fracture of the frontal bone with an extension in the left orbital roof (black arrow).

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Fig. 13. — Fracture through the left orbital floor in a pregnant woman. A-B: Coronal (A) and sagittal (B) low dose CBCT (32 µSv) showing an inferior displaced segment of the orbital floor (white arrows). The small displaced segment is extremely well visualized even at the lowest irradiation dose and weakest possible resolution (0.4 mm) that can be achieved on CBCT. For further protection the patient was wearing a radiation protective coat during the examination.

Fig. 14. — Nose fractures (two different patients). A: 3D virtual reality CBCT reconstruction of the nose showing 2 fracture lines running through the right lateral wall of the nose (arrows). B: 3D virtual reality CBCT reconstruction of the nose showing a fracture through the bridge (white arrow) and the left lateral wall (black arrow) of the nose.

are more missed than detected (21). 3D imaging techniques are able to detect most of these fractures which remain invisible on the 2D X-ray’s. Nevertheless the use of conventional CT and MDCT was rejected because the much higher radiation dose did not match the questionable advantages, even in the more severe cases. The use of small FOV low dose 3D CBCT imaging changed this and it replaces today 2D X-ray imaging when imaging is needed or can be justified in these patients.

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Skull base - vertex Tumoral lesions of the skull base and vertex are best studied on MR. However, CBCT becomes valuable when calcifications inside the lesion must be demonstrated or excluded, and when a preoperative “bony” roadmap is required (Fig. 15, 16). Only the bone must be visible on these images and this explains why low dose high resolution CBCT can replace MDCT for these indications. Another indication to use low dose

CBCT is the evaluation of the thickness of the frontoparietal bone. This region is the harvest place for autologous calvarian split thickness bone grafts which are used to perform a “sinus lifting” or “bone augmentation” procedure in patients in whom not enough alveolar bone is available to warrant useful oral implant placement. These patients are scanned with their head and neck in anteflexion. In this position the upper jaw, the sinuses and the frontoparietal bone can be imaged together

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C A

and hence the radiation dose is kept to a minimum while “dentascan” information about the maxilla, potential sinus problems (sinusitis, problems at the level of the OMU) and the “thickness” of the cranial donor site can all be assessed on one single CBCT study (22). Once the grafts are taken from the donor site the latter is filled up with hydroxyapatite, lyofilised bone, or with pharmaceutical products like Palaco ® or Norian® (Fig. 17) Swallow test - pharyngography During a CBCT study 360 images are taken during the routine 20 second 360° rotation of the X-ray tube and flat panel detector around the patient’s head. This means that 18 images per second are acquired. This is a lot more than the 6-8 images/sec that can routinely be acquired with standard X-ray equipment and approaches the dynamic resolution

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Fig. 15. — Juvenile angiofibroma with skull base involvement. A: Sagittal Gd-enhanced T1-weighted images showing the enhancing angiofibroma (white arrow) with destruction of the floor of the sphenoid sinus and extension into this sinus (black arrow). B: Sagittal CBCT confirming the bony destruction at the central skull base (black arrow). C: Axial CBCT demonstrating the destruction of the vomer (black arrow) and anteromedial wall of the right vidian canal (white arrow). D: Coronal CBCT illustrating the destruction of the floor of the sphenoid sinus (black arrow).

of videofluoroscopy. Videofluoroscopy is today the imaging technique of choice to perform barium/Gastrografin swallow tests and pharyngography but is expensive and unavailable in many hospitals. In these hospitals CBCT might become a good alternative for a videofluoroscopy swallow study or video pharyngography. The dynamic resolution of CBCT remains inferior to that of videofluoroscopy but its spatial resolution is higher (Fig. 18) while the radiation dose, 50 µSv for 18 images/ second is lower than that of the conventional dynamic X-ray techniques which is 75 µSv for 6 images/second. Therefore one must be able to halt the CBCT rotation during the acquisition of the 360 images. This is today only available on some modified CBCT systems on which the feasibility was tested. It goes without saying that only CBCT systems made to study patients in the sitting position can be used for this application. The

results were excellent and it is clear that this technique has the potential to become the imaging technique of choice for sites where videofluoroscopy is not available. The major drawback is that the FOV only allows visualization of the oral cavity, nasopharynx, oropharynx, hypopharynx and larynx region and that the thoracic esophagus is not visualized. Therefore this technique cannot be used when the entire course of the oesophagus must be assessed but is ideally suited to perform pharyngo graphies. Temporal bone imaging Imaging of the temporal bone is challenging. The structures to be studied are extremely small and are located in or are surrounded by extremely dense bone. For many years conventional CT and MDCT were the preferred imaging techniques but a high radiation dose was needed. In-

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A C Fig. 16. — Chondrosarcoma with calcifications inside the tumor. A: Axial T2-weighted images showing a lesion at the level of the right petro-occipital fissure with very high signal intensity (white arrow), compatible with a chondrosarcoma. B: Coronal Gd-enhanced T1-weighted image through the lesions illustrates that it is a solid enhancing lesion (white arrow). C: Low dose axial CBCT shows the presence of calcifications (white arrows), supporting the diagnosis of chondrosarcoma, a diagnosis which was later histologically confirmed.

B deed, today temporal bone CT is probably one of the studies with the highest radiation burden. The resolution of these studies was situated between a routine moderate 625 µm and a highest achievable resolution of 230 µm. CBCT of cause had the potential to acquire images with a better spatial resolution of 75 -150 µm at a lower radiation dose (23). Depending on the technique and MDCT system used the radiation dose can be reduced to 50% and in some cases even to 14% when CBCT imaging is used. Another advantage is that CBCT is less sensitive to metal artifacts from metal containing pistons and middle ear implants, cochlear implants or from metal artifacts coming from outside the

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temporal bone (24-25)(Fig. 19). The major problem is however that this high resolution on CBCT can only be achieved with a long acquisition time of 40 seconds. This makes the technique vulnerable to movement artifacts and can result in the need for “retakes” resulting in a higher used radiation dose or even in a non-diagnostic study if the patients is not able to cooperate enough . Therefore the patient must be extremely well immobilized. This is more difficult in the sitting or standing position and therefore CBCT systems that can study the patients in the supine position are better suited for temporal bone imaging. The patients must also be instructed not to swallow and to breathe through the nose dur-

ing the scan as swallowing causes a movement of more than 100 µm and therefore severely degrades image quality. It is clear that small children and edentulous elderly patients or patients who are unable to co-operate enough are better studied using fast MDCT. In addition, more powerful X-ray tubes are needed to study the dense temporal bone structures. This is why today the best results are achieved when CBCT systems are used with an X-ray source which is able to deliver 110 kV and up to 10-20 mA. Even with these more powerful CBCT systems the image quality can still be degraded by noise when one is dealing with a “large or voluminous” head. In these patients it is wiser to go for a lower resolution of 150 µm providing images with a better contrast resolution and less noise. The development of more powerful CBCT systems could therefore again improve the quality of these temporal bone studies at a radiation dose lower or equal to the low dose protocols used today on the best MDCT systems. This would

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Fig. 17. — CBCT scanning protocol for preprosthetic cranial bone grafting of the atrophic maxilla Simultaneous CBCT imaging of the maxillary receptor site, sinuses and cranial donor site. A: Coronal CBCT through the frontoparietal vertex with the head slightly in anteflexion. This allows simultaneous scanning and visualization of the maxilla receptor site, sinuses and cranial donor site. Harvest place (white arrow). B: Axial CBCT through the parietal skull, harvest place (white arrow).

Fig. 18. — Dynamic CBCT, 18 frames per second, in a patient who underwent hemimandibular resection and reconstruction with a metal plate. The epiglottis shows a normal downward bending during swallowing (grey arrow) but in spite of this normal epiglottic function contrast is flowing down the trachea (white arrows). Contrast in the ventricle of Morgagni (black arrow).

be acceptable even at an equal radiation dose because the resolution and quality of the CBCT images would then be better than what can be achieved with MDCT in almost all patients. Moreover this could open the possibility of routine 75-85 µm imaging and/or faster acquisition (rotation) times. These more powerful systems are today only needed for temporal bone studies and some musculoskeletal (MSK) studies and are not needed for dental imaging. Hence access to these more powerful systems can then best be restricted to those users who are performing the above mentioned studies that might require a higher radiation dose. It is possible to image both temporal bones together (single rotation with a 15 x 5 cm FOV) or separately (two separated rotations with a 8 x 8 x 5 cm FOV). The radiation dose of both techniques is similar as is the image quality . In our experience the slightly higher resolution that is achieved when the temporal bones are imaged separately does

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Fig. 21. — CBCT double oblique reformatted high resolution images (150 µm resolution) of the middle ear in two patients with a congenital middle ear malformation. Stapedial artery (A), congenitally narrowed oval window/footplate (B). A: CBCT image in a patient presenting with tinnitus on the right side, demonstrating the presence of a stapedial artery between the crurae of the stapes (black arrow). Normal thickness of the footplate (white arrow). Notice the presence of a ventilation tube in the thickened drum. B: CBCT image in a patient with congenital conductive hearing loss on the left side. The posterior part of the oval window or footplate is calcified and thickened (white arrow). Only the anterior 2/3 of the oval window and/or footplate are open (black arrow). Capitulum of the stapes with attachment of the stapedius muscle tendon (grey arrow).

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Fig. 19. — CBCT used to verify the position of a cochlear implant (Cochlear Nucleus Freedom with 22 electrode-array contact points). A: Parasagittal CBCT reconstruction through the electrode array showing the 22 electrode contacts without any metal artefacts. Normal position inside the cochlea with the first electrode (1) inside the basal turn. B: Axial CBCT image through the basal turn of the cochlea demonstrating the normal position of the electrode array inside the scala tympani (1) with a normal open scala vestibuli (2).

Fig. 20. — CBCT in a patient with conductive hearing loss: lysis of the incudostapedial junction on the right side. A: Axial CBCT of the right middle ear with a spatial resolution of 150 µm showing demineralization of the lenticular process of the incus (white arrow) and stapes capitulum (grey arrow). Surgery confirmed the findings and the ossicular chain was repaired. B: Axial CBCT of the left middle ear showing the normal mineralization of the lenticular process of the incus (white arrow) and stapes capitulum (grey arrow).

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Fig. 22. — CBCT double oblique reformatted high resolution images (150 µm resolution) of the middle ear in two different patients with otosclerosis. A: Fenestral otosclerosis with a thickened grayish appearance of the footplate (black arrow). The fissula antefenestram is normal. Type 1 (Veillon) otosclerosis. Compare with the normal thickness of the footplate in B. B: Fenestral otosclerosis with a hypodens otospongiosis area in the fissula antefenestram (grey arrow), just anterior to the footplate with a size of less than 1 mm. Type 2a (Veillon) otosclerosis. Normal thickness of the footplate (white arrow).

not justify the 100% more time that must be invested. Preliminary results of an ethical committee approved comparative study between CBCT and MDCT showed that the majority of the checked anatomic structures were better or even only seen on CBCT (20) and the superiority of CBCT over MDCT was more pronounced in the coronal plane. This is explained by the fact that the coronal MDCT images are reformatted and this is needed as the radiation dose in the axial plane is already relatively high making additional separate scanning in the coronal plane unacceptable. The higher resolution allows making diagnoses which could not be made or were more difficult to make with MDCT and apply for lesions of the external, middle and inner ear (26). In patients with chronic otitis media the lysis of the lenticular process or long process of the incus (Fig. 20), inflammatory changes between incus and malleus, subtle tympanosclerosis, incudostapedial luxation, the thin walls of the cholesteatoma sac fol-

lowing auto evacuation, etc. can all be seen on CBCT images. The higher resolution of CBCT also makes it easier to detect ossicular fractures, dehiscent facial nerve canals, congenital inner and middle ear malformations etc (Fig. 21). The diagnosis of a congenital middle and/or inner ear malformation frequently has to be made early in life and in these very young patients the CBCT study has to be performed under anesthesia, hence anesthetic gases must be available in the CBCT room. A MR study is most often also required for inner ear malformations which are then performed during the same anesthesia session. The major gain of CBCT over MDCT is in the detection of otosclerosis, stapes – stapes footplate – oval window (Fig. 22), and dehiscent superior semicircular canal lesions (Fig. 23). The subtle changes on the footplate or at the fissula antefenestram in otosclerosis, can sometimes only be detected on CBCT. The use of high resolution CBCT also allows detection of stapes, footplate/oval window abnor-

malities and lesions caused by congenital malformation (e.g. aplasia of the stapes or crura of the stapes, aplasia or hypoplasia of the oval window) by chronic otitis media (e.g. tympanosclerosis with calcifications on stapes and/or footplate), etc. Finally, the positive MDCT diagnosis of superior semicircular canal dehiscence or “third window) is often corrected as negative on CBCT as the very thin bony wall of the superior semicircular canal is only detectable on images with a resolution close to 100 µm. The above explains why CBCT has the potential to and is already replacing MDCT. The main reason why CBCT is not used for temporal bone imaging today are availability of a high quality CBCT (today only 3 to 4 CBCT systems have the quality to perform temporal bone studies), the longer acquisition time – computer calculation time – slower and more complicated workstation, and the less user friendly and more time consuming “PACS” connection. From the diagnostic and quality point of view CBCT is ready

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Fig. 24. — Fracture of the lunate and scaphoid bone, missed on conventional X-rays. A-B: Axial 150 µm resolution images through the wrist showing a subtle non-displaced fracture through the anterior part of the lunate bone (white arrow) and through the posterior part of the scaphoid bone (black arrow) which could only be demonstrated on CBCT.

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Fig. 23. — Dehiscent superior semicircular canal imaging: positive on MDCT, negative on CBCT A: Reformatted coronal CT image shows a dehiscent superior semicircular canal (white arrow). In order to reduce the dose the patient was scanned in the axial plane and coronal reformatted images, with some loss of resolution as a consequence, were made. B-C: Coronal (B) an paracoronal CBCT images parallel to the superior semicircular canal (C) with the same resolution (150 µm) and quality as the axial images and which can therefore show the thin bony wall of the superior semicircular canal (black arrow).

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Fig. 25. — CBCT-arthrography in a patient with osteochondritis dissecans of the elbow. A-B: Coronal (A) and sagittal (B) high resolution 150 µm CBCT images through the elbow showing a loose body and the destructed cartilage at the level of the capitulum of the humerus (white arrow) and a second loose body proximal to the trochlea (black arrow). Bone erosions/defects (grey arrows).

to replace MDCT and its superiority will only increase with the ongoing technical improvements of CBCT systems. Musculoskeletal imaging

Fig. 26. — Non-union of a scaphoid bone fracture, follow-up after surgery. Fractures through the scaphoid bone treated with a scaphoid bone screw. Notice the non-union of the fractures (white arrows) and the absence of metal artefacts.

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Patients were examined in the sitting or standing position on almost all of the first available CBCT systems. Therefore the only MSK structure that was examined at that time was the cervical spine. However the initial CBCT systems couldn’t provide the needed spatial resolution and quality to match the quality of MDCT. Even with the advent of more powerful CBCT systems the visualization of the lower cervical vertebra remained a problem. Even the latest most powerful CBCT systems are unable to deliver X-rays which can visualize the lower cervical vertebra after passing through the shoulders. Also the limited field of view makes visualization of the “entire” cervical spine difficult in larger patients. Nevertheless the newer high-end

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Fig. 27. — Follow-up study after arthrodesis procedure of the ankle. Coronal (A) and sagittal (B) high resolution (150 µm) images of the ankle show the presence of three screws which are hardly disturbing the visualization of the surrounding bone. The joint space between the tibia and talus is still open (black arrows) and there is also bone resorption around the screws (white arrows) confirming the clinical doubt about normal evolution to arthodesis.

Fig. 28. — Sialolithiasis in Wharton’s duct Axial (A) and coronal (B) CBCT through the floor of the mouth showing a duct stone in Wharton’s canal (white arrows).

CBCT systems proved their value in the evaluation of local bone lesions and in difficult cases where metal artifacts on MDCT and MR make evaluation of the vertebra impossible. Musculoskeletal CBCT became possible with the advent of systems that looked like a small CT and that could examine the patient in the su-

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pine position on a trolley or systems with a ring design through which an arm or leg could be put. Again resolution and image quality were very variable depending on the system. The best systems however offer 100125 µm high quality images of the fingers, wrist (27), elbow, foot, ankle and knee and are also able to image

long bones of the extremities, even when osteosynthetic bone-plates and screws are present (28). And above all this is achieved at a lower radiation dose than on MDCT. Hence CBCT is gradually replacing MDCT and MR replaces MDCT when soft tissue information is needed. Detection of fractures which are invisible

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or doubtful on conventional X-rays, verification of healing fractures and non-union especially when osteosynthetic material is present (29), assessment of benign tumors and degenerative changes of the bony structures, arthrography (30) etc. are some of the excellent CBCT applications in the extremities and the above mentioned joints. Musculoskeletal CBCT is today already the fastest growing new indication and in the future more powerful systems using larger flat panel detectors could even increase the share of this application. Miscellaneous imaging A less frequent indication is the diagnosis of salivary gland calculi when ultrasound cannot solve this problem. The high resolution and low radiation dose make CBCT suited to detect these calculi (31). Moreover these calculi often occur in younger patients and in the areas close to the eyes, two reasons to go for the technique with the lowest radiation dose. CBCT sialography is another new possible technique (32). A different less frequent indication is dacryocystography. It is possible to put some Iodine containing contrast material in the eye and to visualize the lacrimal canaliculi and sac with CBCT and to check if the nasolacrimal duct is patent. Again CBCT offers high resolution at a low radiation dose which is important in this area so close to the lens. CBCT is also used for 3D-analysis of the airway in patients with cleft lip and/or palate (33), obstructive sleep apnea (34) and in patients who underwent orthognatic surgery (35). Endodontics - Periodontology As described above, CBCT vendors developed high-end systems which enabled sinus, temporal bone and MSK imaging. The very high resolution that can be achieved with these systems in turn opened new possibilities in the endodontic and periodontal field. Visualisation of a fourth molar tooth root canal, tooth ankylosis, subtle dental fractures, evaluation of the dental development stage etc. are only some of the many new indications but this is beyond the scope of this “non-dental applications” paper. References 1. Casselman J.W., Quirynen M., Lemahieu S.F., Baert A.L., Bonte J.:

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JBR–BTR, 2013, 96 (6) Computed tomography in the determination of anatomical landmarks in the perspective of endosseous oral implant installation. J Head Neck Pathol, 1988, 7: 255-264. 2. Jacobs R.: Dental cone beam CT and its justified use in oral health care. JBR-BTR, 2011, 94: 254-265. 3. Pauwels R., Beinsberger J., Collaert B., Theodorakou C., Rogers J., Walker A., Cockmartin L., Bosmans H., Jacobs R., Bogaerts R., Horner K.: The SEDENTEX CT project consortium: effective dose range for dental cone beam computed tomography scanners. Eur J Radiol, 2012, 81: 267-271. 4. Loubele M., Bogaerts R., Van Dijck E., Pauwels R., Vanheusden S., Suetens P., Marchal G., Sanderink G., Jacobs R.: Comparison between effective radiation dose of CBCT and MSCT scanners for dentomaxillofacial applications. Eur J Radiol, 2009, 71: 461-468. 5. Ludlow J.B., Ivanovic M.: Comparative dosimetry of dental CBCT devices and 64-slices CT for oral and maxillofacial radiology. Surg Oral Med Oral Pathol Oral Radiol Endod, 2008, 106: 106-114. 6. Miracle A.C., Mukherji S.K.: Conebeam CT of the head and neck, part 1: physical principles. AJNR Am J Neuroradiol, 2009, 30: 1088-1095. 7. Miracle A.C., Mukherji S.K.: Conebeam CT of the head and neck, part 2: clinical applications. AJNR Am J Neuroradiol, 2009, 30: 1285-1292. 8. De Vos W., Casselman J., Swennen G.R.J.: Cone-Beam computerized tomography (CBCT) imaging of the oral and maxillofacial region : A systematic review of the literature. Int J Oral Maxillofacial Surg, 2009, 38: 609-625. 9. Olszewski R., Cosnard G., Macq B., Mahy P., Reychler H.: 3D CT-based cephalometric analysis: 3D cephalometric theoretical concept and software. Neuroradiol, 2006, 48: 853-862. 10. Swennen G.R., Schutyser F.: Threedimensional cephalometry: spiral Multi-slice vs conebeam computed tomography. Am J Orthod Dentofacial Orthop, 2006, 130: 410-416. 11. De Clerck H., Nguyen T, Koerich de Paula L., Cevidanes L.: Three-dimensional assessment of mandibular and glenoid fossa changes after bone-anchored Class III intermaxillary traction. Am J Orthod Dentofacial Orthop, 2012, 142: 25-31. 12. Albuquerque M.A., Gaia B.F., Cavalcanti M.G.P.: Comparison between multislice and cone-beam computerized tomography in the volumetric assessment of cleft palate. Med Oral Pathol Oral Radiol Endod, 2011, 112: 249-257. 13. Wörtche R., Hassfeld S., Lux C.J., Müssig E., Hensley F.W., Krempien R., Hofele C.: Clinical application of cone beam digital volume tomography in children with cleft lip and palate. Dentomaxillofac Radiol, 2006, 35: 88-94. 14. Zoumalan R.A., Lebowitz R.A., Wang E., Yung K, Babb J.S., Jacobs J.B.:

Flat panel conebeam computed tomography of the sinuses. Otolaryngology-Head and Neck Surgery, 2009, 140: 841-844. 15. Maillet M., Bowles W.R., McClanahan S.I., John M.T., Ahmad M.: Conebeam computed tomography evaluation of maxillary sinusitis. J Endod, 2011, 37: 753-757. 16. Pazera P., Bornstein M.M., Pazera A., Sendi P., Katsaros C.: Incidental maxillary sinus findings in orthodontic patients: a radiographic analysis using cone-beam computed tomography (CBCT). Orthod Craniofac Res, 2011, 14: 17-24. 17. Zain-Alabdeen E.H., Alsadhan R.I.: A comparative study of accuracy of detection of surface osseous changes in the temporomandibular joint using multidetector CT and cone beam CT. Dentomaxillofacial Radiol, 2012, 41: 185-191. 18. Barghan S., Tetradis S., Mallya S.M.: Application of cone beam computed tomography for assessment of the temporomandibular joints. Australian Dental J, 2012, 57: 109-118. 19. Librizzi Z.T., Tadinada A.S., Valiyaparambil J.V., Lurie A.G., Mallya S.M.: Cone-beam computed tomography to detect erosions of the temporomandibular joint: effect of field of view and voxel size on diagnostic efficacy and effective dose. Am J Orthod Dentofacial Orthop, 2011, 140: e25-e30. 20. Shintaku W.H., Venturin J.S., Noujeim M.: Applications of conebeam computed tomography in fractures of the maxillofacial complex. Dental Traumatology, 2009, 25: 358366. 21. Oluwasanmi A.F., Pinto A.L.: Management of nasal trauma – widespread misuse of radiographs. Brit J Clin Governance, 2000, 5: 83-85. 22. De Ceulaer J, Swennen G, Abeloos J, De Clercq C.: Presentation of a conebeam CT scanning protocol for preprosthetic cranial bone grafting of the atrophic maxilla. Int J Oral Maxillofac Surg, 2012, 41 : 863-866. 23. Dahmani-Causse M., Marx M., Deguine O., Fraysse B., Lepage B, Escudé B.: Morphologic examination of the temporal bone by cone beam computed tomography: comparison with multislice helical computed tomography. Eur Ann Otorhinolaryng Head and Neck diseases, 2011, 128: 230-235. 24. Ruivo J., Mermuys K., Bacher K., Kuhweide R., Offeciers E., Casselman J.W.: Cone beam computed tomography, a low-dose imaging in the postoperative assessment of cochlear implantation. Otol Neurotol, 2009, 30: 299-303. 25. Trieger A., Schulze A., Schneider M., Mürbe D.: In vivo measurements of the insertion depth of cochlear implant arrays using flat-panel volume computed tomography. Otol Neurotol, 2010, 32: 152-157. 26. Penninger R.T., Tavassolie T.S., Carey J.P.: Cone-beam volumetric tomogra-

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phy for applications in the temporal bone. Otol Neurotol, 2011, 32: 453-460. 27. De Cock J., Mermuys K., Goubau J., Van Petegem S., Houthoofd B., Casselman J.W.: Cone-Beam computed tomography: a new low dose, high resolution technique of the wrist, presentation of three cases with technique. Skeletal Radiol, 2012, 41: 93-96. 28. Zbijewski W., De Jean P., Prakash P., Ding Y., Stayman J.W., Packard N., Senn R., Yang D., Yorkston J., Machado A, Carrino J.A., Siewerdsen J.H.: A dedicated cone-beam CT system for musculoskeletal extremities imaging: design, optimization, and initial performance characterization. Am Assoc Phys Med, 2011, 38: 47004713. 29. Smith E.J., Al-Sanawi H.A., G ammon B., St. John P.J., Pichora D.R., Ellis R.E.: Volume slicing of cone-beam com-

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CONE BEAM CT — CASSELMAN et al puted tomography images for navigation of percutaneous scaphoid fixation. Int J CARS, 2012, 7: 433-444. 30. Wihlm R.R., Le Minor J.-M., Schmittbuhl M., Jeantroux J., Mac Mahon P., Veillon F., Dosch J.-C., Dietemann J.-L., Bierry G.: Cone-beam computed tomo graphy arthrography: an innovative modality for the evaluation of wrist ligament and cartilage injuries. Skeletal Radiol, 2012, 41: 963-969. 31. Dreiseidler T, Ritter L, Rothamel D, Neugebauer J, Scheer M, Mischkowski R.A.: Salivary calculus diagnosis with 3-dimensional cone-beam computed tomography. Oral Maxillofacial R adiol, 2010, 110: 94-100. 32. Li B., Long X., Cheng Y., Wang S.: Cone beam CT sialography of stafne bone cavity. Dentomaxillofac Radiol, 2011, 40: 519-523. 33. Yoshihara M., Terajima M., Yanagita

353 N., Hyakutake H., Kanomi R., Kitahara T., Takahashi I.: Three-dimensional analysis of the pharyngeal airway morphology in growing Japanese girls with and without cleft lip and palate. Am J Orthod Dentofacial Orthop, 2012, 141: S92-101. 34. El A.S., El H., Palomo J.M., Baur D.A.: A 3-dimensional airway analysis of an obstructive sleep apnea surgical correction with cone beam computed tomography. J Oral Maxillofac Surg, 2011, 69: 2424-2436. 35. Park S.B., Kim Y.I. Son W.S., Hwang D.S., Cho B.H.: Cone-beam computed tomography evaluation of short- and long-term airway change and stability after orthognatic surgery in patients with Class III skeletal deformities: bimaxillary surgery and manbibular setback surgery. Int J Oral Maxillofac Surg, 2012, 41: 87-93.

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A Rare Cause of Intraabdominal Hematoma: Rupture of Mesenteric Artery Branch Aneurysm Y. Gunduz1, S. Sipahi2 , R. Kara1, A. Tamer3 Superior mesenteric artery (SMA) aneurysm is the third most common splanchnic artery aneurysm. Unlike other splanchnic artery aneurysm, isolated aneurysms of the SMA branches are rare. They are usually asymptomatic and difficult to detect until they rupture and cause abdominal pain and hypovolemic shock. Thus, most cases are diagnosed after the occurrence of complications. In this report, we described a 76 year-old woman who had two saccular aneurysms in the superior mesenteric arterial branch(es). One of them was ruptured and partly thrombosed. The patient had acute renal failure secondary to massive intraabdominal hemorrhage. Key-words: Aneurysm, mesenteric.

Superior mesenteric artery aneurysm (SMA) is the third most common splanchnic artery aneurysm, accounting for 5.5% of these lesions (1). Unlike other splanchnic artery aneurysm, isolated aneurysms of the SMA branches are rare. They are usually asymptomatic and difficult to detect until they rupture and cause abdominal pain and hypovolemic shock. Thus, most cases are diagnosed after the occurrence of complications (2). The aim of this case report was to describe the imaging features of two saccular superior mesenteric artery aneurysms that one of them thrombosed and ruptured and created acute renal failure secondary to a giant abdominal hematoma. Case report A 76-year-old woman with hypertension and diabetes was admitted to the emergency department with a 24-hour history of epigastric pain. She also reported several episodes of nausea and vomiting associated with dizziness. Upon admission to the hospital, physical examination revealed abdominal tenderness and a vague mass on palpation. The patient was hypotensive (systolic blood pressure = 80 mmHg), tachycardic (heart rate = 126 beats per minute) and her hemoglobin level was 8.8 g/dL. The patient was stabilized with 2 liters of crystalloid solution. An urgent abdominal ultrasono graphy revealed a large mass 10 x 6.5 cm. Laboratory findings showed an extremely high level of mg/dL and serum creatinine 9.8

Fig. 1. — Cross-sectional imaging with noncontrast CT shows intraabdominal hypodense mass lesion.

blood urea nitrogen 222 mg/dL levels. A computed tomography scan of the abdomen was performed without intravenous administration of contrast material due to the patient’s increased creatinine level, it revealed a massive intraabdominal hematoma (Fig. 1). After first evaluation, because the patient had acute tubular necrosis progressing to acute renal failure, she was urgently started and maintained on hemodialysis for several times. After hemodynamic and clinical stabilisation, CT angiography and MR imaging with contrast was performed and demonstrated two

From: Department of 1. Radiology, 2. Nephrology, 3. Internal Medicine, Sakarya University Medical Faculty, Sakarya, Turkey. Address for correspondence: Dr Y. Gunduz, M.D., Sakarya University, Medical Faculty, Department of Radiology, 54100 Korucuk, Sakarya, Turkey. E-mail: dryasemingunduz@yahoo.com

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saccular aneurysms arising from anterior side branche of the SMA (probably middle colic artery) adjacent to the transverse colon and that a collection compatible with hematoma contrasted circumferential wall but no in central zone (Fig. 2, 3, 4). The larger measured 26 mm in diameter and it was ruptured and partial thrombosed, and the smaller one measured 7 mm in diameter. Surgical repair was performed through a midline transperitoneal approach under general anesthesia. The surgeon performed ligations of arterial branches with true aneurysms. The patient’s postoperative course was excellent. Discussion SMA aneurysm is the third most common splanchnic artery aneurysm, accounting for 5.5% of these

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Fig. 2. — T1-weighted contrast enhanced fat-suppressed axial plane (A) shows that a collection compatible with hematoma contrasted circumferential wall but no in central zone. T1-weighted contrast enhanced fat-suppressed axial plane (B) shows two saccular aneurrrsyms arising from side branches of the SMA adjacent to posterior side of the transverse colon and containing dense and homogen contrast material in the lumen like abdominal aorta.

Fig. 3. — CT angiography (A) showing that two saccular aneursyms that on the left had partially thrombosed dissecting lumen and dens contrast material within both aneurysm sac like aortic lumen. CT angiogram in the coronal plane (B) demonstrates that a saccular aneurysm containing diffuse contrast material and partial thrombosis in the lumen and a hematom which is right posteroinferor side of aneurysm and in contact with it.

lesions (1). These aneurysms may be saccular or fusiform and are most commonly placed at the first proximal 5 cm of the artery. The most common cause of SMA aneurysm is considered to be infection; however a recent report suggested that an infectious etiology accounted for less than 5% of these aneurysms. Other causes include atherosclerosis, connective tissue disease, cystic medial necrosis, pancreatitis and trauma (3). However, the etiology of the superior mesenteric aneurysm in our patient has not been established. The most common symptom is intermittent abdominal discomfort that progresses to persistent severe

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epigastric pain. Nausea, vomiting, hemobilia, jaundice and gastrointestinal bleeding may occur occasionally. SMA aneurysms may thrombose, causing mesenteric ischemia or rupture, resulting in excessive hemorrhage, thus rupture is the most fatal complication and when occured mortality rate reaches up to 30% (4). In our patient, SMA aneurysm was ruptured and she had acute renal failure caused by significant bleeding into intraabdominal space and in our opinion the hematoma is located in the transverse mesocolon or in the mesenterium. Arteriography is an excellent interventional tool, which can be used

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for both detection and treatment in an acute setting. In practice however, multidetector CT angiography is probably the most frequently used technique for the diagnosis. Recent advances in CT vascular imaging and multi-detector CT with 3D postprocessing allows for an accurate representation of vascular course and caliber (5, 6). Intimal flap and mural thrombus are key factors for diagnosing rupture and dissection at the SMA using contrast-enhanced CT images. However, the intimal flap cannot always be detected; therefore, the mural thrombus might be the only imaging evidence. In addition, contrast enhanced 3D MR angiography and ultrasound are also widely used and they have provided a highly accurate representation of abdominal splanchnic vessels (7, 8). In our patient, abdominal USG revealed a large mass 10 x 6.5 cm. After clinical stabilisation CT angio graphy with contrast showed two saccular aneurysms arising from anterior side branche of the SMA adjacent to the transverse colon. The larger aneursym was ruptured and a significant amount of intraluminal thrombus. SMA aneurysms should be treated sooner once the diagnosis is established in order to minimize morbidity and mortality (4, 9). Several methods of treatment of SMA aneurysm have been reported including ligation of the SMA with or without excision, obliterative aneurysmorrhaphy, revascularization of the SMA with autogenous vein graft or prosthetic graft, and recently endovascular placement of the covered stent grafts (3). Surgery was performed to our patient because of the size, thrombus formation in the sac, the risk of intestinal ischemia and presence of massive bleeding. The surgeon performed ligations of arterial branches with true aneurysms under general anesthesia. The patient’s post operative course was uneventful. In conclusion, the purpose of this report is to describe the pitfalls of diagnosis and define an appropriate management strategy in patients with SMA branch aneursym. SMA aneursym should be suspected in all patients complaining of abdominal or back pain, hypotension, and presenting with a pulsatile mass. The mass may be obscured in patients with a large abdominal circumference. An episode of syncope can be indicative of orthostatic hypotension secondary to bleeding. Early diagnosis would be useful, since the natural

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Fig. 4. — T1-weighted contrast enhanced fat-suppressed, coronal plane (A) shows a saccular aneurysm arising from side branche of the SMA observing a homogeneous and intense contrast in the lumen. T1-weighted contrast enhanced fat-suppressed, coronal plane (B) shows that a collection suggesting hematoma contrasted circum ferential wall and extending from the left posterolateral wall of saccular aneurysm.

course can be tragic without timely treatment. References 1. Kopatsis A., D’Anna J.A., Sithian N., Sabido F.: Superior mesenteric artery aneurysm: 45 years later. Am Surg, 1998, 64: 263-266.

2. Masayuki A., Masashi J., Yoshio M.: Spontaneous dissecting aneurysm of the main trunk of the superior mesenteric artery. Jpn J Surg, 1995, 25: 468470. 3. Stanley J.C., Zelenock G.B.: Splanchnic artery aneurysms. In: Rutherford R.B., editor. Vascular Surgery. 4th ed. Philadelphia: WB Saunders; 1995, pp 1572-1573.

4. Carr S.C., Mahvi D.M., Hoch J.R., Archer C.W., Turnipseed W.D.: Visceral artery aneurysm rupture. J Vasc Surg, 2001, 33: 806-811. 5. Moll F.L., Powell J.T., Fraedrich G., Verzini F., Haulon S., Waltham M., et al.: European Society for Vascular Surgery. Management of abdominal aortic aneurysms clinical practice guidelines of the European society for vascular surgery. Eur J Vasc Endovasc Surg, 2011, 41 Suppl 1: S1S58. 6. Grierson C., Uthappa M.C., Uberoi R., Warakaulle D.: Multidetector CT appearances of splanchnic arterial pathology. Clin Radiol, 2007, 62: 717723. 7. Tsai H.Y., Yang T.L., Wann S.R., Yen M.Y., Chang H.T.: Successful angiographic stent-graft treatment for spontaneously dissecting broadbase pseudoaneurysm of the superior mesenteric artery. J Chin Med Assoc, 2005, 68: 397-400. 8. Kaufman J.A., Geller S.C., Petersen M.J., Cambria R.P., Prince M.R., Waltman A.C.: MR imaging (including MR angiography) of abdominal aortic aneurysms: comparison with conventional angio graphy. AJR, 1994, 163: 203-210. 9. Lee W.A.. Superior mesenteric artery aneurysm reconstruction. J Vasc Surg, 2003, 37: 1131.

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Hemangiomatosis of the spleen in a patient with KlippelTrénaunay syndrome S. Dekeyzer1-2, B. Houthoofd1, A. De Potter3, M. Van Bockstal3, P. Smeets1, D. Vogelaers2 Klippel-Trénaunay syndrome is a rare disorder characterized by a triad of port-wine stains, varicose veins, and bony and soft tissue hypertrophy usually involving an extremity. Visceral involvement in Klippel-Trénaunay syndrome is rare, but has been described in the colon, small bowel, bladder, kidney, spleen, liver, mediastinum and brain. In this paper we present the case of a 45-year-old woman with Klippel-Trénaunay syndrome in whom routine physical examination unexpectedly revealed the presence of a left upper quadrant mass. Abdominal US, contrast enhanced CT and whole-body PET-CT demonstrated multiple large cystic lesions within a massively enlarged spleen. Based on the clinical history and imaging findings diffuse hemangiomatosis of the spleen was suspected. This diagnosis was confirmed by pathologic examination after splenectomy. Key-words: Spleen, diseases – Angioma.

Hemangioma is the most common primary benign neoplasm of spleen and usually represents a small localized tumor. Diffuse hemangiomatosis of the spleen is a variant of hemangioma in which the splenic parenchyma is widely replaced by vascular proliferations. This condition may be confined to the spleen or may occur as a manifestation of systemic angiomatosis. Associations of splenic hemangiomatosis with Beckwith-Wiedeman syndrome, KlippelTrénaunay syndrome and blue rubber bleb naevus syndrome have been reported. In this paper we present the case of a patient with KlippelTrénaunay syndrome with an incidentally discovered splenomegaly caused by diffuse hemangiomatosis. This case-report emphasizes the importance of the presence of visceral vascular malformations in patients with Klippel-Trénaunay syndrome. Case presentation A 45-year-old woman with Klippel-Trénaunay syndrome presented at our hospital with a 2,5 year history of daily attacks of breathlessness and palpitations, often accompanied by faintness and paresthesias in the hands and mouth. The symptom pattern was very suggestive of chronic hyperventilation attacks and further questioning revealed that the patient had been living under a lot of stress the last couple of years. The patient also mentioned a chronic left hypochondrial pain.

On physical examination chest and heart sounds were normal. Varicose veins and cutaneous capillary malformations were observed on the upper left leg along with soft tissue hypertrophy leading to an increase in the girth of the leg. Physical examination of the abdomen unexpectedly revealed the presence of a left upper quadrant mass extending from the costal margin to the pelvis which was tender to palpitation. On abdominal ultrasound (US) multiple large cystic lesions were observed within a massively enlarged spleen (Fig. 1). Complementary contrast enhanced abdominal computed tomography (CT) demonstrated a significantly enlarged spleen with multiple large and several smaller cystic lesions involving the entire spleen (Fig. 2). A whole-body PET-CT was performed to exclude the possibility of cystic splenic metastases from an unknown primary. No FDGcaptation was observed in or surrounding any of the lesions on PETCT and no other lesions suggestive of neoplasm could be observed (Fig. 3). Routine serum biochemistry was normal without evidence of hypersplenism on the peripheral blood picture. Echinococcus serology was negative. For diagnostic reasons, but also in view of the size of the spleen and the presence of chronic left hypochondrial pain, elective splenectomy was performed. Macroscopic and microscopic examination revealed the presence of multiple cavernous

From: 1. Department of Radiology, 2. General Internal Medicine, Infectious Diseases and Psychosomatic diseases, 3. Anatomical Pathology, Universitair Ziekenhuis (University Hospital) Gent, Ghent, Belgium. Address for correspondence: Dr S. Dekeyzer, M.D., Bijlokestraat 17, 9070 Destelbergen, Belgium. E-mail: sven.dekeyzer@Ugent.be

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hemangiomas with large, central fluid containing cavities, replacing the entire splenic parenchyma (Fig. 4). The patient’s postoperative period was uneventful, and she was discharged home after 1 week. Discussion In 1900 the French physicians Klippel and Trénaunay described two patients who presented with a triad of varicose veins, port-wine stain and bony and soft tissue hypertrophy of an extremity. In 1918 Parkes-Weber described a patient with a similar triad and the additional finding of arteriovenous fistulae. Today, some authors use the term Klippel-Trénaunay-Weber syndrome to describe those patients who have clinically significant arteriovenous malformations as a component of their Klippel-Trénaunay syndrome. Other authors prefer to separate the original triad and the triad with the addition of arteriovenous malformations and use the term Parkes-Weber syndrome to describe this latter condition (1). Making the distinction is probably wise given the increased morbidity associated with arteriovenous malformations. Today Klippel-Trénaunay syndrome (KTS) is defined as a combination of capillary cutaneous malformations, varicose veins or venous malformations and bony or soft tissue hypertrophy (1). Usually this triad is isolated to one extremity; however, multiple extremity, unilateral and even whole body involvement have been reported. While the leg is the most commonly affected site, the arms, trunk and rarely the head may also be involved. The syndrome affects males and females equally, has no racial predilection, and manifests at birth or during early infancy or childhood. The lower limb is the site

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Fig. 1. — Abdominal US showed a massively enlarged spleen with several large anechogenic cystic lesions.

Fig. 3. — No FDG-captation was observed in or surrounding any of the lesions on PET-CT examination. No lesions suggestive for primary neoplasm were observed. Notice the presence of the extensive vascular malformation in the left thigh.

In the general population splenic hemangiomas, although unusual, represent the most common benign primary tumor of the spleen with an Fig. 2. — Venous phase contrast-enhanced abdominal CT overall incidence of 0.03%-14.5% showed and enlarged spleen with multiple large and several based on autopsy findings (13). smaller cystic lesions. No contrast enhancing lesions were Splenic hemangiomas are usually observed. less than 2 cm in size, only rarely attain a large size and may appear single or multiple. In KTS generally of malformations in approximately significant cause of morbidity and 95% of patients and lesions are usumortality. In patients with gastro- multiple lesions are observed. Hemangioma of the spleen usually has a ally limited to the skin (1). intestinal or genito-urinary tract insilent clinical picture. However, large Vascular malformations may involvement bleeding is the most reor multiple lesions causing signifivolve other areas than the affected ported symptom and this can range cant splenomegaly may lead to fullextremity and may vary in their from occult blood loss to massive, ness and left upper quadrant disdepth of involvement as well as in life-threatening hemorrhages and comfort. At microscopic examination their surface area distribution. Some consumptive coagulopathy. Splenic hemangiomas are characterized by vascular malformations extend to involvement in patients with KTS an unencapsulated proliferation of the muscle or bone of an affected has been documented in the form of dilated vascular channels that are extremity or even engage visceral splenomegaly due to splenic vein lined with a single layer of endotheorgans. Visceral involvement in pastenosis (7), hemangiolymphangiolium and filled with red blood cells. tients with KTS is rare, but has been matosis (8), lymphangiomatosis (9) The vascular channels that form described in the small bowel (2), and hemangiomatosis (10). In our splenic hemangiomas vary in size colon (3), bladder (4), kidney (5), patient pathologic analysis showed from capillary to cavernous. Microliver (6), spleen (7-10), mediastithat the observed splenic lesions scopically, splenic hemangiomas are num (11) and brain (12). When preswere multiple cavernous hemangioindistinguishable from hemagiomas ent visceral involvement can be a mas.

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Fig. 4. — Histology of the spleen showed multiple large (C) and several smaller (arrows) cavernous hemangiomas lined by flattened endothelium and with a large number of erythrocytes in the lumen. No mitoses or dysplastic changes were noticed. A diagnosis of multiple cavernous hemangiomas of the spleen was made (hematoxylin and eosin staining with original magnification 4x objective).

in other areas of the body, such as the liver. However, cystic areas are more common in splenic hemangiomas due to cystic degeneration caused by central thrombosis and haemorrhage and may lead to atypical imaging characteristics (15). In these lesions CT may show some degree of peripheral enhancement; the cystic component does not enhance. In our patient no peripheral enhancement was observed. Generally the prognosis for splenic hemangiomas is good and clinical follow-up does not usually include intervention. Spontaneous rupture with haemorrhage is a risk with larger (> 4 cm) lesions however, and rupture has been reported to occur in up to 25% of such cases (16). Rupture of splenic hemangiomas can occur either spontaneously or due to minor trauma. Recently Karakayali et al reported a case of spontaneous spleen rupture in a patient with KTS and diffuse splenic hemangiomatosis, illustrating that elective splenectomy may be indicated in these patients even when they are asymptomatic (17). Other complications of splenic hemangiomas include hypersplenism and Kasabach-Merritt syndrome. Malignant transformation has also been reported, but these cases may represent primary haemangiosarcoma.

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Conclusion KTS is a rare disorder with a wide variability of manifestations. Visceral manifestations are uncommon, but may probably not be as rare as previously believed as they may go unrecognized in asymptomatic or oligosymptomatic patients. In our patient diffuse hemangiomatosis of the spleen was only incidentally discovered during a routine physical examination. The atypical imaging characteristics of splenic hemangiomas are due to the more frequent cystic degeneration caused by central thrombosis and haemorrhage in splenic compared to hepatic hemangiomas. Elective splenectomy should be considered in patients with diffuse hemangiomatosis due to the increased risk of spontaneous or traumatic rupture. References 1. Berry S.A., Peterson C., Mize W., Bloom K., Zachary C., Blasco P., Hunter D.: Klippel-Trénaunay syndrome. Am J Med Genet, 1998, 79: 319-326. 2. Brown R., Ohri P.G., Ghosh P., Jackson J., Spencer J., Allison D.: Case report: Jejunal vascular malformation in Klippel-Trenaunay syndrome. Clin Radiol, 1991, 44: 134-136. 3. Myers M.B.: Treatment of colonic bleeding in Klippel Trenaunay Weber

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syndrome with combined partial colectomy and endoscopic laser. Dig Dis Sci, 1993, 38: 1351-1353. 4. Kocaman O., Olponat A., Aygün C., Gürbüz Y., Sarisoy H.T., Celebi A., Sentürk O., Hülagü S.: Lower gastrointestinal bleeding, hematuria and splenic hemangiomas in Klippel- Trenaunay syndrome: a case report and literature review. Turk J Gastro enterol, 2009, 20: 62-66. 5. Fligelstone L.J., Campbell F., Ray D.K., Rees R.W.: The Klippel-Trenaunay syndrome: a rare cause of hematuria requiring nephrectomy. J Urol, 1994, 151: 404-405. 6. Haber M., Reuben A., Burrel M., Oliverio P., Salem R.R., West A.B.: Multiple focal nodular hyperplasia of the liver associated with hemihypertrophy and vascular malformations. Gastroenterology, 1995, 108: 12561262. 7. Hamano K., Hiraoka H., Kouchi Y., Fujioka F., Esato K.: Klippel-Trenau nay syndrome associated with splenomegaly: report of a case. Surg Today, 1995, 25: 272-274. 8. Jindal R., Sullivan R., Rodda B., Arun D., Hamady M., Cheshire N.J.W.: Splenic malformation in a patient with Klippel-Trenaunay syndrome: A case report. J Vasc Surg, 2006, 43: 848-850. 9. Nusser C.A., Tuggle D.W., Mclanahan K.B., Leonard J.C.: Splenic lymphangioma. An unusual manifestation of the Klippel-Trenaunay- Weber syndrome. Clin Nucl Med, 1995, 20: 844-845. 10. Pakter R.L., Fishman E.K., Nussbaum A., Giargiana F.A., Zerhouni E.A.: CT findings in splenic hemangiomas in Klippel-TrenaunayWeber syndrome. J Comput Assist Tomogr, 1987, 11: 88-91. 11. Kuo P.H., Chang Y.C., Liou J.H., J.M.: Mediastinal cavernous Lee hemangioma in a patient with KlippelTrenaunay syndrome. Thorax, 2003, 58: 183-184. 12. Jacksch H., Bewermeyer H., Dreesbach H.A., Heiss W.D.: Cerebral haemorrhage in arteriovenous malformation associated with KlippelTrenaunay syndrome. J Neurol, 1986, 233: 48-50. 13. Elias A.H.: The clinical course of splenic hemangioma with emphasis on spontaneous rupture. Arch Surg, 1983, 196: 681-88. 14. Urrutia M., Mergo P.J., Torres G.M., Ros P.R.: Cystic masses of the spleen: radiologic-pathologic correlation. Radiographics, 1996, 16: 107-129. 15. Husni E.A.: The clinical course of splenic hemangioma with emphasis on spontaneous rupture. Arch Surg, 1961, 83: 681-688. 16. Karakayali F., Basaran C., Ayvazoglu Soy E., Karakus S., Yabanoglu H., Moray G., Haberal M.: Spontaneous spleen rupture and rectus sheath hematoma in a patient with KlippelTrenaunay syndrome: report of a case. Surg Today, 2010, 40: 154-157.

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MRI WHIRPOOL SIGN IN MIDGUT VOLVULUS WITH MALROTATION IN PREGNANCY S. Kouki1, A. Fares2, S. Alard1 Midgut volvulus is a rare complication of pregnancy with high morbidity and mortality rates. Clinical diagnosis may be difficult in pregnant women. Ionizing radiation imaging modalities are not advised. Ultrasonography (US) is safer but sometimes is unable to reveal the characteristic whirlpool sign of midgut volvulus. Magnetic resonance imaging (MRI) contributed to confirm diagnosis in our case. We present here a case of 34-year-old pregnant woman at 14 weeks of gestation who presented with abdominal pain, nausea and vomiting. US was not conclusive. MRI revealed the typical whirlpool sign of midgut volvulus. Key-word: Intestines, volvulus.

Midgut malrotation is a congenital intestinal anomaly which can predispose to a volvulus. It affects commonly the pediatric age group and the incidence is gradually decreased with age. Failure to diagnose the midgut volvulus during pregnancy carries a high mortality and morbidity rate for both mother and fetus. The potential hazards from ionizing radiation techniques as computed tomography (CT) on pregnancy make US is ideal to diagnose acute abdomen during pregnancy, but the displacement of intra-abdominal organs with the enlarged uterus makes some limitation of US role. In this case we used MRI as another reliable imaging technique to confirm the diagnosis of midgut volvulus during pregnancy. Case report A 34-year-old pregnant woman presented at 14 weeks gestation with subacute abdominal pain associated with intermittent nausea and vomiting for one month before. She had no relevant medical history except non complicated pregnancy with normal vaginal delivery six years ago. The clinical examination revealed a distended abdomen with epigastric pain on palpation. Laboratory examination was normal. Ultrasound showed a vascular intestinal mass in the epigastric area without any other intra-abdominal abnormalities (Fig. 1). MRI was advices to confirm the origin of this mass, which revealed a characteristic whirlpool sign of midgut volvulus (Fig. 2). The patient has

Fig. 1. — Transverse US: non specific mass in the epigastric area (arrows).

been transferred immediately to the operation room for surgery which confirmed the radiologic diagnosis. Discussion Midgut malrotation is a type of congenital intestinal anomalies resulting from a complete nonrotation or an incomplete counterclockwise rotation of the primitive intestinal loop around the superior mesentery artery (SMA) during fetal development. The failure to complete rotation results in a narrow base of the mesentery, which can predispose to neonatal midgut volvulus and may be a bowel obstruction (1).

From: 1. Department of Radiology, CHU Saint Pierre, Brussels, 2. Radiology resident, AZ Middelheim Antwerp, Belgium. Address for correspondence: Dr S. Kouki, Dpt of Radiology, CHU Saint Pierre, 322 Rue Haute, B-1000 Brussels, Belgium. E-mail: koukisemi@yahoo.fr

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Midgut volvulus is a rare complication of pregnancy. Until 1990 there are only 10 cases of midgut volvulus in pregnancy have been reported (2). Since that date we found only 4 other cases in the literatures. The risk of volvulus is highest between 16 and 20 weeks of pregnancy when the uterus moves from the pelvis to the abdomen and at 36 weeks when the fetal head descends into the pelvis (3). The clinical symptoms of intestinal volvulus such as vomiting and abdominal pain and distension can be masked with pregnancy which gives the radiology a critical role to diagnose midgut volvulus. The diagnosis of gut malrotation is generally made by means of upper gastrointestinal (UGI) contrast study particularly in the pediatric age group. UGI can easily show the duodenum and duodenojejunal flexure located to the right of the spine (1).

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Conclusion

Fig. 2. — Abdominal MRI: axial T1-weighted slices after contrast injection showing the whirlpool sign enables the imaging diagnosis of midgut volvulus. Clockwise rotation of the small bowel (duodenum and jejunum) around the axis of the superior mesentery artery and vein.

CT scan with or without UGI contrast study may be more contributory for the diagnosis of midgut volvulus in adult group because of its high availability. The above two techniques carry high fetal and maternal risks from radiation. MRI has been used safely in our patient to confirm the diagnosis because she was allergic to iodine. US has been demonstrated as valid in pediatric population (4), and has been reported in adults (5). In adults, US is feasible but without the same relevance than in pediatric patients (5). In pregnancy, both CT and MRI have contra-indications: CT for irradiation and MRI in 1st and 2nd trimes-

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ter. Both techniques are sometimes used in pregnancy when balance between risk and benefit has been discussed for outcome of mother and the fetus (6). The safety committee for the Society of Magnetic Resonance Imaging has indicated that “MRI may be used in pregnant women if other non-ionizing forms of diagnostic imaging are inadequate or if the examination provides important information that would otherwise require exposure to ionizing radiation”. It is recommended that pregnant patients be informed that, to date, there has been no indication that the use of clinical MR imaging during pregnancy has produced deleterious effects (7).

Mid-gut volvulus is a rare complication of pregnancy. Late diagnosis can carry a high mortality and morbidity rate for both mother and fetus. Clinical diagnosis is often difficult and delayed due to unspecific symptoms in pregnant women. Ultrasonography is the first-line diagnostic tool in acute abdomen during pregnancy but it can be inconclusive where MR imaging can play an important role in diagnosis of midgut volvulus. For our patient, surgical intervention was based on the MRI diagnosis. References 1. Epelman M.: The whirlpool sign. Radiology, 2006 Sep, 240: 910-911. 2. Kantor H.M.: Midgut volvulus in pregnancy. A case report. J Reprod Med, 1990, 35: 577-580. 3. Redlich A., Rickes S., Costa S.D., Wolff S. Small bowel obstruction in pregnancy. Arch Gynecol Obstet, 2007, 275: 381-383. 4. Shimanuki Y., Aihara T., Takano H., et al.: Clockwise whirlpool sign at color Doppler US : an objective and definite sign of midgut volvulus. Radiology, 1996, 199: 261-264. 5. Danse E.M., Van Beers B.E., Clapuyt P., et al.: Mesenteric Whirlpool Sign Detected at Color Doppler Ultra sound: Diagnostic Value in Adults. Emerg Radiol, 1997, 4 : 371-374. 6. Unal A., Sayharman S.E., Ozel L., Unal E., Aka N., Titiz I., Kose G.: Acute abdomen in pregnancy requiring surgical management: a 20-case series. Eur J Obstet Gynecol Reprod Biol, 2011, 159: 87-90. 7. Shellock F.G., Crues J.V.: MR procedures: biologic effects, safety, and patient care. Radiology, 2004, 232: 635-652.

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Hypothalamic hamartoma L. Topff1, G. Gelin1 Hypothalamic hamartomas are rare congenital malformations presenting with central precocious puberty, gelastic epilepsy and developmental retardation. We report a case of an 11-month-old girl with recurring bloody vaginal discharge. Diagnosis of hypothalamic hamartoma was made on the basis of clinical findings and specific features on magnetic resonance imaging of the hypothalamic region. Key-word: Hamartoma.

Hypothalamic hamartomas are rare congenital malformations presenting with central precocious puberty, gelastic epilepsy and developmental retardation. The disease manifests early in life and may occur in neonates. The prevalence is estimated as high as 1 in 50.000-100.000 (1). The diagnosis of hypothalamic hamartomas is based on clinical and radiologic features. The use of MR imaging has increased the incidence of these lesions. In this article, we present a case of hypothalamic hamartoma and review its radiologic characteristics through published cases, with an emphasis on MR appearance. Case report An 11-month-old girl presented with a recurring bloody vaginal discharge for 3 months. Physical examination revealed pubic hair growth and breast enlargement. The infant had normal psychomotor development. Her weight and height corresponded to the 50th percentile for age. However, her skeletal age was 2.5 years according to the GreulichPyle method. MR imaging of the hypothalamic and pituitary region was performed in order to establish the cause for precocious puberty. The protocol included axial and sagittal TSE T2weighted images (Fig. 1), coronal T1 pre- and post-gadolinium images (Fig. 2), and sagittal T1 post-gadolinium images (Fig. 3). The study showed a well-circumscribed round lesion, 8 mm in diameter, in the interpeduncular cistern. The lesion was located posterior of the pituitary stalk, caudal of the mammillary bodies and against the pons and near

the basilar artery. It was homogeneous and isointense to adjacent brain parenchyma on T1- and T2weighted images. Gadolinium-enhanced images revealed no contrast enhancement of the nodule. These findings were consistent with a hypothalamic hamartoma. As surgical resection was too risky due to the anatomic location of the lesion, the infant received medical treatment with gonadotropin-releasing hormone (GnRH) agonist tripto relin. Discussion Hypothalamic hamartomas are ectopic, non-neoplastic masses of normal neuronal tissue. The pathogenesis of precocious puberty in patients with hypothalamic hamartomas is considered to be the result of ectopic secretion of gonadotropinreleasing hormone (GnRH) or glial factors (2). The radiological presentation of hypothalamic hamartoma is a wellcircumscribed solid lesion attached to or embedded in the hypothalamus. The diameter of the lesion can be 5 to 50 mm and is usually between 10 to 30 mm (3). MR imaging is superior to computed tomography in displaying the exact size and anatomic location. The signal intensity of the hypothalamic hamartoma is generally isointense to that of n ormal grey matter on T1-weighted images and slightly hyperintense or isointense on T2-weighted images (3-9). The lesion does not enhance after the administration of gadolinium. The size of the lesion remains stable over time (3). Differential diagnosis of hypothalamic hamartoma in children with

From: 1. Department of Medical Imaging, Ziekenhuis Oost-Limburg, Genk, Belgium. Address for correspondence: Dr L. Topff, Department of Medical Imaging, Ziekenhuis Oost-Limburg, Schiepse Bos 6, 3600 Genk, Belgium. E-mail: laurens@topff.be

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precocious puberty includes optic glioma, astrocytoma, craniopharyngioma, lymphoma, and germ-cell tumor (3, 10). The detection of cysts, calcifications, contrast enhancement and tumor growth suggests neoplastic lesions. Boyko et al. (7) noted that pedunculated hypothalamic hamartomas are correlated with precocious puberty while sessile hamartomas are correlated with seizures. Arita et al. (5) further investigated the relationship between MR findings and clinical manifestations of hypothalamic hamartomas in a retrospective study. They classified hypothalamic hamartomas into two categories based on imaging findings. The parahypothalamic type hamartoma is located in the suprasellar cistern and is only attached to the floor of the third ventricle or suspended from the floor of the third ventricle by a peduncle. Most patients in this category exhibited precocious puberty and had no seizures or developmental retardation. The intrahypothalamic type hamartoma is involved or enveloped by the hypothalamus and distorts the third ventricle. The patients in the latter category presented primarily with epilepsy, but developmental retardation and precocious puberty could also be associated. Furthermore, Freeman et al. (8) found that epileptogenic hamartomas are malformations of the mammillary region and are attached to one or both mammillary bodies. These findings suggest a role for these structures in epileptogenesis. The treatment options of hypothalamic hamartoma associated with precocious puberty are long-acting GnRH agonists and surgery. GnRH therapy is the first choice to safely and effectively stop pubertal maturation (3). The treatment of seizures is more complex and includes antiepileptic drugs and surgical intervention. We conclude that MR imaging is important in establishing the diagnosis of hypothalamic hamartoma in patients with central precocious

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Fig. 1. — Axial (A) and sagittal (B) TSE T2-weighted MR images demonstrating a well-circumscribed lesion in the interpeduncular cistern (arrows). It is located caudal of the mammillary bodies. The lesion was isointense to adjacent brain parenchyma.

Fig. 2. — Coronal T1 (A) pre- and (B) post-gadolinium MR images demonstrating a lesion in the interpeduncular cistern without contrast enhancement and isointense to adjacent brain tissue (arrows).

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Fig. 3. — Sagittal T1 post-gadolinium MR image demonstrating the location of the lesion adjacent to the pons (arrows). There was no contrast enhancement of the lesion.

uberty. The lesion is generally iso p intense relative to normal grey matter on T1-weighted images and does not enhance after contrast medium administration. Understanding the anatomic location of the lesion in relation to the adjacent structures is useful in the preoperative assessment and prognosis.

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References 1. Weissenberger

A.A., Dell M.L., Liow K., et al.: Aggression and psychiatric comorbidity in children with hypothalamic hamartomas and their unaffected siblings. J Am Acad Child Adolesc Psychiatry, 2001, 40: 696-703. 2. Jung H., Ojeda S.R.: Pathogenesis of precocious puberty in hypothalamic

hamartoma. Horm Res, 2002, 57: 3134. 3. Arita K., Kurisu K., Kiura Y., Iida K., Otsubo H.: Hypothalamic hamartoma. Neurol Med Chir (Tokyo), 2005, 45: 221-231. 4. Barral V., Brunelle F., Brauner R., Rappaport R., Lallemand D.: MRI of hypothalamic hamartomas in children. Pediatr Radiol, 1988, 18: 449-452. 5. Arita K., Ikawa F., Kurisu K., et al.: The relationship between magnetic resonance imaging findings and clinical manifestations of hypothalamic hamartoma. J Neurosurg, 1999, 91: 212220. 6. Lona Soto A., Takahashi M., Yamashita Y., Sakamoto Y., Shinzato J., Yoshizumi K.: MRI findings of hypothalamic hamartoma: report of five cases and review of the literature. Comput Med Imaging Graph, 1991, 15: 415-421. 7. Boyko O.B., Curnes J.T., Oakes W.J., Burger P.C.: Hamartomas of the tuber cinereum: CT, MR, and pathologic findings. AJNR Am J Neuroradiol, 1991, 12: 309-314. 8. Freeman J.L., Coleman L.T., Wellard R.M., et al.: MR imaging and spectroscopic study of epileptogenic hypothalamic hamartomas: analysis of 72 cases. AJNR Am J Neuroradiol, 2004, 25: 450-462. 9. Bruninx G., Widelec J., Delcour C.: Gelastic epilepsy and precocious puberty due to hypothalamic hamartoma. JBR-BTR, 2003, 86: 146-147. 10. Valdueza J.M., Cristante L., D ammann O., et al.: Hypothalamic hamartomas: with special reference to gelastic epilepsy and surgery. Neurosurgery, 1994, 34: 949-958.

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CT features of groove pancreatitis subtypes S. Dekeyzer, S. Traen, P. Smeets1 Groove pancreatitis is a rare form of chronic pancreatitis affecting the pancreaticoduodenal groove, a potential space bordered by the pancreatic head, duodenum and common bile duct. Two forms of groove pancreatitis have been described: the segmental form, which involves the groove and the pancreatic head; and the pure form, which affects the groove only. Differentiation between groove pancreatitis and pancreatic head carcinoma can be difficult, both clinically and radiologically. In this article we present the clinical and imaging findings of two patients with pure and segmental groove pancreatitis respectively. Key-word: Pancreatitis.

In 1973 Becker was the first to describe a distinct form of chronic pancreatitis characterized by fibrous scarring of the anatomic space between the head of the pancreas, the duodenum and the common bile duct (1). The term “groove pancreatitis” was introduced in 1982 by Stolte et al to describe this special form of chronic pancreatitis (2). In 1991 Becker and Mischke classified groove pancreatitis into a pure form, involving the groove only, and a segmental form, involving the groove and the pancreatic head (3). Despite increased exposure in the literature since then, the disease remains largely unfamiliar to most physicians and as a consequence the reported prevalence varies greatly, ranging from 2.7% to 19.5% and 24.5% in three series of patients undergoing pancreaticoduodenectomy for chronic pancreatitis (2-4). In this article we present the imaging findings of groove pancreatitis in two patients with pure and segmental groove pancreatitis respectively. Case presentation 1: pure groove pancreatitis A 54-year old woman consulted at the department of gastro-enterology because of intermittent right hypochondrial pain radiating to the back occasionally accompanied by vomiting. The pain typically started and gradually increased during and after meals. The patient reported a total weight loss of 3 kilograms over a period of three months. Laboratory investigations, including liver enzymes, inflammatory parameters and tumour markers CEA and CA 19-9 were normal. Serum pancreatic enzymes were not tested.

Abdominal ultrasound (US) ruled out bile stones and showed no other abnormalities. Gastroscopy was negative for gastric or duodenal ulcers, but abnormal duodenal mucosa was observed at the level of the bulboduodenal junction. An endoscopic retrograde pancreaticoduodenography (ERCP) was performed and came back negative. Contrast enhanced computed tomography (CT) of the abdomen revealed a hypodense non enhancing soft tissue lesion in the pancreaticoduodenal groove (Fig. 1A) and extensive infiltration of the fat around the head of the pancreas and the D2 segment of the duodenum (Fig. 1B). A cystic lesion of 2 cm was seen in the medial wall of the duodenum extending to the head of the pancreas (Fig. 1C and 1D). During endoscopic ultrasound (EUS) an irregularly margined hypoechogenic lesion of 16 mm was observed in the bulboduodenal wall extending to the head of the pancreas along with multiple small peripancreatic and perioduodenal lymph nodes. Several small cystic lesions in the medial duodenal wall and a small amount of free fluid were also seen. A fine needle aspiration of the hypoechogenic lesion was performed and no signs of malignancy were found. On the basis of the clinical features combined with the results of CT and EUS a diagnosis of pure groove pancreatitis was made and the patient was started on an intramuscular somatostatin analogue. Analgesia was prescribed and the patient was advised to avoid smoking and alcohol consumption. At follow-up consultation there was considerable clinical improvement and a follow-up EUS performed after two months showed regression of the

From: 1. Department of Radiology and Medical Imaging, UZ Gent, Ghent, Belgium. Address for correspondence: Dr S. Traen, Visserij 160 bus 7, 9000 Gent. E-mail: S ophie.Traen@UGent.be

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hypo-echogenic lesion in the medial bulboduodenal wall and of the small cystic lesions in the medial wall of the D2 segment of the duodenum. The patient remains in further follow-up. Case presentation 2: segmental groove pancreatitis A 49-year old man presented at the emergency department with acute intermittent pain in the epigastrium radiating to the chest and the right shoulder. The pain was accompanied by nausea and vomiting. Two weeks earlier the patient experienced a similar episode of epigastric pain. There was anorexia and a total weight loss of 2 kilograms over two weeks. The patient smoked 5 cigarettes a day (one pack a day till 2008) and drank 4 to 10 beers a day. He had a history of coronary artery bypass surgery. Blood analysis showed a normal CRP and white blood cell count. S erum lipase was elevated (258 U/L) as well as gamma-glutamyltransferase (608 U/L) and CA19.9 (55.82 U/L). Transabdominal US showed a mass of 5 to 6 cm between the gallbladder and the pancreatic head (Fig. 2). The mass contained several small calcifications and cysts. This mass’ borders were not clearly definable and could not be distinguished from the pancreatic head. At EUS an irregularly delineated hypo-echogenic mass in the pancreaticuoduodenal groove extending to the head of the pancreas was observed as well as multiple small cysts in the duodenal wall. CT scan before and after contrast administration revealed a soft tissue mass with delayed enhancement in the pancreaticoduodenal groove extending to the head of the pancreas (Fig. 3A). Several small calcifications were seen in the had of het pancreas. The D-2 segment of the duodenum was thickened and the medial duodenum wall contained several small cystic lesions (Fig. 3B).

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Fig. 1. — Venous-phase CT abdomen in a 54-year old woman with pure groove pancreatitis. Images from cranial to caudal show a hypodense sheetlike mass in the groove between the pancreatic head and the duodenum (A) and extensive infiltration of the paraduodenal fat (B). There is thickening of the medial duodenum wall and a cyst in this thickened duodenal wall extending to the groove area (white arrows) (C-D).

vised to quit drinking and smoking. During follow-up there was a favorable evolution of the clinical symptoms as well as a decrease in gamma-GT and a normalization of serum lipase and CA 19.9. Control EUS showed complete resolution of the mass in the groove and pancreatic head. After two months the treatment with the somatostatin analogue was stopped. Discussion

Fig. 2. — Transabdominal ultrasound in a 49-year old man shows a 5-6 cm mass between the pancreas and gallbladder. The mass could not be clearly delineated from the duodenum and pancreatic head and contained several small calcifications and cysts (not seen on this image).

On the basis of the clinical and imaging features a diagnosis of segmental groove pancreatitis was

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made. Treatment was started with a subcutaneously injected somatostatin analogue. The patient was ad-

Groove pancreatitis mainly affects middle-aged men with a moderate to severe history of alcohol consumption. The disease has only been sporadically described in women. The clinical presentation resembles that of chronic pancreatitis, with postprandial abdominal pain of varying severity. Impaired motility and duodenal stenosis often lead to early satiety, vomiting and weight loss. Jaundice is unusual. The duration of the symptoms can range from a few

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Fig. 3. — Arterial (A-C) and venous (D) phase CT-scan in a 49-year old man with segmental groove pancreatitis. Images from cranial to caudal show a sheetlike hypodense mass in the groove between the pancreatic had and the duodenum (A). Extension can be seen in the pancreatic head and the swollen pancreatic head can not be clearly delineated from the lesion in the groove area (B-C). The duodenal wall is thickened and contains several small cysts (black arrows) (D).

weeks to more than one year. Blood tests often show a slight elevation of serum pancreatic enzyme markers and occasionally of liver function test. Tumour markers are rarely elevated (1-3). The major histopathologic feature of groove pancreatitis is the presence of scar tissue and fibrosis in the pancreaticoduodenal groove with sparing of the pancreatic parenchyma in the pure form and variable involvement of the pancreatic head in the segmental form. The duodenum is always involved by a chronic inflammatory process leading to fibrosis and stenosis. Concomitant hyperplasia of Brunner’s glands is almost always present. Cystic changes in the duodenal wall are often observed. These can reach large size, extending to the groove area and simulating paraduodenal wall cysts, while in fact these represent a dilated accessory duct of Santorini and its branches (2, 3, 5). The pathogenesis of groove pancreatitis is still unclear. Most patients with groove pancreatitis have a history of alcohol abuse, suggesting that alcohol is at least a precipitating

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cofactor for the development of the disease. The preferential location of the duodenal lesions around the minor papilla and the typical involvement of the groove region (which is drained by the accessory duct) suggests the presence of some anatomic or functional variation that renders this region particularly susceptible to the injury by alcohol (5). The lack of knowledge on the etiology of groove pancreatitis is reflected in the literature by the numerous names given for this disorder such as cystic dystrophy of heterotopic pancreas, paraduodenal wall cyst, periampullary duodenal wall cyst, pancreatic hamartoma of the duodenal wall and myoadenomatosis. These various terms each represent different microscopic facets of the lesion. Adsay and Zamboni have introduced the term “paraduodenal pancreatitis” in an attempt to unify these different pathologic entities. The authors preferred this term over groove pancreatitis as the findings are predominantly found on the duodenal wall in the area of the minor papilla rather than in the pancreaticoduodenal groove (5). However, to avoid confu-

sion we will stick with the term groove pancreatitis for the remainder of this article. The imaging manifestations of groove pancreatitis have already been described on several imaging modalities (6-13). On computed tomography (CT) the classic finding in the pure form of the disease is a poorly enhancing plate-like hypodense soft tissue lesion between the pancreatic head and the duodenum. This lesion may demonstrate delayed enhancement reflecting its fibrous nature (6). Additional findings include duodenal wall thickening and stenosis as well as cystic-like lesions in the medial wall of the duodenum or in the groove area. In the segmental form of groove pancreatitis the lesion also involves the pancreatic head. This can result in mild dilatation of the pancreatic duct. In the pure form of the disease the pancreatic duct usually appears normal. Even in cases of extensive disease the peripancreatic vessels are preserved, showing no signs of thrombosis or encasement. On MRI the most characteristic finding of pure groove pancreatitis is

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a sheet-like mass between the head of the pancreas and the duodenum associated with duodenal wall thickening (7). In the segmental form of the disease the pancreatic head is involved as well, and a focal mass-like lesion adjacent to the groove area and extending in the pancreatic head can be seen along with dilatation of the main pancreatic duct. The mass in the groove and/or the pancreatic head is hypo-intense on T1-weighted images and iso- to slightly hyperintense on T2-weighted images (8). The variation in the T2-signal is associated with the duration of the disease with subacute disease exhibiting brighter T2 images because of edema, and chronic disease exhibiting lower signal because of fibrosis (9). Peripheral mass enhancement can be seen on images immediately post gadolinium. On delayed imaging progressive-centripetal enhancement may be observed (10). These imaging features reflect the fibrous nature of the lesions. Cysts are seen in most cases of groove pancreatitis in the groove area and/or in the duodenal wall with high signal intensity on T2-weighted images. The differential diagnosis of the pure form of groove pancreatitis includes acute pancreatitis with phlegmon along the groove, duodenal cancer and cholangiocarcinoma. MR can be useful for differentiating pure groove pancreatitis from acute pancreatitis with phlegmon in the groove, since the phlegmon in the groove always shows bright signal intensity on T2-weighted images (11). MRCP is useful for differentiating pure groove pancreatitis from distal cholangiocarcinoma, as in groove pancreatitis often a smooth long stricture of the distal intrapancreatic portion of the bile duct is seen, as opposed to an irregular and abrupt stricture in distal cholangiocarcinoma (12). In cases of segmental groove pancreatitis, the most difficult and challenging differential diagnosis is pancreatic carcinoma. This is particularly

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true for cases of pancreatic carcinoma that have a significant fibrous component and therefore may display delayed enhancement similar to that seen with groove pancreatitis (13). An important differentiating feature is the normal appearance of the peripancreatic vessels in groove pancreatitis, which may be slightly displaced by the mass, but never show signs of obstruction or encasement. In contrast pancreatic carcinoma extending to the peripancreatic tissue or the duodenum is expected to invade and obstruct the peripancreatic vessels (12). MRCP may also be useful for differentiating segmental groove pancreatitis from pancreatic head carcinoma, as the intrapancreatic portion of the common bile duct in patients with groove pancreatitis has a long, smooth, narrowed configuration, while in patienys with pancreatic head carcinoma a circumscribed, irregular ductal stenosis or complete ductal obstruction tends to be seen (9). The initial management of the disease consists of conservative treatment, resembling that of chronic pancreatitis and including bed rest, fasting, analgesia and alcohol abstinence. The effectiveness of this treatment on clinical symptoms, laboratory data and imaging findings should be evaluated after 4-6 weeks. The symptoms improve with conservative treatment in most patients. Surgical treatment is reserved for cases of untreatable pain or when imaging alone or in combination with pathology cannot rule out malignancy. In conclusion, although groove pancreatitis is a rare form of chronic pancreatitis, radiologists should always keep this entity in mind when dealing with a mass in the pancreaticuoduodenal space, especially when associated with duodenal wall thickening and cysts. References 1. Becker V.: Bauchspeigeldruse. In: Spezielle pathologische Anatomie, Bd. VI. Edited by Doerr W., Seifert G.,

Uhlinger E., Eds. Printed by Springer, Berlin/Heidelberg/New York, 1973, 252-445. 2. Stolte M., Weiss W., Rosch W.: A special form of segmental pancreatitis: “groove pancreatitis”. Hepatogastroenterology, 1982, 29: 198-208. 3. Becker V., Mishke U.: Groove Pancreatitis. Int J Pancreatol, 1991, 173-182. 4. Yamaguchi K., Tanaka M.: Groove pancreatitis masquerading as pancreatic carcinoma. Am J Surg, 1992, 163: 312-316. 5. Adsay N.V., Zamboni G.: Paraduodenal pancreatitis: a clinico-pathologically distinct entity unifying “cystic dystrophy of heterotopic pancreas”, “paraduodenal wall cyst”, and “groove pancreatitis”. Sem Diagn Pathol, 2004, 21: 247-254. 6. Itoh S., Yamakawa K., Shimamoto K., Endo T., Ishigaki T.: CT findings in groove pancreatitis: correleation with histopathologic findings. J Comput Assist Tomogr, 1994, 18: 911-915. 7. Irie H., Honda H., Kuroiwa T., Hanada K., Yoshimitsu K., Tajima T., Jimi M., Yamaguchi K., Masuda K.: MRI of groove pancreatitis. J Comput Assist Tomogr, 1998, 18: 911-915. 8. Ishigami K., Tajima T., Nishie A., Kakihara D., Fujita N., Asayama Y., Ushijima Y., Irie H., Nakamura M., Takahata M., Takahata S., Ito T., Honda H.: Differential diagnosis of groove pancreatic carcinomas vs. groove pancreatitis: Usefulness of the portal venous phase. Eur J Radiol, 2010, 74: 95-100. 9. Blasbalg R., Baroni R.H., Costa D.N., Marchado M.C.C.: MRI features of groove pancreatitis. AJR, 2007: 73-80. 10. Castell-Monsalve F.J., Sousa-Martin J.M., Carranza-Carranza A.: Groove pancreatitis: MRI and pathologic findings. Abdom Imaging, 2008, 33: 342348. 11. Robinson P.J., Sheridan M.B.: Pancreatitis: computed tomography and magnetic resonance imaging. Eur Radiol, 2000, 10: 401-408. 12. Triantopoulou C., Dervenis C., Giannakou N., Papailiou J., Prassopoulous P.: Groove pancreatitis: a diagnostic challenge. Eur Radiol, 2009, 19: 1736-1743. 13. Shanbhogue A.K., Fasih N., Surabhi V.R., Doherty G.P., Shanbhogue D.K., Sethi S.K.: A clinical and radiologic review of uncommon types and causes of pancreatitis. RadioGraphics, 2009, 29: 1003-1026.

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Sylvius aqueduct septum T. Coolen1, L. Médart2, M. Tebache2, L. Collignon2 We present a case of chronic hydrocephalus discovered in adulthood through an episode of acute decompensation. Multimodal imaging revealed the cause of this hydrocephalus to be a membranous septum of the aqueduct of Sylvius, a condition for which few reports exist. Key-word: Brain, hydrocephalus.

Case report A 42-year-old man with no significant past medical history was admitted to the emergency room with a complaint of severe headache and nausea for the last 24 hours. Lower limbs weakness was noted upon physical examination. A non-contrast followed by a contrast-enhanced computed tomography (CT) examination of the head was performed (Fig. 1 and 2) and revealed severely dilated lateral and third ventricles, with an Evans’ index estimated at 0.42, effacement of cortical sulci over the convexity and periventricular halo-shaped hypodensity. Sylvius aqueduct was found to be also enlarged, but the fourth ventricle appeared within normal limits. No mass or other density abnormality was seen. These findings were in keeping with chronic hydrocephalus related to the major enlargement of the lateral and third ventricles and signs of cerebrospinal fluid (CSF) transependymal resorption, in acute decompensation, presenting with intracranial hypertension symptoms. The patient underwent emergent right ventricular catheterization with a subcutaneous Rickham’s reservoir as to relieve the acute symptoms. Etiologic workup performed a few days later comprised a CT ventriculography with injection of a watersoluble contrast medium (Omnipaque 240, GE Healthcare) through the Rickham’s reservoir (Fig. 3 and 4) and a magnetic resonance imaging (MRI) including time-of-flight, gradient echo and flow-sensitive sequences (Fig. 5 and 6). It revealed a Sylvius aqueduct stenosis by a membrane-like obstacle at its junction with the 4th ventricle. The tectal plate is displaced posteriorly,

Fig. 1. — Non contrast-enhanced head CT multiplanar reformation (MPR) coronal slice displaying severely enlarged lateral ventricles and periventricular hypodensities (arrowhead) compatible with transependymal CSF resorption.

as typically seen in distal aqueduct stenosis (1). Moreover, these post-surgical head examinations showed significant re-enlargement of cortical sulci and decreased third ventricle floor bulging, accounting for diminished intracranial pressure and treatment success. Opacification of the 4th ventricle during ventriculography demonstrates permeability of the membranous obstacle, at least when ventricles are in a less dilated state.

From: 1. Department of Radiology, University of Liège, Liège, Belgium, 2. Department of Radiology, Centre Hospitalier Régional de la Citadelle, Liège, Belgium. Address for correspondence: Dr T. Coolen, M.D., Department of Radiology, Saint-Pierre University Hospital, rue Haute 322, B-1000 Brussels, Belgium. E-mail: tim.coolen@ulb.ac.be

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MRI ruled out other local abnormalities; especially there was no evidence of vascular pathologies, tumors or signs of micro-bleeds. CSF flow through the Sylvius aqueduct after ventricular derivation is shown to be non hyperdynamic as suggested by the absence of flow void on the sagittal T2w images and the absence of flow intensity on the flow-sensitive sequence. The patient fared well and underwent an endoscopic third ventriculocysternostomy a few weeks later with no early complications. Discussion Sylvius aqueduct is the most common site of blockade of CSF flow through the ventricles (1).

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Fig. 2. — Contrast-enhanced head CT MPR median slice showing dilated aqueduct of Sylvius (arrowhead) and third ventricle with bulging of its floor (thick arrow), but normal appearing fourth ventricle (thin arrow). The subarachnoid spaces over the convexity are narrowed.

Fig. 3. — CT ventriculography MPR median slice showing decreased third ventricle floor bulging (thick arrow) and increased subarachnoid space over the convexity (arrowhead), a stenosis by a membrane-like structure in the distal portion of the Sylvius aqueduct (thin arrow), and opacification of the 4th ventricle, cisterna and subarachnoid spaces over the convexity.

Presentations of benign aqueduct stenosis in adulthood is not infrequent (2) and constitutes the first cause of obstructive hydrocephalus in adults (3). Differential diagnosis may be classified into primary and secondary causes. Secondary causes encom-

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Fig. 4. — CT ventriculography volume rendering technique fter stripping of the skull structures showing the stenosis of the a aqueduct (arrow).

Fig. 5. — Sagittal maximum intensity projection of a flow- sensitive MR sequence tuned to CSF velocities displaying the absence of flow in the aqueduct of Sylvius (circle).

pass extrinsic space occupying lesions while primary causes are intrinsic lesions of the aqueduct and have been classified by Russell into four types (1): stenosis (normal aqueduct cells within one abnormally narrow aqueduct), forking (division into two or more channels), gliosis

(reaction to injuries such as infection, hemorrhage or toxins) and membranous occlusion. The latter is usually distally located and is formed by a gliotic membrane. Our patient had no history of congenital infection, meningitis or subarachnoid hemorrhage. MRI

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Conclusion We presented a case of chronic hydrocephalus discovered in adulthood through an episode of acute decompensation. Multimodal imaging revealed the cause of this hydrocephalus to be a membranous septum of the aqueduct of Sylvius, a condition for which few reports exist. We think that partial permeability of the membrane and compensation mechanisms explain the late presentation of the patient, with no previous obvious symptoms. The acute episode is likely to be due to functional worsening of the obstacle by ventricular deformation. References Fig. 6. — Sagittal T2-weighted SE MR slice confirms the embrane-like obstacle in the caudal part of the aqueduct of m Sylvius (arrow). The tectal plate is displaced posteriorly (arrowhead) in this distal aqueduct stenosis. Note the absence of the normal CSF flow void in the aqueduct.

xploration revealed no signs of neoe plastic lesions or remote bleeding. The membranous obstacle in the distal part of the aqueduct was clearly demonstrated on the CT ventriculography and the T2W sagittal sequence. This lesion is likely to be developmental and idiopathic in its nature. Few cases of such membranous occlusions have been reported in the late seventies (4, 6). Mechanisms of compensation to increased CSF pressure upstream to the obstacle in chronic obstructive hydrocephalus, e.g. increased periventricular capillary CSF resorption, account for many phenomena in the physiopathology (7). In this setting,

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ventricular expansion is allowed under near normal intracranial pressure and cerebral perfusion is diminished. Sylvius aqueduct stenosis is not a stable condition (1). Functional processes such as deformation of the brain stem due to the ongoing enlargement of the supratentorial ventricles may worsen the obstacle and precipitate acute intracranial hypertension. Opacification of the 4th ventricle and subarachnoid spaces in the postdrainage CT ventriculography study pleads for residual permeability through the membrane, at least when the ventricles are in a decompressive state.

1. Cinalli G., Spennato P., Nastro A., Aliberti F., Trischitta V., Ruggiero C., et al.: Hydrocephalus in aqueductal stenosis. Child’s nervous system: ChNS: official journal of the International Society for Pediatric Neurosurgery, 2011, 27: 1621-1642. 2. Harrison M., Robert C., Uttley D.: Benign aqueduct stenosis in adults. J Neurol, Neurosurg & Psych, 1974, 37: 1322-1328. 3. Tisell M.: How should primary aqueductal stenosis in adults be treated? A review. Acta Neurol Scand, 2005, 111: 145-153. 4. Gökalp H., Tascioglu A.: Membranous occlusion of the aqueduct of Sylvius. Surg Neurol, 1977, 8: 103. 5. Murphy M.J., Lyon L.W., Carlstrom T.A., McDonnell D.E.: Normal pressure hydrocephalus due to membranous obstruction of the sylvian aqueduct. Neurology, 1978, 28: 835. 6. Ludwiczak R., Dietemann J., Wackenheim A.: CT and pneumo graphic studies of membranous occlusion of the aqueduct of Sylvius. A case report. Neuroradiology, 1979, 18: 53-55. 7. Egnor M.: Radiological assessment of hydrocephalus: new theories and implications for therapy. Neurosurgical Review, 2004, 27 (3).

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radIologIcal aspect of fungus ball wIthIn a mucocele of the sphenoId sInus M.F. Inci1, F. Özkan1, A. Aksoy2, M. Kelles¸3 Paranasal sinus fungus ball is within the non-invasive forms and is characterized by the presence of aggregated hyphae that do not invade the sinus mucosa. Mucoceles are benign, expansile, cyst-like lesions of the paranasal sinuses. The mucoid secretions of mucoceles are usually sterile. However, secondary infections, mostly bacterial, may lead to the development of pyocoeles. Although an association between a fungus ball and a mucocele is rare in the paranasal sinuses, this disease entity should be considered in the differential diagnosis of expansile, cystic sinus lesions. In this article, clinical and radiological findings of a 61-year-old male patient with isolated sphenoid sinus fungus ball within a mucocele presented with headache and periorbital pain were discussed with recent literature. Key-word: Fungus ball, mucocele, sphenoid sinus, computed tomography.

Fungal sphenoid sinusitis is an infectious disease caused by the development of a fungus in the sphenoid sinus. It is considered rare but its incidence appears to increase (1). Fungal sinusitis has been classified into invasive and noninvasive forms. Paranasal sinus fungus ball is within the non-invasive forms and is characterized by the presence of aggregated hyphae that do not invade the sinus mucosa (2). Mucoceles are benign, expansile, cyst-like lesions of the paranasal sinuses (1). The mucoid secretions of mucoceles are usually sterile. However, infections of paranasal sinuses, mostly bacterial, may lead to the development of pyocoeles. In contrast, sphenoid sinus fungus ball within a mucocele is extremely rare (3). In this article, clinical and radiological findings of a 61-year-old male patient with isolated sphenoid sinus fungus ball within a mucocele presented with headache and periorbital pain were discussed with recent literature. Case report A 61-year-old male patient presented to our hospital with a complain of blood stained nasal discharge off and on for the last 6 months and occasional postnasal discharge and moderately left sided periorbital pain and headache. The patient’s visual acuity and fields were bilaterally normal and he had no history of nasal surgery and allergies. The patient had already taken medical treatment

Fig. 1. — Axial unenhanced computed tomography scan shows a large, expansile, low attenuation mass and the typical hyperattenuating fungus ball with calcific foci (arrows) in the left sphenoid sinus.

for his complaints in the form of the antibiotics, local and systemic decongestants. He did not have any systemic medical disease. Physical examination revealed no abnormalities and no significant evidence of respiratory tract infection. All his routine laboratory investigations including hematological, serological

From: 1. Department of Radiology, 2. Department of Ophthalmology, 3. Department . of Otorhinolaryngology, Sütçü Imam University, School of Medicine, Kahramanmaras¸, Turkey. . Address for correspondence: Dr M.F. Inci, M.D., Kahramanmaras¸ Sütçü Imam Univer.sity, School of Medicine, Department of Radiology, Kahramanmaras¸, Turkey, Sütçü Imam Universitesi Tıp Fakültesi Radyoloji AD., 46200, Kahramanmaras¸, Turkey. E-mail: drfatihinci@gmail.com

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and allergy tests were within normal limits. Endoscopic examination of the nasal cavity was unremarkable, with the exception of edema in the sphenoethmoidal recess and a slight fullness of the anterior wall of the sphenoid sinus. Keeping in mind his past treatment history, a computed tomography scanning (CT) of paranasal sinuses and brain were ordered. CT scanning of the paranasal sinuses revealed a large, expansile, low-attenuation heterogeneous mass in the left sphenoid sinus, and which consisted of high-density material containing calcifications (Fig. 1). CT

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Fig. 3. — Axial (A) and coronal (B) T2-weighted magnetic r esonance imaging scans shows a low signal intensity lobulated, expansile, non-homogeneous mass in the left sphenoid sinus (arrows).

Fig. 2. — Axial bone-window CT image shows expanded sinus and focal areas of erosion from pressure necrosis at posterior wall of the left sphenoid sinus (arrow).

images also showed expanded sinus and focal areas of erosion from pressure necrosis at posterior wall of the left sphenoid sinus as typically seen in fungus ball (Fig. 2). No abnormality was detected on the CT scan in any of the other sinuses and brain. Then, a MRI study was ordered to rule out any complication of this lesion and tumoral process accompany to this lesion. T1- and T2-weighted magnetic resonance imaging (MRI) scans showed a lobulated, expansile, non-homogeneous sphenoid sinus mass. The mass had high T1-weighted and low T2weighted signal intensities (Fig. 3, 4). The pre-operative diagnosis was a mucocele with high protein content according to endoscopic and radiologic findings. The patient was underwent endoscopic sinus surgery under local anesthesia. The sphenoid sinus was filled with mucus and cream-colored fungus ball. The fungus ball and mucous secretions were successfully drained endoscopically. The material evacuated was sent for fungal smear and histopathology. Fungal smear was positive and the histopathological examination was suggestive of aspergillosis. The sinus mucosa did not show any invasion by the fungus. Patient has been completely relieved of his symptoms for the last 3 months and is on regular follow up.

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Fig. 4. — Sagittal T1-weighted magnetic resonance imaging scans shows high signal intensity lobulated mass in the left sphenoid sinus (arrows).

Discussion Fungus ball is described as a noninvasive accumulation of a dense conglomeration of fungal hyphae in a paranasal sinus. The pathophysiology of the fungus ball is not totally understood, existing some theories to try to explain its appearance. The most widely accepted pathogenesis theorizes a deficient mucociliary clearance mechanismin which fungal organisms deposited in the paranasal sinuses are inadequately cleared. Organisms germinate, replicate, and incite an inflammatory response within the paranasal sinus. The fungus ball represents a tangled collection of fungal hyphae in the absence of allergic mucin (4). A muco-

cele is an expansile lesion of the paranasal sinuses. The coexistence of a fungus ball within a mucocele can be explained by the hypothesis that the fungus ball within the sinus causes recurrent infections, which leads to obstruction of the sinus ostium and the development of a mucocele (3). Fungus ball tends to occur in older individuals with an apparent female predilection. Afflicted individuals are usually immunocompetent. Patients are either asymptomatic or have minimal symptoms. Individuals commonly describe a chronic pressure sensation involving one of the paranasal sinuses (5). Other common symptoms of fungus ball are purulent posterior rhinorrhea, nocturnal cough, purulent unilateral anterior

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rhinorrhea and nasal obstruction. Ocular disorders are not uncommon; they include diplopia, paralysis of oculomotor nerves, and/or decreased visual acuity (6). CT scan is the cornerstone of radiological diagnosis of sphenoid sinus disease. Fungus ball appears as a subtotal or total sphenoid sinus opacity which is usually heterogeneous (7). Spontaneous hyperdensities often appear within the sinus opacity, owing to the content of the FB in iron, manganese, and calcium (6). A few cases may demonstrate radioopaque densities within the sinus opacity which represent microcalcifications or dense hyphae (1, 6). Common findings are bone thickening or sclerosis of sinus walls. Foci of partial bone erosion of sphenoid sinus walls can occasionally be found on CT, even if the FB itself is not invasive (7). MRI is not very helpful in the diagnosis. Bone is not well seen on MRI, and both air and fungus ball are hypointense on T2 images, which does not help to clarify the content of the sinus. Hyperdensities seen on the CT are not easily identified on MRI. MRI can be performed to rule out another cause of the headache, or to evaluate complications (7). A differential diagnosis has to be kept in mind, including allergic fungal sinusitis, mucocele, cholesterol granuloma (8). In allergic fungal sinusitis, CT scans show mixed high and low attenuation in the involved sinus. Areas of highly attenuated CT signal correspond to fungal and mucous material (9). Mucoceles often present as homogeneous opacifications on CT, hypointense lesions on T1 weighted MRI, and hyperintense lesions on T2weighted MRI. In contrast-enhanced MRI images, the sinus mucosa enhances as a thin line surrounding the mucocele. However, the MRI appearance of mucoceles varies depending on their protein concentration, which changes over time (10). Cholesterol granulomas are seen with high signal intensity on both T1and T2-weighted MRI images, related to the paramagnetic effect of methaemoglobin and granulations (11). Although mucoceles with high concentrations of protein may appear similar to cholesterol granulomas on

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T1-weighted MRI images, mucoceles have a lower signal intensity on T2weighted scans, compared with cholesterol granulomas. In our case, MRI showed a high signal intensity lesion on T1W and low signal intensity lesion on T2W images in the left sphenoid sinuses. High protein and low water concentration of allergic fungal mucin and high concentration of various metals such as iron, magnesium, and manganese concentrated by the fungal organisms responsible for iso/high signal intensity on T1W and low signal intensity on T2W images on MRI (12, 13). Therefore, fungus ball within a mucocele can mimic an aerated sinus because of its specific MRI features as seen in our case. CT is the useful tool to make the distinction. In our case, CT images showed a lobulated, heterogeneous, low-attenuation, cystic lesion of the left sphenoid sinus with calcifications, There were also focal areas of erosion from pressure necrosis at posterior wall of the sphenoid sinus and an increased central opacity on CT images as typically seen in fungal ball. The only curative treatment for fungus ball within mucocele is surgery, which allows removal of fungal debris from the affected sinus and re-establishes its proper ventilation and drainage. Antifungal medications are generally unnecessary and should be reserved for the immunocompromised patient. Two endoscopic approaches are used to open the sphenoid sinus in case of isolated fungus ball: the transnasal approach and the posterior transethmoidal approach (14). Sphenoid sinus fungus ball within a mucocele is extremely rare. Although the advance of the diagnostic methods and the examinations of image, the diagnosis still remains a challenge. The fungus ball must be considered in all the patients with chronic sinusitis, when it does not respond to medical treatment. Understanding the clinical presentation and knowing its characteristic radiologic features allows the radiologist to play a crucial role in alerting the clinician to use appropriate diagnostic techniques for confirmation. Prompt diagnosis and initiation of appropriate treatment are essential

to avoid a protracted or serious outcome. References 1. Klossek J.M., Serrano E., Peloquin L., Percodani J., Fontanel J.P., Pessey J.J.: Functional endoscopic sinus surgery and 109 mycetomas of paranasal sinuses. Laryngoscope, 1997, 107: 112-117. 2. Grosjean P., Weber R.: Fungus balls of the paranasal sinuses: a review. Eur Arch Otorhinolaryngol, 2007, 264: 461-470. 3. Lee D.H., Kim S.K., Joo Y.E., Lim S.C.: Fungus ball within a mucocele of the sphenoid sinus and infratemporal fossa: case report with radiological findings. J Laryngol Otol., 2012, 126: 210-213. 4. Ferguson B.J.: Fungus balls of the paranasal sinuses. Otolaryngol Clin North Am, 2000, 33: 389-398. 5. DeShazo R.D., Chapin K., Swain R.E.: Fungal sinusitis. N Engl J Med, 1997, 337: 254-259. 6. Nicolai P., Lombardi D., Tomenzoli D., Villaret AB., Piccioni M., Mensi M., Maroldi R.: Fungus ball of the paranasal sinuses: experience in 160 patients treated with endoscopic surgery. Laryngoscope, 2009, 119: 2275-2279. 7. Leroux E., Valade D., Guichard J.P., Herman P.: Sphenoid fungus balls: clinical presentation and long-term follow-up in 24 patients. Cephalalgia, 2009, 29: 1218-1223. 8. Grillone G.A., Kasznica P.: Isolated sphenoid sinus disease. Otolaryngol Clin North Am, 2004, 37: 435-451. 9. Sun G.H., Elluru R.G.: Radiology quiz case 2. Allergic fungal rhinosinusitis (AFRS). Arch Otolaryngol Head Neck Surg, 2010, 136: 307-309. 10. DiNardo L.J., Mellis M.G.: Cystic schwannoma of the sphenoid sinus and skull base. Ear Nose Throat J, 1993, 72: 816-818. 11. Kang H., Kim J.K., Kim Y.: Association of cholesterol granuloma and aspergillosis in the sphenoid sinus. Korean J Radiol, 2008, 9: 30-33. 12. Aribandi M., McCoy V.A., Bazan C.: Imaging features of invasive and noninvasive fungal sinusitis: a review. Radiographics, 2007, 27: 1283-1296. 13. Khattar V.S., Hathiram B.T.: Radiologic Appearance in Fungal Rhinosinusitis. Otorhinolaryngology Clinics, 2009, 1: 15-23. 14. Karkas A., Rtail R., Reyt E., Timi N., Righini C.A.: Sphenoid sinus fungus ball. Eur Arch Otorhinolaryngol, 2012, 1. DOI 10.1007/s00405-012-2121-5. Epub ahead of print.

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Giant retroperitoneal liposarcomas: Diagnostic approach with multidetector computed tomography and magnetic resonance imaging K. Hekimoglu1 Liposarcomas are the most common mesenchymal tumors of the retroperitoneal space. Retroperitoneal liposarcomas are usually grown slowly and frequently reach a very large size before clinical recognition. Precise diagnosis and distinct multiplanar evaluation is essential for complete resection of these tumors. Here in we reported two cases with giant retroperitoneal liposarcomas which were evaluated multiplanary with multidetector computed tomography and magnetic resonance imaging. Key-word: Liposarcoma.

Soft-tissue sarcomas are rare tumors and represent less than 1% of all malignancies. Of all soft tissue sarcomas 10% to 15% are located in the retroperitoneum. Liposarcomas are the most common soft tissue sarcomas in adults and the second most frequent retroperitoneal tumours (1). They are most commonly located in the soft tissues of the extremities, but other sides such as retroperitoneum can be involved (2). Retroperitoneal liposarcomas (RLs) grow slowly in the very expandable retroperitoneal space in the deeply hidden and clinically silent retroperitoneum. Total resection of the tumour is the aim, including adjacent organs if necessary. But, its prognosis is poor due to tumor relapse and only complete surgical removal produces a “cure” (3). Multidetector computed tomography (MDCT) and magnetic resonance imaging (MRI) are very important for diagnosis of RLs with fast multiplanar imaging techniques especially for huge ones. Hereby we demonstrated the facility of multiplanar evaluating of giant RLs with MDCT and MRI on two of our patients. Case reports Case 1 A 52-year-old woman admitted to our hospital with a one year history of abdominal pain, distension, dyspepsia, and alteration of intestinal habits. She did not have any loss in weight, on the contrary she put on weight. On physical examination, her abdomen had a marked disten-

sion and a palpable huge mass was filling the whole of her abdomen. Laboratory findings were considered as normal, also tumor markers (Carcino embryonic antigen and CA19-9) were within the normal limits. Abdominal ultrasound revealed a huge retroperitoneal solid mass which was filling all abdominal cavity. MDCT scan had been obtained using 16-section multidetector row CT (Sensation 16, Siemens Medical Solutions, Erlangen, Germany). Intravenous contrast-media had been administred and 60 sec delayed portal phase had been performed on CT scan. After MDCT scan, MRI was performed with a 1.5 T scanner (InteraBest, Philips Medical Systems, Netherland, 2000). Scanning orientations were transvers and coronal balanced FFE Turbo spin-echo (TSE) T1 weighted images (TR/TE : 500 ms/15 ms, flip angle 80°) and TSE T2 weighted images (TR/TE: 1600/70 ms). T2 images were on coronal plane with spectral presaturation with inversion recovery (SPIR) sequence for fat-suppressed imaging. Contrast-enhanced T1 weighted MR images also obtanied with intravenous injection of gadopentantate dimeglumine (Magnevist, Schering, Germany) (0.1 mmol/kg of body weight). On overall evaluation of tumor with MDCT and MRI the lesion had thickened, irregular septas and minor nodulary components. On contrast-enhanced images, sclerosing components of the mass were enhanced homogeneously on MDCT and MRI. These were the sclerosing components of the well differentiat-

From: 1. Department of Radiology, University of Baskent, School of Medicine, Ankara, Turkey Address for correspondence: Dr K. Hekimoglu, Department of Radiology, Baskent Universitesi, Fevzi Cakmak Cad 10 sok. No 45, Bahc¸elievler, Ankara 06490 Turkey. E-mail: korayhekim@yahoo.com.tr

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ed liposarcoma, showed CT attenuation and MR signal intensity that approximated the characteristics of muscle (Fig. 1). The tumor did not involve the major vascular structures, and the organs. The lesion was hypointense relative to muscle on T1 and T2 weighted TSE images, and showed slightly enhancement (Fig. 2). MDCT attenuation and MRI signal intensity of the lesion was equal to fat tissue and with drop-out on fat-suppressed STIR images (Fig. 3). The T1 weighted criteria for well-differentiated liposarcoma were thick septation and nodularities with non-fatty signal intensity within tumors as this case. Thus, imaging on fat-suppressed STIR images, lesion was considered well-differentiated liposarcoma also when linear or nodular well-defined hyperintens septas were detected inside suppressed fatty lesion. No distant metastasis was detected. Histological examination revealed a well-differentiated liposarcoma. Case 2 A 70-year-old woman was admitted to emergency department of our hospital with severe abdominal pain, distension, nausea, dyspepsia, anorexia, and abdominal tenderness. She had almost one-year of abdominal pain, and her complaints had significantly increased in the past two months. The abdomen was enlarged and a very large soft mass was palpable throughout the abdomen. Laboratory findings showed no significant changes. Abdominal ultrasound revealed a hypoechoic huge mass in retroperitoneal region that was displacing the right colon, and right kidney anteriorly and medially. MDCT imaging demonstrated a very large retroperitoneal mass of fat density that was filling right abdomen-pelvic cavity totally and left abdomen cavity partially. The lesion was com-

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Fig. 1. – Noncontrast (A) and contrast-enhanced (B) CT images show a large fatty mass which is filling a very big portion of the abdominal cavity and displacing right kidney to medially and ventrally.

Fig. 2. – Contrast-enhanced axial (A) and coronal (B) T1 weighted TSE images show heterogeneously enhancing hyperintense lesion (white arrow) appears isointense in relation to subcutaneous fat and linear sclerosing components of the lesion (black arrow).

Fig. 3. – Coronal T2 weighted TSE (A) image shows giant abdominal fatty mass with homogeneously hyperintense in relation to subcutaneous fat. At the same location with T2 TSE SPIR sequence (B) image shows fat suppression of the lesion and hyper intense sclerosing septas (arrows).

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pressing the liver superiorly. Right colon and sigmoid colon were seriously compressed by the mass anteriorly and the other colon segments was dilated due to obstruction of passage. Right kidney displaced superomedially also (Fig. 4). General condition of patient was bad and after MDCT scan, patient was sent to intensive-care unit. In this case, MRI could not be done due to bad condition of the patient. On histopathological examination, mature largesized multivacuolated atypic fat cells demonstrated. This phenomenon was diagnosed as a well-diffentiated liposarcoma. As soon as later, patient was died in intensive-care unit due to cardio-pulmonary arrest. Discussion Liposarcoma is a malignancy of adipose tissue mostly found in the soft tissue of limbs, retroperitoneum, trunk, and mediastinum. Although slight male predominance can be seen in patients (4). However, the patients that we studied were women. Liposarcoma and leiomyosarcoma are the most frequent diagnosed sarcomas in the retroperitoneal space. Thus, 25-35 % liposarcomas consist of soft tissue sarcomas located in the retroperitoneal region (5). Liposarcomas usually grow slowly and frequently reach a very large size before recognised clinically and they generally present with symptoms of discomfort or palpable mass and causes disturbances in adjecent structures. On pathology, recognition of lipoblasts is the key finding in histological diagnosis of liposarcoma. Liposarcomas is currently classified into five groups: well-differentiated (or atypical lipoma), pleomorphic, myxoid, round-cell and dedifferentiated liposarcoma subtypes. Prognosis of liposarcomas varies on the basis of the subtypes. Well-differentiated lipo sarcoma is considered a lowgrade malignancy and myxoid liposarcoma is considered an intermediate-grade malignancy tumors. Pleomorphic and round-cell liposarcomas are considered high-grade malignancies with high rates of local recurrence and metastases (6). Like our cases, well-differentiated liposarcomas show a predominant presence of mature fat cells, and the amount of widely diffused lipoblasts is relatively low . US imaging is very restricted valuable for detection in liposarcomas. They show hyperechoic or mixt echo texture on US imaging. But, with this modality detection of borders of

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sarcomas. Thin septal structure (sclerosing component) which also is one of the well-differentiated subtypes, showed similar signal intensity that approximated the characteristics of muscle. Less fatty liposarcomas composed of myxoid, pleomorphic, or round-cell subtypes have been reported (8). In conclusion, RLs generally had large sizes because of their silent characteristics. At the time of diagnosis, the huge sizes of lesions should be evaluated carefully. On comparing the pathology, different subtypes of RLs exhibit varying MRI features, depending on tumor histological components. So, we emphasize that multiplanar imaging and evaluating of giant RLs with MDCT and MRI may be helpful for exact diagnosis and for predicting the prognosis. Fig. 4. – Coronal MDCT image shows giant retroperitoneal fatty tumor with septa which is filling all of right abdominal and pelvic cavity (arrow). Displacement to left of the retroperitoneal and intraperitoneal organs also seen.

huge lesions generally unsufficient such as giant RLs. However, combined evaluation with computed tomography (CT) and MRI are the most effective radiological procedures determining the extend and invasions of RLs. These modalities are also valuable in the follow-up and are useful in detecting recurrence early. In last years, MDCT has become a useful modality for exact diagnosis and multiplanar evaluation of huge abdominal masses. Today, determining the distinct borders, extent of the lesions, and invasions can be easily made by MDCT. All of them reveal fat-tissue density and intensity values. After detecting the lipoid masses with MDCT, MRI is very helpful for distinguishing lipoma from liposarcoma with fat-suppressed T2 images or short tau inversion recovery (STIR) imaging (7). In characterization of liposarcomas, CT imaging of a lipomatous mass is very likely to be a liposarcoma if it contains streaky densities or

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solid areas of soft-tissue density in addition to areas of pure fat density. Well-differentiated liposarcomas can have thickened, irregular septa and nodular components with attenuation on MDCT scans approximating that of muscle. In both of our cases were well-differentiated subtype, and they showed these typical patterns on MDCT and MRI. For the evaluation of MRI, fat accounting for 75% of the entire tumor, will be hyperintense on T1-weighted images, intermediate-intense signal on T2-weighted images and dropout on MRI fat –suppresed sequences images. The fat-suppression techniques (short tau inversion recovery-STIR) are sensitive enough in the diagnosis of liposarcomas (4). Focal areas of well-differentiated liposarcomas on T2-weighted images may have hyperintense signal relative to that of fat. Fat within the tumor may lead to diagnosis of liposarcoma, although abdominal tumors with fat are not always lipo-

References 1. Antinori A., Antonacci V., Magistrelli P.: Giant retroperitoneal liposarcoma. Am J Surg, 2002, 184: 56-57. 2. Evans H.L.: Liposarcomas and atypical lipomatous tumors: a study of 66 cases followed for a minimum of 10 years. Surg Pathol, 1988, 1: 41-54. 3. Rossi C.R., Nitti D., Foletto M., et al.: Management of primary sarcomas of the retroperitoneum. Eur J Surg Oncol, 1993, 19: 355-360. 4. Linehan D.C., Lewis J.J., Leung D., Brennan M.F.: Influence of biologic factors and anatomic site in completely resected liposarcoma. J Clin Oncol, 2000, 18: 1637-1643. 5. Yildirim O., Namdaroglu O.B., Menekse E., Albayrak A.L.: Giant welldifferentiated liposarcoma of retroperitoneum. Bratisl Lek Listy, 2008, 109: 418-420. 6. Kim T., Murakami T., Oi H., et al.: CT and MR Imaging of Abdominal Liposarcoma. Am J Roentgenol, 1996, 166: 829-833. 7. Galant J., Marti-Bonmati L., Saez F., Soler R., Alcala-Santaella R., Navarro M.: The value of fat-supressed T2 or STIR sequences in distinguishing lipoma from well-differentiated liposarcoma. Eur Radiol, 2003, 13: 337343. 8. Song T., Shen J., Liang B.L., Mai W.W., Li Y., Guo H.C.: Retroperitoneal liposarcoma: MR characteristics and pathological correlative analysis. Abdom Imaging, 2007, 32: 668-674.

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Ground-glass pattern fibrous dysplasia of frontal sinus D. Chourmouzi1, E. Psoma1, A. Drevelegas2 The case of a 5-year-old boy with ground-glass pattern craniofacial fibrous dysplasia (FD) presenting with progressive swelling in the right frontal region is reported. The imaging findings with computed tomography and magnetic resonance imaging (MRI) findings are presented. The differential diagnosis with inspissated mucocele is discussed as well. Fibrous tissue could be hypo dense on CT. Post-contrast enhancement of the lesion on MRI is the key for diagnosis. Key-word: Paranasal sinuses.

Fibrous dysplasia (FD) is a non- inherited benign developmental skeletal disorder, in which abnormal differentiation of osteoblasts leads to replacement of normal marrow and cancellous bone by immature bone and fibrous stroma. In case of monostotic, fibrous dysplasia of craniofacial bones the frontal and sphenoid bones are most commonly involved. We report a new case of groundglass pattern fibrous dysplasia of frontal sinus in a 5-year old boy, mimicking inspissated mucocele on CT.

Case report A 5-year-old boy presented with a 2 year history of progressive swelling in the right frontal region. His medical history was unremarkable. Physical examination revealed protrusion in the right frontal region and slight proptosis, however with no effect at the visual ability. Computed tomography (CT) demonstrated a large lesion expanding the frontal sinus, involving the nasal cavity and ipsilateral ethmoid sinuses as well. The lesion had well defined margins, and it was hypodense in the range of water. A calcified area was depicted centrally (Fig. 1). The right ocular bulb was displaced anteroinferiorly. The differential diagnosis of the lesion on CT was between an expanded airless sinus cavity filled with inspissated mucocele and a benign fibroosseous lesions of frontoethmoid area. On MRI the lesion demonstrated low-signal intensity on both T1- and T2- weighted spin-echo sequences, and enhanced markedly after intravenous injection of Gd- DTPA. The calcified area showed an even lower

Fig. 1. — Computed tomography with bone window images (A, B) shows a hypo dense lesion with well defined margins expanding the right frontal sinus. A calcified area is seen centrally.

signal intensity on both T1- and T2weighted SE sequences (Fig. 2). The enhancement of tissue filling the frontal sinus with the additional presence of central sclerotic lesion favoured the diagnosis of benign fibro osseous lesions of frontoethmoid area. The patient was referred to surgery with a diagnosis benign fibroosseous lesions of frontoethmoid area, and cranioplasty was performed for excision. Specimens from lesion were sent for histological examination. The histopathology was consistent with craniofacial fibrous dysplasia. Discussion Fibrous dysplasia (FD) is a non inherited benign developmental skeletal disorder of unknown origin in which abnormal differentiation of

From: 1. Diagnostic Radiology Department Interbalcan Medical Center Thessaloniki Greece, 2. Radiologic Department, Aristotle University of Thessaloniki, Thessaloniki, Greece. Address for correspondence: Dr D. Chourmouzi, M.D., Diagnostic Radiology Department Interbalcan Medical Center Thessaloniki Greece. E-mail:dchourm@hol.gr

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osteoblasts leads to replacement of normal marrow and cancellous bone by immature bone and fibrous stroma. Even though it may be an incidental finding, it may be also complicated by pathologic fracture, and rarely by malignant or sarcomatous degeneration in 0.5% of cases. The commoner monostotic form of FD, characterized by single-bone involve ment primarily in the extremities and ribs, tends to become quiescent with cessation of growth. The polyostotic form affects multiple bones usually in a unilateral distribution and may continue to progress beyond puberty. When polyostotic FD is associated with precocious puberty and skin pigmentations, it is termed the syndrome (1). McCune-Albright When monostotic fibrous dysplasia occurs adjacent to cranio-facial bones, the result is a very rare bone disease called cranio-facial fibrous dysplasia (CFD). It has been reported that FD of the paranasal air sinuses usually develops as a result of extension of the disorder into the sinuses from adjacent facial osseous tissue. The most common clinical sign of craniofacial FD is swelling. Other reported presenting signs and

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Fig. 2. — MR images: axial fat-sat T1-weighted image (A), axial STIR image (B), xial (C) and coronal (D) a post-gadolinium T1-weighted with fat saturation. The lesion a demonstrated low-signal intensity on both T1- and STIR sequences, and enhanced markedly after intravenous injection of Gd-DTPA.

symptoms such as visual loss or dizziness depend on the area of involvement (2, 3, 4). Radiologic findings in computer tomography can demonstrate the changes in the bones and are classified in three types: the ground-glass pattern (56%), the homogeneously dense pattern (23%), and the cystic variety (3, 5-7). Density levels on CT range, depending on the fibrous tissue and maturity of bone content. The sclerotic and the ground glass appearances are easily recognized as FD by the thickening of the bone. FD with a cystic appearance usually develops in the frontoethmoidal region and sometimes the cysts within the lesion cannot be differentiated from the presence of mucocele (8).

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On MRI the affected bones usually have a low- to intermediate-signal intensity on both T1- and T2-weighted sequences, probably owing to the replacement of the marrow cavity by fibrous tissue. However, the lesions may have quite variable signal intensity on T2-weighted images, where they may appear hyperintense depending on the activity of the lesions. On postgadolinium MR images, affected bones show variable enhancement, reflecting vascularity of the fibrocellular tissue. MRI offers greater specificity in neurovascular and ocular involvement and in detection of other soft tissue lesions (9). In our case, CT-scan revealed expansion of the right frontal sinus, ballooning of the affected area with a

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“ground-glass” appearance. The density of the lesion was 40 HU that was less than the usually reported density of 300-600 HU of craniofacial FD. A central sclerotic area was seen as well. The lesion extended toward the orbital roof and ethmoid sinuses, had well-defined lobulated margins and it was protruding in the anterior cranial fossa compressing the frontal lobe. On MRI the expanded frontal sinus had intermediate signal intensity on T1-weighted images and low signal intensity on T2-weighted images. The central sclerotic area showed low signal intensity on both sequences. After the administration of contrast medium intense contrast enhancement of the tissue filling the frontal sinus was depicted. Intermediated enhancement of central sclerotic area was seen as well. The differential diagnosis of the lesion was between an expanded airless sinus cavity filled with inspissated mucocele and a benign fibroosseous lesions of frontoethmoid area. Sinonasal secretions may have a spectrum of MR signal intensity, ranging from hyperintense to signal void with all pulse sequences. These findings must be kept in mind when interpreting images of patients with suspected chronic sinusitis. In such cases, accurate differentiation may require contrast-enhanced MR images, where most tumors show solid enhancement, unlike mucoceles, which exhibit only mural enhancement, if at all (10). In our case the enhancement of tissue filling the frontal sinus with the additional presence of central sclerotic lesion favoured the latest diagnosis. Association of a craniofacial FD with a mucocele is a very rare occurrence that has been reported. This complication most probably results from the involvement and subsequent occlusion of the recesses of the sinuses by the dysplastic process, as it has been reported in other studies (6). The management of fibrous dysplasia is not surgical unless it causes unacceptable or progressive deformity, cranial nerve compromise, severe headache, or development of a malignancy. In our case despite normal vision of the patient, surgical management was chosen because of protrusion in the right frontal region and slight proptosis. Under general anesthesia, the patient underwent resection of the lesion. He exhibited marked cosmetic improvement and experienced no complications of surgery. To date, the patient has made favorable

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rogress and no sequela related to p the surgery has occurred. Conclusion The presurgical diagnosis of craniofacial fibrous dysplasia depends mainly on CT and MR scan images. Our report emphasises the radiologic appearance of frontal sinus fibrous dysplasia and the differential diagnosis with inspissated mucocele. Despite the relatively low density of fibrous tissue on CT, post-contrast enhancement on MRI was the key of the differential diagnosis. The MRI is highly sensitive in detecting enhancement of solid lesions, in mapping the relationship of a tumor with its adjacent structures and in providing sufficient correlation with histological findings. The radiologist’s goal is to be able to recognise this rare entity in order to guide treatment options.

References 1. Fitzpatrick K.A., Taljanovic M.S., Speer D.P., Graham A.R., Jacobson J.A., Barnes G.R., Hunter T.B.: Imaging Findings of Fibrous Dysplasia with Histopathologic and Intraoperative Correlation. AJR, 2004, 182: 13891398. 2. Michael C.B., Lee A.G., Patrinely J.R., Stal S., Blacklock J.B.: Visual loss associated with fibrous dysplasia of the anterior skull base. Case report and review of the literature. J Neurosurg, 2000, 92: 350-354. 3. Prepageran N., Sreetharan S.S.: Fibrous Dysplasia of the Temporal Bone. Clinical Radiology Extra, 2003, 58: 49-50. 4. Grasso D.L., Guerci V.I., Di Emidio P., De Vescovi R., Ukmar M., Cattaruzzi E., Zocconi E.: Case Report: Dizziness as presenting symptom of monostotic fibrous dysplasia. International Journal of Pediatric Otorhinolaryngology Extra, 2006, 1: 138-141.

5. Tabrizi R., Ozkan B.T.: Craniofacial Fibrous Dysplasia of Orbit. J Craniofac Surg, 2008, 19: 1532-1537. 6. Atasoy C., Ustüner E., Erden I., Akyar S.: Frontal sinus mucocele: a rare complication of craniofacial fibrous dysplasia. Clin Imaging, 2001, 25: 388-391. 7. Aygun D., Sahin H.: Fibrous dysplasia of the frontal sinus: an uncommon cause of frontal lobe abscess. Journal of Clinical Neuroscience, 2004, 11: 904-906. 8. Muraoka H., Ishihara A., Kumagai J.: Fibrous dysplasia with cystic appearance in maxillary sinus. Auris Nasus Larynx, 2001, 28: 103-105. 9. Casselman J.W., De Jonge I., Neyt L., De Clercq C., D’Hont G.: MRI in craniofacial fibrous dysplasia. Neuroradiology, 1993, 35: 234-237. 10. Dillon W.P., Som P.M., Fullerton G.D.: Hypointense MR signal in chronically inspissated sinonasal secretions. Radiology, 1990, 174: 73-78.

NEWS FROM THE MUSEUM

In order to commemorate the 1914-18 War, the Belgian Museum of Radiology will organize a photographic exhibition entitled “Radiology goes to the Front from 1914 until 2014.” The Army Cultural and Social Central Office support this new exhibition. It will be displayed – with the help of the Military Medical Service – in the Military Hospital Reine Astrid, rue Bruyn 200/1120 Brussels. On this occasion, the preview of the documentary-fiction “Marie Curie, a Woman on the Front” will be projected. This film is a co-production of the French company CAPA DRAMA and the Belgian one Be-FILMS, for France Televisions and the RTBF. The screening as well as the private viewing of the exhibition, to both of which you are invited, will take place the Friday 14th March. The meeting will close with a friendship’s drink! Further information about these events can be found on the following website: www. radiology-museum.be

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PRIMARY BONE LYMPHOMA IN A 10-YEAR-OLD BOY J. Kreutz1, J. Khamis1, E. Bauduin1, N. Francotte2, T. Khuc3 Primary bone lymphoma has been defined as a solitary lesion in bone, without concomitant involvement of the extra osseous hematopoietic system, with no evidence of extra osseous disease within 6 months of the onset of symptoms. The vast majority of cases are of the large B-cell non-Hodgkin type. They are rare bone tumor. Distinguishing primary bone lymphoma from other bone tumors is important because the former has a better response to therapy and a better prognosis. Key-words: Bone neoplasms, diagnosis – Children, skeletal system.

Case report A 10-year old boy was admitted at the emergency department because of right arm pain without traumatic lesion. X-ray shows a lytic diaphyseally centered lesion associated to a periostal reaction (Fig. 1). On the same day, an MRI of the humerus is performed. T1-weighted images show an intramedullary 12 cm long lesion. Post gadolinium T1-weighted sequences reveal a nonhomogeneous enhancement of the lesion. Contrast uptake is only observed in the distal third (Fig. 2). Two biopsies are performed because of the nonhomogeneous gadolinium uptake pattern. The first biopsy was obtained in the proximal third and was negative, and a second puncture was made in the distal third and made the diagnosis of B-cell lymphoma. No other localization was found on whole body MR, positron emission tomography and bone marrow analysis 15 months after the onset of pain. Discussion Bone mass is a frequent radiological finding on pediatric radiology. There are no specific clinical features. The patient presents with complaints of pain, local swelling, palpable mass or pathologic fractures. Primary lymphoma of bone is a rare malignant condition that accounts for less than 5% of all primary bone tumors (2). The radiographic appearance is variable and non-specific. Primary lymphoma of bone most often involves the diametaphysis of a major long bone and has an aggressive pattern of lytic bone destruction described as a «moth-eaten» or permeative

pattern, and an associated softtissue mass (3). In young patients, the most frequent diagnoses include Ewing’s sarcoma, metastatic neuroblastoma and osteomyelitis (1). Normal-appearing radiographs are reported (2). MRI characteristics are also non-specific findings. T1-weighted images reveal areas of low signal intensity within the marrow. Peritumoral edema and reactive marrow produce high signal intensity on T2-weighted images. Post gadolinium T1-weighted images demonstrate areas of enhancement within the lesion. Soft-tissue masses can be found, with or without extensive cortical destruction (2). Radionuclide bone scans show increased tracer uptake in 98% of patients (3). Osseous involvement of disseminated malignant lymphoma, which is not uncommon, is indistinguishable from primary bone lymphoma by radiological or MR imaging characteristics. Moreover, patholgical findings cannot make the difference. The diagnosis implies the exclusion of any evidence of nodal or disseminated disease (2), which carries a poorer prognosis. The survey may include an entire body MR imaging, positron emission tomography, or even bone marrow analysis. Primary lymphoma involving the bone has an excellent prognosis. A combined radiotherapy and chemotherapy treatment leads to better results than single modality treatment, with a 5-year cause-specific survival rate of 95% (4). The differentiation of residual tumor and treatment-associated changes, including tumor necrosis and granulation tissue, may be challenging on MR images of bone tumors after treatment. FDG PET is the gold-standard for staging and

From: Department of 1. Medical Imaging, 2. Pediatrics, 3. Surgery, Liège, Belgium. Address for correspondence: Dr J. Kreutz, Dpt of Medical Imaging, CHU Liège, Sart Tilman, Avenue de l’Hôpital 1, B-4000 Liège 1, Belgium. E-mail: jkreutz@student.ulg.ac.be

Fig. 1. — X-ray of the humerus showing a mediodiaphyseal lytic lesion with a «moth-eaten» cortical aspect.

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Fig. 2. â&#x20AC;&#x201D; First MRI examination T1 (A), T2 (B): intramedullary lesion and periosteal oedema. Post-gadolinium T1 (C): nonhomogeneous enhancement, guiding the biopsy, which was positive only in the distal third.

evaluating treatment response. A recent study performed by Mengiardi et al. (5), analyzes MRI changes during and after treatment. They conclude that in a successfully treated patient, MRI shows a rapid decrease in tumor volume with complete disappearance of the soft tissue component. Minor signal abnormalities of bone marrow without clinical relevance may persist for up to 2 years (5). In our case, MRI of the humerus in alternation with complete body MRI is performed every 3 months. The first control shows a decrease in

tumor volume but persistence of bone signal anomalies. In all controls, decrease in volume and in signals anomalies is showed. The last control is performed 1 year and 6 months after first diagnosis. References 1.

Mirra J., Picci P., Gold R.: Bone tumors: clinical, radiologic, and pathologic correlations: Edited by Mirra J., printed by Lea et Febiger Philadelphia, 1989, pp 1119-1185. 2. Krishnan A., Shirkhoda A., Tehranzadeh J., et al.: Primary bone

lymphoma: radiographic-MR imaging correlation. RadioGraphics, 2003, 23: 1371-1387. 3. Mulligan M., McRae G., Murphey M.: Imaging features of primary lymphoma of bone. AJR, 1999, 173: 16911697. 4. Beal K., Allen L., Yahalom J.: Primary bone lymphoma: treatment results and prognosis factors with long-term follow-up of 82 patients. Cancer, 2006, 106: 2652-2656. 5. Mengiardi B., Honegger H., Hodler J., et al.: Primary lymphoma of bone: MRI and CT characteristics during and after successful treatment. AJR, 2005, 184: 185-192.

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Post EVAR endovascular revision of late onset stent graft collapse due to Type 1 endoleak in a complicated case with left limb occlusion and solitary kidney S. Akpinar1, M. Parildar2, B. Alicioglu1 Type 1 endoleak is one of the most frequent complication usually seen at the initial phase of EVAR procedure. Balloon dilatation is mostly used to oversize the proximal or the distal part of the orifice to stabilize the attachment of the graft stent to the aortic wall. Late onset of type 1 endoleak with graft stents may cause severe lumen compression of the stent and aneurysm enlargement which might cause a serious problem especially in a patient whose graft stents left iliac branch is thrombosed and the left leg is supplied by the bypass graft from right CFA. Although operation was advised by the endovascular specialists the procedure was done in our hospital as the patient preferred the endovascular method instead of open surgery. Key-word: Aorta, stenosis or occlusion.

Endoleak was first defined by as persistent blood flow outside the graft and within the aneurysm sac. Endoleak has been classified according to the source of perigraft flow into four groups (1-3): Type I

Proximal or distal graft attachment site leaks, Type II Retrograde flow into the aneurysm sac from aortic side branches such as lumbar arteries or the inferior mesenteric artery, Type III Caused by a defect in the graft either due to fabric disruption or disconnection of a modular overlap, Type IV Graft wall porosity. The most serious endoleaks are type I and III which are associated with aneurysm enlargement and rupture. Secondary intervention to correct these endoleaks is almost always necessary. Whilst rupture has been reported with type II endoleaks, these are considered to have a more benign course and a conservative approach to management is taken unless there is evidence of continuing sac enlargement. Stent-grafts are subjected to distraction forces in vivo due to the pulsatile blood flow. These distraction forces act longitudinally and challenge the graft fixation and overlap zones. The stent-graft resists these forces due to its fixation mechanisms which include the radial force of the sealing stent and the barbs which engage the aortic wall. The distraction force is dependent on the pa-

Fig. 1. — 3D volume rendering reconstructed CT scan showing infrarenal abdominal aortic aneurysm extending to the iliac arteries. Right kidney is operated and there is compensating hypertrophy of the left kidney. Note the coeliac artery aneurysm.

tient’s blood pressure and the crosssectional area reduction between the proximal/aortic and distal/iliac sealing stents (4). Failure of fixation will lead to migration or modular disconnection with late type I or type III endoleak and risk of aortic rupture. Graft limb distortion with subsequent thrombosis can also occur secondary to migration. The detection of migration during post-operative surveillance is important as it usually leads to preventive intervention to prevent graft failure.

From: 1. Radiology Department of Near East University Hospital, Radiology Department, Cyprus, Turkey, 2. Radiology Department Ege University Medical Faculty, Izmir, Turkey. Address for correspondence: Dr B. Alicioglu, Near East University Medical Faculty Hospital, Radiology Department, Near East Boulevard Nicosia, Mersin 10, Cyprus, Turkey. E-mail: alicioglu.b@gmail.com

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Wireform fractures have been reported in most stent-grafts. The fracture may lead to diminished stent strength and loss of radial force which can result in migration. Additionally the jagged ends of the fractured metal may cause tears in the fabric and subsequent endoleak. These fractures are best seen on plain abdominal radiographs. Case report Sixty-seven years old male patient with Type 2 DM, hypertension, had infrarenal fusiform abdominal aortic aneurysm (Fig. 1) and treated with EVAR method using ANACONDA greft stent (Terumo inc Japan) one year ago. After the first EVAR application the left iliac artery stent branch

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Fig. 4. — Extension of the right limb of the graft stent in the sagittal reconstructed scan. Fig. 2. — Axial CT scan. Type 1 endoleak compressing the right limb of the graft stent. Left limb is occluded.

Fig. 3. — Coronal MIP reconstruction displays compression of the right limb of the graft stent; left limb is occluded. Hypoperfusion of the lower pole of the left kidney is also seen.

was thrombosed and the patient had to have by pass surgery from right external iliac artery to the left common femoral artery for the salvage of the left leg. The by pass graft was working well and the left lower extremity flow was normal after the procedure and follow up Doppler scans. No endoleak was found on the control scans. Right kidney was operated 5 years ago and the left renal orifice was 2 cm above the first aortic graft stent proximal orifice. One year later the patient was complaining of both limb pain on exercise. Abdominal dynamic CT scan was done to evaluate the patency of the stent and the diameter of the aortic aneurysm (Fig. 2). On MDCT scan Type 1 endoleak was noted at the ab-

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dominal aortic aneurysm anteriorly compressing the native aortic stent and the bifucation stents towards the aortic posterior wall . The aortic and iliac patent lumen size was diminished due to the recanalised aortic aneurysm (Fig. 3, 4). The patient also had right groin infection ongoing from the previous stenting procedure. The patient was proposed surgery for the revision of the aortic aneurysm but the patient chose to have the interventional approach. The patient was taken to the angiography room after the blood tests revealing that the blood urea and creatinine results were normal. Left axillary puncture is done first to understand if it is possible to pass through the compressed aortic graft

segment to the right iliac artery. When it was noted that hydrophilic exchange guidewire proceeds to the right iliac artery, pigtail catheter was placed to the compressed stent lumen. Then a stiff guidewire was proceeded to the left renal artery proximal segment before its bifurcation to prepare the renal artery for the chimney stenting method (5). As the right iliac artery stent was also collapsed a 11mm diameter wall stent was placed in the graft stents lumen to both prevent graft migration while pushing the stiff body of the instrument carrying the cuff and to increase the tension force to push the compressed graft stent to the iliac walls (Fig. 5). A stent cuff was planned to extend at the top of the initial stent to overcome the type 1 endoleak and to sustain the flow of the aortic stent graft. In case of the risk of obliterating the left renal artery orifice while opening the cuff, and that it might be difficult afterwards to place a stent in position, a 4 cm graft stent is placed to the renal artery with 2/3 of the stent segment extending to the suprarenal aortic segment. Then Anaconda’s fish mouth type cuff is placed at the distal part of the previous stent 1/2 of the cuff overlapping the main graft stent and balloon dilatation is made to expand the cuff to fit the main body (Fig. 5). After the graft stent placed to the renal artery was opened, it was observed that the proximal end extending to the aorta was almost bearing the aortic intimal surface. As its placement would cause trouble in the future balloon dilatation was done to direct the orifice of the proximal part upwards to be parallel to the

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Fig. 6. — Control CT scan after the second intervention

References Fig. 5. — Angiography cuff extension is inserted to the proximal of the graft stent. By chimney method, graft stent is placed to the left renal artery extending to the abdominal aorta. Wall stent is inserted to the compressed right limb.

aortic wall instead of leaning it. But the result was not as efficient as it was expected still carrying the risk of occlusion or diminished flow in future. So an additional wall stent was opened inside the graft stent shaped upwards parallel the aortic wall to direct the inflow to the renal artery (Fig. 5). Control runs were made to check the Type 1 endoleak, left renal artery flow and he right iliofemoral artery flow. There was no endoleak and all the arteries were filling well. Control studies were done in the first, third month with colour Doppler; in the sixth month with the MDCT scans and no relapse was noted (Fig. 6). Discussion At wide neck infrarenal aortic aneurysms, the possibility of endoleak is increasing as the aneurysm neckrenal artery orifice distance decreases, as the angiographer is trying to place the aortic graft as stable as he can. On the other hand if the endoleak occurs after a while the procedure is completed it becomes more difficult to place the cuff at the top of the initial graft stent. The main problem is the stent free aortic segment is usually wider and as you want to stabilize the cuff extending upwards there is a risk of cuffs displacement, as the Anaconda’ s opening is like a

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fish mouth in time its opening as a ring rises the question whether it will obliterate the renal arteries orifice. In that case we are obliged to use the chimney method to guarantee the nearest and the only renal artery. Although the compressed aortic graft from the anterior endoleak sac seems like to have very less luminal contrast flow in MDCT, the flexible texture of the graft stents makes it easier to pass a new cuff through it. But there is a risk of aortic grafts iliac limb displacement when passing the cuff through the iliac route, opening a more stable and stiff wall stent should be considered. There are new types of aortic graft stents which decrease the groin complications as they can be placed by direct puncture without surgically opening the puncture site (6). They also have the advantage that they could be placed at very short necks below the infrarenal aneurysm free aortic segments compressing the aortic wall with silicone fillings found at the proximal segments of the graft stents (6,7). The new technologies early results show that the endoleak complications and migration of the proximal part of the stent will lessen soon, which are the disadvantages of the method which also rises the cost expenses of the method (8).

1. White G.H., Yu W., May J.: Endoleak – a proposed new terminology to describe incomplete aneurysm exclusion byan endoluminal graft. J Endovasc Surg, 1996, 3: 124-125. 2. White G.H., May J., Waugh R.C., Waugh R.C., Yu W.: Type I and type II endoleaks: a more useful classification for reporting results of endoluminal AAA repair. J Endovasc Surg, 1998, 5: 189-191. 3. White G.H., May J., Waugh R.C., Waugh R.C., Chaufour X., Yu W.: Type III and type IV endoleak: toward a complete definition of blood flow in the sac after endoluminal AAA repair. J Endovasc Surg, 1998, 5: 305-309. 4. Sutalo I.D., Liffman K., LawrenceBrown M.M.: Experimental force measurements on a bifurcated endoluminal stent graft model: comparison with theory. Vascular, 2005, 13: 98-106. 5. Bruen K.J., Feezor R.J., Daniels M.J., Beck A.W., Lee W.A.: Endovascular chimney technique versus open repair of juxtarenal and suprarenal aneurysms. J Vasc Surg, 2011, 53: 895904. 6. Laborde J.C., Kipshidze N., Ruiz C.E.: A novel 14F endograft for abdominal aortic aneurysm: first in man. Catheter Cardiovasc Interv, 2010, 76: 10591064. 7. Krievins D.K., Holden A., Savlovskis J., Calderas C., Donayre C.E., Moll F.L., et al.: Eur J Vasc Endovasc Surg, 2011, 42: 38-46. 8. Krievins D.K., Holden A., Savlovskis J., Calderas C., Donayre C.E., Moll F.L., et al.: EVAR using the Nellix Sac-anchoring endoprosthesis: treatment of favourable and adverse anatomy. Eur J Vasc Endovasc Surg, 2011, 42: 3846.

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unusual presentation of osteopoikilosis P. Simoni1, J. Denut1, S. Ben Mustapha1, E. Bianchi2, E. Mutijima2, V. Alvarez-Miezentseva2, O. Malaise3 We present a case of osteopoikilosis in a 74 year-old woman with hip pain, presenting multiple osteoblastic lesions of the axial skeleton including an osteoblastic large lesion of her left femur. The imaging findings on X-rays and computed tomography are provided along with the discussion of the differential diagnosis on the basis of the recent literature. Key-words: Bones, diseases.

Case report A 74 year-old woman was referred for a 2-month history of pain and limitation of movement of her left hip. There was no history of trauma. X-rays revealed a single osteoblastic lesion localised at her proximal left femur (Fig. 1). Computed tomography (CT) showed a 2 cm large osteoblastic lesion of left proximal femur with multiple radial peripheral spiculae and other smaller osteoblastic lesions of the hip and the proximal femora not detectable on X-rays (Fig. 2). Technetium-99m (99mTc) bone scan (not shown) and the 18F-fluorodeoxyglucose (FDG) positron emission tomography combined with computed tomography (FDG-PET/CT) (not shown) were unremarkable. Due to the appearance and localization of the osteoblastic lesions, a diagnosis of osteopoikilosis was suspected. A biopsy of the proximal left femur confirmed the diagnosis. Discussion Osteopoikilosis (OPK) is a rare and benign dystrophic disease of the bone (1). In OPK multiple osteoblastic bone lesions are found within the trabecular bone. OPK is typically localised at the metaphyses and epiphyses of the appendicular skeleton (2, 3). The axial skeleton and skull are usually spared. OPK can mimic osteoblastic bone metastases (4, 5). The estimated prevalence of the OPK is 1 in 50 000 individuals. OPK is incidentally found in subject of all ages with no sex predilection (4). The OPK is due to a mutation of LEMD3 gene (6). Most cases of OPK are sporadic. Nevertheless, an autosomal dominant inheritance has been reported (6). Rarely inherited

Fig. 1. — X-rays of the hip and proximal femora: a femoral osteoblastic solitary bone of 2,2 cm lesion is noted in the left femoral neck (white arrowhead).

OPK can be associated with connective tissue nevi (Buschke-Ollendorff syndrome) (6). In most clinical settings, OPK is asymptomatic and bone changes are incidentally detected on imaging. However, mild pain has been reported in up to 15-20% of cases (7). On X-rays and Computed Tomo graphy (CT), OPK presents as multiple appendicular enostosis measuring < 1 cm (1). The osteoblastic lesions observed in OPK are round or oval-shaped with spiculated margins in continuity with the nearby trabecular bone, the elementary lesion sharing the same appearance of a classical bone island. No transitional zone is observed around the osteoblastic spots (4). Bone lesions of OPK have usually a symmetrical distribution at the epiphyses and metaphyses of the appendicular skeleton. This pattern of distribution is virtually diagnostic of OPK (3). The main differentials diagnosis of OPK include osteoblastic metastases, bone mastocytosis, Bourneville’s disease and bone sarcoidosis (1).

From: Department of 1. MSK imaging, 2. Pathology, 3. Rheumatology, University Hospital of Liège (CHU), Liège, Belgium Address for correspondence: Dr P. Simoni, Service of MSK Imaging, University Hospital of Liège, Domaine du Sart Tilman Bât. 45, B-4000 Liège, Belgium. E-mail: Paolo.Simoni@chu.ulg.ac.be

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Osteoblastic metastases are usually located in the axial skeleton. They may be heterogeneous and a transitional surrounding zone of abnormal can be observed. In systemic mastocytosis multiple osteoblastic lesions are found in late phase of the bone involvement and they are located at the metaphyses and the diaphyses of the appendicular skeleton. An irregular thickening of the cortical is usually associated (8). Bone lesions in Bourneville’s disease, bone lesions are associated with a periosteal reaction and different degrees of hyperostosis. Bones lesions of Bourneville’s disease can occur anywhere in bones including the axial skeleton and the extremities. Calvarium is typically involved (4). A bone scan can be performed in case of doubt, as in our case, when lesions larger than 1 cm are found (1). Osteoblastic lesions of OPK are generally small and Technetium99m (99mTc) bone scan doesn’t show any tracer uptake. However, a positive bone scan does not rule out OPK (10). The 18- Fluoro-deoxyglucose Positron Emission Tomography (18FDG-PET) was unremarkable in our patient but not enough data are

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Fig. 2. — Computed tomography (CT) (A-D axial slices, thickness 1 mm; E-F coronal reformatted images, slice thickness 1,5 mm): CT revealed other osteoblastic spots of the hip bone and the proximal femora of less than 1 cm (white arrowheads) . Like the large lesion of the left femur, these smaller osteoblastic lesions appear well marginated and speculated. No transitional zone is observed.

Fig. 3. — Histology specimen of the lesion of the left femoral neck (H&E stain; magnification x20). The cortical bone (C) is within the trabecular bone (T). Absence of periosteum covering the cortical bone.

available in literature about OPK appearance on18FDG-PET. As in our patient, histology can corroborate the diagnosis of OPK in case of the doubt (Fig. 3). Histology shows the islands of mature cortical bone with thickened sclerotic irregular laminae interspersed in the cancellous bone (2). The absence of periosteum around the cortical bone confirms its intramedullary origin (Fig. 3). In conclusion, OPK is an uncommon benign dystrophic disease of the bone. The imaging findings are quite typical in vast majority of cases. Bone scan and biopsy can be performed in atypical presentations to

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rule out bone metastases. Bone metastases and rare conditions such as bone mastocytosis and Bourneville’s disease should be taken into account in the differential diagnosis. References 1. Di Primio G.: Benign spotted bones: a diagnostic dilemma. CMAJ, 2011, 183: 456-459. 2. Serdarog˘lu M., Capkin E., Uçüncü F., Tosun M.: Case report of a patient with osteopoikilosis. Rheumatol Int, 2007, 27: 683-686. 3. Carpintero P., Abad J.A., Serrano P., Serrano J.A., Rodríguez P., Castro L.: Clinical features of ten cases of osteo-

poikilosis. Clin Rheumatol, 2004, 23: 505-508. 4. Avila N.A., Dwyer A.J., Rabel A., Darling T., Hong C.-H., Moss J.: CT of Sclerotic Bone Lesions: Imaging Features Differentiating Tuberous Sclerosis Complex with Lymphangioleiomyomatosis from Sporadic Lymphangioleiomymatosis1. Radiology, 2010, 254: 851-857. 5. McArdle A., O’Riordan C., Connolly E.M.: Osteopoikilosis mas querading as osseous metastases in breast cancer. Breast Cancer, 2011. 6. Hellemans J., Preobrazhenska O., Willaert A., Debeer P., Verdonk P.C.M., Costa T., Janssens K., Menten B., Van Roy N., Vermeulen S.J.T., Savarirayan R., Van Hul W., Vanhoenacker F., Huylebroeck D., De Paepe A., Naeyaert J.-M., Vandesompele J., Speleman F., Verschueren K., Coucke P.J., Mortier G.R.: Loss-of-function mutations in LEMD3 result in osteopoikilosis, Buschke-Ollendorff syndrome and melorheostosis. Nat Genet, 2004, 36: 1213-1218. 7. Aghdashi M.A., Aghdashi M.M., Rabiepoor M.: Osteopoikilosis: pain as a presenting symptom in three family members. Clin Med Insights Arthritis Musculoskelet Disord, 2011, 4: 29-32. 8. Fritz J., Fishman E.K., Carrino J.A., Horger M.S.: Advanced imaging of skeletal manifestations of systemic mastocytosis. Skeletal Radiol, 2012. 9. Jelinek J.S., Mark A.S., Barth W.F.: Sclerotic lesions of the cervical spine in sarcoidosis. Skeletal Radiol, 1998, 27: 702-704. 10. Tuncel M., Caner B.: Osteopoikilosis: a major diagnostic problem solved by bone scintigraphy. Rev Esp Med Nucl, 2012, 31: 93-96.

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SPECIAL ARTICLE Optimizing communication between the radiologist and the general practitioner L.B.O. Jans, J.M.L. Bosmans, K.L. Verstraete, R. Achten1 Adequate communication between radiologist and referring general practitioner (GP) is mandatory in a good practice clinical setting. Several hurdles may interfere with good communication. Inappropriate imaging requests or incomplete clinical details conveyed to the radiologist may result in inappropriate imaging and interpretation. GPs may find the radiology report confusing or may feel it takes too much time to receive the reports. Communication issues may dissatisfy GPs and make them look for alternative providers for imaging referrals. In the digital era, electronic radiology request forms, digital access for the GP to radiology images and reports and networks centralizing patient data may all help to improve communication between radiologist and GP. In this paper we outline practical ways of improving this communication. Key-words: Radiology and radiologists.

The radiology report is the primary tool by which the radiologist communicates his/her findings to the referring physician. The report provides answers to the clinical question, emphasizes the clinical importance of radiological findings and may mention important additional findings beyond the remit of the clinical question. In Belgium, the iconographic documents and the report can reach the GP by several ways. The diminishing number of radiology departments where films are still in use, hand these documents to the patient, together with a printed document containing the report. Departments using PACS generally provide the images and the radiology report as well as a dedicated DICOM reader on a single CD-ROM. In addition to that, a growing number of departments mail the encrypted report to the referring physician by means of a third party server. The relationship between the radiologist and the general practitioner is clearly different that with hospitalbased specialists, and so are their respective means of communication. While hospital-based specialists requiring additional information can visit the radiology department and attend multidisciplinary meetings, clinicians in a primary care setting lack this benefit. GPs rely on e-mail and telephone if they require additional information (1).

Another difference is that GPs rely much more on the radiology report than do specialists (1). They highly value the clinical opinion of the radiologist, and the form and content of the report should be in accordance with their expectations (1-3). Radiologists should therefore dictate imaging studies in time, produce accurate reports with clear conclusions tailored to the GP and his clinical question, apply electronic means of communication if these are available, and establish direct contact with GPs where appropriate, depending upon clinical scenarios (3). Doing so is not only good medical practice, it is also in the interest of the radiologist. GPs dissatisfied with the quality of reports and communication could turn to alternative providers for their imaging referrals (3). For this purpose, existing systems for information interchange with general practice should be improved and new ways to improve communication explored and implemented. To avoid uncoordinated initiatives and prevent confusion, guidelines for referral and for the electronic communication and information transfer across the GP-radiologist interface should be developed (2). GP referral to the radiologist Referral guidelines for GPs Radiology is expanding rapidly. Imaging techniques that once were

From: 1. Department of Radiology and Medical Imaging, Ghent University Hospital, Gent, Belgium. Address for correspondence: Dr L.B. Jans, M.D., Ph.D., Department of Radiology and Medical Imaging, Ghent University Hospital, De Pintelaan 185, B-9000 Gent, Belgium. E-mail: Lennart.jans@UGent.be

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state-of-the-art have become obsolete, while the introduction of new techniques (e.g. multislice CT, dual energy CT, perfusion CT and MR) has made it more difficult for the GP to request the optimal imaging study to answer a particular clinical question. Reducing radiation exposure by preventing inappropriate imaging studies should be a concern for both radiologists and referring clinicians. In the conclusion of a report, radiologists can give limited advice concerning the best technique to investigate similar cases in the future. However, the radiology report is there to provide adequate diagnostic information, not to replace a refresher course for GP’s (2). Moreover, offering unsolicited advice may be considered offensive. Guidelines that lead GPs to requesting the proper imaging study can help to reduce radiation risks, prevent repeat studies, boost the accuracy of the imaging process, and eventually contribute to installing the right treatment. Guidelines describe quality problems at the GP-radiologist interface and seek solutions to such problems. Professional leaders facilitate the GP- radiologist interface by means of consensus discussions and support the use of these guidelines to improve cooperation (4). In Belgium, radiology referral guidelines are available for GPs, but they are not compulsory (5). Paper vs electronic request form Sending imaging requests electronically from the GP’s office to the radiology department well before the appointment can prevent the

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loss of request forms and help the radiologistto anticipate the requested study. This in turn may lead to contacting the referring GP for additionalinformation where necessary and in some cases even to suggestinga more appropriate study. Patient-centered approach As patients (in Belgium) time and again are free to visit any physician, the radiologist may be unfamiliar with the patient presenting at his department, despite his/her long medical history. Conversely, the patient is free to present the results of the study to a GP or even a specialist other than the one who requested it. In such a system, access to a (nationwide) electronic patient record system can be considered a necessity in the interest of optimal diagnosis and treatment. Information systems would be able to track the imaging studies a patient has already undergone and suggest, guide or discourage additional studies (4). Radiologist communication to GP The radiology report It is important that radiologists try to imagine what the clinician will deduce from a report. Erroneous interpretation by the referring clinician can have important consequences in malpractice cases. Poor communication is a causative factor in up to 80% of malpractice lawsuits involving radiologists. In most cases, the referring clinician did not react adequately to the message in the report, as a consequence of which prompt diagnosis or therapy were postponed. If the radiologist expresses himself more strongly in the reports, GPs will act much sooner (3). With continued progress in radiological information systems, radiologists can produce standardized tabulated reports more easily. In structured reporting (SR) systems, the radiologist completes a set of data fields in a preformatted template. The result is a consistently structured report that is easy to read and to compare with earlier reports. These structured reports have been shown to be favoured over prose reports by GPs (1, 3, 8). The radiology report is a method of communicating the expertise and clinical judgement of the radiologist to the GP. Specific guidelines for reporting to GPs include the following advices (3, 4, 6, 7):

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Examination: GPs are not particularly interested in the technical details of the examination, but think that suboptimal technical quality should be mentioned. The date and type of comparative studies should also be stated. History: Including the clinical question into the report will inspire the GP more confidence, since it shows that the radiologist has read and understood the question. The clinical history may be added automatically to computer-generated reports. Findings: – Reports should be in the present tense and findings organized in a logical manner, the most important first. – The findings should be reported in clear, exclusively descriptive terms. Interpretations should be restricted to the conclusion of the report. – Only relevant negative or incidental findings should be mentioned. GPs do not appreciate measurement of normal structures. If the report contains results of measurements, their meaning should be stated. – Unfamiliar abbreviations are to be avoided. Conclusion: In a 1988 survey in Arizona, only 38% of the referring clinicians (hospital specialists and GPs combined) read the entire report and 18% read it only if the conclusion was unclear; 43% read only the conclusion if the report was longer than one page (8). In contrast, in a large-scale survey in the Netherlands and Flanders (Belgium) in 2008-2009, two thirds of the referring specialists and GPs denied only reading the conclusion and more than eight out of ten agreed the descriptive part should also be read (1). Whatever the truth is, the conclusion is an essential part of the report and is considered mandatory in longer reports in all guidelines. When dictating the conclusion, the radiologist should observe the following guidelines: – Answer the clinical question. In case of equivocation, try using the first person to add a personal touch.

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– Give a diagnostic opinion and avoid the hedge. Provide a clear list of differential diagnoses: a rambling list gives the impression of diagnostic uncertainty. – What is clear to a specialist may need to be highlighted to a nonspecialist. GPs appreciate detailed advice on further non-radiological (97%) and radiological (96%) investigation in the conclusion. – The radiologist should proofread the report before verifying it, minimizing clinical risk from error ( eg. “asymmetric” can easily be mis typed as “symmetric”). If findings are conveyed to the referring clinicians the time and means of communication should be recorded (3, 6). Preliminary vs final report In an emergency situation or other cases in which immediate action is required, the results of an examination are to be communicated to the referring clinician verbally. If such preliminary findings have been conveyed to the GP, it is generally advocated that the information conveyed has to be repeated in the final report. If a preliminary report undergoes substantive change before finalization, this should also be clearly communicated to the referring clinician (3). Communication of final report Developing systems for appropriate information exchange between the radiology department and primary care providers is an absolute necessity. Guidelines and recommendations for electronic communication and information transfer for GPs and access to electronic patient records across the GP-radiologist interface is essential (4). The final report and images may reach the referring GP in several ways: 1. In an urgent situation, preliminary findings can be conveyed to the GP by telephone. 2. Data carriers (paper or CD) with radiology report and images may be handed to the patient or can be posted to the referring GP’s office. 3. Radiology departments may mail the encrypted report to the referring physician by means of a third party server. 4. GPs may log in to a local network, allowing them access to the hospital/ radiology practice server

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and obtain restricted information from their patients. Secure, fast and reliable access may be provided by a virtual particular network (VPN). 5. Nationwide electronic patient file databases may contain all medical reports available from a patient. Access for GPs to these electronic patient records, including radiology reports and images, requires sophisticated security systems, such as electronic passport identification systems (eg. eID-viewer). ’E-health platforms and radiology: a Belgian perspective’ In the last decade, several large Belgian hospitals implemented their own electronic platform (e.g. Medibridge®), allowing referring GPs to access the radiology reports of studies they had requested, often secured through virtual private network (VPN) connections. These local networks created a strong connection between referring physician and radiologist. However, the functionality, authentication and authorisation between hospitals differed and the impossibility of data sharing between hospitals hindered efficient communication. Consecutively 5 regional ‘e-health hubs’ were created in Belgium linking hospitals. Imaging data remained stored locally in the participating hospitals, but GPs could retrieve data of their patients from allied regional hospitals. These regional hubs represented an opportunity for radiology to share infrastructure and services between hospitals thus optimizing return on investment.

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Subsequently Belgian governance obliged all hospital to join a hub and facilitated interconnection of the 5 regional hubs in 2012, thus creating a ‘metahub’ (9). The metahub represents a collaborative e-health platform for all actors in healthcare: not only for professionals (doctorhospital-caretaker), but also for patients, pharmacy, governance and research. Storage of data remains decentralized, in the hospital were examinations are obtained. The uniform functionality of the e-health platform facilitates access to all actors in healthcare. The patient authorises access to data by informed consent (opt- in system, e.g. the patient chooses if the GP has unlimited access to his/her file or may only view results of examinations he has requested). Healthcare actors will only be granted access to (specific) patient data if a therapeutic relation is affirmed. Authentication for login to the platform will be by means of encrypted e-ID-viewer technology. It is clear that e-health platforms will have a great impact not only on GP-radiologist communication, but will also affect daily radiology practice in the near future. Conclusion Good communication between GPs and radiologists implies three basic requirements: facilitation of the GP-radiologist interaction through guidelines and the use of electronic request forms, radiology reports tailored to the GPs needs, with prompt validation of final reports, and organization of local or nationwide electronic healthcare

platforms allowing optimal data exchange between GP and radiologists. References 1. Bosmans J.M., Weyler J.J., De Schepper A.M., Parizel P.M.: The radiology report as seen by radiologists and referring clinicians: results of the COVER and ROVER surveys. Radiology, 2011, 259: 184-195. 2. Bosmans J.M., Peremans L., De Schepper A.M., Duyck P.O., Parizel P.M.: How do referring clinicians want radiologists to report? Suggestions from the COVER survey. Insights Imaging, 2011, 2: 577-584. 3. Wallis A., McCourbie P.: The radiology report- are we getting the message across? Clin Radiol, 2011, 66: 10151022. Kvamme 4. O.J., Olesen F., Samuelsson M.: Improving the interface between primary and secondary care: a statement from the European Working Party on Quality in Family Practice (EQuiP). Quality in Health Care, 2001, 10: 33-39. 5. Belgian Federal Department of Health, Safety of the Food Chain and Environment. Guidelines medical imaging. URL: http://www.health. belgium.be/eportal/Healthcare/ Consultativebodies/Doctorscolleges/ Medicalimagingandnuclearmedici/ recommandationmedicalimaging/ 19064778?ie2Term=radiologie&ie2 section=83 6. Grieve F.M., Plumb A.A., Khan S.H.: Radiology reporting: a general practictioner’s perspective. Br J Radiol, 2010, 83: 17-22. 7. ACR Practice Guideline for communication of diagnostic imaging. Reston, Virginia, USA: Am Coll Radiol, 2005. 8. Clinger N.J., Hunter T.B., Hillman B.J.: Radiology reporting: attitudes of referring clinicians. Radiology, 1988, 169: 825-826. 9. URL:https://e-health.fgov.be

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IMAGES IN CLINICAL RADIOLOGY Transfusional iron overload presenting as choroid plexus hemosiderosis D.E. Sossa, F. Chiang, A.R. Verde, D.G. Sossa, M. Castillo

Case 1. A 16-year-old female patient with a history of Diamond-Blackfan Anemia (DBA) treated with repeated transfusions every 3-4 weeks and chelation therapy since infancy presents with transient syncope. Her symptoms progress to include headache, dizziness, and numbness of her right arm, right side of her face, lips, and tongue. MRI of the brain was performed, demonstrating a small frontal subarachnoid hemorrhage (not shown) and dark signal intensity throughout the choroid plexus (Fig. A, B) on susceptibility-weighted imaging (SWI). Case 2. A previously healthy 22-year-old female was found to have profound anemia and thrombocytopenia. She was transferred to our institution and acute lymphocytic leukemia (ALL) was diagnosed. Regular transfusions were given as part of treatment regimen with the first trans fusion 6 months ago. Brain MRI showed “blooming” artifact is visible in the lateral ventricles on SWI sequences, indicating iron deposits of the choroid plexus (Fig. C, D). Comments

Many clinical conditions include transfusion of red cell concentrates in their treatment with the purpose of alleviating insufficient supply of oxygen to tissues, low concentration of hemoglobin, and/or reduced oxygen carrying capacity and inadequate physiological mechanisms of compensation (1). The human body has no active mechanisms for the excretion of iron. In each transfusion the patient receives iron in excess (approximately 250 mg) which gradually accumulates in many tissues causing morbidity. When ferritin is trapped in lysosomal membranes it is termed hemosiderin which is an abnormal and insoluble form of iron (2). Hemosiderosis or iron overload is a pathological condition characterized by deposition of excess iron (hemosiderin) in body tissues. Hemosiderin initially accumulates in the reticuloendothelial system (spleen, bone marrow, and liver) but when these are saturated, deposition occurs in normal body tissues (3). Central nervous system (CNS) iron deposition may involve the choroid plexus, pituitary gland, cortical surfaces, and occasionally the basal ganglia. The choroid plexus is affected first due to its role in brain iron homeostasis and its absence of a blood brain barrier. This combination along with its high blood supply and high surface area increases the uptake of some nutrients such as iron. CNS iron deposition tends to be asymptomatic except in the pituitary where it results in hypopituitarism. There is no cure for iron overload but early treatment with chelating agents in superficial siderosis is promising (4, 5). DBA is a rare, genetically heterogeneous, macrocytic anemia presenting early in infancy. Its incidence is approximately 1: 100,000 live births. Laboratory findings include erythroid aplasia, reticulocytopenia, and possible mutation in the ribosomal gene for protein S19. Corticosteroids are first line therapy, although patients refractory to standard treatment necessitate regular blood transfusions as in our case. As a result, many patients with DBA will develop hemosiderosis due to iron overload (4). ALL is a highly aggressive neoplasm of precursor cells committed to the B-cell or T-cell lineage and represents nearly 25% of all childhood cancers. Chemotherapy is utilized as a first line treatment to reduce the burden of disease as quickly as possible and to restore normal bone marrow function. Packed RCC transfusions are used as needed during treatment (5). SWI is a high-spatial-resolution 3D gradient-echo MRI sequence which is particularly sensitive to compounds such as blood products, non-heme iron, and calcium that distort the local magnetic field homogeneity producing a “blooming” artifact (7). It is possible that in patients suspected of having CNS hemosiderosis SWI should be the imaging method of choice. Presence of cerebral hemosiderosis is a rare condition, but may alter systemic treatment of the underlying disease. Therefore it is important to detect it and, if possible, set up therapies focused in avoiding potential CNS complications.

References 1. 2. 3. 4. 5.

Liumburo G., Bennardello F., et al.: Reccomendations for the transfusion of red blood cells. Blood Transfus, 2009, 7: 49-64. Anderson G.J.: Mechanisms of iron loading and toxicity. Am J Hematol, Dec 2007, 82 (12): 1128-31. Levy M., Liinas R.H.: Update on a patient with superficial siderosis on deferiprone. Am J Neuroradiol, 2012, 33: E99-100. Kira R., Ohga S., Takada H., Gondo K., Mihara F., Hara T.: MR choroid plexus sign of iron overload. Neurology, 2000, 55: 1340. Rouault T.A., Zhang D.-L., Jeong S.Y.: Brain iron homeostasis, the choroid plexus, and localization of iron transport proteins. Metab Brain Dis, 2009, 10: 1007. 6. MacKenzie A., Kasner M.: Therapeutic developments in acute lymphoblastic leukemia. Blood and Lymphatic Cancer: Targets and T herapy, 2012, 2: 145-158. 7. Tong K.A., Ashwal S., Obenaus A., et al.: Susceptibility-weighted MR imaging: a review of clinical applications in children. AJNR Am J Neuroradiol, 2008, 29: 9-17. Department of Radiology, Neuroradiology Division, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.

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IMAGES IN CLINICAL RADIOLOGY Macrocephaly in an 8-month-old infant K. Ramakers1, W. Siemons2, L. Meylaerts2

An 8-month-old infant presents with macrocephaly and a mild motoric deficit. The pediatrician asks a complementary MR examination to exclude hydrocephalus. MR-images show diffuse swelling of white matter with preservation of the corpus callosum and the internal capsule. Also the occipital periventricular and subcortical white matter is better preserved than the rest of the cerebral white matter (A, axial T2 weighted image). The cerebellum seems normal (B, coronal T2 weighted image). The anterior temporal white matter is rarified (C, sagittal T1 weighted image, arrow). Axial T2 FLAIR image (D, arrow) shows a lower signal intensity in the anterior temporal subcortical white matter than in the cortex. Diagnosis of van der Knaap’s disease or MLC (megalencephalic leukencephalo pathy with subcortical cysts) was made. Comment

Megalencephalic leukencephalopathy with subcortical cysts (MLC) is an infantileonset inherited disease of the brain white matter, also called van der Knaap disease. It is very rare and consanguinity and inbreeding contribute to its occurrence. MLC is a genetic disease with a defect in brain water and ion homeostasis and volume regulation by astrocytes. This defect results in chronic white matter edema. At birth, most infants are healthy and develop a macrocephaly in absence of other neurological signs. Most patients are mildly delayed in achieving unsupported walking and have an unstable gait. They become wheelchair-dependent as teenagers. Cognitive capabilities are normal or mildly decreased. Many patients living in their 40s and 50s are known. MRI shows diffuse white matter abnormality with swelling of the abnormal white matter. Subcortical cysts are invariably present in the anterior temporal region but frequently also in the frontal and parietal regions. In children cysts may not yet be present, but anterior temporal white matter can be rarified, as in our case. Over time, the abnormal cerebral white matter becomes less severely swollen and atrophy follows, leading to widened lateral ventricles and subarachnoid spaces. Prominent atrophy is usually seen only in adults. The combination of macrocephaly and diffuse cerebral white matter abnormalities can be seen in Alexander disease, Canavan disease, L-2-hydroxyglutaric aciduria, congenital muscular dystrophy with merosin deficiency, and sometimes in infantileonset GM1 and GM2 gangliosidoses. In MLC The severity of the white matter disease contrasts with the presence of no or only mild clinical signs at this age. Reference

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1. Van der Knaap M.S., Boor I., Estévez R.: Megalencephalic leukoencephalopathy with subcortical cysts: chronic white matter oedema due to a defect in brain ion and water homoeostasis. Lancet Neurol, 2012, 11: 973-985.

1. Department of Radiology, UZ-Gasthuisberg, Leuven, 2. Department of Radiology, Ziekenhuis Oost-Limburg, Genk, Belgium.

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IMAGES IN CLINICAL RADIOLOGY Pituitary stalk interruption syndrome S. Dekeyzer1, N. Herregods 1, V. Meersschaut 1, J. De Schepper 2

A 5-year-old boy presented at the department of Pediatrics because of parental concerns about his delayed growth which had been slowing since the age of 2.5 years. The patient had no significant familial, perinatal or past medical history. At clinical examination, no abnormalities were present. His stature was below the 5th percentile. Laboratory investigations showed normal serum values of TSH, FT4 and prolactin, but an abnormally low IGF-1 concentration. Bone age (Gruelich and Pyle) was 3 years and 6 months, more than one year below his chronological age. MRI of the brain was performed to rule out a hypothalamichypophyseal lesion (Fig. A-D). Midsagittal T1-weighted MR imaging revealed a small sella with a hypoplastic anterior pituitary gland (dotted arrow). The pituitary stalk was extremely hypoplastic and barely perceptible (dashed arrow). An ectopic posterior pituitary gland (solid arrow) was observed as an area of T1 high signal intensity at the median eminence in the floor of the third ventricle between the right and left optic tract (small arrows). Comment

Pituitary stalk interruption syndrome (PSIS) is a congenital midline defect characterized by the triad of a small or absent anterior pituitary gland, a small or absent pituitary stalk and an ectopic posterior pituitary (EPP) lobe located at the median eminence in the floor of the third ventricle. In some patients, the abnormalities may be limited to EPP or to an interrupted pituitary stalk. PSIS is associated with several midline and/or cerebral malformations and with pituitary endocrinopathy. Contrary to what one might expect, the most frequent presentation of the latter is not diabetes insipidus, but either isolated growth hormone deficiency (IGHD) or multiple anterior pituitary hormone deficiency (MPHD). The endocrine outcome seems to be a progressive onset of pituitary hormone deficiencies leading to panhypopituitarism, usually with maintenance of the posterior pituitary function. In general , MPDH is more frequent in cases of EPP with complete absence of the pituitary stalk, whereas IGHD is more common in cases of EPP with a visible but hypoplastic pituitary stalk. Cerebral malformations associated with PSIS include periventricular nodular heterotopia, bilateral perisylvian syndrome (polymicrogyria of both lips of the Sylvian fissure), cerebellar dysgenesis and septo-optic-pituitary dyplasia (bilateral optic nerve hypoplasia and agenesis of the septum pellucidum). Extrapituitary abnormalities include renal anomalies, such as unilateral renal agenesis or hypoplasia, and dental anomalies, such as single central incisors. The causes of PSIS are still unknown. Mechanical pituitary stalk rupture or pituitary stalk ischemia during breech delivery have long been been implicated as major causes of PSIS. More recent studies favor defects during early embyrogenesis. Those defects may be genetic or the result of exposure to environmental factors during pregnancy. This theory of abnormal organogenesis is supported by the presence of other structural brain and/or body malformations in some patients and by the existence of rare familial forms of PSIS. MR imaging is the technique of choice in the diagnosis of children with IGHD or MGHD. If PSIS is diagnosed from MRI, there is no other possible diagnosis. The treatment is based on the replacement of the deficient hormones. In case of a partial of complete pituitary stalk agenesis, a close follow-up for evolving pituitary hormone deficiencies in needed. As patients progress from IGHD to MPHD, the stalk and adenohypophysis tend to become smaller. Reference

1. Kulkarni C., Moorthy S., Pullara S.K., Rajeshkannan R., Unnikrishnan A.G.: Pituitary stalk transection syndrome: Comparison of clinico-radiological features in adults and children with review of literature. Indian J Radiol Imaging, 2012, 22: 182-185.

Department of 1. Radiology and Medical Imaging, 2. Pediatrics, UZ Gent, Ghent, Belgium.

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12/12/13 14:03

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IMAGES IN CLINICAL RADIOLOGY Sister Mary Joseph nodule I. De Kock, S. Dekeyzer, B.S. Smet, L. Delrue1 A 64-year-old female presented with a three-month history of decreased appetite, nausea and progressive abdominal distension. Physical examination revealed a distended abdomen with a fluid wave and a hard perium bilical bluish swelling (Fig. A). Because intra-abdominal malignancy was suspected, a contrast- enhanced computed tomography of the abdomen was performed which showed a pelvic mass originating from the left ovary, omental and peritoA neal metastases, ascites, and a lobulated mass through the umbilicus with infiltration of the surrounding subcutaneous fat (Fig. B, C). Diagnostic laparoscopy and histopathological analysis of the obtained ovarian samples confirmed the diagnosis of metastatic ovarian carcinoma. A Sister Mary Joseph nodule (SMJN) is a metastatic umbilical lesion originating from intra-abdominal or pelvic malignant disease. It can be a sign of undiagnosed malignancy or a symptom or sign of disease progression or recurrence in a patient with known disease. Its incidence is low, occurring in 1%-3% of all intra-abdominal or pelvic malignancies. Sister Mary Joseph (1856-1939), a superintendent nurse and surgical assistant of Dr. William Mayo at St. Mary’s hospital (now the Mayo Clinic) in Rochester, Minnesota, USA, was the first to notice the association between the umbilical node and intra-abdominal malignancy while preparing patients for surgery. In 1949, the English surgeon Sir Hamilton Bailey (1894-1961) coined the term ‘Sister Mary Joseph nodule’ in his book B ‘Physical Signs in Clinical Surgery’ in honor of its discoverer. SJMN presents as a firm indurated umbilical nodule. The surface can be fissured or ulcerated, and it may have bloody, mucinous, serous or purulent discharge, depending on the primary tumor. The lesion has been described as variously coloured (white, bluish violet and brownish red) with or without pruritus. It is variable in size with a diameter often less than 5 cm, although some nodules may reach up to 10 cm. Patients with SMJN often present with a number of clinical symptoms consistent with intra-abdominal malignancy like abdominal pain or distension, nausea, anorexia, weight loss, or ascites. However, in up to 30% of cases SMJN is the first and only sign of a malignancy. In men, the gastrointestinal tract, particularly the stomach (20%), is the most common location of the primary malignancy, whereas in women gynecologic malignancies, especially ovarian and endometrial cancers, are the most common. Primary tumors in many other sites like gall bladder, pancreas, liver, small intestine, lung, breast, kidney, fallopian tubes, prostate and bladder have also been reported to cause SMJN. About 15% to 30% of all cases have an unknown origin. Histology usually reveals adenocarcinoma; however, there have been reports of umbilical metastases from sarcoma, mesothelioma, lymphoma and melanoma. The exact mode of spread is not known and mechanisms of umbilical seeding from primary tumors remain unclear. Contiguous extension from the anterior peritoneal surface is thought to be the most important method. Hematogenous spread through the extensive arterial and venous networks of the abdominal wall or lymphatic spread to the umbilical region C are other probable routes of metastatic spread. Direct extension along the ligaments of embryogenic origin (round ligament of the liver, vitelline duct, urachus) has also been postulated as a method of metastasis. SMJN represents umbilical metastases; and therefore, both treatment and prognosis depend on the primary tumor. However, the presence of this nodule often indicates an advanced internal malignancy and is generally associated with poor prognosis. Physicians need to be aware of this rare clinical entity so that they can promptly diagnose the primary malignancy or its progression or recurrence. Reference 1. Abu-Hilal M., Newman J.S.: Sister Mary Joseph and her nodule: historical and clincal perspective. Am J Med Sci, 2009, 4: 271273. 1. Department of Radiology and Medical Imaging, Ghent University Hospital, Ghent, Belgium.

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IMAGES IN CLINICAL RADIOLOGY Aqueductal stenosis secondary to Whipple’s disease F. Chiang, A.R. Verde, D.E. Sossa, D.G. Sossa, M. Castillo1 We present a 54-year old male with a history of Whipple’s Disease (WD) diagnosed 21 years previously and proven by an inguinal lymph node biopsy. Antibiotic therapy was initiated upon confirmation of gastrointestinal (GI) involvement via colonoscopy. On the most recent occasion, the patient presented with a 3-week history of ataxic gait, short-term memory loss, incontinence, oculofacial skeletal myorhythmia, and tinnitus. MRI showed markedly enlarged lateral and 3rd ventricles compatible with hydrocephalus. 3D constructive interference in steady state (CISS) images showed a small web traversing the distal cerebral aqueduct with cephalad dilatation (Fig. A). Post contrast images showed enhancement within the stenotic part of the aqueduct (Fig. B). Comments

WD is a rare, chronic inflammatory infectious disease of the GI system caused by the gram-positive bacillus Tropheryma whipplei. While GI involvement is the most prevalent presentation, WD can present as a multi-systemic disease affecting the CNS. Neurological involvement occurs either in the context of GI WD or “de novo” without GI involvement. The prevalence of CNS involvement is approximately 20-40% in patients with known WD and 5% of them present with isolated neurologic symptoms. Clinical CNS manifestations of WD are variable. Cognitive dysfunction and behavioral changes are most common with 2 characteristic clinical findings: oculomasticatory myorhythmia and oculo-skeletal myorhythmia. Ataxia, epilepsy, and focal cerebral signs have also been described in CNS WD. CT and MRI, although non-specific, are the best imaging tools in the evaluation of CNS WD. Contrast MRI is the most valuable modality as it can show direct parenchymal involvement often seen as small subependymal round enhancing lesions and hydrocephalus as in our patient. CISS sequences offer excellent spatial and contrast resolution and aid in ventricular evaluation. Indeed, when used in patients with hydrocephalus, CISS shows obstructing webs not seen in conventional MRI which alter treatment and prognosis in such patients. Using CISS sequences we demonstrated a stenosis in the aqueduct of Sylvius which was accompanied by a contrast enhancing subependymal area. Obstructive hydrocephalus due to aqueductal stenosis in CNS WD is B a rare but described entity. For this reason, rather than classify the hydrocephalus as idiopathic, we think it is important to study these patients with T1 post contrast sequences and look for subependymal enhancement representing inflammation and the presence of the bacillus in this location. This is important because in some of these patients long-term antibiotic therapy will result in resolution of hydrocephalus and avoid ventricular shunting and its complications as the latter is the treatment of choice in idiopathic hydrocephalus. Reference 1. Seneca V., Imperato A., Colella G., Cioffi V., Mariniello G., Gangemi M.: Recurrent acute obstructive hydrocephalus as clinical onset of cerebral Whipple’s disease. Clin Neurol Neurosurg, 2010, 112: 717-721.

1. Department of Radiology, Neuroradiology Division, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.

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12/12/13 14:06

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IMAGES IN CLINICAL RADIOLOGY Marked increase of breast density due to a levonorgestrel-releasing intrauterine device J. Gossner1 A 44- year old woman presented with bilateral breat pain and a feeling of increasing “tenderness” over the last year. Clinical examination as well as ultrasound performed by her obsterician was unremarkable. Mammo graphy was performed at our department. No suspicious mass or microcalcifications were found. A marked increase in breast density (ACR 4) compared to the previous exam two years previously (ACR 2) was evident (Fig. A, B). The patient reported about the insertion of a levonorgestel- relasing intrauterine device about one an a half year ago (Mirena®, Bayer Healthcare, Leverkusen, Germany). No systemic hormonal intake was reported (oral or transdermal) and clinical history was unremarkable. Especially there were no pathologies with a possible increase in breast density (radiation therapy to the chest, diabetes, congestive heart failure). There was no recent pregnancy. Comment

Physiologically there is a decrease in breast density in time. This may be reversed by oral hormonal therapy. About 25% of women undergoing hormonal replacement therapy show an increase in breast density. This is an important side effect, because with increased density the sensitivity of mammographic screening for breast cancer substantially decreases. A levonorgestrel-releasing intruterine device is used for contraception. It delivers a small amount of levonorgestel, a progesteron like hormone, into the uterine cavity for about 5 years. There is only one patient series examining the changes in breast density with the use of such an intruterine device. Lundström et al studied 20 postmenopausal women with a levonorgestrel- relasing intruterine device and oral intake of estradiol, in this series 30% of women shows an apparent increase in breast density (1). No reports on changes of breast density in premenopausal women using a levonorgestrel- relasing intruterine device for contrception where found d our patient seems to be the first decribed case. Radiologists should include systemic effects of topical applied hormones in their differential diagnosis of increasing breast density. Reference 1. Lundström E., et al.: Digitized assessment of mammographic breast densitiy in patients who received low-dose intrauterine levornorgestrel in continuous combination with oral estradiol valerate: a pilot study. Fertil Steril, 2006, 85: 989-995.

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1. Department of Clinical Radiology, Evangelisches Krankenhaus Göttingen-Weende, Göttingen, Germany.

12/12/13 14:13

JBR–BTR, 2013, 96: 397.

IMAGES IN CLINICAL RADIOLOGY The hypodense artery sign in acute cerebral infarction J. Bogdan, D. Rommel1

A 77-year-old man was admitted with severe stenosis of both left anterior descending and circumflex coronary arteries and mitral valve regurgitation. He underwent mitral valve replacement and coronary artery bypass grafting (CABG). During the second post operative day, sedation having been stopped, the patient presented a left hemiplegia and homolateral central facial paralysis. Head CT performed in emergency showed a large hypodense area in the right cerebral hemisphere (arrowheads on Fig. A) corresponding to an infarction in the right middle cerebral artery territory as well as a bifurcated longitudinal hypodensity (arrows on Fig. A). CT angiography (Fig. B) demonstrated a hypodense filling defect located in the right segment of the middle cerebral artery (arrow) with a -56 HU negative density value suggesting its fatty embolic nature. Thrombolytic treatment is not effective in this pathology and due to the patient’s age decompression craniotomy was not indicated. He died one month later due to general deterioration. Comment

Causes of cerebrovascular infarction after cardiac surgery are many. Most frequently, emboli originate in the heart, particularly in the setting of atrial fibrillation. Persistent atrial fibrillation is the most significant risk factor for stroke after mitral valve replacement. Emboli can also propagate from the carotid arteries as a complication of stenotic or complicated atherosclerotic plaques. Cerebral fat embolism is a rare cause of thromboembolic stroke. Fat emboli that usually originate from long bone fractures are most commonly described in the trauma and orthopedic literature, but are also described after cardiac surgery with sternotomy and paradoxically brain embolization in patients with venous-arterial shunt in the lung and patients with patent foramen ovale. In other cases, mitral valve replacement procedure may dislodge a macroscopic portion of fat from the cardiac or surrounding tissue which subsequently embolizes in the cerebral artery, or the fat embolus may originate from a fatty atherosclerotic plaque within the carotid artery or aortic arch. In our case, the diagnosis of fat embolism was suggested on the B basis of the negative attenuation values of the arterial cerebral defect in the context of cardiac surgery. A hypodense middle cerebral artery sign associated with acute stroke from a fat embolus has been described in 3 cases in the literature, all of them with a poor vital prognosis. Reference 1. Lee T.C., Bartlett E.S., Fox A.J., Symous S.P.: The hypodense artery sign. AJNR, 2005, 26: 2027-2029.

1. Department of Medical Imaging, Cliniques Universitaires Saint-Luc, Brussels, Belgium.

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12/12/13 14:14

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IMAGES IN CLINICAL RADIOLOGY Extruded disc herniation in the posterior epidural space

▲

P. Tritschler1, P. Mailleux1, B. Devyver²

✶

A 59-year-old patient was referred to the radiology department with a history of chronic left cruralgia which was already treated by radio frequency under fluoroscopy on D12 and L1 roots. Blood tests were normal. The patient had no previous medical or surgical history. A lumbar spine MRI was performed (sagittal T1, T2 and axial T1, T2, with and without Gadolinium injection). The MRI shows a left postero-lateral herniation with an upward migration from L2-L3 disc (Fig. A, white arrowhead). We can also see a frank thickening of the left L2 nerve root (Fig. B). In addition, the MRI also shows a mass located posterolaterally to the thecal sac (Fig. A white arrows, C, D, E), close to the ligamentum flavum already in the postero-lateral area of the spinal canal. This mass is hyperintense on T2 weighted images and isointense on T1 weighted images compared to the adjacent disc (Fig. A, D). On T1 weighted images after Gadolinium injection, the mass presents a heterogeneous peripheral ring enhancement which evokes a granulation tissue in first hypothesis. It was not an arthrosynovial cyst, there was no communication with the zygapophysial joints and the mass has no high hyperintense signal on T2 weighted images. There is no argument in favor of a ligamentum flavum lesion, indeed, in our case, the ligamentum flavum is well circumscribed with a hypointense signal on T1 and T2 weighted images. Dural lesions like neurinoma or schwannoma is less likely, this kind of lesions are hyperintense on T2 weighted images with a frank enhancement after Gadolinium injection. Spondylodiscitis could be excluded because L2-L3 disc is hypointense on T2 images, there is no irregularity or edema of the endplates and protein C reactive protein is normal. Our first hypothesisis was an extruded disc fragment at the posterior epidural space. An orthopedic surgeon performed a laminectomy of L2 and L3 and confirmed the presence of a large extruded fragment from L2L3 disc at the posterior epidurals pace, extending upwardly in the left L2 root and into the L2-L3 left foramen.

Comment Migration of an extruded disc fragment to the posterior epidural space is limited by the presence of several anatomical obstacles at the anterior epidural space. According to Schellinger et al, the anterior epidural space is dorsally defined by the posterior longitudinal ligament and lateral membranes, ventrally by the periosteum of the vertebral body. Anterior epidural space is also divided into two lateral compartments by the medial septum. Laterally, nerve roots play also a role of barrier to the migration of an excluded fragment. According to Ebeling, migration of cranial fragment is more frequent with posterolateral herniation and caudal migration is more frequent with back middle herniation. The differential diagnosis includes arthrosynovial cyst, ligamentum flavum lesion, spondylodiscitis, hemangioma, neurinoma and dural lesions. MRI is considered as the best imaging technique to characterize extruded disc fragment in particular at the posterior epidural space. Excluded fragments are characterized by a hypointense signal on T1 weighted images, and 80% of cases show a hyperintense signal intensity on T2 weighted images compared to the degenerated disc of origin. Most cases reported a peripheral contrast enhancement around the fragment due to the presence of an inflammatory response with granulation tissue and neovascularization. Serious complications such as cauda equina or conus medullaris syndromes are exceptionally reported, nevertheless if this complication is suspected, urgent laminectomy and discectomy are necessary. The best therapeutic option for extruded disc fragment at the posterior epidural space is often considered to be surgery. To conclude, the diagnosis of an extruded disc fragment at the posterior epidural space can be difficult because it is an infrequent localisation, with a multitude of differential diagnosis. MRI with contrast injection is an important tool for the detection of this type of pathology. Reference 1. Chen C.Y., Chuang Y.L., Yao M.S., Chiu W.T., Chen C.L., Chan W.P.: Posterior epidural migration of a sequestrated lumbar disk fragment: MR imaging findings. AJNR Am J Neuroradiol, 2006, 27: 1592-1594.

1. Department of Medical Imaging, 2. Department of Orthopedic Surgery, Clinique St Luc, Bouge, Belgium.

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IMAGES IN CLINICAL RADIOLOGY Pulmonary hematoma pseudotumor

presenting

S. Dekeyzer, I. De Kock, B. Smet, S. Van Meerbeeck1

A 65-year old man presented at the emergency department with acute shortness of breath, chest pain, cough and haemoptysis. The patient is an ex-smoker with a total of 35 pack years and an extensive medical history, including a serious traffic accident with neuro trauma, chronic obstructive pulmonary disease, degenerative spine and hip disease, ethylism, a type A aortic dissection and atrial fibrillation. His medication list is extensive and includes a broncho dilator, an antiepileptic, several antihypertensive drugs, pain medication, amiodarone, acetylsalicyc acid and subcutaneous low molecular weight heparin. Chest X-ray showed a rounded opacity in the mediobasal segment of the right lower lobe that could not be seen on previous radiographs (Fig. A). Biochemistry demonstrated an elevated CRP (48 mg/L) and elevated D-dimers (2190 ng/ml). CT thorax was performed to rule out pulmonary embolism. CT thorax showed a sharply demarcated relatively hyperdense mass (mean density on pulmonary artery phase images of 46 HU) with a maximum diameter of 5,5 cm in the mediobasal segment of the right lower lobe abutting the distal vena cava superior (Fig. B). An endobronchial ultrasounded (EBUS) guided biopsy of the lesion was performed. Pathologic examination showed pulmonary tissue with signs of hemorhage and fibrotic changes. No signs of malignancy were seen. An old thorax CT made in another hospital revealed that the location of the mass corresponded exactly with the location of a large bulla (Fig. C). Based on this new information the diagnosis of pulmonary hematoma within a bulla was made. Comment

Pulmonary hematomas are generally caused by thoracic injury. Pulmonary hematomas in trauma patients occur when there is a laceration of the lung parenchyma. Normal lung tissue surrounding a laceration pulls back from the laceration due to the normal pulmonary elastic recoil, resulting in a round or oval cavity in the lung. This traumatic cavity can filled with air (pneumatocoele), blood (traumatic hematocole or pulmonary hematoma), or both air and blood (traumatic hematopneumatocoele). Spontaneous (i.e. non traumatic) pulmonary hematomas are rare and only a few case reports can be found in the medical literature. They are generally attributed to anticoagulation therapy, but their exact disease mechanism remains unclear. Several authors claim that spontaneous bleeding occur in preexisting bullae or cysts. Other authors have suggested that pulmonary haemorrhaghe occurs first, followed by secondary infection and angionecrosis, which in term promotes bleeding into the new formed cyst. The presence of an older CT proved the hematoma in our patient occurred in a preexisting bulla. Pulmonary hematomas present on CT as nodules or masses C with a relative high attenuation that decrease in volume over time (vanishing tumors). In the non traumatic setting, they can be mistaken for malignancies. The high density of the lesions can help in making the diagnosis, as few pulmonary entities present with high-density non-calcified pulmonary lesions (talcosis, amiodarone lung). The presence of previous chest CT’s can also be helpful to detect a hematoma in a pre-existing bulla or cyst. Reference 1. Gil-Bello D., Castaner E., Ballardo X., Zidan A., Pomares X., Mata J.M.: Pulmonary hematoma secondary to anticoagulant therapy: imaging findings. Eur J Radiol, 2007, 63: 105-109. Department of Radiology, UZ Gent, Ghent, Belgium.

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IMAGES IN CLINICAL RADIOLOGY Cubonavicular coalition B. De Keyzer1, P. Øvreeide1, I. Crevits1

A 40-year old woman, known with bilateral pedes planovalgi presented to the hospital, with mechanical pain of some time duration. There was no history of trauma. Clinical examination revealed a decreased range of motion of the right subtalar joint. An X-ray of the foot showed blurring of the cubonavicular joint, with focal degenerative changes (Fig. A, black arrow). A sonography was performed, showing signs of synovitis of the intertarsal and subtarsal joints. On MRI, a narrowed and hazy cubonavicular joint was seen on sagittal STIR (Fig. B) and T1 (Fig. C), and on axial STIR (Fig. D) and T1 (Fig. E) with subchondral cyst formation and bone marrow edema (white arrows). Diagnosis of cubonavicular coalition was made. Conservative treatment was suggested. In case of worsening of symptoms surgical resection is an option. Comment

Tarsal coalitions have a low prevalence (1-2%). Talocalcaneal and c alcaneonavicular coalitions are the most frequent. Cubonavicular coalition represents only 1% of all coalitions in the literature reviewed (1, 2). The cause of tarsal coalitions has been attributed to failure of differentiation and segmentation of the embryonic mesenchyma during the first trimester of intrauterine development (1). Tarsal coalition is the most common cause of a rigid flat foot in chilB C dren, adolescents, and young adults (2). Symptoms of pain may develop as a result of altered biomechanics intertarsal joints, thus generating inflammatory processes (2). Plain radiography can be diagnostic in certain cases of tarsal coalition. In cases in which plain radiographic studies are equivocal or difficult to interpret and when tarsal coalition is suspected, MRI or CT should be performed. MRI and CT have the advantage of differentiating osseous from nonosseous coalitions and can evaluate the degree of joint involvement. They can also depict associated degenerative changes (1). On CT imaging, there is cortical contiguity in case of osseous coalition. In case of nonosseous coalition, changes may be subtle, with narrowing of the joint space and minimal marginal reactive bone changes (1, 2). MR imaging of the ankle and hindfoot should be performed in three planes: axial or oblique axial, coronal and sagittal. For the evaluation of most tendon, ligament and articular abnormalities T1-weighted, fast D E spin-echo proton density-weighted and fast spin-echo T2-weighted images are generally sufficient. The use of at least one fat-suppressed sequence, usually in the sagittal or coronal plane, is recommended to help identify bone marrow and soft-tissue edema or inflammatory change (1). On MR imaging, in osseous coalitions, there is bone marrow contiguity across the fused articulation. In non-osseous coalitions, the joint space is reduced. An area of signal intensity similar to that of fluid or cartilage may indicate a cartilaginous coalition. In fibrous coalitions, an area of intermediate- to low-signal intensity may be present in the joint space (2). Cubonavicular coalition should be included in the differential diagnosis in young patients presenting with foot pain. References 1. Sarage L.A., et al.: Cuboid-navicular Tarsal Coalition: Report of a Small Case Series with Description of a Surgical Approach for Resection. J Foot and Ankle Surg, 2012, 51: 783-786. 2. Newman J.S., Newberg A.H.: Congenital Tarsal Coalition: Multimodality Evaluation with Emphasis on CT and MR Imaging. Radiographics, 2000, 20: 321-332.

1. Department of Radiology, H. Hart Hospital, Roeselare, Belgium.

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PROCEEDINGS OF THE CARDIAC – CT COURSE held in Brussels on 16.03.2013 Cardiac CT angiography: technical aspects in 2012 O. Ghekiere1, A. Nchimi2 With the advent of the multidetector computed tomography (CT), cardiac computed tomography angiography (CCTA) has become a viable non-invasive method to rule out obstructive coronary artery diseases (CAD) due to its excellent negative predictive value. CCTA is mainly indicated in those patients presenting with clinically low-to-intermediate pretest likelihood for CAD. Despite its high diagnostic accuracy for detection of obstructive coronary artery disease, insufficient temporal, spatial or contrast resolution may sometimes provide incomplete or even misleading images of some coronary segments. These image artifacts are the main cause for misinterpretation regarding the presence of CAD and the successful use of

CCTA depends on operator awareness of these potential pitfalls. CCTA image quality determinants and artifacts CCTA is technically complex and subject to constraints that may result in image artifacts. Key factors determining CCTA image quality include temporal resolution, spatial resolution, contrast resolution and noise. Artifacts that may reduce image quality include blurring (Fig. 1), stairstep (Fig. 2) and blooming artifacts, low attenuating, streak, windmill or rod artifacts, vessel tracking artifacts, the omission of the region of interest, pseudostenosis and non-depiction of one or several coronary artery segments. Insufficient tissue-contrast, limited spatial and temporal resolution, and radiation dose have until now prevented

B Fig. 2. — Stairstep artifacts of the left anterior descending artery (arrows in A) due to cardiac arrhythmia (HR between 37 and 51 beats per minute in B) in this prospective ECG-triggered acquisition.

CCTA being widely used in other clinical applications such as myocardial function or dynamic perfusion. Recent advance

B Fig. 1. — Cardiac motion-related blurring artifact of the second segment of the right coronary artery (arrows in A) due to high heart rate (average heart rate of 75 beats per minute in B) in this prospective ECG-triggered acquisition.

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The rate of CCTA failure has substantially diminished as a result of recent vendor-specific technological advances in temporal, spatial and contrast resolution, noise reduction and arrhythmia detection. Due to these improvements, and despite radiation dose concerns, CCTA may yet become the one-shot-stop examination for both coronary artery disease and advanced applications such as perfusion assessment. Obviously this prospect warrants further clinical investigation. Bibliography 1. Budoff M.J., Dowe D., Jollis J.G., Gitter M., Sutherland J., Halamert E., Scherer M., Bellinger R., Martin A., Benton R., Delago A., Min J.K.: Diagnostic performance of 64-multi-

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detector row coronary computed tomographic angiography for evaluation of coronary artery stenosis in individuals without known coronary artery disease: results from the prospective multicenter ACCURACY (Assessment by Coronary Computed Tomographic Angiography of Individuals Undergoing Invasive Coronary Angiography) trial. J Am Coll Cardiol, 2008, 52: 1724-1732. Vanhoenacker P.K., Heijenbrok-Kal M.H., Van Heste R., Decramer I., Van Hoe L.R., Wijns W., Hunink M.G.: Diagnostic performance of multidetector CT angiography for assessment of coronary artery disease: meta-analysis. Radiology, 2007, 244: 419-428. Kroft L.J., de Roos A., Geleijns J.: Artifacts in ECG-synchronized MDCT coronary angiography. AJR, 2007, 189: 581-591. Choi H.S., Choi B.W., Choe K.O., Choi D., Yoo K.J., Kim M.I., Kim J.: Pitfalls, artifacts, and remedies in multidetector row CT coronary angiography. Radiographics, 2004, 24: 787-800. Nicol E.D., Arcuri N., Rubens M.B., Padley S.P.: Considerations when introducing a new cardiac MDCT service. Avoiding the pitfalls. Clin Radiol, 2008, 63: 355-369. Nakanishi T., Kayashima Y., Inoue R., Sumii K., Gomyo Y.: Pitfalls in 16-detector row CT of the coronary arteries. Radiographics, 2005, 25: 425-438. Mahesh M., Cody D.D.: Physics of cardiac imaging with multiple-row detector CT. Radiographics. 2007;27: 1495-1509.

JBR–BTR, 2013, 96 (6) 1. Department of Radiology, CHC Clinique St-Joseph, Liège Belgium, Department of Radiology, CHU Sart Tilman Liège, Belgium.

Imaging of the aortic root and ascending aorta R. Salgado, P. M. Parizel1 Introduction In recent years there has been increasing interest in the non-invasive imaging of the aortic root and ascending aorta. This is in part due to the exploration of the capabilities of CT-imaging in the assessment of the aortic valve, including the evaluation of aortic valve stenosis and insufficiency. Recent advances in transcatheter valve implantation techniques targeted at the aortic valve have also spurred interest in the non-invasive evaluation of the complex anatomy of the aortic root. Finally, the ascending aorta is a sometimes underestimated source of acute chest pain. Aortic valve and root While the aortic valve has traditionally three cusps (Fig. 1), many variations can exist. Up to 1-2% of the population has a bicuspid valve (Fig. 2). Its presence has potential important clinical consequences, as a bicuspid aortic valve is more susceptible to premature degeneration, and is associated with a varying degree of

aortic valve dysfunction. Consequently, when a dilated ascending aorta is observed in a young adult, a bicuspid aortic valve has to be considered (Fig. 3). Secondary to wear and tear, a bicuspid valve can present with thickened and partially calcified cusps at a relatively young age. Nevertheless, the amount of calcification by itself cannot be adequately used as a predictive marker for valve dysfunction (Fig. 3). Finally, a bicuspid valve can be associated with other congenital anomalies, including an aortic coarcatio. A morphologically normal aortic root incorporates three sinuses of Valsalva of equal size and a tricuspid valve. In analogy with the variation in numbers of cusps, significant discrepancy in the development of these sinuses and cusps can exist (Fig. 4). As such, an aortic valve with a hypoplastic cusp and associated smaller sinus can consequently mimick a ‘true’ bicuspid valve (Fig. 5). CT has proven to be an excellent tool in the evaluation of valve morphology, often acting complimentary to the echocardiography-derived evaluation. While magnetic resonance (MR) imaging and echocardiography are traditionally the methods of choice in the evaluation of aortic valve dysfunction, several studies have demonstrated the ability of ECG-gated CT studies to correctly assess both aortic valve stenosis and regurgitation (Fig. 6). In contrast to the mentioned traditional imaging modalities, this evaluation requires an additional radiation exposure which can be substantial. Therefore, we do not recommend this in routine practice, its use better reserved for application on a case-bycase basis.

Fig. 1. – The aortic root has a double-oblique orientation, but a rough initial cross-sectional reformation can be obtained by aligning the imaging plane in an oblique fashion along the aortic valve cusps (dashed line) on a coronal reformatted image (A). The aortic root has three sinuses of Valsalva (asterisk in B), and contains a normally tricuspid aortic valve.

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Fig. 2. – Double-oblique reformatted cross-sectional contrastenhanced CT image in a 42-year-old man demonstrating the typical appearance of a bicuspid aortic valve. Note that there are only two sinuses of Valsalva (asterisk).

Fig. 4. – A 52-year-old man with an acquired functionally bicuspid valve. The cross-sectional reformatted contrast-enhanced CT image reveals three sinuses of Valsalva (asterisk), but only two cusps. This functionally bicuspid appearance can be the end result of fusion between two cusps, in this case secondary to a decade-old valve infection. As such, originally tricuspid aortic valves can become functionally bicuspid.

Fig. 3. – Coronal contrast-enhanced CT image demonstrating a premature degenerated bicuspid valve in a 36-year-old woman with extensive valve calcifications and thickened cusps. Note the dilated ascending aorta, a common associated finding secondary to the hemodynamic effects of aortic valve dysfunction.

Fig. 5. – A 65-year-old man with a hypoplastic left coronary cusp on a cross-sectional contrast-enhanced CT image through the aortic valve. The hypoplastic left coronary cusp and left sinus of Valsalva make this valve appear almost bicuspid. Many variations exist in the morphology of the aortic valve. While CT can deliver excellent image quality, the associated radiation exposure and the lack of true functional information makes it not suitable for routine valve evaluation. Consequently, the application of CT for the evaluation of valve morphology must be restricted on a case-by-case basis, and always in conjunction with the findings of echocardiography and magnetic resonance imaging.

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Fig. 6. â&#x20AC;&#x201C; Evaluation of aortic valve stenosis and insufficiency using CT. Panel A illustrates the normal opening of the valve during systole. Panel B conversely demonstrates the only slight systolic valve opening in an 82-year-old man with critical aortic valve stenosis. Panel C shows the normal closing of the aortic valve in the end-diastolic phase of the cardiac cycle. Panel D reveals in the same cardiac phase a residual opening corresponding with aortic valve insufficiency. Functional aortic valve evaluation is traditionally reserved for echocardiography and magnetic resonance imaging. CT is, despite its excellent planimetric capabilities, not routinely indicated herefore.

Pre-operative evaluation of the aortic annulus With the development of transcatheter valve implantation techniques for treatment of critical aortic valve stenosis, considerable attention is currently given to the optimal pre-procedural evaluation of the aortic annulus dimensions using noninvasive techniques. While echocardiog-

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raphy, most notable transesophageal ultrasound, has been successfully used in different trials for the evaluation of annular dimensions, it is now widely recognized that the excellent three-dimensional capabilities of CT can make a significant contribution in optimizing annular sizing. Several CT-based studies of the annular dimensions have indicated an oval annular morphology in a majority of cases, in

contrast to the circular contour which was always assumed using two-dimensional techniques like echocardiography. Current research concentrates, among others, in establishing the optimal integration of different imaging tools for achieving optimal transcatheter valve size selection for a given patient, and to subsequently prevent or minimize paravalvular regurgitation.

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Fig. 7. – Evolution from an intramural hematoma to a classic dissection in a 32-year-old man with acute chest pain. On admission, the sagittal contrast-enhanced CT image (A) reveals a clear intramural hematoma (white arrows), with a small entry site (black arrow) just distally from the left subclavian artery, and no clear re-entry site. This image shows the clear distinction between one channel of flowing blood (large true lumen T), and one channel of stationary blood (intramural hematoma). However, after 6 days a new CT examination now shows several entry- and re-entry sites with two channels of flowing blood and a consequently larger false lumen. This changed appearance now represents a classic form of (in this case type-B) aortic dissection, and illustrates the varying morphology of the acute aortic syndrome.

Acute aortic syndrome The term ‘acute aortic syndrome’ is used to indicate the trilogy of acute aortic dissection, intramural hematoma and penetrating atherosclerotic ulceration as aortic-based causes of acute chest pain. However, contemporary criticism points out that the distinction between these three causes is conceptually flawed, as especially acute aortic dissection and intramural hematoma most probably represent two separate presentations of the same clinical entity. Most important, it is now preferred to use ‘intramural hematoma’ as a descriptive term, indicating stationary blood within the aortic wall. This stationary blood is formed as blood from the main (true) lumen enters the aortic wall through a small and often on CT or MR imaging unnoticeable defect in the intima layer. As is often the case,

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there is only an entry site in the aortic wall, and no detectable re-entry site. Consequently, this stationary blood forms a thrombus in the aortic wall, with a ‘false’ lumen that is typically semicircumferential and smaller than the main true lumen. It is furthermore important to recognize that this situation can evolve to a classic aortic dissection. This can occur when one or several re-entry sites develop along the course of the diseased aortic wall (Fig. 7). On such occasion, there is transition to two channels of flowing blood, with often the false lumen having a larger cross-sectional diameter than the true lumen. Bibliography 1. Ueda T., Chin A., Petrovitch I., et al.: A pictorial review of acute aortic syndrome: discriminating and over

lapping features as revealed by ECGgated multidetector-row CT angio graphy. Insights Imaging, 2012, 3: 561-571. 2. Goffinet C., Kersten V., Pouleur A.C., et al.: Comprehensive assessment of the severity and mechanism of aortic regurgitation using multidetector CT and MR. Eur Radiol, 2010, 20: 326-336 3. Feuchtner G.M., Müller S., Bonatti J., et al.: Sixty-four slice CT evaluation of aortic stenosis using planimetry of the aortic valve area. Am J Roent genol, 2007, 189: 197-220. 4. Lehmkuhl L., Foldyna B., Von Aspern K., et al.: Inter-individual variance and cardiac cycle dependency of aortic root dimensions and shape as assessed by ECG-gated multi-slice computed tomography in patients with severe aortic stenosis prior to transcatheter aortic valve implantation: is

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it crucial for correct sizing? Int J ardiovasc Imaging, 2013, 3: 693-703. C 5. Achenbach S., Delgado V., Hausleiter J., et al.: SCCT expert consensus document on computed tomography imaging before transcatheter aortic valve implantation (TAVI)/transcatheter aortic valve replacement (TAVR). J Cardiovasc Comput Tomogr, 2012, 6: 366-380. 1. Department of Radiology, Antwerp University Hospital, Edegem, Belgium. Non-coronary applications of cardiac CT (with MR correlation) S. Dymarkowski1 The high diagnostic accuracy and high negative predictive value of cardiac multidetector row computed tomography (MDCT) to evaluate coronary artery stenoses is very well known, and as such, this technique has been put forth as the most promising non-invasive exam. Additionally, the full volumetric dataset allows for analysis of a wide range of other cardiac pathologies. Left ventricular volumes and systolic function can be accurately assessed, if both systolic and diastolic frames are acquired. The same holds true for evaluation of (artificial) cardiac valves. Furthermore, accurate high-resolution visualization of the atria, pulmonary veins and the cardiac venous system is often sought by the cardiologist performing electrophysiological procedures. The newest technological advances allow these exams to be performed at relatively low radiation doses. This brings novel applications such as stress- perfusion imaging and cardiac dual energy imaging into the picture and opens the door towards CT imaging of myocardial infarction and ischemia. Cardiac function assessment Assessment of global systolic function can be achieved by reconstructing a 4D retrospective gated spiral acquisition in different phases throughout the cardiac cycle (typically a phase every 10% of the RR interval) to identify end-diastolic and end-systolic phases. By delineating the endocardial surface and by using the Simpson method, the LV volumes are obtained. The accuracy of MDCT-derived functional parameters has been extensively investigated and compared with other imaging modalities such as gated single-photon emission computed tomography (SPECT) and magnetic resonance imaging (MRI) and has been found to be both a very reproducible and accurate means to quantify LV volumes and LV ejection fraction. In recent years however, the habit of obtaining retrospectively gated scans has strongly declined, since newer acquisition algorithms such as the ‘step and shoot’ prospective gating method and the emergence of single heartbeat acquisitions have allowed for a dramatic decrease in radiation dose, but these

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Fig. 1. — Circulite left ventricular assist device. 3D VRT reconstruction of the in- and outflow canullae.

schemes only acquire information about the second part of the cardiac cycle, thus disallowing any functional evaluation. A motivated choice has to be made by the radiologist, based on the clinical history and depending on what information is to be gained, whether to choose for a lowdose scan or a full functional 4D evaluation. Imaging of cardiac valves Homologous to the situation described for cardiac function, the high spatial resolution allows for detailed analysis of the cardiac valves. Cardiac CT provides important information on the presence of (peri)valvular and annular calcifications, variations in the number of valve leaflets, and recently more specifically on the aortic valve anatomy, geometry, and valve area in patients considered for transarterial aortic valve implantation (TAVI) (Fig. 1). In selected cases, imaging of artificial valves and assist devices can be considered, since the new fast acquisition algorithms and artifact-reducing reconstruction kernels allow accurate anatomical and functional visualization in case of valve dysfunction. The exact value of valvular assessment by cardiac CT is largely still under investigation, re-emphasized by its grading in the recent Appropriateness Criteria for Cardiac Computed Tomography and Cardiac Magnetic Resonance Imaging, from the American College of Cardiology, as an ‘uncertain indication’ (Fig. 2). Imaging of the atria and the cardiac venous system In patients with drug-resistant atrial fibrillation, transcatheter radiofrequent

ablation can be used to thermally destroy atrial foci suspect for initiation of these arrhythmias. These procedures are often aided by cardiac CT by identifying the exact pulmonary vein anatomy, of which there are many variants (large or small venoatrial junctions, common ostia or accessory pulmonary veins). In end-stage heart failure, cardiac resynchronization therapy (CRT) has been shown to increase survival and provide systematic relief of symptoms. This procedure requires positioning of a pacing lead near the inferolateral wall of the LV. The main factor determining the success of a transvenous LV lead implantation is cardiac anatomy, particularly of the coronary venous system, which is known to be highly variable. With only a small adaptation of the regular cardiac scanning algorithm, many studies have shown reliable visualization of the cardiac venous anatomy and accurate quantification on the dimensions of the ostium of the coronary sinus and the diameter of the target veins. Imaging of myocardial infarction and ischemia Similar to what is more commonly performed in an MRI setting, cardiac CT can be are acquired during the first pass of a bolus of contrast agent, theoretically allowing hypoperfused areas within the myocardium regions to appear with low attenuation. Although currently perfusion CT is still largely investigational and still under development in preclinical animal models, a good accuracy to detect myocardial infarction has been observed. In similar studies, delayed phase scanning showed delayed hyperenhancement in the infarct area.

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Fig. 2. — Systolic (A) and diastolic (B) image of an artificial mitral valve that shows absence of proper opening of the posterior leaflet.

pericardial disease on diastolic function, or the functional significance of pericardial thickening are rarely assessable by CT, where this is rather comfortably done in echocardiography and cardiac MRI. Conclusions

Fig. 3. — Short-axis (left) and transverse (right) CT image of a cardiac lipoma, arising from the inferobasal interventricular septum.

A significant coronary stenosis will usually not show any signs of decreased perfusion in a resting state. Therefore, also the feasibility of performing adenosine or dipyridamole stress myocardial perfusion imaging has been explored and has shown potential to provide information on stress-induced ischemia in selected patients. Issues of patient safety, unfamiliarity with monitoring requirements and difficulties in acquiring reliable data in patients with drug induced tachycardia during CT have so far limited its wide spread use in clinical practice. Imaging of myocardial masses and pericardial diseases A cardiac mass can often be detected as an incidental finds on cardiac CT performed for other indications. The majority of these lesions are cardiac thrombi, usually located in the left atrium or left atrial appendage in patients with history

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of atrial fibrillation and adjacent to areas of infarction tissue in patients with ischemic heart disease. These thrombi appear as non-attenuating mural masses, usually in high contrast to the iodine within the cardiac chambers. Other masses, such as primary and secondary tumors, or mimics of normal anatomy, may be readily detected by CT, but may prove to be difficult to characterize (Fig. 3). In these cases MRI is the preferred imaging modality since its multiparametric approach allows for more accurate tissue characterization. Pericardial diseases, expressed as focal or generalized thickening, contrast enhancement in inflammatory conditions and calcifications in more chronic settings are easy to investigate with cardiac CT, especially in scenarios where echocardiography is known to underperform, e.g. poor acoustic window due to constitution or in the immediate postoperative setting. Nevertheless, the influence of

Cardiac CT can be considered as a valuable non-invasive imaging modality for the study of different non-coronary cardiac diseases. The ability to perform high quality functional analyses of ventricular and valvular function has been extensively proven, but must be looked at skeptically, since this comes at a significant cost in terms or radiation dose. Cardiac CT is also being increasingly solicited as the preferred modality for planning of different minimally invasive procedures, such as transcatheter ablation of arythmogenic foci within the atria or TAVI and CRT implantations. The use of CT for investigation of myocardial scar formation and ischemia visualization is still in its investigational phase. Bibliography 1. Nasis A., Mottram P.M., Cameron J.D., Seneviratne S.K.: Current and Evolving Clinical Applications of Multidetector Cardiac CT in Assess ment of Structural Heart Disease. Radiology, 2013, 267: 11-25. 2. Hendel R.C., Patel M.R., Kramer C.M., et al.: ACCF/ACR/SCCT/SCMR/ASNC/ NASCI/SCAI/SIR 2006 appropriateness criteria for cardiac computed tomography and cardiac magnetic resonance imaging: a report of the American College of Cardiology Foundation Quality Strategic Directions Committee Appropriateness Criteria Working Group, American College of Radiology, Society of Cardiovascular Computed Tomography,

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Society for Cardiovascular Magnetic Resonance, American Society of Nuclear Cardiology, North American Society for Cardiac Imaging, Society for Cardiovascular Angiography and Interventions, and Society of Interventional Radiology. J Am Coll Car diol 2006;48:1475–1497. Hurlock G.S., Higashino H., Mochizuki T.: History of cardiac computed tomography: single to 320-detector row multislice computed tomography. Int J Cardiovasc Imaging. 2009;25 Suppl 1:31-42. Tops L.F., Krishnàn S.C., Schuijf J.D., Schalij M.J., Bax J.J.: Noncoronary Applications of Cardiac Multidetector Row Computed Tomography. JACC Cardiovasc Imaging, 2008, 1: 94-106 Schuleri K.H., George R.T., Lardo A.C.: Applications of cardiac multidetector CT beyond coronary angiography. Nat Rev Cardiol, 2009, 6: 699710. Rodríguez-Granillo G.A., Ingino C.A., Lylyk P.: Myocardial perfusion imaging and infarct characterization using multidetector cardiac computed tomography. World J Cardiol, 2010, 2: 198-204. Leipsic J., Gurvitch R., Labounty T.M., Min J.K., Wood D., Johnson M., Ajlan A.M., Wijesinghe N., Webb J.G.: Multidetector computed tomography in transcatheter aortic valve implantation. JACC Cardiovasc Imaging, 2011, 4: 416-429. Jongbloed M.R., Lamb H.J., Bax J.J., et al.: Noninvasive visualization of the cardiac venous system using multi slice computed tomography. J Am Coll Cardiol, 2005, 45: 749-753. Wang Z.J., Reddy G.P., Gotway M.B., Yeh B.M., Hetts S.W., Higgins C.B.: CT and MR imaging of pericardial disease. Radiographics, 2003, 23: S167180.

1. Department of Radiology, UZ Leuven, Leuven, Belgium. Acute chest pain and CT: current insights & cost-effectiveness M. Francone, N. Galea, R. Rosati, I. Carbone1 Acute chest pain (ACP) is a common reason of admission at the emergency departments (ED), not infrequently representing a source of challenging dilemmas for clinicians and anxiety for patients with relevant legal implications related to inappropriate therapeutic management (1). The list of differential diagnosis of ACP is extensive and ranges from benign musculoskeletal disorders to life-threatening conditions requiring immediate treatment such as acute coronary syndrome, aortic dissection, rupture of the esophagus, perforating peptic ulcer, pulmonary embolism and tension pneumothorax. Current diagnostic algorithms may reliably rule out serious disorders in most of the cases however there is still persistence of an unacceptable rate of about

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JBR–BTR, 2013, 96 (6) 4-8% of patients with myocardial infarction or acute coronary syndrome who are inappropriately discharged from the ED due to the presence of normal initial cardiac enzyme levels associated with nondiagnostic/non-specific electrocardiographic (ECG) and echocardiographic alterations (2). Furthermore, the growing pressure of legal disputes for malpractice and the reasonable clinical caution in excluding potentially lethal syndrome is a common cause of unnecessary diagnostic procedures and precautionary prolonged hospitalization with obvious economical implications. Although an acute coronary syndrome is ultimately diagnosed in only 10 to 15% of patients who present with ACP, it has been estimated that the mean length of hospitalization is 4.6 days, with an average cost of approximately $23,000 per patient in the US an annual cost over $3 billion (3). Primary objectives of social health systems in Europe and US are to speedup diagnostic algorhythm, improve diagnostic accuracy and, obviously, reduce management costs. In this clinical setting, contrast-enhanced coronary computed tomographic angiography (CCTA) has emerged as a promising non-invasive diagnostic tool, with an high sensitivity and specificity and a ~100% negative predictive for the exclusion of coronary artery disease, potentially allowing to improve clinical care of those patients. A role of CCTA in supporting the triage of patients with suspected acute coronary syndrome has been hypothesized since early 2000’ (4) and its impact on costs and health care has been subject of an extensive recent literature, nevertheless unanimous consensus was not achieved. In particular, great emphasis was given to the so-called “triple rule out” protocol that offers in one-stop-shop exam a complete evaluation of thoracic cardiovascular structure, revealing three severe acute potentially lethal disorders (ischemic heart disease, acute aortic disease or pulmonary embolism). Present article will discuss different acquisition protocols, clinical results and economical implications of CCTA in the clinical setting of ACP. Clinical indications According to current American Heart Association (AHA) guidelines, appropriateness of CCTA in patients presenting with symptoms of ACP has been indicated as “uncertain” in both patients presenting with persistent ECG ST-segment elevation following exclusion of myocardial infarction or with ACP of uncertain cause (score 6 out of 9 for both indications) and inappropriate in presence of a definite diagnosis of myocardial infarction (5). The Asian Society of Cardiovascular Imaging (ASCI) guidelines, categorized clinical appropriateness to the exam according to pre-test probability of disease. Use of CCTA was indicated as “uncer-

tain” in presence of low pre-test probability and “appropriate” in patients with intermediate and high pre-test likelihood (evidence level 7 out of 9 for both) excluding subjects with ST-segment elevation and/or positive cardiac enzymes in which examination was considered inappropriate (6). A similar consensus was recently reported by the Italian sub society of cardiac radiology in which use of CCTA in patients with non-assessable ECG and /or equivocal laboratory biomarkers was scored as class II clinical indication (i.e. diagnostic information of clinical relevance provided) in presence of ACP whereas the triple rule out protocol application was regarded as potentially useful but still investigational (7). The “Triple Rule Out” Protocol Ideal CCTA protocol should represent the best compromise between the need for a comprehensive and reliable evaluation of all thoracic cardiovascular structures at the lowest radiation dose possible. Recent technological advances enable an accurate and detailed imaging of coronary arteries, thoracic aorta and pulmonary arteries in a single contrast-enhanced ECG-gated CT scan. Although the examination is potentially feasible even on 16-slice CT scanner, it is recommended to use last generation machines (64-slice or greater) implemented by radiation dose reduction tools and dedicated cardiac post-processing software. Use of a preliminary unenhanced prospectively ECG-gated acquisition covering the entire thoracic aorta might be helpful to provide information regarding distribution and amount of coronary artery calcium and to eventually detect hyperdense vascular rims reflecting intramural aortic hematoma at the cost, however, of an increased patient’s exposure. The choice to apply retrospective or prospective ECG-synchronization techniques is conditioned by the available technology and patient’s heart rate, keeping in mind the general concept that the combination of a stable and sinus heart rhythm and a heart rate of less than 65-70 beats per minute (depending on the scanner generation) is mandatory to obtain adequate image quality. Radiation doses of retrospectively gated 64-slice CT range between 7 to 14 mSv when dose modulation strategies are applied whereas in prospectively ECG-gated triggering, a significant effective dose reduction is realistically feasible with a dose of 5 to 7 mSv, less than that from nuclear myocardial perfusion imaging. Recently, a high pitch dual-spiral cardiothoracic comprehensive protocol using a last generation dual source CT scanner has been proposed in patients with undifferentiated acute chest pain, allowing to minimize patient’s individual exposure to an average 3.8 mSv. Heart-rate control can be achieved in most of the cases intravenously administering a short-acting beta-blocker (like

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metoprolol 5-20 mg or esmolol 10 mg/ mL) few minutes prior to the examination excluding patients with general contraindications to the drug (asthma, sinus bradycardia and hypotension, atrioventricular block etc). Preliminary administration of sublingual nitroglycerin could also be useful to dilate coronary arteries. Test bolus or bolus tracking protocol are strongly advisable to determine the optimal timing of contrast injection and when bolus tracking is selected we suggest to use a threshold of 120-140 HU and a region of interest placed within the ascending aorta. Contrast medium administration protocol should be adapted to the covered surface of body, however a bolus of 80–110 mL of contrast medium at a rate of 4-5.0 mL/s followed by a 40 mL saline flush is usually adequate to obtain an optimal vascular enhancement within the entire acquisition window. Further technical aspects about the CT scan protocol are provided in a large expert consensus recently published (8).

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Images interpretation Radiological report of patients admitted with ACP should be promptly prepared and communicated to the referring clinical team of the ED in order to speed-up diagnostic workup; utilization of a prefilled initial and final patient’s report form has even been suggested on this regard (4). A complete evaluation of both cardiac and non-cardiac structures needs to be provided, to rule out pulmonary embolism and aortic dissection and to exclude nonvascular causes of chest pain potentially affecting patient’s management (eg. pneumotorax, pneumonia, pleural or pericardial effusion). Coronary arteries evaluation should include detailed description of location, extent and morphological features of plaques, with particular attention to soft density lesions and to the so-called “napkin-ring sign” with is characterized by the presence of a ringlike attenuation pattern resembling the thin-cap fibroatheroma recognized as a precursor lesion for plaque rupture (9) (Fig. 1). A strong prognostic value of CCTA was recently demonstrated, independent of traditional risk factors and calcium scoring, in a patient’s cohort of 457 subject presenting with ACP in which the absence of plaques was associated with no clinical event in a follow-up period of 11 months (10). Comprehensive cardiac evaluation should combine morphological information obtained from coronary arteries analysis with functional (ejection fraction, regional wall motion) and perfusional data, in order to correlate non-invasive angiographic findings with status of corresponding vascular territory (Fig. 2) (11). Combined evaluation of regional wall motion abnormalities and myocardial perfusion defects has shown to improve detection of acute myocardial infarction with a sensitivity of 94% and specificity of 97%, using cardiac biomarkers and single photon emission CT (SPECT) myocardial

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Fig. 1. — CCTA in a 63-year-old patient admitted at the ER due to recent atypical angina, presenting with negative ECG and enzymes. Curved planar reconstruction show the presence of an eccentric soft tissue lesion located in mid left anterior descending artery, causing moderate luminal stenosis (A). An high grade lesion is also located at the origin of left posterior descending artery (C) and was successfully treated with coronary stenting. Corresponding selective coronary angiography images are displayed in figures B and D.

perfusion imaging as reference standard (12). Moreover, detection of regional myocardial perfusion defect has an additional diagnostic value to CCTA, reducing rates of false positive an improving the positive predicting value from 67% to 90.1%, if compared to rest sestamibi single-photon emission CT myocardial perfusion imaging (SPECT-MPI) (13). Cost-effectiveness Analysis of CCTA cost-effectiveness in the clinical setting of ACP has been a subject of interest in a large number of recently published papers, either based on simulated models of clinical and economic outcomes and on large patient’s cohorts or metanalysis.

Main findings emerged from literature were the following: 1) Use of CCTA allows a higher rate of patient’s discharge from ER with a shorter length of stay as compared to the standard of care (SOC) (14). Litt and colleagues (3) reported a remarkable 27% difference in the rate of early discharge of patients who underwent CCTA as compared to SOC with a significantly reduced median length of ER stay of 18.0 hours vs 24.8 hours. Similar results were found in a large metanalysis of four large trials reported reporting a significant reduction patient’s stay, including both ED or total hospital stay (15). 2) The majority of authors found a cost saving ranging between 15% and 38% when use of CCTA was compared to

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Fig. 2. — Left anterior descending artery post-traumatic focal dissection in a 26-year-old patient following a severe motorbike accident (A). Corresponding thin-slice volume rendering reconstruction shows the presence of a large perfusion defect located in the mid anterior-septal left ventricular wall perfectly matching distribution territory of the dissected vessel (B, arrows).

Conclusions

Fig. 3. — Bar chart showing analysis of CCTA cost effectiveness compared to standard of care. Data are plotted from reference #15 and derived from the metanalysis of 4 large clinical trials focused on patients with ACP. ROMICAT II study results are differentiated in discharged (ER only) vs hospitalized (hosp) patients.

SOC, mostly in patients with low- to intermediate-risk of disease (14-16) (Fig. 3). 3) CCTA allows higher detection of coronary arteries disease with subsequent increase of percutaneous and stenting procedures as emerged from the pooled data of a large study population 1,869 patients undergoing CCTA

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vs 1,397 undergoing SOC, with subsequent cost increase of 3.9% in case of hospitalization of CCTA patients (17). In positive CCTA patients, therefore, the increase of downstream testing and procedures may cause a cumulative mean cost of care similar to the SOC group.

The very high negative predictive alue of CCTA for CAD minimizes risk of v undetected acute coronary syndromes providing relevant impact on patient’s prognosis and clinical management (3, 16). CCTA in ACP is a fast, feasible, and robust imaging technique which is becoming widely available in the ER with an acceptable dose exposure when using last generation scanners combined with appropriate dose reduction strategy. It allows a rapid patient’s discharge with significant health-care costs reduction and improved individual therapeutic management. On the other hand, the presence of an high-grade stenosis does not necessarily reflect an acute coronary syndrome and non-invasive angiographic findings should be necessarily combined with complementary functional/perfusional tests to rule-out underlying myocardial ischemia due to the assumption that coronary physiology is the critical decision point for consideration of revascularization. Additional limitations to widespread utilization of CCTA in this setting rely on the current limited availability of dedicated cardiac imaging specialist and on the still high number of false positive cases related to the presence of extensive vascular calcifications with intraluminal beam hardening artifacts. The future is anyway probably going in the direction of CCTA as acknowledged by clinical guidelines and appropriateness criteria of the main national and international medical societies and witnessed by the extensive literature

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strongly supporting its utilization in large clinical trials. References 1. Kolansky D.M.: Acute coronary syndromes: morbidity, mortality, and pharmacoeconomic burden. Am J Managed Care, 2009, 15: S36-41. 2. Hoffmann U., Pena A.J., Cury R.C., et al.: Cardiac CT in emergency department patients with acute chest pain. Radiographics : a review publication of the Radiological Society of North America, Inc 2006, 26: 963-78; discussion 979-980. 3. Litt H.I., Gatsonis C., Snyder B., et al.: CT angiography for safe discharge of patients with possible acute coronary syndromes. New Engl J Med, 2012, 366: 1393-1403. 4. White C., Read K., Kuo D.: Assessment of chest pain in the emergency room: what is the role of multidetector CT? Eur J Radiol, 2006, 57: 368372. 5. Taylor A.J., Cerqueira M., Hodgson J.M., et al.: ACCF/SCCT/ACR/AHA/ ASE/ASNC/NASCI/SCAI/SCMR 2010 appropriate use criteria for cardiac computed tomography. A report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, the Society of Cardiovascular Computed Tomography, the American College of Radiology, the American Heart Association, the American Society of Echocardiography, the American Society of Nuclear Cardiology, the North American Society for Cardiovascular Imaging, the Society for Cardiovascular Angiography and Interventions, and the Society for Cardiovascular Magnetic Resonance. J Am Coll Cardiol, 2010, 56: 1864-1894. 6. Asci C.C.T., Group C.M.R.G.W., Tsai I.C., et al.: ASCI 2010 appropriateness criteria for cardiac computed tomography: a report of the Asian Society of Cardiovascular Imaging Cardiac Computed Tomography and Cardiac Magnetic Resonance Imaging Guideline Working Group. Int J Cardiovasc Imag, 2010, 26 Suppl 1: 1-15. 7. di Cesare E., Carbone I., Carriero A., et al.: Clinical indications for cardiac computed tomography. From the Working Group of the Cardiac Radiology Section of the Italian Society of Medical Radiology (SIRM). Radiolo gia Medica, 2012, 117: 901-938. 8. American College of Cardiology Foundation Task Force on Expert Consensus D, Mark D.B., Berman D.S., et al.: ACCF/ACR/AHA/NASCI/ SAIP/SCAI/SCCT 2010 expert consensus document on coronary computed tomographic angiography: a report of the American College of Cardiology Foundation Task Force on Expert Consensus Documents. J AmColl Cardiol, 2010, 55: 2663-2699. 9. Kashiwagi M., Tanaka A., Shimada K., et al.: Distribution, frequency and clinical implications of napkin-ring

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sign assessed by multidetector computed tomography. J Cardiol, 2013. 10. Nance J.W. Jr., Schlett C.L., Schoepf U.J., et al.: Incremental prognostic value of different components of coronary atherosclerotic plaque at cardiac CT angiography beyond coronary calcification in patients with acute chest pain. Radiology, 2012, 264: 679-90. 11. Francone M., Carbone I., Danti M., et al.: ECG-gated multi-detector row spiral CT in the assessment of myocardial infarction: correlation with non-invasive angiographic findings. Eur Radiol, 2006, 16: 15-24. 12. Cury R.C., Feuchtner G.M., Batlle J.C., et al.: Triage of patients presenting with chest pain to the emergency department: implementation of coronary CT angiography in a large urban health care system. AJR, 2013, 200: 57-65. 13. Feuchtner G.M., Plank F., Pena C., et al.: Evaluation of myocardial CT perfusion in patients presenting with acute chest pain to the emergency department: comparison with SPECTmyocardial perfusion imaging. Heart, 2012, 98: 1510-1517. 14. Hoffmann U., Truong Q.A., Schoenfeld D.A., et al.: Coronary CT angiography versus standard evaluation in acute chest pain. New Engl J Med, 2012, 367: 299-308. 15. Hulten E., Pickett C., Bittencourt M.S., et al.: Outcomes after coronary computed tomography angiography in the emergency department: a systematic review and meta-analysis of randomized, controlled trials. J Am Coll Cardiol, 2013, 61: 880-892. 16. Hoffmann U., Bamberg F.: Is computed tomography coronary angiography the most accurate and effective noninvasive imaging tool to evaluate patients with acute chest pain in the emergency department?: CT coronary angiography is the most accurate and effective noninvasive imaging tool for evaluating patients presenting with chest pain to the emergency department. Circulation Cardiovascular Imag, 2009, 2: 251-263; discussion 263. 17. Hulten E., Pickett C., Bittencourt M.S., et al.: Meta-analysis of coronary CT angiography in the emergency department. Eur Heart J Cardiovasc Imag, 2013. 1. Department of Radiological, Oncological and Pathological Sciences, “Sapienza” University of Rome, Rome, Italy. Prosthetic heart valve assessment: a novel application for cardiac CT Ricardo P.J. Budde Grant: This work is supported by a grant from the Dutch Heart Foundation (NHS2009B014) This article is a brief summary of the presentation about prosthetic heart valve (PHV) imaging by CT given by the author at the recent cardiac-CT course 2013 in Brussels.

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Heart valve disease (stenosis or insufficiency) is common and affects mainly the aortic and mitral valve. There is no known method (medication, lifestyle or otherwise) that halts or reverses the disease process. If the is valve severely stenotic or insufficient, heart valve replacement (or repair in case of mitral valves) with a PHV is inevitable (1). Two types of prosthetic heart valves are used: mechanical and biological PHV. Mechanical PHV are composed of metal alloys and/or carbon whereas biological PHV are composed of pericardium or animal tissue. Biological PHV do often have a supporting frame work that contains metal elements. Mechanical PHV are designed to last lifelong but also require lifelong anticoagulation therapy. Biological PHV have the advantage of being much less thrombogenic and thus do not require anticoagulation. However, they are prone to wear and have a limited (1020 years) lifespan. Although often being a lifesaving intervention, having a PHV presents the patient with a chronic disease with associated morbidity (bleeding due to anticoagulation, endocarditis and pros thesis dysfunction) and reduced life expectancy (1). Other modes of PHV dysfunction include obstruction by pannus formation underneath the PHV and thrombosis. Echocardiography and fluoroscopy (for mechanical PHV) are the techniques used for PHV assessment (1, 2). Unfortunately they are often unable to determine the cause of PHV dysfunction (2). There is a role for cardiac CT to assess PHV and determine the cause of dysfunction as a complementary technique to echocardio graphy and fluoroscopy (3, 4). PHV imaging by CT Image quality In the last 5 years the abilities of CT for PHV assessment have become subject of intense research. Our own research line on PHV imaging combines in-vitro and patient studies. The in-vitro studies use a dedicated perfusion set-up to optimize scan protocols aimed to reduce radiation exposure and at the same time reduce PHV induced artefacts. Using this set-up we have demonstrated that most PHV types generate only a limited amount of artefacts and have a good image quality on CT (Figure 1) (5). Artefacts can be reduced using prospective acquisitions, higher KV settings and iterative reconstruction (6-8). Only Bjork Shiley and Sorin mono leaflet PHV that contain cobalt chromium generate extensive artefacts that prohibits assessment with CT (3,5). Obstructive dysfunction Obstructive dysfunction of a PHV manifests itself as an increased pressure gradient over the PHV on echocardiography (1, 2). The most important etiologies that need to be differentiated between are pannus, thrombus and patient prosthesis mismatch. The latter is basically

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Fig. 1. — Volume rendered CT images of a bileaflet Carbomedics PHV and a monoleaflet Medtronic Hall PHV. too small a PHV for the size of the patient and is a diagnosis by exclusion. Differentiation between thrombus and pannus is difficult by echocardiography but clinically extremely important (2). Pannus requires reoperation whereas thrombosis can be treated with thrombolysis. CT is able to visualize both pannus and thrombus and the location of the lesion can be used to discriminated between both (9). However, no data on the diagnostic accuracy of CT is available from large patient series yet. Endocarditis Endocarditis is an especially devastating complication after PHV implantation that is associated with high mortality and morbidity. CT is helpful to establish the presence and extent of periannular complications such as mycotic aneurysms (10). Due to the complex anatomy, CT has an advantage over echocardiography due to its ability to reconstruct images in any desired imaging plane. This information can be vital to the surgeon to optimize pre-operative planning. Guidelines So what are the current recommendations for the use of CT for PHV assessment? The 2010 appropriate use criteria state that the use of CT is appropriate for “Characterization of prosthetic cardiac valves” (11): In the most recent ESC guideline on valvular heart disease the authors state: “CT provides useful additional information if valve thrombus or pannus are suspected (1). In our review article (4) we propose a flowchart for the use of CT depending on the specific etiology of PHV dysfunction.

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Conclusion PHV assessment is a promising new application for cardiac CT that can provide complementary information to echocardiography and fluoroscopy. CT can be especially valuable to determine the cause of obstructive PHV dysfunction and determine the extent of PHV endocarditis. Acknowledgements The work presented is performed by the valve imaging group in the University Medical Center Utrecht and the Academical Medical Center Amsterdam that is composed of Radiologists, Cardiologists and Cardiac Surgeons. References 1. Vahanian A., et al.: Guidelines on the management of valvular heart disease (version 2012): Joint Task Force on the Management of Valvular Heart Disease of the ESC and the EACTS. Eur Heart J, 2012, 33: 2451-2496. 2. Girard S.E., Miller F.A. Jr., Orszulak T.A., Mullany C.J., Montgomery S., Edwards W.D., Tazelaar H.D., Malouf J.F., Tajik A.J. Reoperation for prosthetic aortic valve obstruction in the era of echocardiography: trends in diagnostic testing and comparison with surgical findings. J Am Coll Car diol, 2001, 37: 579-84. 3. Habets J., Mali W.P.Th.M., Budde R.P.J.: MDCT angiography in the evaluation of prosthetic heart valve dysfunction. Radiographics, 2012, 32: 1893-905. 4. Habets J., Budde R.P.J., Symersky P., Brink van den R.B.A., Mol de B.AJ.M.,

Mali W.P.Th.M., Herwerden van L.A., Chamuleau S.A.J.: Diagnostic challenges in evaluation of left-sided prosthetic heart valve dysfunction. Nat Rev Cardiol, 2011, 17: 466-78. 5. Symersky P., Budde R.P.J., Prokop M., Mol de B.A.J.M.: MultidetectorRow computed tomography imaging characteristics of mechanical prosthetic valves. J Heart Valve Disease, 2011 20: 216-222. 6. Habets J., Symersky P., Mol de B.A.J.M., Mali W.P.Th.M., Leiner T., Budde R.P.J.: A novel iterative reconstruction algorithm allows reduced dose multidetector-row CT imaging of mechanical prosthetic heart valves. Int J Cardiovasc Imag, 2012, 28: 156775. 7. Symersky P., Habets J., Westers P., Mol de B.A.J.M., Prokop M., Budde R.P.J.: Prospective ECG-triggering reduces prosthetic heart valve induced artifacts compared with retrospective ECG-gating on 256-slice CT. Eur Radi ology, 2012, 22: 1271-7. 8. Habets J., Symersky P., Leiner T., Mol de B.A.J.M., Mali W.P.Th.M., Budde R.P.J.: Artifact reduction strategies for prosthetic heart valve CT imaging. Int J Cardiovasc lmaging, 2012, 28: 2099-2108. 9. Symersky P., Budde R.P.J., Mol de B.A.J.M., Prokop M.: Comparison of multidetector-row computed tomo graphy to echocardiography and fluoroscopy for the evaluation of patients with mechanical prosthetic valve obstruction. Am J Cardiol, 2009, 104: 1128-34. 10. Fagman E., Perrotta S., Bech-Hanssen O., Flinck A., Lamm C., Olaison L., Svensson G.: ECG-gated computed tomography: a new role for patients with suspected aortic prosthetic valve endocarditis. Eur Radiol, 2012, 22: 2407-14. 11. Taylor A.J., Cerqueira M., Hodgson J.M., Mark D., Min J., O’Gara P., et al.: ACCF/SCCT/ACR/AHA/ASE/ASNC/ NASCI/SCAI/SCMR 2010 appropriate use criteria for cardiac computed tomography. J Am Coll Cardiol, 2010, 56: 1864-94.

1. Department of Radiology, University Medical Center Utrecht, Utrecht, the Netherlands.

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REPORT ON THE SYMPOSIUM ORGANIZED IN ANTWERP ON 23.05.2013: NEW MILESTONES IN VASCULAR INTERVENTIONS M.H. Voormolen, O. d’Archambeau, T. van der Zijden, F. De Belder, J. Maes, F. Delrue, H. Fransen, P.M. Parizel1

During the last decade, we have witnessed nothing short of a revolution in angiography and vascular (neuro)interventional radiology. Developments in technology and equipment have opened a fascinating world of near-limitless possibilities. Minimally invasive endovascular treatments have been developed and optimized for numerous indications where, previously, open surgery was the only option. Thanks to the implementation of new angiographic equipment and new materials (such as stents, coils, catheters, etc.), we are now able to treat patients with less invasive means. In order to deal with complex vascular lesions, multidisciplinary teams (with active participation of various medical specialists) have found their way to the angiography suite and vascular intervention unit, which has become a viable alternative to the operating room (OR). This has led to a significant increase in the number of vascular procedures and interventions performed in the department of radiology. The department of radiology at Antwerp University Hospital has invested in the installation of two new angiography suites, to accommodate the diverse caseload, with optimal flexibility and workflow control. One room contains a biplane high- resolution angiography unit, which is mainly used for interventional neuroradiology procedures; the o ther suite is equipped with an articulated robotic arm, which makes hybrid procedures possible, and is mainly used for non-neuro applications. Both installations have allowed our specialists to provide excellent clinical patient care, with superb image clarity, while lowering the radiation dose. The success of this project, and the growing interest for minimally invasive multidisciplinary approaches to (neuro)vascular diseases, has encouraged us to organize a symposium entitled “New milestones in vascular interventions”. This event took place on 23rd May 2013 at Antwerp University Hospital,

Fig. 1. — Vascular interventional radiologists at Antwerp University Hospital in the angiography suite with the robotic C-arm. From left to right: Dr J. Maes, Prof Dr P.M. Parizel (chair, Dept of Radiology), Dr O d’Archambeau (section chief angiography and vascular interventional radiology), Prof Dr M. Voormolen, Dr F. De Belder and Dr T. van der Zijden (Dr H. Fransen and Dr F. Delrue are absent).

and the faculty highlighted the latest developments in vascular interventions. Speakers from the department of radiology (angiography and vascular intervention unit (Fig. 1)) joined forces with specialists from various clinical disciplines to present an overview of new milestones in vascular interventions. Prof Paul Parizel (professor and chair, Dept of Radiology) opened the symposium, welcomed the participants, and thanked the audience for their interest and support. The first keynote speaker, prof Phillipe Jorens (chief of the Medical Council at Antwerp University Hospital, chair Dept of Intensive Care) emphasized that investing in equipment and human resources for angiography and interventional radiology is expensive, but ultimately provides a positive costbenefit balance, for the patient and for the hospital. One of the missions of an academic center is to develop new treatments and to provide the setting in which this can be achieved. The current and (future) possibilities

From: 1. Department of Radiology, Antwerp University Hospital, Antwerp, Belgium. Address for correspondence: Prof. Dr M.H.J. Voormolen, M.D., Ph.D., Department of Radiology, Antwerp University Hospital, Wilrijkstraat 10, 2650 Edegem, Belgium. E-mail: maurits.voormolen@uza.be

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of the angiography equipment were highlighted by Dr Heinrich Kolem (CEO angiography and interventional X-ray systems business unit, imaging and therapy systems division, Siemens Healthcare, Germany). Optimized X-ray programs for various procedures, 3D angiography, CT angiography, flow- and perfusion imaging, help to improve diagnostic and therapeutic vascular procedures, with limited radiation exposure for both patient and performing staff. In this new era of invasive vascular procedures and multidisciplinary teams, support from our colleagues from the department of anesthesiology is crucial. Dr Luc Sermeus (senior staff member, Dept of Anesthesia, medical coordinator operating theater) emphasized the difficulties and risks of performing procedures under general anesthesia outside the OR. The last decade has seen a progressive change in the type of procedures performed in the angiography suite. It is not so long ago that the majority of examinations were diagnostic (digital subtraction) angiography procedures. They were mainly used to diagnose various vessel diseases, such as stenoses and occlusions of the major peripheral arter-

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ies. Nowadays, diagnostic catheter angiography has been largely replaced by other, non-invasive modalities such as CT-angiography or MR-angiography. Continuous improvements in multi-detector CTtechnology have made it possible to scan a large area with thin slices, at high speed, and with a limited radiation exposure. These sections can be computer processed on a workstation in order to generate volume rendered images and 3D images in every plane. Thus, in many centers CT-angiography has become the method of first choice for imaging of vascular diseases. Disadvantages of CT-angiography remain the need for iodinated contrast agents, and the radiation dose. These shortcomings can be (partially) avoided by performing MR-angiography, which has the great advantage over CT that no ionizing radiation is used. MR-angiography can be performed with intravenous injection of a Gd-chelate contrast agent, but, in many cases, MR-angiography images can be produced without the use of a contrast medium (time-of-flight angiography, either in 3D or 2D mode). The technological improvements of CT- and MR-angiography have led

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to a decrease in the number of diagnostic catheter angiography procedures for imaging vascular diseases. However, the decrease in the number of diagnostic procedures has been more than compensated by the spectacular growth of therapeutic procedures, and vascular interventional (neuro)radiologists are busier now than ever before. During the last decade, vascular interventional treatments of all kinds of vessel diseases, from head to toe, have become the procedure of choice, thereby replacing certain types of surgical procedures (e.g. neurosurgery, vascular surgery). The fast-paced development in interventional vascular (neuro)radiology has also opened new indications, most notably in the treatment of cerebral and peripheral vascular diseases, and more recently also in oncologic diseases. The success of vascular interventions is driven by the improvement of materials, such as (micro-) catheters, guide wires, balloons, stents, (micro-) coils etc, which have made access to and treatment of vascular diseases possible. At the same time, improvements in the design and capabilities of angiography units have provided more detailed imaging op-

tions with greater spatial and contrast resolution and 3D imaging. Thanks to the implementation of flat panel technology in new generation equipment, it is also possible to generate CT-like images with the angiography unit. Interventional (neuro)radiologists have come out of the dark, and have entered a brave new world that was traditionally the hunting ground of neurosurgeons, vascular surgeons and other medical specialists. This evolution has led to a more and more multidisciplinary approach to vascular diseases, where radiologists have both a diagnostic and a therapeutic role. At Antwerp University Hospital, interventional neuroradiologists are not only the mere purveyors of a technical procedure, but are also involved in the selection of patients, choice of treatment, and follow-up. Our interventional neuroradiologists have out-patient consultations, and take full responsibility for patient management before, during and after the procedure. Of course, this is done in close collaboration with neurosurgeons, and for each patient the best therapeutic option is discussed. During the symposium “New milestones in vascular interven-

Fig. 2. — A. Axial slice of a brain CT scan showing a subarachnoid hemorrhage in a 43-year old woman who presented with acute headache. B. The patient is transferred to the biplane angiosuite. C. Cerebral 3D angiography of the left internal carotid artery is reconstructed on the workstation showing a 5 mm saccular aneurysm on the anterior communicating artery (arrow). D. Selective angiography shows the aneurysm (arrow) in the optimal work projection. E. The first coil is inserted through a micro catheter (small arrow). A supportive balloon micro catheter (large arrow) was placed to help occlude the aneurysm with coils. F. Angiography after occlusion with 6 micro coils shows that the aneurysm (arrow) is excluded from the circulation.

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Fig. 3. — A. Hybrid procedure performed in the angiography suite in a 72-year old man with a left “cold leg” due to arterial occlusion of the femoral artery. B. First, surgical endarteriectomy of the left common femoral artery was done. The left femoral artery bifurcation is exposed. C,D. Subsequent catheter angiography of the groin and upper left leg shows a patent femoral bifurcation, but an occlusion of the proximal left superficial femoral artery (SFA) (arrow). The deep femoral artery is patent. E. Recanalisation of the SFA with a guide wire. F. Percutaneous transluminal dilatation with a 5 mm diameter and 30 mm long balloon catheter. G. Control angiography of the left leg shows reopening of the SFA.

tions”, several speakers highlighted the most frequently performed vascular interventions in the department of radiology. During the first session, the close collaboration with vascular neurosurgeons was presented by several speakers. Prof Tomas Menovsky (vice-chair, Dept of Neurosurgery) emphasized that the integrated interdisciplinary treatment approach has resulted in a steady increase of the number of patients with neurovascular disorders referred to our department. He presented an overview of the latest developments in neurosurgical vascular techniques. A close collaboration between neurosurgery and interventional neuroradiology, in a non-competitive environment, improves patient care, and offers our patients the best-suited treatment option. Prof Menovsky

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gave two examples to illustrate this joint approach: the combined treatment of complex intracranial aneurysms by surgical vascular bypass techniques and endovascular vessel or aneurysm occlusion, and the combined approach of stepwise endovascular occlusion of intracranial arteriovenous malformations (AVMs) and subsequent surgical excision was shown. The next speaker, Prof Maurits Voormolen (senior staff member, Dept of Radiology, interventional neuroradiologist), presented an overview of state-of-the-art endovascular treatment of intracranial aneurysms and illustrated the possibilities of the newest biplane angiography equipment (3D, CT etc). All techniques, from simple coil occlusion to balloon and stent assistedcoiling were reviewed (Fig. 2). The

final speaker in this session was dr Thijs Van der Zijden (staff member, Dept of Radiology, interventional neuroradiologist), who showed the increasing use of mechanical thrombectomy in stroke patients, for opening blocked blood vessels. In patients with acute ischemic strokes, who do not respond to intravenous thrombolysis, mechanical thrombectomy with endovascular removal of the clot in the intracranial artery, can be very useful in selected stroke patients. He presented an overview of the indications, techniques, complications, financial implications, and future developments, as well preliminary results of the first 25 patients treated at Antwerp University Hospital. The next session was dedicated to the collaboration with vascular surgeons, with a focus on peripheral

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Fig. 4. — A. Nuclear PET scan with 18FDG in a 71-year old man with colorectal cancer shows multiple liver metastases (arrows). Normal uptake in the brain and kidneys. B. Selective angiography of the celiac trunk showing the arterial vascular anatomy of the upper intestinal organs with the hepatic (small arrow), gastroduodenal (large arrow) and spleen arteries (arrowhead). C. Volume rendered image of a 3D angiography of the common hepatic artery showing the hepatic artery (small arrow), the large liver metastasis (MTX), gastroduodenal artery and sidevessels (large arrow), and the left gastric artery (arrowheads). D. Angiography after proximal coil occlusion of several arteries originating from the hepatic artery (including the gastroduodenal artery) to ensure that the radio active microspheres are selectively delivered to the liver and not to other organs. E. Manual injection of the radioactive microspheres. F. CT control with the angiography C-arm (axial slice in the upper abdomen) during embolization shows that the large liver metastasis (MTX) is treated (no enhancement).

vascular interventional procedures. Prof Paul Van Schil (chairman, Dept of Thoracic and Vascular surgery), emphasized the importance of partnership between interventional vascular radiology and surgery, and the importance of an up-to-date angiography unit with OR facilities. The next speaker, dr Patrick Lauwers (senior staff member, Dept of Thoracic and Vascular surgery), presented the evolution of peripheral and hybrid vascular procedures, from basic percutaneous transluminal angioplasty (PTA) to the most recent EVAR (EndoVascular Aortic aneurysm Repair). In hybrid procedures the patient undergoes both (minimal) vascular surgery and endovascular treatment during the same operative session under general anesthesia (Fig. 3). The final session of the meeting was dedicated to the multidisciplinary management approach in oncologic patients, for example for the treatment of hepatic tumors. Dr Ivan Huyghe (senior staff member, Dept of Nuclear medicine), explained the contribution of nuclear medicine in

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preparing and monitoring radioactive drugs used in endovascular embolization of liver tumors. Dr Olivier d’Archambeau (senior staff member, Dept of Radiology, section chief angiography and interventional radiology) illustrated advanced techniques in chemo-embolization in patients with liver tumors (Fig. 4). He explained in detail the (angiographic) diagnostic examinations and extensive vascular interventions, needed for the treatment of patients with liver tumors by endovascular radio-embolisation with radioactive micro-particles. This technique is known by the acronym SIRT (Selective Internal Radiation Therapy). Prior to selective SIRT embolization of the liver, all collateral arterial connections have to be occluded. This can be checked by performing an abdominal CT scan while using the flat panel detector in the angiography suite. Next, the radioactive SIRT is administered in the angiography suite. Afterwards, the room needs to be checked for remaining radioactive material and decontaminated if necessary. This new multi-

disciplinary treatment approach illustrates the immense evolution of the vascular interventional possibilities. At the end of the symposium, Prof Paul Parizel, summarized that the astounding developments in vascular and interventional radiology serve to confirm the pivotal role of the vascular interventional radiologist in multidisciplinary treatment teams. The disadvantage of this evolution is the huge investment to be made in equipment and staff, while most of the discussed vascular interventions receive only limited reimbursement in Belgium, or, in some cases, no reimbursement whatsoever. In conclusion, up-to-date angiography equipment offers a unique opportunity for multidisciplinary collaboration with specialists from other departments. Such a partnership creates a win-win situation for all the medical specialists involved, but especially for our patients who receive the best care, in a minimally invasive working environment.

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ABSTRACTS OF PAPERS presented at the Annual Symposium of the SRBR - KBVR, on November 16, 2013 SAMENVATTINGEN VAN DE UITEENZETTINGEN voorgesteld aan het Jaarlijks Symposium van de KBVR, op 16 november 2013 RESUMES DES COMMUNICATIONS présentées lors du Symposium Annuel de la SRBR, le 16 novembre 2013 A short history of the Royal Belgian Radiological Society : from skeletal X-rays to whole body imaging J. Pringot1 Founded in 1895 as the Belgian Radiological Society by a handful of enthusiastic surgeons and physicians, the current Royal Belgian Radiological Society (RBRS) has grown into a vibrant mainly scientific society with more than thirteen hundred members. Due to the remarkable contribution of its members, mastering without delay the technological and technical innovations and their clinical expertise, the RBRS has consolidated its influence not only nationally but also internationally mainly through its affiliation with the European Society of Radiology and the organization of the International (global) Congress of Radiology on Brussels in 1981. Remaining a national organization, it has maintained a critical manpower fostering mutual emulation for excellence in research and clinical work. In consideration of the trend towards sub-specialization initiated by neuroradiology, different subspecialized sections have been created and more recently a rapprochement with the more professionally oriented organization the National Union of Radiologists is on its way. Without going into much detail the historical development of the RBRS will be revisited and major events highlighted during four successive periods: before WWI, between WWI and WWII, from the end of WWII to the sixties, and from the seventies to today. Finally, future possible challenges will be envisaged. 1. Editor-in-Chief JBR-BTR, Professor of Radiology, Consultant radiologist Clinique St Elisabeth, Avenue De Fré 206, 1180 Brussels. Anterior skull base and olfactory apparatus Th. Duprez1 Imaging modalities for olfactory work-up MRI is the best suited imaging modality for cranial nerves imaging.

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The capability of MRI to give accurate and reproducible measurements of the bulb triggered the inclusion of the technique into the multi-modal work-up of olfactory disorders. Our standard examination protocol includes 1.5-mm-thick T2-weighted images in Fast Spin-Echo (FSE) mode in the coronal plane which is the best suited technique for anatomical olfactory overview, parenchymal lesion detection, and olfactory bulb (OB) volumetry. Whole brain coverage remains mandatory for detecting parenchymal contusions. We defined the normal range of OB volume from about 40 to 60 mm³ in a ‘local’ normative cohort. Such variation may be explained by differences in measurement technique but also by intrinsic variations due to the MR system characteristics, postprocessing consoles, and computer programs used for measurements. We advocate the use the same MR system for all olfactory tract (OT) examinations, to use the same contouring technique on the same post-processing console – to be done by sufficiently experienced operators –, and ultimately to recruit a normative cohort of sex- and age- related normal controls to build a ‘local’ reference. We prefer 3T imaging for olfactory imaging but did not find significant penalty to 1.5T images when compared to 3T ones. Residual indication for highresolution CT is trauma because of exquisite depiction of bone, but with the inherent limitation of limited soft tissue contrast. The absence of relevant soft tissue information – except for mucosal thickening – precludes the routine use of Cone Beam CT (CB-CT) for olfactory disorders, except when bone work-up is restrictively desired. X-Ray plain films have obviously become obsolete and catheter angiography, MRA, CTA and PET-CT have no primary indications in the purpose. Overview of olfactory tract disorders Congenital anosmia Patients who say they have never had any sense of smell and in whom

olfactory dysfunction is assessed by functional tests are reputed as ‘congenitally anosmics’ a fter ruling out any acquired cause for olfactory dysfunction. MR examination may demonstrate severely hypoplastic or absent OB together with flattening or even absence of olfactory sulcus. Congenital anosmia may be isolated or associated to hypogonadotropic hypogonadism in the so-called Kallmann’s syndrome. Idiopathic olfactory loss Patients who are consulting for olfactory loss and who declare to have had ‘normal’ sense of smell before the present episode are reputed to have ‘idiopathic’ olfactory loss (IOL) when all common causes for the condition have been ruled out. Those patients have significantly decreased OB volumes when compared with a mirror cohort of sex- and agematched control. Non neoplastic acquired olfactory loss 1. Trauma Trauma is a leading cause of lfactory dysfunction. Parenchymal o posttraumatic lesions can be observed throughout the OT at MRI, and bone disruption at CT scanner. In some cases, the imaging work-up fails to reveal any damage to the olfactory pathways, except atrophy of the OB which is putatively secondary to de-afferentiation because of the shear-injury of the olfactoria fila on their way through the cribriform plates of ethmoid. Strong relationship between OB volume and posttraumatic olfactory dysfunction has already been evidenced by many studies. 2. Infection Patients complaining from postinfectious olfactory loss are usually middle-aged women who suffer from persisting smell disturbances in the disease course of an acute – probably viral – upper airways infection. The sense of smell is usually decreased both quantitatively (hyposmia) and qualitatively with

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D E Fig. 1. — MR anatomy of the olfactory tract (from reference #1, with permission). A. Coronal 2D 2-mm-thick T2-weighted slice through olfactory bulbs (OB) in Fast Spin Echo technique (FSE). Hypointense OBs surrounded by bright cerebrospinal fluid (CSF) are well seen within olfactory grooves (OG) of ethmoid bone on both sides of the midline (white arrows). Gyri recti (white stars) are separated from the adjacent medial orbital gyri (black arrows) by the olfactory sulci (OS) (thin dotted arrows). B. Coronal 2D 2-mmthick FSE T2-weighted slice in a more posterior location than previous view showing thinner olfactory tracts (OT) (arrows). C. Transverse reformatted view of a 3D FSE T2-weighted sequence using driven equilibrium (DRIVE®) acquisition showing OBs (arrows) and the OTs (dotted arrows) running through olfactory grooves (OG) at inferior border of gyri recti and medial orbital gyri. D. Sagittal reformat of the same 3D FSE T2-weighted DRIVE sequence than in previous image showing the olfactive tract as a whole from OB to cribriform substance. Observe well delineation of OB (black arrow), proximal (paired arrows) and distal (dotted arrow) OT, but poor individualization of its intermediate segment because of its close contiguity to the bone. Olfactory filia linking the extra-cranial olfactory neuro-epithelium to the OBs through the openings of ethmoid cribriform plates are well seen (white dotted arrows). The presence of thin crossing vessels (thin white arrows) may be confusing as shown in Fig. 5. E. Main central projection areas of the sense of smell drawn on a transverse T1-weighted section: orbitofrontal olfactory area (A) is the main central neo-cortical projection having thalamic inter-connections through medial dorsal nucleus. Piriform (B) and entorhinal (C) cortices are prominent palleo-cortical projection areas without intermediate thalamic connections.

misinterpretation of odours (parosmia). Chronic rhinosinusitis Patients with chronic rhinosinusitis (CRS) frequently complain from olfactory impairment. Dysfunction of the olfactory neuroepithelium due to interaction with mucosal inflammatory mediators and physical impossibility for odorant molecules to reach the olfactory cilia due to obstruction, mucosal edema, and polyp formation are putatively synergistic mechanisms for the disorder.

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Patients with slight to moderate inflammation of paranasal sinuses had significantly larger OB volumes than patients with higher-grade CRS. Intrinsic olfactory tract neoplasms Schwannomas of the OT can be bserved because of the presence of o ensheating glial cells within olfactory glomeruli. Esthesioneuroblatoma is the paradigmatic neuroblastoma of the 1st cranial nerve which may arise from either the nasal olfactory neuroepithelium or from the intracranial OT.

Extrinsic benign neoplasms impinging on the OT Meningiomas are frequently observed benign tumors causing smell dysfunction. The tumor size and the degree of lesion impingement on OT are poorly related to the severity of smell complaints. Malignancies invading the olfactory tract. Ethmoid carcinoma and meningeal carcinomatosis are most frequently involved malignancies in secondary olfactory dysfunction by local invasion.

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synergistically contributes to accurate radiological diagnosis and prognosis of smell disturbances. References 1. Duprez T.P., Rombaux P.: Imaging the olfactory tract (cranial nerve #1). Eur J Radiol, 2010, 74: 288-298. 2. Buschhüter D., Smitka M., Puschmann S., Gerber J.C., Witt M., Abolmaali N.D., Hummel T.: Correlation between olfactory bulb volume and olfactory function. NeuroImage, 2008, 42: 498-502.

1. Department of Radiology and Medical Imaging, Université Catholi que de Louvain, Cliniques Universitaires Saint-Luc, Brussels.

Interventional radiology in the head and the neck H. Tanghe1 The indications for vascular interventions in the Head and the Neck are: 1. Intractable epistaxis. 2. Penetrating neck trauma. 3. Craniofacial vascular lesions. 4. Preoperative tumor embolization. 5. Rupture of vessels, damaged by cancer or infection. 6. (Carotid stenting).

C Fig. 2. — Post-viral damage to the OT (from reference #1, with permission). 2 mm-thick FSE T2-weighted coronal views in all three cases. A. Normal control with eutrophic OB on both sides (thick arrows). B. Patient with post-viral hyposmia exhibiting asymmetric atrophy of the OBs, the right-sided one (thin arrow) being more damaged than the left-sided one (thicker arrow). C. Patient with severe anosmia and cacosmia showing symmetri cal severe atrophy of OBs (thin arrows).

Neurodegenerative disorders Many studies have highlighted early olfactory disturbance in patients with idiopathic Parkinson’s disease (IPD) or with Alzheimer’s disease (AD). Decreased OB volumes may precede for several years the

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onset of other symptoms than olfactory dysfunction. Conclusions Quantitative measures of olfactory bulb volume and morphological depiction of structural abnormalities

Epistaxis is a common, usually benign and self-limiting disease. Anterior epistaxis is the most common type. The bleeding comes from the anterior septum, locus Kisselbachi and does not require special treatment. Posterior epistaxis comes from the fossa nasalis posterio or posterior septum. It is rare and requires active treatment. Intractable epistaxis is defined as a nosebleed that does not respond to posterior nasal packing. The treatment of choice is embolization, with a success rate of 90%. Penetrating neck trauma can cause multiple vessel lesions in the neck and of course other parenchymal, vertebral and spinal cord lesions. Don’t be satisfied when you have found one vascular lesion The best diagnostic imaging method is a CTangiography. Indication for endovascular treatment are: serious bleeding from a branch vessel, bleeding from a hole in the side wall of a major vessel, bleeding from a transsection of a major vessel, traumatic A-V fistula. The technique used depends on the situation. Craniofacial vascular lesions are classified as vascular proliferations

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or vascular malformations. Several interventional techniques are possible: a direct puncture approach, an endovascular approach, with a variety of possible agents. Combined treatment with plastic surgery is common. Preoperative tumour embolization is indicated in paraganglioma, juvenile angiofibroma. The goal is the diminution of the peroperative blood loss, the shortening the operation time, the easier identification of surgical important structures and a to achieve a higher rate of radical tumour removal. The principle of a preoperative tumor embolization is the selective obliteration of the intratumor vasculature, while preserving the normal supply to the surrounding tissues. Thus a distal occlusion of a feeding vessel is not appropriate. You must be aware of the multiple dangerous connection that exists between the external carotid territory on the one side and the internal carotid and vertebral territory on the other side. Sudden non traumatic rupture of a major neck artery can occur in advanced head and neck cancer and in severe infections, like necrotizing otitis externa (“malignant otitis externa) with expansion to the carotid loge. It is always a debate in a specific patient, yes or not, to treat this emergency situation, giving the prognosis of the underlying disease, the problems of catheterisations and the frequent poor clinical condition of this patients. Carotid or vertebral stenting for the treatment of stenotic atherosclerotic disease in the major neck arteries is almost gone today, as also the skills of the people who did these procedures several years ago. The indications nowadays are limited. 1. Section of Neuroradiology / Head & Neck Radiology, Department of Radiology, Erasmus Medical Centre, Rotterdam, The Netherlands, Postbus 2040, 3000 CA Rotterdam, The Netherlands. E-mail: h.l.j.tanghe@erasmusmc.nl

Tracheal imaging W. De Wever1 Chest X-ray is traditionally the first step in the evaluation of tracheal disease. However, tracheal disease is usually overlooked initially on radiography. The spectrum of tracheal disorders is diverse. Abnormalities of the trachea can be classified as congenital, infectious, inflammatory,

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infiltrative, traumatic or neoplastic. Diseases of the trachea can be focal or diffuse and can cause luminal widening or luminal narrowing. The diagnosis and differential diagnosis of tracheal disease is based on the appearance of the tracheal wall on inspiratory CT scans, on changes in the tracheal wall during expiration, and on the location and extent of the tracheal abnormalities. Axial, thin, inspiratory and expiratory CT i mages are the standard of reference for the evaluation of tracheal disease. Twodimensional multiplanar reformations are useful for the evaluation of the extent of these abnormalities. Anatomy of the trachea The trachea is a cartilaginous and fibromuscular tube-structure. In the chest, in general, the trachea is midline in position, often displaced slightly to the right at the level of the aortic arch. It extends from the level of the cricoid cartilage (level of C6) to the carina, (level of T4-T5). At the carina the trachea bifurcates into left and right main stem bronchus (1). The trachea is divided into an extrathoracic and an intra-thoracic part at the point where it passes posteriorly to the manubrium. In adults, the length of the trachea on CT, measured during inspiration, is approximately 11-13 cm. The extra-thoracic part measures 2 to 4 cm (2) . The shape of the trachea during inspiration is semi-oval with a coronal diameter of 13 to 25 mm in men and 10 to 21 mm in women, and a sagittal diameter of 13 to 27 mm in men and 10 to 23 mm in women (2). Measurement error of the tracheal diameter can occur if the measurement is not perpendicular to the plane of scanning. The tracheal index can be calculated as a ratio of the coronal diameter (mm) by the sagittal diameter (mm). The normal value is approximately one (3). The anterior and lateral wall of the trachea is composed by 16 to 22 horseshoe bands of cartilage. From inside out, the tracheal wall is composed of several layers: mucosa, submucosa, cartilage or muscle, and adventitia. The posterior tracheal wall lacks cartilage and is made of a thin membrane supported by the trachealis muscle (4). On CT, the tracheal wall appears as a 1 to 3 mm soft tissue stripe outlined by air in the lumen and mediastinal fat on the outer side. The posterior wall appears thinner and gives a variable contour to the shape of the trachea due to the lack of cartilage. The posterior wall can appear flat, convex or

slightly concave depending on the level of inspiration (2). The posterior wall of the trachea either flattens or bows slightly forward during expiration. In normal subjects there is up to a 35% reduction in AP tracheal lumen in forced expiration, whereas the transverse diameter decreases only by 13% (5). The angle of the tracheal bifurcation, also called the carinal angle, can vary. The carinal angle is wider in individuals with an enlarged left atrium, in females, in obese patients, and in people with the carina located closer to the spine (1). Imaging modalities The plain chest radiograph is traditionally the first step in the evaluation of t racheal disease. However radiography is relatively insensitive to airway changes and large airway disease is overlooked initially (6). The diagnosis of tracheal disease is often based on the appearance of tracheal wall on inspiratory the scans, changes in the tracheal wall with expiration, and the location and extent of tracheal abnormalities (4). Computed tomography (CT) can improve the detection and characterization of tracheal disease, and multi detector CT (MDCT) is the imaging modality of choice for the diagnosis of tracheal disease (7). The newer multi detector scanners of 64-128 etector and collimators as rows of d thin as 0.625 create a near isometric resolution voxel of 0.4 mm. Slices are reconstructed, with 50% overlap, in the transaxial plane. A rotation time of approximately 500 ms allows a significant decrease in cardiac pulsation artifacts and allows a good analysis of the trachea. State-of theart, 320-detector CT scanners can cover 16 cm of tissue in 350 ms, and hence can image the entire trachea with just a single gantry rotation and allow for dynamic cine imaging of the trachea during respiration. MDCT scanners generate an isotropic voxel data set, which allows for the creation of high-resolution, 2-dimensional multiplanar, and 3D image reconstructions of the trachea in simply a few minute. The unique inherent natural contrast of the airways and lung parenchyma permits imaging with a relatively lower radiation dose without significant loss of information (100-120 kV, 60-160 mAs). Imaging is obtained in suspended inspiration (2) (8, 9). Axial CT images provide precise anatomical information about the airway lumen and wall, as well as

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about adjacent mediastinal and lung structures. Multiplanar 2-dimensional reformations and 3-dimensional reconstruction images can provide a more anatomically meaningful display of the airways and adjacent structures. These CT images have been shown to enhance the detection, localization, and determination of the extent of lesions; the evaluation of their relationship with adjacent structures; characterization of the airway disease; and clarification of complex congenital airway abnormalities (10). Axial CT imaging Axial CT images serve today as the reference standard for the imaging of the trachea because this imaging technique can evaluate the wall of the trachea in the best way. This imaging technique provide detailed information of the size and shape of the airway, wall thickness, presence of calcification, presence of intraluminal lesions, and delineate the relationship of the airways to adjacent mediastinal structures. However, on axial CT images, subtle stenoses of the trachea can be overlooked, the craniocaudal extent of a disease may be inaccurate estimated, complex airway anatomy may be poorly defined, and evaluation of airways oblique to the axial plane may be limited. Expiratory or dynamic expiratory scans may be obtained after or during forced exhalation to show tracheomalacia (2, 4, 11).

Two-dimensional multiplanar reformation 2D multiplanar reformation images of the airways serve as a diagnostic complement to the axial source images and can be simply and interactively generated in real time at the CT console or workstation. Two-dimensional multiplanar reformation images can be displayed in a coronal, sagittal or oblique plane or curved reformations along the long axis of the airways. Two-dimensional multiplanar reformation images improve the detection of airway stenoses, precisely define airway disease extent in multiple planes, clarify complex congenital airway abnormalities, and may help identify sites of airway disruption (11). Multiple adjacent thin slices can be stacked together to generate a thick slab or multiplanar volume reformation image. Slice thickness can be altered to any dimension. In general, slice thicknesses of 3 to 7 mm give adequate image information. Minimum intensity projection (mIP) projects the pixels with the lowest attenuation values in a 2-D format. The trachea-bronchial tree and any lucent abnormalities, such as diverticula or fistulous communications, can be displayed well on mIP reconstructions (11, 12). 3D reconstruction 3D reconstructions include external and internal renderings of the airways. External 3D rendering of the

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airways is equivalent to CT bronchography. With his technique, the inner surface of the trachea and airways can be depicted and their relationship with adjacent structures can be demonstrated. 3D segmentation provides a rapid anatomic overview of the airways. Recognition of mild and focal airway stenoses, and more relevant information on the shape, length, and severity of these stenoses scan be provided in an easy way (11). Internal 3D rendering of the airways is equivalent to virtual bronchoscopy (VB). This VB enables the viewer to navigate through the lumen of the airway to the sixth-order and seventh-order subdivisions. VB is a useful noninvasive method of assessment of airway stenoses, which cannot be evaluated on conventional bronchoscopy when passing the stenosis is impossible. VB may obviate the need for invasive conventional bronchoscopy in certain circumstances and in special subgroups of patients such as young children, very sick patients or elderly patients who may not be able to tolerate bronchoscopy. VB does not permit tissue sampling, which can be done with endoscopic bronchoscopy (11, 13). Spectrum of tracheal diseases The spectrum of tracheal disorders is diverse. Abnormalities of the trachea can be classified as congeni-

Table I. — Spectrum of tracheal diseases. Tracheal disease

Congenital

Diffuse disease Luminal dilatation • Mounier-Kuhn • Ehlers-Danlos syndrome Luminal narrowing • Tracheal web

Infectious / inflammatory / infiltrative •

• • • • • • • •

Focal disease Luminal narrowing • • • •

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Tracheal ring Vascular rings Pulmonary sling Mediastinal vascular anomalies

Traumatic

Neoplastic

Saber-Sheath trachea

Tracheo-bronchomalacia Relapsing polychondritis Wegener granulomatosis Acute infectious tracheobronchitis Chronic trachea-bronchitis associated with autoimmune diseases Amyloidosis Sarcoidosis Tracheopathiaosteochondroplastica • Idiopathic tracheal stenosis • Intubation related stenosis • Stricture post tracheostomy

• Benign neoplasms • Primary malignant neoplasms • Secondary malignant neoplasms

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Table II. — Tracheal diseases: pathology and CT findings. Tracheal disease

Pathology

Tracheal localization

CT-findings

Saber-Sheath trachea

Weakness of cartilage

Intrathoracic trachea

• Decrease of coronal diameter, increase of sagittal diameter • Inward bowing of the tracheal wall • More pronounced on expiratory scans

Acute post-intubation stenosis

• Mucosal edema • Granulation tissue

Intrathoracic trachea

• Eccentric or concentric soft tissue thickening on the internal side of the trachea • Normal aspect of the cartilage • Outer tracheal wall has a normal appearance

Chronic stenosis

• Weakness of cartilage • Thickening of mucosa and submucosa

Intrathoracic trachea

• Focal tracheal narrowing during or after forced expiration

Wegener’s granulomatosis

Mucosal and submucosal inflammation and ulceration

• Extrathorac trachea (subglottis) • Intrathoracic trachea (variable degree)

• Circumferential wall thickening • Narrowing of the tracheal lumen

Amyloidosis

Amyloid deposition in the submucosa

• Extrathoracic trachea • Intrathoracic trachea

• Concentric, smooth or nodular thickening of the submucosal wall • Concentric calcification or ossification may occur • No tracheomalacia

Tracheobronchopathia osteochondroplastica

Osseous and/or cartilaginous nodules in the submucosa

• Extrathoracic trachea • Intrathoracic trachea

• Nodular thickening of the tracheal wall with calcified nodules on the inner aspect of the lumen • Posterior membrane is normal • Malacia is not present

Tracheobronchomegaly

Atrophy of cartilaginous, muscular and elastic components of the tracheal wall

• Extrathoracic trachea • Intrathoracic trachea

• Thinning of the tracheal wall • Tracheal diameter of more than 3 cm at 2 cm above the aortic arch • Tracheal diverticulosis can be seen. • Trachea tends to collaps with forced expiration

Relapsing polychondritis

Inflammation of the cartilage

• Extrathoracic trachea • Intrathoracic trachea

• Wall thickening limited to the anterior and lateral tracheal wall • Posterior membrane is spared • Collaps of the cartilage with narrowing of the lumen • Inner and outer border of the thickened tracheal wall are smooth

Recurrent respiratory papillomatosis

Exophytic lesions in the airway

• Extrathoracic trachea • Intrathoracic trachea

• Well circumscribed tracheal wall lesions with progressive mass-like protrusions • Airway obstruction may occur • No extension beyond the trachea or bronchial wall

Sarcoidosis

Granulomas in mucosa or submucosa

• Extrathoracic trachea • Intrathoracic trachea

• Regular or nodular wall thickening with smooth or irregular luminal narrowing

tal, infectious, inflammatory, infiltrative, traumatic or neoplastic (7). Diseases of the trachea are focal or diffuse, depending on the extent of the disease and cause airway luminal widening or luminal narrowing. Focal diseases causing luminal narrowing include malignant or benign tumor and tracheal strictures caused by trauma or medical intervention. Diffuse luminal narrowing of the airway is caused by various infiltrative and infectious diseases (2). Diseases of the trachea are summarized in Table I. Differential diagnosis is based on the a ppearance of the tracheal wall on inspiratory and expi-

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ratory scans. Recognizing specific tracheal wall abnormalities is of primary importance because specific diseases tend to affect different components. Correlation between pathological findings and CT findings of different tracheal diseases is summarized in Table II.

diameter with an inward bowing of the tracheal wall. This finding is more expressed on expiratory CT scans. This abnormality is only present at the level of the intrathoracic trachea (2, 4, 7).

Saber-sheath Trachea Saber-Sheath trachea is a common finding and almost always associated with chronic obstructive pulmonary disease. Due to a weakness of the cartilage, this disease is marked by a decrease in the coronal dia meter and an increase in the sagittal

Acute post-intubation stenosis r esults from mucosal edema or granulation tissue. On CT, an eccentric or concentric soft tissue thickening on the internal side of the trachea with a normal aspect of the cartilage is seen. The outer tracheal wall has a normal appearance. Expiratory CT

Tracheal stenosis

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images show little change in tracheal diameter. Chronic stenosis post- intubation or tracheostomy shows tracheal narrowing due to deformity of the tracheal cartilage or posterior membrane with or without thickening of the mucosa and submucosa. Tracheomalacia results from weakness of the tracheal cartilage with a narrowing of the intrathoracic trachea on CT during or after forced expiration (2, 4, 14). Wegener’s granulomatosis Mucosal and submucosal inflammation and ulceration involves the trachea. Subglottic involvement is most typical with a variable involvement of the distal trachea. Destruction of the tracheal cartilage may occur. Axial CT images show a circumferential wall thickening and narrowing of the tracheal lumen (2, 4, 7). Amyloidosis Tracheobronchial amyloidosis is a rare condition. Amyloid is deposit in the submucosa. The entire trachea is involved. On CT, diffuse amyloidosis leads to concentric, smooth or nodular thickening of the submucosal tracheal wall. The tracheal cartilage is normal, but concentric calcification or ossification may occur. There is no tracheomalacia (4, 7). Sarcoidosis Sarcoidosis is a systemic disease of unknown cause. Large airway involvement is unusual. Sarcoidosis will affect the larynx and upper trachea in 1% to 3% of patients. The distal part of the trachea is affected infrequently. Narrowing of the airway may be secondary to extrinsic compression from enlarged lymph nodes or may be the result of granuloma formation within the airway mucosa and submucosa. The most common CT finding is regular or nodular wall thickening. This may result in smooth or irregular luminal narrowing (7, 15). Tracheobronchopathia osteochondro plastica Tracheobronchopathia osteochondroplastica is characterized by development of osseous or cartilaginous nodules or both in the sub mucosa. These nodules are associated with tracheal cartilage, sparing the posterior membrane. CT findings include thickening of the tracheal wall with small calcified nodules along the inner aspect of the lumen

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with protruding into the tracheal lumen. Malacia is not present (4). Mounier-Kuhn syndrome (Tracheobronchomegaly) Tracheobronchomegaly is a rare condition characterized by marked dilatation of the trachea and mainstem bronchi. Tracheobroncho megaly is characterized by atrophy of cartilaginous, muscular and elastic components of the tracheal wall. Axial CT images show a thinning of the tracheal wall and a tracheal diameter of more than 3 cm at 2 cm above the aortic arch. Tracheal diverticulosis can be seen. The trachea tends to collapse with forced expiration (2, 4, 7). Relapsing Polychondritis Relapsing polychondritis is characterized by recurrent episodes of cartilage inflammation. Diffuse tracheal inflammation is limited to the cartilage and perichondrium and does not affect the mucosa and submucosa. CT usually shows wall thickening limited to the anterior and lateral tracheal wall. The posterior membrane is spared. There is collapse of the cartilage with narrowing of the lumen. Calcification of the cartilage can be present. The inner and outer borders of the thickened tracheal wall are smooth. The luminal narrowing may be fixed or tracheomalacia may be present (4, 7). Recurrent respiratory papillomatosis (RRP) RRP is the result of infection of the upper respiratory tract by human papilloma virus. RRP is characterized by benign exophytic lesions in the airway, most commonly involving the larynx and central trachea-bronchial tree. The lesions give rise to tracheal wall irregularities with progressive mass-like protrusions. Airway obstruction may occur. These lesions tend to be well circumscribed and do not give rise to extension beyond the trachea or bronchial wall (2).

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References 1. Minnich D.J., Mathisen D.J.: Anatomy of the trachea, carina, and bronchi. Thorac Surg Clin, 2007, 17: 571-585. 2. Laroia A.T., et al.: Modern imaging of the tracheo-bronchial tree. World J Radiol, 2010, 2: 237-248. 3. Grenier P.A., et al.: Multidetector-row CT of the airways. Semin Roentgenol, 2003, 38: 146-157. 4. Webb E.M., Elicker B.M., Webb W.R.: Using CT to diagnose nonneoplastic tracheal abnormalities: appearance of the tracheal wall. AJR Am J Roent genol, 2000, 174: 1315-1321. 5. Ederle J.R., et al.: Evaluation of changes in central airway dimensions, lung area and mean lung density at paired inspiratory/expiratory high-resolution computed tomography. Eur Radiol, 2003, 13: 2454-2461. 6. Kwong J.S., Muller N.L., Miller R.R.: Diseases of the trachea and mainstem bronchi: correlation of CT with pathologic findings. Radiographics, 1992, 12: 645-657. 7. Kang E.Y.: Large airway diseases. J Thorac Imaging, 2011, 26: 249-262. 8. Boiselle P.M.: Imaging of the large airways. Clin Chest Med, 2008, 29, 181-193, vii. 9. Boiselle P.M., Lee K.S., Ernst A.: Multidetector CT of the central airways. J Thorac Imaging, 2005, 20: 186-195. 10. Chen Q., et al.: Evaluation of tracheobronchial diseases: comparison of different imaging techniques. Korean J Radiol, 2000, 1: 135-141. 11. Lee K.S., Boiselle P.M.: Update on multidetector computed tomography imaging of the airways. J Thorac Imaging, 2010, 25: 112-124. 12. Beigelman-Aubry C., Brillet P.Y., Grenier P.A.: MDCT of the airways: technique and normal results. Radiol Clin North Am, 2009, 47: 185-201. 13. De Wever W., et al.: Multidetector CTgenerated virtual bronchoscopy: an illustrated review of the potential clinical indications. Eur Respir J, 2004, 23: 776-782. 14. Lee K.S., et al.: Multislice CT evaluation of airway stents. J Thorac Imag ing, 2005, 20: 81-88. 15. Bartz R.R., Stern E.J.: Airways obstruction in patients with sarcoidosis: expiratory CT scan findings. J Thorac Imaging, 2000, 15: 285-289.

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

Conclusion Recent advantages in CT technology and post-processing techniques allow for a noninvasive and accurate evaluation of the trachea. In particular, axial CT images are essential for the evaluation of the tracheal wall. Twodimensional multiplanar reformations are useful for the evaluation of the extent of tracheal abnormalities.

Head and neck cancer imaging M. Lemort1 As it concerns tumor identification, assessment of local extent and T staging, both Computed Tomography (CT) and Magnetic Resonance (MR) are extremely well performing to give the surgeon the best view be-

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Fig. 1. — Recurrence of a basal cell carcinoma. T1weighted post Gd FSE sequence obtained at 3.0 T with parallel imaging and surface coil. Note the minute disruption of the mandible cortical bone.

fore surgery, if this is the treatment of choice. They may be performed either alone or in combination, the choice being dependent from the anatomical site of the lesion and the clinical condition of the patient. The quality of morphological depiction of the tumor is permanently improving with technical refinements: ultra-fast imaging at high resolution for CT, new sequences and faster techniques for MRI, together with improvement in resolution and 3D acquisition (Fig. 1). However, morphological information on local extent is not the only point of concern in multidisciplinary discussion. Combination of therapies and the appropriate sequence of chemotherapy, radiotherapy, and/or surgery is largely depending of regional evaluation, particularly for nodal metastases, which are a remaining weakness of CT and MR, despite the initial hope placed in diffusion weighted imaging (DWI) techniques, which are still under evaluation. FDG PET-CT has only partly fulfilled this expectation. Furthermore, as oncology enters in an era of individualized treatment options depending of factors related to the biology and microenvironment

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Fig. 2. — Non Hodgkin lymphoma of the left tonsil. Fused image from FDG PET and T2W FSE MRI with fat saturation.

of the tumors, new imaging markers are needed to predict response. Another challenging point is the monitoring of patient after treatment and particularly the early detection of recurrence, which may be an utmost important point not only to improve survival, but also to achieve the best quality of life for the patient along the course of the disease. MR DWI and dynamic contrast- enhanced (DCE) MRI are under investigation for at least three main indications: • Detection of metastatic lymph nodes (even in sub-centimetric nodes) • Detection of recurrence in posttherapeutic follow-up (differential diagnosis between fibrosis, necrosis, and recurrence) • Prediction and/or follow-up of response to treatment For invaded lymph node detection, DWI probably is most valuable for squamous cell carcinoma (SCC) and moderately small nodes (4 to 10 mm) in combination with morphological imaging at N staging (1). Sufficient evidence is lacking however, and more prospective studies are needed.

DWI or DCE MRI may also be useful in case of suspected post-treatment recurrence, or standard posttreatment planned examinations and may complement a positive posttreatment PET to improve specificity (2). In addition, it may be an alternative to PET for late recurrences since PET-CT is less efficient for this indication. There is a rationale and preliminary evidence to include new imaging biomarkers as DWI or DCE-MRI in treatment evaluation and/or planning for head and neck patients. A lot of work has to be done to ensure minimal standardization and quality control for these methods before they can be included in clinical research as surrogate markers. DCE CT thanks to the extremely high speed of the last generation of CT devices could also be used for assessment of tumor perfusion for predicting sensitivity to radiotherapy or response to anti-angiogenic drugs. It could be easier to set up and perform in these patients than DCE MRI. Recent introduction of fast dualenergy CT devices could also open new opportunities in tumor assessment and reduction of the needed dose of contrast media (3).

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Finally, hybrid technologies such as combined PET-MRI should also bring new opportunities in head and neck cancer imaging (Fig. 2). Head and neck cancer imaging remains an ever-changing and challenging field that promises exciting evolution in the following years. References 1. Vandecaveye V, De Keyzer F, Vander Poorten V, Dirix P, Verbeken E, Nuyts S, et al. Head and neck squamous cell carcinoma: value of diffusion-weighted MR imaging for nodal staging. Radiology. 2009;251:134-146. 2. Furukawa M, Parvathaneni U, Maravilla K, Richards TL, Anzai Y. Dynamic contrast-enhanced MR perfusion imaging of head and neck tumors at 3 Tesla. Head Neck. 2013, 35:923-929. 3. De Cecco CN, Darnell A, Rengo M, Muscogiuri G, Bellini D, Ayuso C, et al. Dual-Energy CT: Oncologic Applications. AJR, 2012, 24;199(5_ Supplement):S98-S105.

1. Dpt of Medical Imaging, Institut Jules Bordet, Brussels, Belgium. Noninvasive imaging of the neck vessels: focus on treatment-oriented imaging of the carotid artery P. Vanhoenacker, P. Leyman1 Non-invasive imaging of the internal carotid arteries (ICA) is indicated in several clinical settings: 1. Patients undergoing evaluation for acute stroke. 2. Transient ischemic attacks (TIA) 3. Cervical bruits 4. Prior to coronary artery bypass graft surgery: controversial The choice of modality for non- invasive carotid artery assessment depends on the clinical indications for imaging and the skills available in individual centers. In our hospital, ultrasound (US) of the carotids forms the mainstay of carotid imaging, whereas CT angiography (CTA) an MR Angiography (MRA) are problemsolving modalities. Ultrasound Carotid duplex ultrasonography (US) is the standard of care for the initial diagnosis of carotid artery bifurcation disease. Meta-analyses of published criteria for CDUS have demonstrated sensitivities of 98%and specificities of 88% for d etecting > 50% ICA stenosis; and 94% and 90% respectively for detecting > 70% ICA stenosis

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Utilizing gray-scale B-mode imaging, color and Doppler flow provide all of the imaging tools required to determine the severity of ICA stenosis. The absence or presence of hemodynamically significant disease in the ICA is determined by an increase in Doppler-derived blood flow velocity. Therefore, the accuracy of the exam is dependent upon the accuracy of the spectral Doppler waveform interrogation, which is the single most important criterium for treatment decisions. Plaque imaging is promising but so far has little clinical value and plays no important role in treatment decisions. Technique, pitfalls and interpretation will be demonstrated. MRA The techniques used for carotid MRA are time-of-flight imaging (TOF-MRA), either with 2D or 3D acquisition, and g adolinium contrast enhanced angiography (CEMRA). TOF-MRA relies on the movement of magnetized blood through the volume being imaged. CE-MRA is less dependent on blood flow for vascular contrast, and gives better visualization of the arterial lumen. CE-MRA tends to overestimate the degree of stenosis (compared with DSA), but the rate of misclassification appears to be low enough to neutralize the risks of conventional catheter angiography. Some pitfalls, post-processing techniques and an integration algorithm with US will be presented. Blood pool agents are promising and allow imaging with higher resolution. Plaque imaging is promising, but as in US remains largely a research tool. CTA CTA has several advantages over DUS and MRA for carotid imaging: – It has better overall spatial resolution than MRA – It is less susceptible to artifacts than MRA – it provides information about surrounding anatomy, such as osseous structures, useful in surgical planning – Because CT has high spatial resolution and is unaffected by slow flow, CTA is the most appropriate non-invasive method to differentiate between near-occlusion and occlusion

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Disadvantages include – Heavy, circumferential calcification of the ICA can cause beam hardening artifact. This can be alleviated to some extent by the use of double-energy CT. – risks associated with the use of iodinated contrast agents and radiation e xposure to radiosensitive tissues (lenses and thyroid gland) Plaque imaging with CT is not well established. The role of vasa vasorum has been studied and enhancement of the vasa vasorum adjacent to severe carotid plaque during arterial phase CTA suggests a higher likelihood of symptomatic disease (TIA or stroke). Conclusion Safe, accurate and reliable carotid imaging is critical in treatment of stroke caused by carotid disease. Initial imaging is done with high-quality US. MRA or CTA may be helpful in providing ancillary information to assist in planning therapy. All noninvasive imaging modalities have limitations, and imagers must appreciate them, in order to provide optimum care. 1. Dpt of radiology, OLV Ziekenhuis Aalst, Aalst, Belgium.

New trends in radiation protection for diagnostic medical exposures L. Van Bladel1 A first part of the talk will be devoted to recent findings and interpretations that arise from the sciences underpinning radiation protection. Both advances in radiobiology and epidemiology will be discussed. A second part will be devoted to observations with regard to medical imaging practice in Europe and beyond from the perspective of radiation protection. We will take a closer look at examination frequencies and at typical doses that result from given types of examinations. There will be a short reminder on the system of radiation protection and how it is developed at international level . This part will be completed by challenges for radiation protection that result from recent developments in imaging practice. The conclusions and “call for action” of IAEA’s International Conference on Radiation Protection in Medicine, held in December 2012 in Bonn, Germany, will be presented.

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The recently approved draft European Directive that modifies the current Directive 97/43/Euratom (medical exposures or “med” directive) will be discussed, in particular where new requirements could have direct implications for daily radiological practice. Finally, we will discuss the policy of the Belgian radiation protection competent authority, its involvement in HERCA, the European umbrella organisation, the recent achievements and on-going discussions at national, European and international level. 1. Federal Agency for Nuclear Control, Brussels, Belgium.

Dose reduction strategies in CT imaging F. Zanca1 In the past years, concerns have been raised regarding the potential risk of cancer induction from computed tomo graphy (CT), due to its exponentially increased use in medicine. While there is no doubt regarding its clinical benefit when used for appropriate indications, keeping radiation dose as low as reasonability achievable remains fundamental for decreasing such risk and increase p atient protection. There are several way to reduce patient dose in CT. The first is independent of the CT scanner technical parameters and relates to the concept of justification. Indeed, the main principles proposed by the International Commission on Radiological Protection (ICRP) as applicable to patient protection are justification and optimization. Justification requires that the net benefit to be positive and its implementation in clinical practice is mainly based on the application of referral guidelines for medical imaging. This has been addressed by several organization, as the European Commission or national organizations, e.g. the Belgische Consilium Radiologicum (1). Unfortunately, a correct use of referral guidelines remains a challenge for the healthcare systems, due to its impact on the workflow, resources and costs. For example, brain CT still makes a large part of our daily clinical practice, while it has been shown that -according to the guidelinesmany CT brain examinations could be replaced by MRI. The higher cost, the lower availability of MRI and the need to help the patient immediately makes this choice less probable.

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I mportant to r emember is that justification is in the hands of the professionals rather than of the competent regulatory authority: it is a shared responsibility between referring physician and radiologist. Once referral for CT examination has been justified, the radiologist has to e nsure that the examination is carried out with a good technique, this has to do with the optimization process. Within this process the radiation dose to the patient should be limited, while providing sufficient image quality. Possibilities for dose reduction relates to standard rules like minimal anatomical length of the imaging, patient positioning at isocenter, reducing the reference tube load setting or reducing the number of multiphase images, which should always be applied. Indeed patients undergoing CT examinations may be exposed to high doses even with an optimized protocol, just because such simple methods are overlooked. For example, with the introduction of faster and faster devices with higher tube load performance, there is a tendency to e xtend the imaging area beyond the area of interest, with the consequence of an unnecessary extra dose (2). Next, even when these conditions are met, there are additional opportunities to reduce dose which mainly relates to technical innovations as proposed by manufacturers: automatic tube current modulation (TCM), (automatic) selection of tube potential, adaptive collimation, new reconstruction algorithms (e.g. iterative reconstruction techniques) and protocol tailoring to patient size and age (3). All these aspects of dose reduction strategies in CT will be discussed and some results of ongoing studies will be reported, as summarized below. STUDY 1 Inner ear CT imaging: influence of iterative reconstruction techniques on dose and image quality In this study we assessed the otential of Sinogram Affirmed Iterap tive Reconstruction (SAFIRE) relative to filtered backprojection (FBP) in terms of dose and image quality (IQ), for temporal bone computed tomo graphy (CT). Two cadaver heads were scanned on 128-slice multi-detector-row CT (SOMATOM Definition Flash) using the standard-of-care inner ear protocol (140 kV, 220 fixed mAs) and dose reduced protocols at 200, 180 and 160 mAs (10, 20, 30% dose reduction

respectively). In addition, the standard-of-care with lower potential (120 kV) but higher mAs (250) (30% dose reduction) was also used. Data were reconstructed with FBP and SAFIRE (strength 5), using very sharp filters. Objective and subjective measurements were performed to assess image quality. Specifically, o bjective noise and Hounsfield units were measured in the native axial (0.4 mm slice, 0.2 mm increment) and reformatted coronal and axial (0.8 mm slice, 1 mm increment) temporal bone images. Signal and noise were calculated and the two techniques were compared (Student t-test). For the subjective evaluation of image quality, two experienced head and neck radiologists assessed the images for visibility of ear structures and for diagnostic acceptability, using a 5-point scale (1 = insufficient; 5 = excellent). Results shows that objective noise was significantly lower for SAFIRE respect to FBP for the native images (117 ± 6.6 vs 132 ± 8.1, p < 0.01), while for the reformatted images no difference was observed between FBP and SAFIRE (p>0.05). The signal followed the same trend. Subjective image quality instead was significantly better for FBP (p-value < 0.001, SAFIRE median score 3 vs 4 for FBP). The highest average IQ score (4.5) was observed for the routine and for the 120kV protocol. Being the latter associated with a 30% dose reduction respect to the routine protocol, it became the clinically in use protocol. In conclusion, compared to FBP, SAFIRE enabled significant reduction of objective image noise for the high resolution native images. However, overall i mage quality was significantly better for FBP, possibly because of the extreme strength of 5 for SAFIRE and of the images reformatting. In future lower strength of SAFIRE should be assessed and axial native images could be used instead of the reformatted ones. Figure 1 (left) shows the measured noise in the images as a function of dose (each dose level represent a protocol) for both FBP and SAFIRE images; on the right the average score for the subjective IQ evaluation is shown, also as a function of dose. As it can be seen the protocol using lower kV (120) and higher mAs (250) shows a comparable image quality to the routine one, but having a lower CTDIvol (55 mGy instead of 75 mGy). STUDY 2 Dose to radiosensitive organs during routine chest CT:

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Fig. 1. — Measured noise in the images as a function of dose for FBP and safire images.

effects of standard and organ-based tube current modulation The aim of current study was to uantify the effect of standard and q organ-based tube current modulation (TCM) on dose to radiosensitive organs (breasts, lungs, heart, thyroid gland) and on image quality in adult female patients of various sizes undergoing chest CT examinations. Four (underweight, normal, overweight and obese BMI index) female cadavers (< 24h) were scanned on 128-slice multi-detector-row CT (SOMATOM Definition Flash) using the standard-of-care protocol (with 4D CareDose TCM) and the X-Care protocol (an organ based TCM approach to reduce direct X-ray exposure for the breasts and thyroid gland). For the comparison in this work, the scanner output (CTDIvol) was matched between the two protocols. Patient and organ doses (breasts, lungs, heart and thyroid) were estimated using PCXMC 2.0 (STUK, Helsinki, Finland), which allows to rescale the phantom according to the patient’s height and weight and to account for TCM. Doses were then plotted as a f unction of patient’s BMI and regression analysis was applied. Image quality was evaluated by measuring the noise (standard deviation of CT numbers) within the lung and heart regions. Results shows that while total mAs delivered per 360° is unchanged with organ-based TCM, patient effective dose was reduced respect to the standard protocol and the reduction decreased in function of patient size (R2 = 95%, range 25% to 4% dose reduction). The dose to the breasts, lungs, heart and thyroid was also decreased, due to the lower amount of x-rays to the anterior respect to the posterior side of the patients and

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Fig. 2. — Graph showing the dose reduction (%) with organ-based TCM respect to the standard protocol for patient dose (E) and organ dose (lungs, breasts, heart, thyroid).

showed an increasing trend with patient size, (R2 = 92%, range 23%-36% for breasts, R2 = 84%, range -2% to 6% for lungs, R2 = 92%, range 11% to 48% for the heart and R2 = 85, range 0% to 21% for the thyroid). Noise was not significantly increased (p > 0.05) with organ-based TCM. In conclusion, compared with routine TCM, organ-based TCM allows for reduction of organ doses (breasts, lungs, heart and thyroid) in chest CT and the reduction increases with patient size. Indeed the higher tube current in the posterior views is contributing to the organ doses more in small (less attenuating) patients. Patient dose is also reduced but the effect is smaller for larger patients. Image quality was not affected.

References 1. http://www.riziv.be/care/nl/doctors/ promotion-quality/guidelines-rx/pdf/ guidelinesnl.pdf (accessed on 25/09/13) 2. Zanca F, Demeter M, Oyen R, Bosmans H. Excess radiation and organ dose in chest and abdominal CT due to CT a cquisition beyond expected anatomical boundaries. Eur Radiol, 2012 Apr, 22(4):779-88. 3. Radiation Dose from Multidetector CT, Editors: D. Tack, M. K. Kalra, P. A. Gevenois. Springer, 2012.

1. Radiology Department UZ Leuven & Imaging and Pathology Department, KUL, Leuven, Belgium.

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ANNUAL GENERAL ASSEMBLY OF THE ROYAL BELGIAN SOCIETY OF RADIOLOGY (RBRS), Leuven, 16.11.2013 Presidential address It was a great honour to serve as your president during the year 2013, and to organize in Leuven the annual symposium, which was well attended. The general assembly of the Royal Belgian Radiological Society has now decided to dissolve the Society, and its scientific mission was absorbed by the new Belgian Radiological Society. The purposes of this new Society are to protect our professional interests, and to foster training, education and scientific work in radiology. By bringing all

these goals under one umbrella, a stronger Society can be build, allowing a more efficient communication and interaction with other stakeholders in the Belgian social security. This is important to safeguard and improve our position amongst other medical caregivers. I wish the new Belgian Radiological Society good luck, and I hope you will continue to support our new Society. Leuven, November 16th 2013, Prof. Dr. Robert Hermans

Honorary Membership Nominees of the RBRS Roberto Maroldi Prof Maroldi was born in 1954, in Vincenza, in the region of Veneto. He studied medicine at the medical school in Verona, graduating in 1979 and later became board certified radiologist at the same university. In 1982 he moved to the department of radiology at the university of Brescia, in the region of Lombardy. He became assistant head of the department in 1989. He was promoted to full professor in 2006, and became chairman of the department in 2007. His main clinical and scientific interest goes to head and neck imaging. He served as president of the section of head and neck radiology of the Italian Society of Radiology, and was for a long time board member of the European Society of Head and Neck Radiology, organizing twice the annual meeting of this Society. To date, Prof Maroldi gave over 300 presentations and invited lectures at national and international meetings, published more than 65 articles and 35 book chapters. Within the world of head and neck imaging, the Brescia school is of high standard and reputation, not in the least by the work by professor Maroldi. He is actively promoting a multidisciplinary approach to head

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Pr R. Maroldi (left) receiving the Honorary Membership diploma from President R. Hermans. and neck pathology. His rigourous attention to technical details, as well as his meticulous analysis of the imaging findings, constitute important points of reference to all of us. Apart from being an academecian and scientist, prof Maroldi is a keen sportman; in his younger times, he

represented his country as member of the Italian athletics sportsteam. Because of his important contributions to radiology, and the field of head and neck imaging in particular, the RBRS has the honour to bestow on professor Maroldi the honorary membership of the Society.

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Hervé Tanghe Dr Tanghe was born in 1952 in Antwerpen, and studied medicine at the Katholieke Universiteit Leuven. After a short residency in Internal Medicine in Antwerpen, he trained as neurologist at the Erasmus Medical Centre University Hospital in Rotterdam, immediately followed by a training as radiologist at the same institution, completed in 1986. After this, he followed several postgraduate training in Neuroradiology and interventional neuroradiology in Amster dam, Nancy, Zürich and Leuven. Since 1987 Dr Tanghe is staff member of the department of radiology at the Erasmus Medical Centre in Rotterdam, being responsible for both neuroradiology and head and neck radiology. In this last field, dr Tanghe mainly focused on temporal bone imaging. Dr Tanghe authored or co-authored about 40 articles in the field of neuroradiology and ear imaging, including interventional aspects, published several book chapters on ear imaging, and widely lectured on these themes both at a national and international level. He currently is the chairman of the official postgraduate subspeciality

Pr H. Tanghe (left) receiving the Honorary Membership diploma from President R. Hermans. course in head and neck radiology and neuroradiology, created by the Dutch Society of Radiology. Dr Tanghe is a fervent sportsman. His sport is fencing, and his best result was a 6th place in the Belgian National Championship.

Because of his important contributions to radiology, and the field of neuroradiology and head and neck imaging in particular, the RBRS has the honour to bestow on dr Tanghe the honorary membership of the Society.

Guy Marchal Professor Marchal was born in 1946 in Ukkel, studied medicine at the Katholieke Universiteit Leuven, and specialized in radiology at the University Hospitals Leuven, became staff member in the department of radiology at the same institution, and was promoted to full professor in 1992. He was member of the board of the RBRS, and served as president of this Society in 1997. From 1997 till 2010, prof Marchal was chairman of the department of radiology at the University Hospitals Leuven. Professor Marchal’s scientific achievements are numerous. His interest shifted over the years from pediatric radiology, over ultrasound to computed tomography and magnetic resonance imaging, with a special interest in non-invasive tissue characterisation by these techniques. He is author or co-author of over 700 papers on medical imaging, and promoted or co-promoted many doctoral works in this field. Quite unique is the collaboration that prof Marchal has fostered with engineers and medical physicists, bringing imaging and patient care to a next level. Prof Marchal has also played an active role in professional is-

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Pr G. Marchal (left) receiving the Honorary Membership diploma from President R. Hermans. sues, making radiological services more efficient, trying to find a betterbalance between available financialresources and imaging capacity. After becoming emeritus, prof Marchal further engaged himself in

helping the development of local medical imaging projects in Africa. Taking all these elements into consideration, the RBRS has the honour to bestow on professor Marchal the honorary membership of the Society.

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Jacques Pringot Dear Colleagues, Dear Friends, As the President of last year symposium, I had asked Professor Pringot if I could pay tribute to him as an honorary member of the Royal Belgian Society of Radiology as it was scheduled. However, for minor medical reasons, it was not possible last year, that is why I am doing it now. I won’t tell you Professor Pringot’s birth date but I can assure you that he does not show his age. He was born in the Belgian Ardennes, it may seem a detail but it has all its significance. First, he went to college in Godinne sur Meuse, in the same region where I am working now (CHU Dinant – Godinne) and then to the University Faculties of Namur. What is interesting and exceptional in his University education is that he has been an internist before becoming a radiologist. He was interested in radiology thanks to Professor Wolfgang Frick during a two-year stay in the academic hospital Nurnberg of the University Erlangen- where he worked as research fellow in internal medicine. After a year in endoscopy he was resident for a second year in radiology. He obtained a doctorate in medicine with a thesis in gastroenterology. In 1965 he was resident in the radiological unit of Professor Pierre Bodart in Herent and obtained in 1966 a diploma of internist at the Catholic University of Louvain (UCL) and was nominated supervisor in Radiology. In 1971, he was appointed lecturer at the Catholic University of Louvain. Starting in 1977, he was Professor of Radiology and in 1988 he was awarded the title of ordinary Professor. The amount of oral scientific presentations and posters he pre sented is really considerable, as well as his publications. The result of his exceptional career looks like a huge c ursus. He is member of many scientific societies and participated in many congresses focused on gastro-enterologic and thoracic radiology. Since 1974, he has been an active member of the Royal Belgian Radiological Society. He is a permanent member of the board and editor-inchief of the “Journal Belge de Radio logie-Belgisch Tijdschrift voor Radio logie” (JBR-BTR) which is an excellent and ever-expanding Journal of Radiology in the World with a current Impact Factor of 0.26.... !

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Pr J. Pringot (left) receiving the Honorary Membership diploma from PastPresident J.F. De Wispelaere. He is also member of a lot of ditorial boards of many well-known e journals. He has received many honorific distinctions like “Award” magna cum laude for RSNA in 1999. Among the scientific publications, some of his book chapters are considered as references mainly in barium Radiology, CT and MRI. Some interesting chapters were also written in collaboration with colleagues of KUL and ULB. Professor Pringot is a pure Belgian! His wife is Flemish and they live in Flanders in the Heverlee area. Professor Pringot is a keen traveller and with his wife Geneviève they visited “Black Africa” where he is going back very soon. It is no coincidence if his favourite hobby is hunting, shall I remind you his Ardennes origin? That means that he didn’t hunt only on the University campus ! He practices this hobby full-time, in particular in Belgium and I am hesitating in asking him to come hunting in my own garden next to Namur because there are many wild boars... Before finishing, let me say a couple of words about his passion for two great historical figures: Alexandre le Grand and Charles Quint, who was also born in Belgium issued from the “Hapsburg” family (called “meridional Netherlands” in 1500). This is where the comparison ends... Jacques Pringot is a true gentleman; he is really not interested in Power. It is his acute intelligence, his

implication in what he believes in and his ability for clinical investigation associated with incontestable humanist qualities that make him someone exceptional! These are the main reasons why the Royal Belgian Radiological Society (soon Belgian Society of Radiology) is paying him tribute today. Last word to characterize Jacques Pringot - but is it a quality or a shortcoming for someone who is a great dreamer: absent-minded ? This is also part of his personality because for him I shall always be Jean- Frédéric and not Jean-François.... Jean-François De Wispelaere President RBRS 2012

Dear President, Ladies and Gentlemen, I feel greatly honored and very proud of this honorary membership which is the highest honor delivered by the Royal Belgian Radiological Society and am deeply grateful to the Board of the Society and more particularly to past-President De Wispelaerewho took the initiative last year and to President Hermans who delivered this impressive diploma. I am also proud that both presidentsare academic colleagues, the first one from UCLouvain where I was ordinary professor of radi ology and now professor emeritus

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and the second one from KUleuven with which departments of radi ology and gastroenterology I had durable special scientific relations. This moment is also right to thank my dear family who allowed without restriction time and space to my professionalactivities, my parents who invested in a best education, my university and my mentors in radiology:

Professor Wolfgang Frik, at the University of Erlangen-Nurnberg in whom department my career as a radiologistwas initiated. Professor Pierre Bodart, in whom department I was a member during 25 years and partner. Professor Heiko Shirakabe from Jutendo University in Tokyo who inspired gastric and colonic double contrast techniques, and Professor

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AlexanderMargulis to whom reference textbook of alimentary tract radiology I was a contributor. Finally, I regard this high honor not only as an appreciation for what has been done for our society but as a stimulus to do further and if possible better for the good of our new Belgian Society of Radiology. I thank you so much. Professor Em. Jacques Pringot

Members of the Symposium Faculty and Board of RBRS in 2013

From left to right: J. Verschakelen, H. Tanghe, R. Maroldi, M. Lemort, D. Henroteaux, C. Delcour, A. Van Steen, J.F. De Wispelaere, R. Hermans, J. Pringot, G. Marchal, Y. Lefèvre

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FORTHCOMING COURSES AND MEETINGS NATIONAL MEETINGS 16-18.01.14 5th LEUVEN COURSE ON HEAD AND NECK CANCER IMAGING Information: www.headandneckimaging.be Monika.philips@uzleuven.be 23.01.14 RBRS – Senology Overdiagnosis in senology: ethical and economic considerations Brussels, Erasme hospital Information: salvatore.murgo@gmail.com 03-07.02.14 Head and neck Brugge Information: walter.rijsselaere@uzbrussel.be 07-08.02.14 14ème MISE AU POINT EN IMAGERIE OSTEO-ARTICULAIRE Brussels, UCL St Luc Organisation: Pr A. Cotten, Pr B. Vande Berg

Information: martine.vanwambeke@uclouvain.be 07-09.02.14 MSUS ADVANCED LECTURES AND DEMONSTRATIONS FOLLOWED BY HANDS-ON TRAINING Brussels Information: medipoint@skynet.be 14.03.14 RBRS – Cardiovascular and Interventional Radiology Liège, CHR Citadelle Information: denis.henroteaux@chrcitadelle.be 25.03.14 RBRS – Pediatric Radiology Brussels, HUDERF Information: catherine.christophe@huderf.be

15-16.05.14 Atelier de colonoscopie virtuelle Liège, Clinique St Joseph Information: anne-marie.mandic@chc.be 13.06.14 RBRS – Cardiovascular and Interventional Radiology Antwerp, UZA Information: olivier.darchambeau@uza.be 02-04.10.14 HRCT of the Lung, Teaching course Leuven – Belgium Information: www.everyoneweb.com/chestradiology monika.philips@uzleuven.be 09.12.14 RBRS – Pediatric Radiology Brussels, Iris Sud Information: mcassart@ulb.ac.be

10-11.05.14 6th SYMPOSIUM MAMMOGRAPHY Oostduinkerke Information: monika.philips@uzleuven.be

RBRS Cardiovascular and Interventional Radiology 14.03.14, 13.06.14

RBRS – Pediatric Radiology 25.03.14, 09.12.14

RBRS – Breast Imaging 23.01.14

RBRS – Head and Neck Radiology 16-18.01.14

Miscellaneous 16-18.01.14, 03.02.14, 07-09.02.14, 10-11.05.14, 15-16.05.14, 02-04.10.14

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

InterNATIONAL MEETINGS 16-17.01.14 DIPLOME INTERUNIVERSITAIRE DE RADIOLOGIE OTO-NEUROOPHTALMOLOGIQUE Facultés de Médecine de Besançon, Dijon, Nancy, Reims, Strasbourg Information: mioduszewska@unistra.fr – http://www-ulpmed.u.strasbg.fr 20-24.01.14 DIPLOME D’UNIVERSITE D’IRM CLINIQUE Université Louis Pasteur, Faculté de Médecine de Strasbourg Information: mioduszewska@unistra.fr – http://www-ulpmed.u.strasbg.fr 03-07.02.14 EMRI – Musculoskeletal MRI of the jointS Vienna, Austria Information: walter.rijsselaere@uzbrussel.be 06-07.02.14 DIPLOME INTERUNIVERSITAIRE DE RADIOLOGIE OTO-NEUROOPHTALMOLOGIQUE Facultés de Médecine de Besançon, Dijon, Nancy, Reims, Strasbourg Information: mioduszewska@unistra.fr – http://www-ulpmed.u.strasbg.fr

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06-11.03.14 ECR 2014 Vienna, Austria Information: www.ecr.org 17-21.03.14 DIPLOME D’UNIVERSITE D’IRM CLINIQUE Université Louis Pasteur, Faculté de Médecine de Strasbourg Information: mioduszewska@unistra.fr – http://www-ulpmed.u.strasbg.fr 24-28.03.14 MSUS STATE OF THE ART REVIEW Entabeni, South Africa Information: mzdipoint@skynet.be 07-08.05.14 6TH MSK ULTRASOUND COURSE Leiden, The Netherlands Information: m.reijnierse@lumc.nl 08-10.05.14 EMRI – BREAST AND FEMALE IMAGING Vienna, Austria Information: walter.rijsselaere@uzbrussel.be 16-18.05.14 1er Weekend SIAD La Palmyre Atlantique, France Information: www.lasiad.org

23-24.05.14 ESSR Sports imaging Meeting Russia, Saint Petersburg Information: www.essr.org voschieva@gmail.com maryam.shahabpour@uzbrussel.be 05-06.06.14 DIPLOME INTERUNIVERSITAIRE DE RADIOLOGIE OTO-NEUROOPHTALMOLOGIQUE Facultés de Médecine de Besançon, Dijon, Nancy, Reims, Strasbourg Information: mioduszewska@unistra.fr – http://www-ulpmed.u.strasbg.fr 16-20.06.14 EMRI – CENTRAL NERVOUS SYSTEM Amsterdam, The Netherlands Information: walter.rijsselaere@uzbrussel.be 26-28.06.14 ESSR 2014 Annual Scientific Meeting Riga, Latvia Information: www.essr.org 17-19.09.14 EMRI – ABDOMINAL AND UROGENITAL Ankara, Turkey Information: walter.rijsselaere@uzbrussel.be

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