Strain analysis reveals subtle systolic dysfunction in confirmed and suspected myocarditis with normal LVEF. A cardiac magnetic resonance study.

AIMS: Lake Louise Criteria (LLC) are time-dependent and some acute myocarditis (AM) with preserved left ventricular ejection fraction (LVEF) could be missed, due to the limited accessibility of Cardiac Magnetic Resonance (CMR). We aimed to assess the potential value of cardiac strain measured by feature tracking (FT) imaging in this population. METHODS AND RESULTS: Eighty-three patients with clinically suspected AM and normal LVEF were divided into 39 "confirmed AM" (positive LLC) and 44 "suspected AM" (negative LLC). An age and gender-matched sample of 42 normal subjects underwent CMR. In all groups, FT-derived biventricular strains and STE- global longitudinal strain (GLS) were assessed, being regularly measurable. Strain values < 5th percentile of the control group were considered abnormal. "Suspected" and "confirmed" AM were similar, except for medium time of CMR evaluation (5.2 vs 1 months from presentation, respectively; p = 0.004). Compared to healthy controls, both "suspected" and "confirmed" AM showed significantly impaired strain values. LV-global circumferential strain (GCS), right ventricular GCS and LV-GLS were abnormal in 15.4% and 15.9%, 20.5% and 15.9%, 7.7% and 9.1% in "confirmed" and "suspected" AM, respectively. STE analysis confirmed the results on LV-GLS, however a weak correlation emerged between STE and CMR-FT LV-GLS (p = 0.08). CONCLUSIONS: Compared to STE, CMR-FT analysis provided a more comprehensive and complementary biventricular strain evaluation that resulted similar in "confirmed" and "suspected" AM with normal LVEF. Conversely, mostly biventricular GCS was significantly reduced in up to 20% of patients, compared to healthy controls.

Preoperative vascular mapping with multislice CT of deep inferior epigastric artery perforators in planning breast reconstruction after mastectomy.

PURPOSE: Our aim was to evaluate the usefulness of computed tomography angiography (CTA) in vascular mapping for planning breast reconstruction after mastectomy using a free flap made with the deep inferior epigastric perforators (DIEP). MATERIALS AND METHODS: We retrospectively evaluated 41 patients, mean age 57 years, scheduled for mastectomy. CTA was performed with a 64-row scanner (Aquilion 64, Toshiba Medical Systems, Japan), with injection of 100 ml of contrast medium (iomeprol 350 mgI/ml, Bracco, Italy) at 4.5 ml/s. Maximum intensity projection (MIP) and three-dimensional volume-rendering (VR) reconstructions were made to mark perforator positions. Presentation frequency, anatomy and artery opacification quality were evaluated. RESULTS: DIEP were always depicted (n=81) and subdivided according to Taylor's classification into type I (65%), type II (28%), and type III (7%). We observed a mean of three (range, 1-5) DIEP arteries on the right and two (range, 1-5) on the left side. The superficial inferior epigastric artery (SIEA) was depicted in 6/41 patients, bilaterally in three cases. Opacification was optimal in 30/41 cases, venous contamination due to late arterial phase in eight and low opacification due to early scan in three. CONCLUSIONS: Studying DIEP with CTA is useful in the surgical planning of breast reconstruction, even though it requires careful optimisation owing to the critical timing of opacification typical of that vascular district.

64-Slice CT urography: 30 months of clinical experience.

PURPOSE: This study sought to assess the diagnostic accuracy of 64-slice computed tomography urography (CTU) in evaluation of the urinary tract. MATERIALS AND METHODS: A total of 322 CTU procedures were carried out in 317 consecutive patients (mean age 64.4 years). The findings were compared with previous and subsequent patient workup considering both laboratory and imaging studies, such as urine cytology, abdominal ultrasound and CT, cystoscopy, retrograde pyelography, surgery and pathology. RESULTS: Out of 322 CTU examinations, 169 showed significant urinary tract changes, whereas 153 revealed no urinary disease, in good agreement with the follow-up. In particular, in bladder evaluation, for which we have a direct comparison with cystoscopy in 125 patients, we calculated a CTU sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and diagnostic accuracy of 85%, 94%, 92%, 89% and 90%, respectively. CONCLUSIONS: CTU was accurate for urinary tract evaluation, but it cannot replace cystoscopy in patients in whom a malignant bladder disease is suspected.

Prevalence of extravascular collateral findings during 64-slice CT angiography of the abdominal aorta and lower limbs.

PURPOSE: The aim of this study was to assess the prevalence of extravascular collateral findings during 64-slice CT angiography of the abdominal aorta (AA-CTA) and lower limbs (LL-CTA). MATERIALS AND METHODS: The images of 536 AA-CTA and LL-CTA examinations performed for suspected aortic and peripheral vascular disease in 500 patients were retrospectively reviewed. Two radiologists evaluated the 5-mm axial images independently using appropriate window settings for the area under investigation. Collateral findings were divided according to their clinical significance into significant, nonsignificant and meriting further investigation. RESULTS: No collateral findings were identified in 97/500 patients (19.4%). In the remaining patients, 821 collateral findings were detected, of which 43 (5.24%) were classified as significant, 135 (16.44%) as meriting further investigation and 643 (78.32%) as nonsignificant. The findings indicative of the presence of a malignant lesion totalled 36 (4.5%). CONCLUSIONS: AA-CTA and LL-CTA demonstrate a nonnegligible prevalence of collateral findings, many of them major. It therefore appears that the evaluation should focus not only on the image reconstructions to identify vascular disease, but also on the native axial images to detect incidental findings.

Computed tomography coronary angiography vs. stress ECG in patients with stable angina.

PURPOSE: This study compared the role of multislice computed tomography coronary angiography (MSCT-CA) and stress electrocardiography (ECG) in the diagnostic workup of patients with chronic chest pain. MATERIALS AND METHODS: MSCT-CA was performed in 43 patients (31 men, 12 women, mean age 58.8+/-7.7 years) with stable angina after a routine diagnostic workup involving stress ECG and conventional CA. The following inclusion criteria were adopted: sinus rhythm and ability to hold breath for 12 s. Beta-blockers were administered in patients with heart rate>or=70 beats/minute. In order to identify or exclude patients with significant stenoses (>or=50% lumen), we determined posttest likelihood ratios of stress test and MSCT-CA separately and of MSCT-CA performed after the stress test. RESULTS: The pretest probability of significant coronary artery disease (CAD) was 74%. Positive and negative likelihood ratios were 2.3 [95% confidence interval (CI) 1.0-5.3] and 0.3 (95% CI: 0.2-0.7) for the stress test and 10.0 (95% CI: 1.8-78.4) and 0.0 (95% CI: 0.0-infinity) for MSCT-CA, respectively. MSCT-CA increased the posttest probability of significant CAD after a negative stress test from 50% to 86% and after a positive stress test from 88% to 100%. MSCT-CA correctly detected all patients without CAD. CONCLUSIONS: Noninvasive MSCT-CA is a potentially useful tool in the diagnostic workup of patients with stable angina owing to its capability to detect or exclude significant CAD.

Assessment of left main coronary artery atherosclerotic burden using 64-slice CT coronary angiography: correlation between dimensions and presence of plaques.

PURPOSE: The aim of this study was to correlate left main (LM) coronary artery dimensions with the presence of atherosclerosis by multidetector-row computed tomography (MDCT) coronary angiography (CA) and to assess coronary atherosclerotic plaques with a semiquantitative method. MATERIALS AND METHODS: Sixty-two consecutive patients (41 men, mean age 60+/-11) with suspected coronary artery disease underwent 64-MDCT coronary angiography. LM dimensions (length, ostial and bifurcation diameters), quantitative [location, Hounsfield unit (HU) attenuation] and qualitative (composition, shape) analysis of plaques within the LM were performed. All patients underwent conventional CA. RESULTS: Thirty patients (mean age 55+/-10) without plaques in the LM presented the following average dimensions: length 10.6+/-6.1 mm, ostial diameter 5.5+/-0.7 mm, bifurcation diameter 4.9+/-0.9 mm. LM plaques (n=36) were detected in 32 patients (mean age 64+/-10) with the following LM average dimensions: length 11.3+/-4.0 mm, ostial diameter 6.0+/-1.2 mm and bifurcation diameter 6.0+/-1.2 mm. Plaques were calcified (40%, mean attenuation 742+/-191 HU), mixed (43%, mean attenuation 387+/-94 HU) or noncalcified (17%, mean attenuation 56+/-14 HU) and were frequently eccentric (77%). Age was significantly different in the two groups (p<0.05). LM diameters of patients with plaques were improved (p<0.05). A moderate correlation was found between the LM bifurcation diameter and the corresponding plaque area (r=0.56). Significant conventional CA lesions of the LM were present in just three patients (5%). CONCLUSIONS: Increased LM diameters are associated with the presence of atherosclerosis. MDCT CA indicates relevant features of LM atherosclerotic burden, as rupture and subsequent thrombosis of vulnerable plaques may develop from lesions characterised as nonsignificant at conventional CA.

64-Slice CT coronary angiography versus conventional coronary angiography: activity-based cost analysis.

PURPOSE: This study was done to analyse the costs of 64-slice computed tomography (CT) coronary angiography and conventional coronary angiography and determine the cost-effectiveness of the two modalities. MATERIALS AND METHODS: Detailed activity-based cost analyses of the two modalities were carried out at the departments of radiology and cardiology of a teaching hospital. The differential costs (equipment, variable, personnel), common costs and external costs were estimated. Finally, the full costs of the two procedures were obtained; the full cost of conventional coronary angiography also considered the cost of 1 day in hospital. The cost-effectiveness of the two procedures at different levels of pretest likelihood of coronary artery disease (CAD) was estimated. RESULTS: The costs of multidetector CT (MDCT) coronary angiography were as follows: differential cost 222.23 euro, common cost 5.50 euro, external cost 2.30 euro and full cost 230.03 euro. The costs of conventional coronary angiography were: differential cost 366.18 euro, common cost 0.50 euro, external cost 9.20 euro, hospitalisation cost 1,652 euro and full cost 2,027.88 euro. Cost-effectiveness analysis showed that the cost per correctly identified CAD patient decreased exponentially with increasing pretest likelihoods of CAD. MDCT coronary angiography was more cost effective than conventional coronary angiography up to a pretest likelihood of 86%. CONCLUSIONS: MDCT coronary angiography has far lower costs than conventional coronary angiography, and its cost-effectiveness is better in the large majority of patients.

Noninvasive evaluation of the celiac trunk and superior mesenteric artery with multislice CT in patients with chronic mesenteric ischaemia.

PURPOSE: This study sought to assess the role of multislice computed tomography (MSCT) in patients with suspected chronic mesenteric ischaemia (CMI). MATERIALS AND METHODS: Forty-five patients (29 men; mean age 68) underwent MSCT angiography of the abdomen for suspected CMI (main clinical finding: postprandial abdominal pain). The scan protocol was detectors/collimation 16/0.75 mm; feed 36 mm/s; rotation time 500 ms; increment 0.4 mm; 120-150 mAs and 120 kVp. A volume of 80 ml of contrast material was administered through an antecubital vein (rate 4 ml/s), followed by 40 ml of saline (rate 4 ml/s). Images were analysed on the workstation with different algorithms (axial image scrolling, multiplanar reconstructions, maximum intensity projection, volume rendering). Targeted central lumen-line reconstructions (curved reconstructions) were obtained along the celiac trunk (CeT) and superior mesenteric artery (SMA). Vessel occlusions and significant (>50%) stenosis were recorded. RESULTS: Image generation and interpretation required 25 min. Stenosis and/or occlusions were detected in 29 (65%) cases on the CeT and in 32 (71%) on the SMA. Of those lesions (n=61), 44 (49%) were classified as not significant. In 16 (35%) cases, there was a simultaneous stenosis and/or occlusion of the CeT and SMA (confirmed by conventional angiography). In six (13%) cases, there were no lesions affecting the CeT, SMA or their branches (confirmed by clinical follow-up). CONCLUSIONS: MSCT angiography can play a major role in the detection of stenosis of the abdominal arteries in patients with suspected CMI.

Renal artery stenosis: comparative evaluation of gadolinium-enhanced MRA and DSA.

PURPOSE: This study was undertaken to evaluate the accuracy of contrast-enhanced magnetic resonance angiography (CE-MRA) in detecting renal artery stenosis using intra-arterial digital subtraction angiography (DSA) as the gold standard. MATERIALS AND METHODS: Thirty-five consecutive patients with possible renovascular hypertension were prospectively studied; 26 of them underwent both MRA and DSA. In these 26 cases, two readers assessed the number of renal arteries, the presence of stenoses and their degree. Results were compared with DSA, and sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and diagnostic accuracy of MRA were determined. Interobserver variability was also calculated. RESULTS: DSA showed 51 main renal arteries (one patient had a single kidney) and six accessory arteries (total number of arteries 57) in the 26 patients considered. Both MRA readers detected all of the 51 main renal arteries and only one accessory vessel. When the presence of stenosis was considered, the readers' results, respectively, were as follows: sensitivity 77% and 72%, specificity 69% and 69%, PPV 86% and 85%, NPV 55% and 50% and diagnostic accuracy 75% and 71%. When the detection of significant stenosis was considered, the results, respectively, were: sensitivity 83% and 83%, specificity 73% and 78%, PPV 60% and 65%, NPV 90% and 91%, and diagnostic accuracy 76% and 80%. Interobserver variation was good when considering stenosis detection (kappa=0.69) and excellent when considering detection of significant stenosis (kappa=0.85). CONCLUSIONS: MRA results do not appear as positive as in the majority of papers in the literature. Multiple reasons can probably be invoked to explain this difference. The mean age of our patients, higher than in many other studies, should be noted and may have accounted for their possible poor cooperation. Moreover, all of the missed significant stenoses were distally located, and therefore, the failure to detect them might be related to the suboptimal spatial resolution of MRA. Nevertheless, MRA showed a high NPV for detecting significant stenoses, a finding of considerable clinical relevance in that it allows patients with normal MRA findings to be spared additional more invasive procedures.

Spectrum of collateral findings in multislice CT coronary angiography.

PURPOSE: The aim of the study was to investigate the prevalence of the noncardiac collateral findings during multislice computed tomography coronary angiography (MSCT-CA). MATERIALS AND METHODS: Six hundred and seventy patients undergoing MSCT-CA with 16-slice and 64-slice CT scanners for suspected atherosclerotic disease of the coronary arteries were retrospectively reviewed. All data sets obtained with a large field of view (FOV) were analysed by two radiologists using standard mediastinal and lung window settings. Collateral findings were divided according to clinical importance into nonsignificant, remarkable and compulsory to be investigated. RESULTS: Eighty-five percent of patients revealed coronary artery disease (CAD). Only 138/670 (20.6%) were without any additional finding. An additional 1,234 findings were recorded: nonsignificant 332 (26.9%), mild 821 (66.53%), compulsory for study 81 (6.56%). A total of 81 patients (12.08%) had significant noncardiac pathology requiring clinical or radiological follow-up. Among these, newly discovered pathologies were revealed in two patients (2.46%). CONCLUSIONS: A significant number of noncardiac findings might have been missed in MSCT-CA scans; the appropriate approach should be as a team trained in cardiology and radiology.

Contribution of CT to treatment planning in patients with GIST.

PURPOSE: The aim of this study was to illustrate the morphological and structural computed tomography (CT) patterns of gastrointestinal stromal tumours (GIST) and to discuss the technique's role in identifying lesions at a higher risk for malignant potential, in treatment planning and in the follow-up of patients with GIST. MATERIALS AND METHODS: We retrospectively reviewed the CT scans of 26 patients who underwent surgery for histologically confirmed GIST of the stomach (20 cases), the duodenum (1), the caecum (1), the small bowel (2), the descending colon (1) and the rectum (1). CT exams were performed with a single-slice scanner and a 5-mm collimation before and after the intravenous administration of contrast material. RESULTS: CT allowed us to correctly define the site, size and structure of lesions in all cases and to identify signs of invasion of neighbouring structures in some cases. The lesions exhibited solid density on the unenhanced scan and poor enhancement after contrast-medium administration; lesion structure was homogeneous in ten cases and inhomogeneous in 16; in one case, histology revealed microcalcification that had not been detected by CT. CONCLUSIONS: CT, with its panoramic capabilities and high contrast resolution, provides essential information for treatment planning and for the follow-up of GIST patients treated with surgery or chemotherapy.

Imaging techniques for the vulnerable coronary plaque.

The goal of this article is to illustrate the main invasive and noninvasive diagnostic modalities to image the vulnerable coronary plaque, which is responsible for acute coronary syndrome. The main epidemiologic and histological issues are briefly discussed in order to provide an adequate background. Comprehensive coronary atherosclerosis imaging should involve visualization of the entire coronary artery tree and plaque characterization, including three-dimensional morphology, relationship with the lumen, composition, vascular remodelling and presence of inflammation. No single technique provides such a comprehensive description, and no available modality extensively identifies the vulnerable plaque. In particular, we describe multislice computed tomography, which at present seems to be the most promising noninvasive tool for an exhaustive image-based quantification of coronary atherosclerosis.

Three-dimensional quantitative assessment of lung parenchyma in cystic fibrosis: preliminary results.

PURPOSE: The aim of this study was to assess the feasibility of three-dimensional (3D) reconstructions and quantitative analysis of the volume of each component of the lung with cystic fibrosis (CF). MATERIALS AND METHODS: Twenty-two patients with CF (mean age 17+/-8 years) were included in the study. The patients underwent an unenhanced single-slice spiral computed tomography (CT) chest scan with the following parameters: collimation 3 mm, table feed 6 mm x rot(-1), reconstruction interval 1 mm, soft tissue reconstruction kernel. Four image data sets were obtained: native axial slices, cine-mode display, virtual bronchographic volume-rendered images with algorithm for tissue transition display and virtual endoluminal views. The lungs were segmented manually from the hilum to the visceral pleura on the axial images, and the entire lung volume was calculated. A histogram was generated representing the fractional volume of tissues, the density of which was within a preset range. A curve was then obtained from the histogram. RESULTS: Native axial images and cine-mode display allowed complete evaluation of lung volumes. Virtual bronchography allowed a better assessment of the distribution of bronchiectasis. Virtual bronchoscopy was limited by the fact that it visualised only the surface, without differentiating mucus from the bronchial wall. Manual segmentation and generation of density-volume curves required 41+/-7 min for each lung. Three curve patterns were identified depending on disease severity. CONCLUSIONS: Volume-density analysis of lungs with CF is feasible. Its main advantage is that image analysis is not analogical, as the assessment is not performed using scoring systems or similar ordinal scales. This technique cannot differentiate acute from chronic findings, and the predictive value of the curve should be assessed.

Analysis of different contrast enhancement patterns after microbubble-based contrast agent injection in liver hemangiomas with atypical appearance on baseline scan.

BACKGROUND: We describe different possible enhancement patterns in liver hemangiomas with atypical appearance on baseline ultrasound after microbubble-based contrast agent injection. METHODS: From a series of 253 consecutive lesions that were indeterminate on baseline ultrasound and then scanned after injection of air-filled microbubble contrast agent, 65 focal liver lesions were retrospectively selected on the basis of a diagnosis of liver hemangioma on multiphase contrast-enhanced computed tomography (n = 23), magnetic resonance imaging (n = 27), or histology (n = 15). Each lesion was scanned during arterial phase (30 s after microbubble injection) and late phase (5 min after injection). On-site sonologists performed retrospective assessment of contrast-enhancement patterns by consensus. RESULTS: Centripetal fill-in preceded (n = 50) or not preceded (n = 3) by peripheral nodular/rim-like enhancement was the prevalently observed contrast-enhancement pattern, equivalent to the typical enhancement pattern of liver hemangiomas on contrast-enhanced computed tomography or magnetic resonance imaging. In the remaining lesions, additional enhancement patterns (diffuse contrast enhancement with rapid fill-in and a late hyper-isoechoic appearance, n = 6; peripheral nodular enhancement with a late hypoechoic appearance, n = 3; or persistent heterogeneous and hyperechoic appearance, n = 3) were observed. CONCLUSION: Different contrast-enhancement patterns are possible in atypical liver hemangiomas after microbubble injection. Typical centripetal fill-in is the prevalent pattern and its evidence allows diagnosis.

Non-invasive coronary angiography with 64-slice computed tomography.

Multislice computed tomography is a rapidly emerging technique for the non-invasive visualization of coronary arteries. Over the past 5 years several scanner generation were introduced with a progressive improvement in the diagnostic accuracy in the detection of coronary artery stenosis in selected patients populations. The introduction of 64-slice technology has further improved the diagnostic performance. This technique is at the edge of clinical implementation and, even though large clinical trials are still missing, an increased demand for these type of studies is observed all over the world. We describe our experience of more than 1 year with 64-slice CT coronary angiography providing clues on reasonable clinical applications.

Primary and secondary malignancies of the penis: ultrasound features.

Cancer of the penis is a rare neoplasm in developed countries but worldwide represents a significant health problem. In this study, the ultrasonographic features of primary and secondary malignant lesions of the penis are described. Squamous cell carcinoma usually presents as a hypoechoic lesion with heterogeneous appearance. Invasions of the corpora cavernosa and the corpus spongiosum are appreciable. B-cell lymphoma presents as well-vascularized mass, a plaque, or ulcers in the penile skin. Penile metastases results from hematogenous or lymphatic spreading of distant tumors or, more frequently, as penile infiltration by tumors from adjacent organs. Diffuse corporeal or nodular involvement can result.

Diagnostic accuracy of 16-row multislice CT angiography in the evaluation of coronary segments.

PURPOSE: To evaluate the diagnostic accuracy of 16-row multislice spiral computed tomography coronary angiography (16-MSCT-CA) for the non-invasive assessment of significant coronary artery stenosis. MATERIALS AND METHODS: We enrolled 40 patients (36 male, aged 59+/-11 yrs) with suspected obstructive coronary artery disease and a heart rate <65 bpm during the scan. The 16-MSCT-CA (Sensation 16, Siemens, Forchheim, Germany) was performed with electrocardiographically-gated technique after the intravenous administration of 100 ml of iodinated contrast material followed by a saline bolus chaser. The scan parameters were: collimation 16 x 0.75 mm, rotation time 0.42 s, feed/rot. 3 mm (pitch 0.25), 120 kVp, 500 mAs. All coronary segments = or >2 mm in diameter were evaluated by two independent observers for the presence of significant coronary artery stenosis (= or >50%). Consensus reading was compared to quantitative coronary angiography. RESULTS: The average heart rate was 55+/-6 bpm. Of the 428 segments of = or >2.0 mm diameter 92 were significantly diseased. Without exclusion of any branches (428), the sensitivity, specificity, positive, and negative predictive values to identify = or >50% obstructed segments were 95.7% (88/92), 95.8% (322/336), 86.3% (88/102), and 98.8% (322/326), respectively. No occluded left main, left anterior descending, circumflex or right coronary artery segments remained undetected. CONCLUSIONS: 16-MSCT-CA in a selected low-heart-rate patient population provides high diagnostic accuracy in the evaluation of significant coronary artery stenosis.