CT-guided infiltration of greater occipital nerve for refractory craniofacial pain syndromes other than occipital neuralgia.

PURPOSE: The purpose of this study was to evaluate the effectiveness of computed tomography (CT)-guided infiltration of greater occipital nerve (GON) for the treatment of refractory craniofacial pain syndromes other than occipital neuralgia. MATERIALS AND METHODS: Fifty-six patients suffering from refractory craniofacial pain syndromes were included between 2011 and 2017. There were 33 women and 23 men with a mean age of 50.7 years±13.1 (SD) (range: 27-74 years). CT-guided infiltration was performed at the intermediate site of the GON with local anesthetics and cortivazol. Twenty-six (26/56; 46%) patients suffered from chronic migraine, 14 (14/56; 25%) from trigeminal neuralgia and 16 (16/56; 29%) from cluster headaches. Clinical success at 1, 3, and 6 months was defined by a decrease of at least 50% of pain as assessed using visual analog scale (VAS). RESULTS: Mean overall VAS score before infiltration was 8.7±1.3 (SD) (range: 6 - 10). Mean overall VAS scores after infiltration were 2.3±3 (SD) (range: 0 - 10) (P<0.01) at one month, 3.5±3.3 (SD) (range: 0 - 10) (P<0.01) at three months and 7.6±1.3 (SD) (range: 1-10) (P<0.01) at six months. After infiltration, clinical success was achieved in 44 patients (44/56; 78.5%) at 1 month, 37 patients (37/56; 66%) at 3 months and 13 patients (13/56; 23%) at 6 months. Clinical success according to the clinical presentation were as follows: 88% (23/26) at one month, 73% (19/26) at 3 months, and 23% (6/26) at 6 months in patients with chronic migraine, 81% (13/16), 69% (11/16) and 31% (5/16) in those with cluster headaches and 57% (8/14), 50% (7/14) and 14% (2/14) in those with trigeminal neuralgia. No major complications due to CT-guided GON infiltration were reported in any patient. CONCLUSION: CT-guided infiltration at the intermediate site of the GON appears as an effective treatment of craniofacial pain syndromes especially in patients with chronic migraine and those with cluster headaches.

Interventional radiology for treatment of bone metastases.

Therapeutic advances in oncology have led to longer survival in many forms of cancer, including those complicated by bone metastases. When a bone metastasis is painful or when there is a risk of fracture, interventional radiology procedures can be carried out for pain control and/or stabilisation. All of these techniques can be performed under local anaesthesia. Cementoplasty and vertebroplasty are stabilisation procedures consisting in the percutaneous injection of acrylic cement into a lytic bone lesion. The effect on pain can be explained by the consolidation of weakened, fractured or pre-fractured bone, but also to a lesser extent by the toxic, chemical and thermal effect of the cement. Tumour ablation techniques include alcoholisation or thermal ablation (by heat with radiofrequency and microwave or cold by cryoablation). Percutaneous thermal ablation of bone tumours is most often performed as a palliative measure resulting in a significant and lasting reduction in symptoms. Radiofrequency ablation consists in placing needles through which an electrical current passes. Microwave ablation acts by causing very high frequency vibrations of water molecules. Cryoablation releases argon gas at the tip of the needle, forming an "ice ball" effectively destroying tumour cells. Any of these techniques can be combined to radiation therapy, performed before or after radiation. Finally, tumour embolisation can have a goal of pain control, or preparation of surgery to reduce the risk of peroperative haemorrhage.

An MRI evaluation of changes in piriformis muscle morphology induced by botulinum toxin injections in the treatment of piriformis syndrome.

PURPOSE: Botulinum toxin (BT) injection is a new treatment for piriformis syndrome (PS). The main purpose of our study was to use MRI to evaluate changes in piriformis muscle morphology after treatment with BT injections. PATIENTS AND METHODS: Twenty patients presenting with PS who had undergone an MRI were included retrospectively: 12 patients treated with BT injections and eight untreated patients. The following parameters were assessed and compared to a normal contralateral muscle: maximum thickness, volume, and Goutallier's classification grade of fatty infiltration of the piriformis and internal obturator muscles. Pain was assessed through a visual analogue scale (VAS). RESULTS: The untreated patients had no significant difference in the volume (P=1.0) or thickness of the piriformis muscle (P=0.61). The treated patients showed a significant reduction in the thickness (-4.2mm; P<0.001) and volume (-74.4mm(3); P<0.001) and an increase in the fatty infiltration (P<0.001) of the piriformis muscle treated by BT injection. Muscular atrophy was correlated with the number of BT injections and with the time until an MRI was performed. There was also significant pain relief after BT treatment. CONCLUSION: BT leads to atrophy and fatty degeneration of the piriformis muscle that can be quantified by MRI and these factors explain why BT injections are effective in the treatment of PS.

Magnetic resonance imaging in patellar lateral femoral friction syndrome (PLFFS): prospective case-control study.

OBJECTIVES: To describe morphologic abnormalities and signs of patellar lateral femoral friction syndrome (PLFFS) detected by magnetic resonance imaging (MRI). MATERIALS AND METHODS: Prospective study of 56 knees (21 patients and 30 controls) studied by 3Tesla MRI. Comparative analysis of clinical data, quantitative and qualitative imaging criteria in a population of patients with anterior knee pain associated with an abnormal MRI signal along the lateral alar folds of the infrapatellar fat pad, a characteristic sign of PLFFS, and a control population with no anterior knee pain or abnormal signal from the infrapatellar fat pad. RESULTS: Patients with PLFFS have anterior and/or lateral knee pain. Their knee has anatomical predispositions for instability, primarily with patella alta (P<0.0001), patellar tilt more than 13.5° (P<0.0001), a patellar nose length less than 9 mm (P=0.0037), a patellar nose ratio less than 0.25 (P<0.0001), a TT-TG distance more than 10 mm (P<0.0001), and a trochlear prominence more than 4 mm (P=0.0056). In 35% of patients, patellar chondropathy is visible, and 48% of patients have patellar or trochlear subchondral abnormalities. CONCLUSION: Anterior, lateral, and medial knee pain may be related to PLFFS. Anatomical predispositions contributing to instability are found in these patients. There may be associated chondropathies and osteochondropathies.

[Gamna-Gandy bodies in cirrhosis: a meaningless finding?]. / Corpuscules de Gamna-Gandy dans la cirrhose : un signe sans intérêt ?

PURPOSE: To determine the presence of Gamna-Gandy bodies (GGB) on MRI in patients with liver cirrhosis. PATIENTS AND METHODS: A total of 117 consecutive patients with cirrhosis followed-up by MRI were retrospectively reviewed. Two groups were defined: the first group included patients with GGB on MRI (n=15), the other group included patients without GGB (n=102). Both characteristics of groups were reviewed using standard cirrhosis criteria evaluation: sex, age, etiology of cirrhosis, Child-Pugh score, presence of esophageal varices, splenomegaly, ascitis, recanalization of the periumbilical veins, and presence of hepatic encephalopathy. Fisher's exact test and student t-test were used to compare both groups. RESULTS: GGB were more frequently observed in patients with splenomegaly (P=0.035). Hemochromatosis was the only etiology for cirrhosis statistically correlated to the presence of GGB (P=0.006) in our series. No other statistically significant association was noted between GGB and other characteristics of our cirrhotic patients. CONCLUSION: Easily identified on all MRI pulse sequences, GGB do not correlate with the severity of cirrhosis. However, they are strongly correlated with the presence of splenomegaly and may be the result of segmental splenic hypertension. They are frequent in patients with hemochromatosis.

[Transient elastography of calcaneal tendon: preliminary results and future prospects]. / Élastographie transitoire du tendon calcanéen: résultats préliminaires et perspectives.

PURPOSE: To evaluate transient ShearWave elastography of the normal Achilles' tendon. PATIENTS AND METHODS: The Achilles' tendon of 30 normal subjects were prospectively assessed using a Rubi V1Sq prototype (Supersonic Imagine). Quantitative elastography maps displayed in kilopascals with a scale of 0 to 600kPa were generated from transverse and longitudinal images at 3 different levels of plantar flexion. Subgroups were compared and analyzed based on proven or suspected variation factors (age, gender, level of physical activity). RESULTS: On sagittal images, mean elasticity was 104±46kPa during extension, 464±144kPa in neutral position and 410±196kPa during maximum dorsiflexion. There was significant increase in elasticity when the Achilles' tendon was maximally stretched (p<0.01). The intra-individual correlation between right and left tendons during ankle extension was good (Pearson Coefficient 0.8; p<0.01). Finally, physically active subjects showed significantly greater elasticity than non-active subjects (p<0.05). CONCLUSION: Transient ShearWave elastography of the Achilles' tendon is a simple technique that provides real-time information about tissue elasticity.

Small bowel obstruction due to broad ligament hernia: computed tomography findings.

We report a case of surgically confirmed small bowel obstruction due to hernia through a defect in the broad ligament. Multi-detector computed tomography (CT) demonstrated the presence and the precise location of this very unusual internal pelvic hernia. Those CT findings are presented here.

CT in predicting abdominal cocoon in patients on peritoneal dialysis.

AIM: To evaluate the computed tomography (CT) signs of encapsulating peritoneal sclerosis (EPS) in patients on peritoneal dialysis (PD) as predictive factors for the evolution to abdominal cocoon (AC). MATERIALS AND METHODS: Clinical features and CT signs of 90 patients on PD were retrospectively reviewed. According to the clinical features, they were divided into three groups (asymptomatic, moderate, or severe). Clinical results were correlated with previously reported CT signs of EPS, i.e., peritoneal thickening, peritoneal calcifications, loculated fluids, small bowel faeces sign, small bowel obstruction, clustered bowel loops, pseudo sac, signs of bowel ischaemia or necrosis. AC was defined at CT by the association of clustered bowel loops and a pseudo sac. Statistical analysis was performed using the Fisher's exact test and the t-test. RESULTS: Although demonstrated in symptomatic patients (p=0.041), the occurrence of AC was not correlated with the severity of the symptoms (p=0.16). Among the CT signs, the presence of loculated fluids (p=0.011), a small bowel faeces sign (p=0.002); and small bowel obstruction (p=0.0001) were found to be statistically correlated with the appearance of an AC. Moreover, the association of loculated fluids, small bowel faeces sign, small bowel obstruction was extremely sensitive and specific in the development of AC (sensitivity=67%, specifity=100%, positive predictive value=100%, negative predictive value=96%). CONCLUSION: CT should be carried out in every symptomatic patient on PD. Indeed, the association of loculated fluid, small bowel faeces sign, and small bowel obstruction enables the prediction of the development of AC, which is likely to curtail PD and require surgery.

[Value of multidetector-row CT in the management of sigmoid volvulus]. / Apport du scanner multi-détecteurs dans la prise en charge des volvulus du sigmoïde.

PURPOSE: To determine the value of multidetector-row CT (MDCT) in the management of sigmoid volvulus. MATERIALS AND METHODS: Twenty-three MDCT examinations showing sigmoid volvulus were retrospectively evaluated and analyzed based on the type of volvulus (mesentericoaxial versus organoaxial), degree of rotation (180 degrees or 360 degrees ), maximum diameter of the volvulized sigmoid loop and presence or absence of the northern exposure sign, signs of bowel wall ischemia, and ascitis. A statistical analysis was performed to determine the correlation between patients characteristics, CT findings, type of management, and histological findings when available. RESULTS: In our study, organoaxial volvulus occurred in older patients (p=0.047), had a higher risk of recurrence (p=0.015) and more frequently required urgent surgical management than mesentericoaxial volvulus. A higher degree of rotation was associated with a more distended volvulized sigmoid colon (p=0.033) and more frequently required surgery. CONCLUSION: In addition to detection of volvulus and signs of bowel wall ischemic, MDCT can characterize the type of volvulus and degree of rotation, findings that may assist in determining the severity of the process and direct towards optimal management, endoscopic or surgical.

[CT guided dual site infiltration in pudendal neuralgia]. / Infiltration scano-guidée en deux sites dans la névralgie pudendale.

PURPOSE: To assess the value of CT guided dual site infiltration in patients with pudendal neuralgia and determine prognostic factors of efficacy. Materials and methods. Retrospective review of 49 patients with suspected pudendal neuralgia who underwent one or multiple injections of local anesthetics and steroids. Patients were classified based on clinical and electrophysiological findings. RESULTS: 70% of patients with typical symptoms of pudendal neuralgia responded favorably to the infiltrations compared to 27% of patients with atypical symptoms (p<0.05). The mean number of infiltrations was 2.2. 84% of responding patients experienced symptomatic relief after the first infiltration. The mean duration of symptomatic relief was 3 months. CONCLUSION: Infiltration is an effective treatment for patients with typical pudendal neuralgia, and should be included in the management of these patients.

[Color doppler ultrasound evaluation of thoracodorsal pedicle quality after axillary lymph node dissection. A way to increase latissimus dorsi flap reliability: about 74 patients]. / Intérêt de l'évaluation échographique systématique du pédicule thoracodorsal après curage axillaire avant la levée du lambeau de latissimus dorsi. A propos de 74 cas.

The latissimus dorsi musculocutaneous flap has been widely used for breast reconstruction. It is a reliable method with low complications. Thoracodorsal pedicle is constant but might have been dissected and injured previously, for example, in case of axillary lymph node dissection. The purpose of our study is to assess the benefit of systematic preoperative echo-doppler imaging of the thoracodorsal pedicle. Seventy-four consecutive patients with unilateral axillary lymph node dissection undergoing latissimus dorsi flap underwent doppler and color duplex sonography of the thoracodorsal pedicle preoperatively. Non operated and contralateral pedicle served as reference. A total of 12.2% patients had differences between operated and non operated pedicle, 9.5% had smaller operated pedicle and 2.7% patients had stenosis with altered blood flow. Stenosis of the pedicle contraindicates, in our unit, latissimus dorsi flap because of altered blood flow. There were no flap necrosis in our series. The percentage of stenosed pedicle in our series is similar to percentage of flap necrosis in the literature. We think that systematic doppler and color duplex sonography of the thoracodorsal pedicle increase the reliability of latissimus dorsi flap by excluding pedicle with altered blood flow.

[Evaluation of the efficacy of CT-guided epidural and transforaminal steroid injections in patients with diskogenic radiculopathy]. / Evaluation de l'efficacité des infiltrations canalaires et foraminales de corticoïdes guidées par TDM dans le traitement des radiculalgies par conflit disco radiculaire.

PURPOSE: To evaluate the efficacy of CT-guided epidural and transforaminal steroid injections in patients with diskogenic radiculopathy. MATERIALS AND METHODS: Seventy patients underwent CT guided injections after failure of medical management. Only patients with minimal degenerative changes and diskogenic monoradicular symptoms were treated. Only two patients with fibrosis were included. RESULTS: 78.6% of patients experienced persistent symptomatic improvement. No difference was noted between lumbar segments and there was no more failures with epidural injections compared to transforaminal injections. Cervical disk herniations responded better than lumbar disk herniations. Good results were obtained in younger patients (M=46.25 years), symptomatic for 3-4 months or less, and with clear radicular symptoms and clinical neurological deficits (hypoesthesia, absent DTR) without motor deficit. No patient with severe spinal stenosis (S-) was included and the disk herniations were small (b1, b2, c1, c2 or d1, d2). Only a single injection was needed. Cortivazol provided superior results compared to dexamethasone. CONCLUSION: CT-guided injections should be included in the therapeutic armamentarium after standard medical management, with cure as the goal.

F-18 FDG PET identification of right atrium metastasis from a vesical carcinoma.

Fluorodeoxyglucose (FDG) positron emission tomography (PET) has been shown to be useful in the diagnosis and staging of various malignancies. The main advantage of PET is its high sensitivity in identifying malignancies at an early stage. The authors present a patient in whom transthoracic echography and MRI revealed a right atrial mass. The diagnosis was difficult between tumor and thrombus, but PET imaging correctly suggested a malignant tumor.

[Interventional MR imaging in musculoskeletal]. / La Résonance Magnétique Interventionnelle en pathologie ostéoarticulaire.

Magnetic resonance (MR) imaging is well established for the diagnosis of musculoskeletal diseases. The excellent tissue contrast and the multiplanar imaging capability have both contributed to the improvement of this technique. The development of fast acquisition techniques, sufficient patient access obtained with open magnet configurations and advances in the technology of MR compatible instruments allow a new approach to interventional radiology. These recently commercially available open-bored high-field magnets allow standard interventions such as biopsies or intra-articular infiltrations. Moreover, new interventions e.g. preoperative marking of soft tissue or bone marrow tumors are now possible with the better tissue contrast of MR imaging.

[Combined bipolar radiofrequency and cementoplasty of bone metastases]. / Radiofréquence bipolaire et cimentoplastie dans le traitement des métastases osseuses.

Bone metastases are the most common cause of pain in cancer patients. Pain management in cancer patients, often revealing the disease and always present at advanced stages, is an important and difficult task. Pain is not always properly controlled by high doses of specific medication, radiation therapy or chemotherapy. When these therapies do not provide adequate pain relief, percutaneous neurolysis, infiltrations, alcoholizations and cementoplasty may be considered. More recently RF ablation has been proposed. On weight-bearing bones, RF can be combined with acrylic cement injection. The authors present here this very effective new technique which is complementary to classical pain management techniques.

[Three-dimensional 3D modeling: First applications in radioanatomy and interventional radiology under CT guidance]. / Modélisation tridimensionnelle des vertèbres types: Premières applications en radioanatomie et radiologie interventionnelle sous guidage tomodensitométrique.

PURPOSE: To model vertebrae in 3D to improve radioanatomic knowledge of the spine with the vascular and nerve environment and simulate CT-guided interventions. METHOD AND MATERIALS: Vertebra acquisitions were made with multidetector CT. We developed segmentation software and specific viewer software using the Delphi programming environment. RESULTS: This segmentation software makes it possible to model 3D high-resolution segments of vertebrae and their environment from multidetector CT acquisitions. Then the specific viewer software provides multiplanar reconstructions of the CT volume and the possibility to select different 3D objects of interest. DISCUSSION: This software package improves radiologists' radioanatomic knowledge through a new 3D anatomy presentation. Furthermore, the possibility of inserting virtual 3D objects in the volume can simulate CT-guided intervention. CONCLUSION: The first volumetric radioanatomic software has been born. Furthermore, it simulates CT-guided intervention and consequently has the potential to facilitate learning interventions using CT guidance.

[Ganglion cyst rupture in the retro-femoral fat: a report of two cases]. / Rupture de kyste mucoïde dans la graisse rétro-fémorale: à propos de deux cas.

Ganglion cysts are ubiquitous cystic lesions without synovial wall and inconstant communication with the articular cavity. The later must nonetheless always be carefully looked for. We report two cases of ganglion cyst rupture in the retrofemoral fat simulating phlebitis with thigh cellulitis. To the best of our knowledge, this has not been previously reported in the literature. Familiarity with this entity ensures adequate medical diagnosis and management, avoiding unnecessary imaging and laboratory work-up and inappropriate use of anticoagulant and antibiotic.

Axe fragment pulmonary embolism. Interest of enhanced multislice helical CT with cardiac synchronised acquisitions.

A case of pulmonary embolism by an axe fragment investigated with enhanced mdCT with cardiac synchronised acquisitions is described. The authors stress the advantages of the techniques versus angiography for the exploration of foreign body pulmonary artery embolism.