CT and MRI diagnosis of silent sinus syndrome.

PURPOSE: The purpose of this study was to determine computed tomography (CT) and magnetic resonance (MR) findings of silent sinus syndrome (SSS) - a rare clinical entity with the constellation of progressive enophthalmos and hypoglobus, facial asymmetry and possible diplopia - due to otherwise asymptomatic maxillary sinus disease. MATERIALS AND METHODS: We reviewed the pre- and postoperative CT and MR images of six patients with a definitive diagnosis of SSS and compared the radiological and clinical findings with those reported in the literature. RESULTS: The CT and MR studies demonstrated in all cases the most characteristic imaging features of SSS reported in the literature. CONCLUSIONS: Both CT and MR imaging enable a diagnosis of SSS to be made, but CT provides a better depiction of all features of SSS necessary for diagnosis and differentiation from other sinus conditions, even in patients without a clinical suspicion of SSS.

Chest radiography in intensive care: an irreplaceable survey?

PURPOSE: This study evaluated the impact and value of bedside chest X-ray in intensive care units. MATERIALS AND METHODS: This observational study considered the bedside chest X-rays performed on 258 consecutive patients (160 men, 98 women; mean age, 58 years) admitted to intensive care units. Stratification of patients according to the reason for hospitalisation and analysis of the reasons for chest X-ray examinations were performed to assess the diagnostic efficacy (DE). RESULTS: DE for chest X-rays was 84.5%, with 15.5% of tests remaining unchanged over time. Patient stratification by disease indicated that the DE was 85.27% in transplant, 90.79% in postoperative care after general surgery, 83.89% in respiratory failure, 82.42% in polytrauma, 90.54% in postoperative care after neurosurgery, 86.6% in postoperative care after vascular surgery, 83.3% in neurological conditions and 93.4% in other diseases. CONCLUSIONS: Chest X-rays performed at the bedside are the most widely used imaging method in the follow-up of critically ill patients. DE is approximately 84.5%. Radiologists should maintain familiarity with the interpretation of this examination.

Contrast-enhanced MR cholangiography (MRCP) with GD-EOB-DTPA in evaluating biliary complications after surgery.

PURPOSE: We assessed the usefulness of contrast-enhanced magnetic resonance cholangiography (CE-MRC) with liver-specific contrast agent in evaluating the biliary tree after hepatic surgery. MATERIALS AND METHODS: A total of 142 patients with suspected biliary complications after liver surgery underwent hepatobiliary MR before and after administration of gadolinium ethoxy benzylic diethylenetriamine pentaacetic acid (Gd-EOB-DTPA). Unenhanced MR cholangiopancreatography (MRCP) and postcontrast MRC were obtained in all patients. Blinded image evaluation and semiquantitative analysis comparing MRCP and CE-MRC were performed by two experienced radiologists. RESULTS: In all cases, optimal postcontrast visualisation of the biliary tract was obtained. In 22 patients, a postsurgical biliary complication was confirmed. MRCP detected 64% of lesions, but in 36% of cases, an alteration was only suspected but not clearly defined. CE-MRC allowed definite diagnosis in 100% of cases. CONCLUSIONS: Hepatobiliary-specific contrast agents allow for accurate and extensive study of biliary tract alterations, especially in assessing postsurgical complications.

[The subclinical involvement of the lung in rheumatoid arthritis: evaluation by high-resolution computed tomography] / L'interessamento polmonare subclinico nell'artrite reumatoide: studio mediante tomografia ad alta risoluzione.

Pulmonary involvement is one of the most frequent extra-articular manifestations of rheumatoid arthritis (RA) and represents a serious complication, being the second cause of death after infection. High-resolution computed tomography (HRCT), owing to its increased sensitivity and diagnostic accuracy respect to the conventional chest radiograph (CXR), allows to detect pulmonary abnormalities in RA patients more frequently than CXR. The aim of this study was to assess pulmonary involvement by HRCT in lifelong non-smoking RA patients without symptoms and clinical signs of pulmonary disease. Seventy-two patients (54 women and 18 men) with a mean age of 56.8+/-10.4 years (range, 40-77 years) and mean duration of disease of 6.9+/-4.7 years (range, 2-12 years) entered the study. 52/72 (72%) were positive for rheumatoid factor (> 20 UI/ml). Standard CXR and HRCT were carried out in each patient. CXR showed a mild interstitial fibrosis in 7 patients (9.7%), whereas HRCT demonstrated pulmonary abnormalities in an higher number of them (22/72 = 30.5%). The most frequent abnormal findings on HRCT were irregular pleural margins (13.8%) and septal/subpleural lines (18%), both compatible with pulmonary fibrosis. Ground-glass opacities were found in 8.3% of the patients. Pulmonary nodules (diameter, range 0,5-2 cm) predominantly located in the subpleural portions of the lung, were demonstrated in the same percentage (8.3%) of patients. Small airway involvement, represented by bronchiectasis/bronchioloectasis, was shown in 15.2% of patients. Subpleural cysts were present in two cases (2.8%). No patient had evidence of honeycombing on HRCT. In conclusion, HRCT is an accurate, non-invasive and safe method of diagnosing lung abnormalities in RA patients without signs and clinical symptoms of pulmonary disease.

Clinical applications of 2D and 3D CT imaging of the airways--a review.

Hardware and software evolution has broadened the possibilities of 2D and 3D reformatting of spiral CT and MR data set. In the study of the thorax, intrinsic benefits of volumetric CT scanning and better quality of reconstructed images offer us the possibility to apply additional rendering techniques to everyday clinical practice. Considering the large number and redundancy of possible post-processing imaging techniques that we can apply to raw CT sections data, it is necessary to precisely set a well-defined number of clinical applications of each of them, by careful evaluation of their benefits and possible pitfalls in each clinical setting. In diagnostic evaluation of pathological processes affecting the airways, a huge number of thin sections is necessary for detailed appraisal and has to be evaluated, and information must then be transferred to referring clinicians. By additional rendering it is possible to make image evaluation and data transfer easier, faster, and more effective. In the study of central airways, additional rendering can be of interest for precise evaluation of the length, morphology, and degree of stenoses. It may help in depicting exactly the locoregional extent of central tumours by better display of relations with bronchovascular interfaces and can increase CT/bronchoscopy sinergy. It may allow closer radiotherapy planning and better depiction of air collections, and, finally, it could ease panoramic evaluation of the results of dynamic or functional studies, that are made possible by increased speed of spiral scanning. When applied to the evaluation of peripheral airways, as a completion to conventional HRCT scans, High-Resolution Volumetric CT, by projection slabs applied to target areas of interest, can better depict the profusion and extension of affected bronchial segments in bronchiectasis, influence the choice of different approaches for tissue sampling by better evaluation of the relations of lung nodules with the airways, or help to detect otherwise overlooked slight pathological findings. In the exploration of the air-spaces of the head and neck, targeted multiplanar study can now be performed without additional scanning by retro-reconstructed sections from original transverse CT slices. Additional rendering can help in surgical planning, by simulation of surgical approaches, and allows better integration with functional paranasal sinuses endoscopic surgery, by endoscopic perspective rendering. Whichever application we perform, the clinical value of 2D and 3D rendering techniques lies in the possibility of overcoming perceptual difficulties and 'slice pollution', by easing more efficient data transfer without loss of information. 3D imaging should not be considered, in the large majority of cases, as a diagnostic tool: looking at reformatted images may increase diagnostic accuracy in only very few cases, but an increase in diagnostic confidence could be not negligible. The purpose of the radiologist skilled in post-processing techniques should be that of modifying patient management, by more confident diagnostic evaluation, in a small number of patients, and, in a larger number of cases, by simplifying communication with referring physicians and surgeons. We will display in detail possible clinical applications of the different 2D and 3D imaging techniques, in the study of the tracheobronchial tree, larynx, nasal cavities and paranasal sinuses by Helical CT, review relating bibliography, and briefly discuss pitfalls and perspectives of CT rendering techniques for each field.

[Subclinical interstitial lung involvement in rheumatic diseases. Correlation of high resolution computerized tomography and functional and cytologic findings]. / L'interessamento polmonare interstiziale subclinico nelle malattie reumatiche. Correlazione fra Tomografia computerizzata con alta risoluzione e i reperti funzionali e citologici.

INTRODUCTION: Rheumatic diseases are frequently associated with interstitial lung disease. Since interstitial fibrosis is an irreversible process, understanding the mechanisms leading to fibrosis is necessary for the development of treatment strategies to prevent irreversible pulmonary damage. High-resolution Computed Tomography (HRCT) is superior to chest radiography in assessing the presence and extent of parenchymal abnormalities in diffuse infiltrative lung diseases and provides a sensitive and noninvasive method of quantifying global disease extent. PURPOSE: The aims of this study were to quantify the severity and extent of subclinical interstitial lung disease as depicted on HRCT and to study the relationship between the patterns of lung disease quantified by HRCT and the functional parameters and bronchoalveolar lavage findings in patients with rheumatic diseases. PATIENTS: Eighty nonsmoking patients (24 patients with systemic sclerosis, 24 with primary Sjögren's syndrome, 20 with rheumatoid arthritis and 7 with dermatopolymyositis) were examined. No patient had any signs or symptoms of pulmonary disease. RESULTS: Thirty-three of 80 patients (41.2%) had abnormal HRCT findings, namely isolated septal/subpleural lines, irregular pleural margins and ground-glass appearance. Chest X-ray showed parenchymal abnormalities in only 15 patients (18.7%) who had evidence of fibrosis on HRCT. Abnormal differential cell counts (alveolitis) at bronchoalveolar lavage were found in 46 of 80 patients (57.5%). Three types of alveolitis were observed: pure lymphocyte alveolitis, pure neutrophil alveolitis, and neutrophil alveolitis associated with lymphocytosis (mixed alveolitis). The patients with neutrophil alveolitis had more extensive disease on HRCT than those with lymphocyte alveolitis or with normal cellular patterns at bronchoalveolar lavage. The extent of a reticular pattern on HRCT correlated with the neutrophil rate (p = 0.001) and total count (p = 0.003) on bronchoalveolar lavage. Eosinophil and lymphocyte rate and total count correlated (p < 0.05) with the extent of the ground-glass pattern on HRCT. Lung volumes were not significantly different among patients with ground-glass pattern and those with reticular patterns on HRCT, while the diffusing capacity for carbon monoxide was significantly lower (p < 0.05) in the latter. CONCLUSIONS: HRCT is a sensitive tool in detecting interstitial lung disease in patients with rheumatic diseases with no signs and symptoms of pulmonary involvement. The relationship between the different HRCT patterns and bronchoalveolar lavage cell profiles can identify patients at higher risk of developing irreversible lung fibrosis. A long-term, prospective follow-up study is needed to determine whether these patients will develop over pulmonary disease.

[Virtual bronchoscopy: the correlation between endoscopic simulation and bronchoscopic findings]. / Broncoscopia virtuale: correlazione tra simulazione endoscopica e reperti broncoscopici.

PURPOSE: We carried out a preliminary clinical validation of 3D spiral CT virtual endoscopic reconstructions of the tracheobronchial tree, by comparing virtual bronchoscopic images with actual endoscopic findings. MATERIALS AND METHODS: Twenty-two patients with tracheobronchial disease suspected at preliminary clinical, cytopathological and plain chest film findings were submitted to spiral CT of the chest and bronchoscopy. CT was repeated after endobronchial therapy in 2 cases. Virtual endoscopic shaded-surface-display views of the tracheobronchial tree were reconstructed from reformatted CT data with an Advantage Navigator software. Virtual bronchoscopic images were preliminarily evaluated with a semi-quantitative quality score (excellent/good/fair/poor). The depiction of consecutive airway branches was then considered. Virtual bronchoscopies were finally submitted to double-blind comparison with actual endoscopies. RESULTS: Virtual image quality was considered excellent in 8 cases, good in 14 and fair in 2. Virtual exploration was stopped at the lobar bronchi in one case only; the origin of segmental bronchi was depicted in 23 cases and that of some subsegmental branches in 2 cases. Agreement between actual and virtual bronchoscopic findings was good in all cases but 3 where it was nevertheless considered satisfactory. The yield of clinically useful information differed in 8/24 cases: virtual reconstructions provided more information than bronchoscopy in 5 cases and vice versa in 3. Virtual reconstructions are limited in that the procedure is long and difficult and needing a strictly standardized threshold value not to alter virtual findings. Moreover, the reconstructed surface lacks transparency, there is the partial volume effect and the branches < or = 4 pixels phi and/or meandering ones are difficult to explore. CONCLUSIONS: Our preliminary data are encouraging. Segmental bronchi were depicted in nearly all cases, except for the branches involved by disease. Obstructing lesions could be bypassed in some cases, making an indication for endoscopic laser therapy. Future didactic perspectives and applications to minimally invasive or virtual reality-assisted therapy seem promising, even though actual clinical applications require further studies.

[Angiography with spiral computed tomography. The basic principles and clinical potentials]. / Angiografia con tomografia computerizzata spirale. Principi di base e possibilità cliniche.

Technical characteristics, acquisition modality and data representations as well as examination protocols and main clinical applications of spiral CT angiography (CTA) are described. The different methods of 2D (MPR, CPR) and 3D (SSD, MIP) data display and their advantages and limitations were investigated. We describe the examination technique representing an important tool to achieve good image quality and to make the correct diagnosis. The clinical effectiveness and the main applications in the body were studied. CTA already has a clinical role for arterial system study, while it is less indicated in the venous system because good and continuous contrast agent opacification is difficult to obtain. In our preliminary experience, CTA can be considered an effective alternative to DSA in the assessment of vascular conditions because it is easier to perform, more rapid and less invasive.

[Three-dimensional computerized modelling of anatomical structures by computerized tomography imaging]. / Modellazione solida robotizzata di strutture anatomiche da immagini con tomografia computerizzata.

The authors built an automatic CT-driven device by which 3D models of biologic structures can be obtained. Original bidimensional densitometric data are recorded on tape and transferred to a mechanical computer-driven arm capable of cutting polystyrene slices reproducing the original biologic structures by means of an original software. The aim of our research was to assess the feasibility of such a device from a practical point of view and to analyze and solve related problems, in order to use the experience thus gained to develop more complex systems. We deliberately set up a device both technologically advanced and simple to be used even by non-specifically trained operators. The system capabilities open new perspectives in many application fields, such as surgery (stereotactic procedures, the making of personalized prostheses, plastic surgery, procedures planning and simulation), treatment (stereotactic radiotherapy), diagnostics (stereotactic biopsy) and educational use.

[Treatment of Plummer's adenoma: correlation between ultrasonography-guided percutaneous injection of ethanol and autoimmunity]. / Trattamento dell'adenoma di Plummer: correlazione tra iniezione percutanea ecoguidata di etanolo e autoimmunità.

The authors investigated the value of percutaneous ethanol injection in the treatment of Plummer's adenoma. Ten patients were studied: they exhibited a single, hot and toxic nodule in the thyroid. Thyroid autoimmunization (TSAb; TMAb; TGAb) and function (T3; T4; TSH; FT3; FT4) were studied in all patients, before treatment and at 1 month and 3 months. Scintigraphy with 99Tc was performed at the same time intervals. In the euthyroid stage, alcoholization was preceded by US and cytology. Three-four ml of ethanol 95 degrees were injected once or twice a week, from a minimum of 3 to a maximum of 8 injections. Treatment was successful in 2 cases; partial success was obtained in 4 cases, and in 4 cases treatment failed. In all successful cases antibodies were negative and the nodules had hypoechoic echostructure, with a peripheral hypoechoic halo and no areas of internal colliquation. Thus, US-guided percutaneous alcoholization seems to be capable of correct indications in hypoechoic nodules not exhibiting areas of colliquative necrosis and with negative antibodies. However, the problem of the dose of alcohol to inject to treat the nodule thoroughly is still to be debated.