PROPELLER diffusion weighted imaging for diagnosis of cholesteatoma in comparison with surgical and histopathological results: emphasis on false positivity and false negativity.

PURPOSE: To investigate the role of non-echo planar diffusion weighted imaging (DWI) using "periodically rotated overlapping parallel lines with enhanced reconstruction" (PROPELLER) sequence for the diagnosis of cholesteatoma compared to surgical and histopathological results in an attempt to determine the factors causing false negative and false positive diagnoses. METHODS: Patients who had PROPELLER DWI before ear surgery were retrospectively reviewed. The presence of a lesion with diffusion restriction on PROPELLER DWI was accepted as positive for cholesteatoma, and the results were compared to the intraoperative and histopathological findings. RESULTS: A total of 112 ears in 109 patients were reviewed. On PROPELLER DWI, a lesion with diffusion restriction was found in 101 (90.2%) ears, while in 11 (9.8%) of the patients, no diffusion restriction was found. Surgery and histopathological analysis revealed a cholesteatoma in 100 (89.3%) ears, while in 12 (10.7%) ears, no cholesteatoma was found surgically. There were 96 (85.7%) true positives, 7 (6.2%) true negatives, 5 (4.5%) false positives and 4 (3.6%) false negatives. The accuracy, sensitivity, specificity, positive predictive and negative predictive values of non-echo planar DWI were calculated to be 91.96%, 96%, 58.33%, 95.05%, and 63.64%, respectively. CONCLUSION: Non-echo planar DWI using PROPELLER sequence has high accuracy, sensitivity and positive predictive value and can be used for the detection of cholesteatoma. The external auditory canal, postoperative ears and small lesions should be evaluated with caution to avoid false results.

Does Gadoterate Meglumine Cause Gadolinium Retention in the Brain of Children? A Case-Control Study.

BACKGROUND: Accumulation of macrocyclic gadolinium agents in children's brains remain to be determined. PURPOSE: To demonstrate whether there is an intracranial macrocyclic gadolinium deposition after multiple contrast-enhanced MRI with gadoterate meglumine in a pediatric population. STUDY TYPE: Retrospective case-control. POPULATION: In all, 45 children (age range: 5-17 years; mean, 13.7 ± 3.4 years) for the study group and 45 healthy children (age range: 5-17 years; mean, 13.7 ± 3.4 years) for the control group. FIELD STRENGTH/SEQUENCE: T1 - and T2 -weighted axial images on a 1.5T scanner. ASSESSMENT: Children with at least three enhanced brain MRIs and an age- and sex-matched control group with an unenhanced brain MRIs were compared in terms of T1 signal intensity (SI). All patients in the study group received gadoterate meglumine intravenously (0.1 mmol/kg). SI measurements were made by drawing six regions of interest (ROIs): dentate nuclei (DN), pons, globus pallidi (GP), frontal white matter (FWM), thalamus (T), clivus, and cerebrospinal fluid (CSF) for both groups on unenhanced T1 -weighted images. STATISTICAL TESTS: Student's t-test was used for comparison of SI. The Pearson correlation was calculated for the correlation between the SI and the number of gadolinium administrations. RESULTS: A significant difference was detected between two groups for DN/CSF, pons/CSF, GP/CSF, thalamus/CSF, and FWM/CSF (P < 0.001, P < 0.001, P = 0.002, P = 0.002, P = 0.024, respectively). There was no significant difference between the two groups for clivus/CSF (P = 0.15). A good correlation between the number of gadoterate meglumine administrations and the SI for DN/CSF, pons/CSF, GP/CSF, and T/CSF (r = 0.80, r = 0.73, r = 0.91, and r = 0.90, respectively) was found. DATA CONCLUSION: A significant T1 SI increase reflecting gadolinium retention in the brain was detected for children with at least three gadoterate meglumine administrations in this series. The number of administrations correlated well with the increased SI. LEVEL OF EVIDENCE: 3 Technical Efficacy Stage: 5 J. Magn. Reson. Imaging 2020;51:1471-1477.

Role of Interface Sign and Diffusion-Weighted Magnetic Resonance Imaging in Differential Diagnosis of Exophytic Renal Masses.

PURPOSE: We aimed to investigate the role of interfaces of exophytic solid and cystic renal masses on magnetic resonance imaging (MRI) and the added value of diffusion-weighted imaging in differentiating benign from malignant lesions. METHODS: The Institutional Review Board approved this retrospective study, and informed consent was waived. A total of 265 patients (109 [41%] women and 156 [59%] men) with a mean age of 57 ± 12 (standard deviation) years were enrolled in this study. Preoperative MRI (n = 238) examinations of patients with solid or cystic renal masses and MRI (n = 27) examinations of patients with Bosniak IIF cysts without progression were reviewed. Solid/cystic pattern, interface types and apparent diffusion coefficient (ADC) values were recorded by 2 radiologists. The diagnostic performance of combining normalized ADC values with interface sign were evaluated. RESULTS: Among 265 renal lesions (109 cystic and 156 solid), all malignant lesions (n = 192) had a round interface. No malignant lesions showed an angular interface. For prediction of benignity in cystic lesions, sensitivity (82.86% vs 56.16%), negative predictive value (92.50% vs 85.71%), and accuracy (94.50% vs 87.92%) ratios of angular interface were higher compared to all (solid plus cystic) lesions. The best normalized ADC cutoff values for predicting malignancy in lesions with round interface were as follows: for all (solid plus cystic), ≤ 0.75 (AUROC = 0.804); solid, ≤ 0.6 (AUROC = 0.819); and cystic, ≤ 0.8 (AUROC = 0.936). CONCLUSIONS: Angular interface can be a predictor of benignity for especially cystic renal masses. The evaluation of interface type with normalized ADC value can be an important clue in differential diagnosis especially in patients avoiding contrast.

Misleading findings of liver-specific MR contrast agent for radiological diagnosis of cysto-biliary communication in hydatid cysts.

OBJECTIVE: To investigate the effectiveness of gadoxetic acid-enhanced magnetic resonance cholangiopancreatography (CE-MRCP) and T2-weighted half-Fourier acquisition single-shot turbo spin-echo (T2W HASTE) sequences for diagnosis of cysto-biliary communication in hydatid cysts compared to surgical results. METHODS: Preoperative abdominal magnetic resonance imaging examinations of patients who underwent surgery for hepatic hydatid cysts were reviewed by two radiologists retrospectively. A total of 45 patients with hydatid cysts were included. Of 45, 27 also had CE-MRCPs. T2W HASTE sequences and CE-MRCPs were investigated separately for cysto-biliary communication. The relationship between radiological and surgical results was analyzed. The interobserver agreement was evaluated. RESULTS: Of 45 hydatid cysts, there were surgically proven 21 cysts without biliary communications and 24 cysts with biliary communications. All cysts with biliary communications were shown on T2W HASTE sequences. There was no leakage of gadoxetic acid into these cysts (n = 24). Sensitivity, specificity, negative predictive value, positive predictive value (PPV), and accuracy of diagnosis of cyst with biliary communication on T2W HASTE sequences was 100%, 63.64%, 100%, 66.67%, and 78.95%, respectively. Specificity (77.78%), PPV (87.50%), and accuracy (91.30%) were increased in ≥ 10 cm cysts. There was almost perfect interobserver agreement (K = 0.81-1.00). CONCLUSION: Leakage of gadoxetic acid inside the cyst indicates biliary communication. However, the lack of leakage does not rule out cysto-biliary communication. When biliary communication is clearly shown on T2W HASTE sequences, it should be reported as cysto-biliary communication even if there is no leakage of gadoxetic acid into the cyst on CE-MRCP.

Percutaneous cholecystostomy: A curative treatment modality forelderly and high ASA score acute cholecystitis patients.

BACKGROUND: Acute cholecystitis (AC) is a common emergency seen by general surgeons. Optimal treatment is laparoscopic cholecystectomy (LC); however, in cases where surgery cannot be performed due to high risk of morbidity and mortality, such as in elderly patients with comorbid diseases, other treatment modalities may be used. Percutaneous cholecystostomy (PC) is one alternative method to treat AC. PC can be used to provide drainage of the gall bladder and control infection. Subsequently, interval cholecystectomy can be performed when there are better conditions. Presently described is experience and results with PC in high risk, elderly patients with AC. METHODS: Medical records of all consecutive patients who underwent PC between January 2011 and January 2014 were identified. Tokyo Guidelines were used for definitive diagnosis and severity assessment of AC. Senior surgeon elected to perform PC based on higher risk-benefit ratio due to comorbidity, age, or duration of symptoms. All PC procedures were performed by the same interventional radiologist under local anesthesia with ultrasonographic guidance. RESULTS: Total of 40 PC procedures were performed during the study period. Of those, 22 (55%) were male and 18 were (45%) were female, with median age of 70.5 years (range: 52-87 years). All of the patients had American Society of Anesthesiologists classification of either 3 or 4. Success rate of PC was 100% with complication rate of 2.5% (n=1). One patient was operated on shortly after PC procedure due to bile peritonitis complication. PC drains were kept in place for 6 weeks. Total of 16 patients (40%) had surgery following removal of PC drain. In 3 (18.8%) cases, conversion from LC was required. Remaining 23 (57.5%) patients did not have subsequent operation after drain removal. No disease recurrence was observed in follow-up. CONCLUSION: When elderly patients present in emergency setting with AC and LC cannot be performed due to comorbid disease or poor general condition, PC can be performed safely. After removal of PC drain, LC may be performed with acceptable conversion rate of 18.8%.

The association of patellofemoral joint morphology with chondromalacia patella: a quantitative MRI analysis.

The relationship of patellofemoral congruency with chondromalacia patellae (CP) was retrospectively evaluated. Lateral patellar tilt angle (LPTA), sulcus angle (SA), trochlear depth (TD), and patella angle (PA) were measured at 301 knee magnetic resonance images and compared between groups with and without CP. In the CP group, LPTA and TD were significantly low (P<.01), SA was high (P<.01), while PA showed no difference (P>.05). The parameters were also compared between groups with mild and severe CP, and no significant difference was found (P>.05). Our results demonstrate that patellar tilt and trochlear dysplasia are related to the presence but not the degree of CP.

The value of ultrasound elastography in differentiation of malignancy in thyroid nodules.

We aimed to determine the value of ultrasound elastography (US-E) using carotid artery pulsation in differentiation of malignant and benign thyroid nodules. One hundred ten nodules were evaluated by US-E, and stiffness scores were compared to biopsy results. When cutoff for malignancy was determined as score 4, sensitivity, specificity, positive predictive value, and negative predictive value were 100%, 95%, 40%, and 100%, respectively. We suggest fine needle aspiration biopsy to be performed in all score 4 nodules, while biopsy may be unnecessary in score 1 nodules. Benign biopsy result in a score 4 nodule should suggest radiological-pathological disagreement, and repeat biopsy should be recommended.

Anomalous left pulmonary artery without sling formation.

A case of aberrant left pulmonary artery originating from the right pulmonary artery resembling pulmonary artery sling malformation, but without true sling formation, is presented. Anomalous left pulmonary artery was accompanied with long-segment proximal tracheal stenosis and other congenital malformations typically associated with PAS complex. The anomalous pulmonary artery passed anterior to the trachea; therefore, no true sling was formed. Because no airway compression by the aberrant left pulmonary artery was detected, the proximal tracheal stenosis was thought to be primary.

Pulmonary multislice computed tomography findings in acute aortic dissection.

OBJECTIVE: To document the type and incidence of pulmonary multislice computed tomography (CT) findings at presentation in patients with acute aortic dissection. MATERIALS AND METHODS: Multidetector CT scans of 36 patients with a diagnosis of acute aortic dissection or intramural hematoma were retrospectively reviewed. RESULTS: Pleural effusion, dependent stasis, mosaic attenuation, interlobular septal thickening, thickening of the peribronchovascular interstitium, vascular enlargement, compression atelectasis were common findings. Additionally air trapping, emphysema, consolidation, nodules, bronchiectasis or scarring were also noted. CONCLUSIONS: Various pulmonary imaging findings may accompany acute aortic dissection. These findings and their clinical significance should be further investigated.

Stent-graft placement for urgent treatment or prevention of bleeding.

BACKGROUND: Stent-graft treatment of the patients with ongoing bleeding may be beneficial in specific situations, especially when preservation of blood flow to the distant organs is important. PURPOSE: To present the results of stent-graft placement for urgent treatment or prevention of the bleeding. MATERIAL AND METHODS: Stent-graft placement was performed urgently for the treatment of active bleeding and/or pseudoaneurysm/aneurysm in 17 patients. Diagnoses were based on clinical findings and/or imaging studies. The etiology was previous major surgery and/or percutaneous intervention in 13, malignancy in one, pancreatitis and pseudocyst in one, multitrauma due to traffic accident in one and unknown cause in one patient. RESULTS: A total of 23 stent-grafts were placed. Angiograms obtained after placement revealed patent stent-graft with no further active extravasation or filling of pseudoaneurysm in 14 patients. Due to persistent bleeding, embolization was performed in two patients. In three patients, the stent-grafts were found to be thrombosed either immediately after placement (n = 1) or at follow-up (n = 2). Stent-grafts were patent in six of nine patients that could be followed (between 3 months and 6 years). CONCLUSION: Urgent stent-graft placement may be an alternative to endovascular embolization or surgery. It may be preferred when embolization is technically difficult or impossible and/or when preservation of blood supply to distal organs is essential such as in liver transplant grafts or extremity salvage.

Polysplenia/heterotaxy syndrome associated with aortic coarctation and multiple venous anomalies: multidetector computed tomography findings.

Polysplenia/heterotaxy syndrome is a rare condition involving multiple gastrointestinal, vascular, and cardiac malformations. We present a previously unreported association of aortic coarctation, double superior vena cava, a left-hand side inferior vena cava with hemiazygos vein continuation and a right retroaortic renal vein with polysplenia/heterotaxy syndrome. Multidetector computed tomography with multiplanar reconstruction images were useful in the detection of these abnormalities.

The Günther-Tulip retrievable filter: a method for assessing tilting of the filter.

PURPOSE: Tilting of the Günther-Tulip filter may be responsible for failure or difficulty to retrieve. Assessment of the filter tilt can be difficult when only AP imaging is available. This study is performed in vitro to develop a simple method to assess the Günther-Tulip filter for tilting. MATERIALS AND METHODS: A model consisting of a plastic tube was used to simulate vena cava. A Günther-Tulip filter was placed centred or tilted within the tube at various positions and radiograms were taken in AP, lateral, and craniocaudally angled projections. The images were analysed to determine the actual degree of tilt, the distance between the limb hooks on AP radiograms and the craniocaudal angulation degree needed to align the limb hooks linearly. RESULTS: When the filter was centred or tilted laterally, all limb hooks of the filter were aligned linearly on AP radiograms. When the filter was tilted in AP or oblique direction, linear alignment of the limb hooks was lost and the ventral and dorsal limb hooks showed separation on AP projection. The amount of separation and the craniocaudal angles to align the filter hooks corresponded to actual tilt angles. CONCLUSION: Loss of linear alignment of limb hooks in AP radiograms may suggest the presence of tilt in the AP plane. Significant separation of limb hooks should be alarming for significant filter tilt, and further evaluation of the filter position by CT scan or lateral cavogram should be obtained prior to planning of the retrieval.

Interventional radiological management of prehepatic obstruction of [corrected] the splanchnic venous system.

PURPOSE: The purpose of this study was to retrospectively evaluate interventional radiological management of patients with symptomatic portal hypertension secondary to obstruction of splanchnic veins. MATERIAL AND METHODS: Twenty-four patients, 15 males and 9 females, 0.75 to 79 years old (mean, 36.4 years), with symptomatic portal hypertension, secondary to splanchnic venous obstruction, were treated by percutaneous methods. Causes and extent of splanchnic venous obstruction and methods are summarized following a retrospective evaluation. RESULTS: Obstructions were localized to the main portal vein (n = 22), intrahepatic portal veins (n = 8), splenic vein (n = 4), and/or mesenteric veins (n = 4). Interventional treatment of 22 (92%) patients included recanalization (n = 19), pharmacological thrombolysis (n = 1), and mechanical thrombectomy (n = 5). Partial embolization of the spleen was done in five patients, in two of them as the only possible treatment. TIPS placement was necessary in 10 patients, while an existing occluded TIPS was revised in two patients. Transhepatic embolization of varices was performed in one patient, and transfemoral embolization of splenorenal shunt was performed in another. Thirty-day mortality was 13.6% (n=3). During the follow-up, ranging between 2 days and 58 months, revision was necessary in five patients. An immediate improvement of presenting symptoms was achieved in 20 patients (83%). CONCLUSION: We conclude that interventional procedures can be successfully performed in the majority of patients with obstruction of splanchnic veins, with subsequent improvement of symptoms. Treatment should be customized according to the site and nature of obstruction.

Transjugular intrahepatic portosystemic shunt prior to cardiac surgery with cardiopulmonary bypass in patients with cirrhosis and portal hypertension.

Because of the increased complications associated with cardiac surgery in patients with cirrhosis and portal hypertension, various preoperative preparations have been utilised. In order to reduce the bleeding risk by decompressing portosystemic collaterals and to correct the fluid shift, we performed transjugular intrahepatic portosystemic shunt (TIPS) in two patients with cirrhosis and portal hypertension prior to major cardiac surgery with cardiopulmonary bypass. Both patients had satisfactory surgical outcome with no bleeding complications. One patient developed hepatic encephalopathy which was managed medically. We believe that preoperative TIPS benefits the patient with cirrhosis and portal hypertension undergoing cardiac surgery by decreasing the major surgical complications through improvement of fluid imbalance and reduction of the bleeding risk. Because of the risks of TIPS, such as encephalopathy and liver failure, preoperative TIPS placement must be reserved for patients with fluid shift or high risk criteria of bleeding.

Endovascular management of acute enteric bleeding from pancreas transplant.

Arterioenteric fistula is a rare but serious complication of enteric drained pancreas transplant, which may lead to massive gastrointestinal bleeding. We present 3 patients with failed enteric drained pancreas transplants and massive gastrointestinal bleeding secondary to arterioenteric fistula. One patient was treated by embolization and the 2 others by stent graft placement. Bleeding was successfully controlled in all cases, at follow up of 5 days, 8 months, and 12 months, respectively. One patient died 24 days after embolization, of unknown causes.

Dynamic contrast-enhanced MRI in the differentiation of posttreatment fibrosis from recurrent carcinoma of the head and neck.

OBJECTIVE: The aim of this study was to investigate the value of dynamic contrast-enhanced magnetic resonance imaging (MRI) in the differentiation of posttreatment fibrosis from recurrent carcinoma, by comparing the dynamic contrast-enhancement characteristics of the lesions. MATERIALS AND METHODS: Twenty-six patients with previously treated carcinoma of the head and neck are studied by conventional and dynamic contrast-enhanced MRI at least 6 months after treatment by radiotherapy and/or surgery. Patients are divided into tumor-positive or -negative groups according to the radiological and clinical follow-up and biopsy. Lesion enhancement ratios at each dynamic sequence are calculated. RESULTS: The tumor-positive group consisted of 11 patients, while the tumor-negative group included 15 patients. Between the two groups, lesion enhancement ratios are found to be significantly different (P<.05). CONCLUSION: Dynamic contrast-enhanced MRI may be a valuable modality in the differentiation of recurrent tumor from posttreatment fibrotic changes of the head and neck.

[Comparison of sonographically guided vacuum-assisted and automated core-needle breast biopsy methods]. / Meme lezyonlarinda US kilavuzlugunda vakum destekli biyopsi (mamotom) ve "tru-cut" biyopsi yöntemlerinin karsilastirilmasi.

PURPOSE: To compare the diagnostic accuracy and complication rates of sonographically guided vacuum-assisted and automated core-needle breast biopsy methods. MATERIALS AND METHODS: Sonographically guided biopsy was performed in 125 solid breast lesions found at mammography and observed at ultrasonography. Vacuum-assisted biopsy was performed in 61 lesions, while automated core-needle biopsy was performed in 64 lesions. The lesions with a benign histological diagnosis were followed radiologically. Those lesions with a histological diagnosis of malignancy or atypical ductal hyperplasia underwent surgical treatment. RESULTS: In the vacuum-assisted biopsy group, 62.3% of the lesions were totally removed. Four lesions in vacuum-assisted biopsy group and two lesions in the automated core-needle biopsy group were diagnosed as atypical ductal hyperplasia histologically. Of the 4 BI-RADS category lesions, three lesions from each group were noted to be malignant. Histological results were not significantly different between the two groups (p>0.05). In both groups, lesions diagnosed as atypical ductal hyperplasia or malignancy showed no difference in the histological diagnosis after excisional biopsy. Complication rates were not significantly different between the two biopsy methods (p>0.05). CONCLUSION: No significant difference was found between sonographically guided vacuum-assisted and automated core-needle breast biopsy methods in terms of diagnostic accuracy and complication rates. However, vacuum-assisted biopsy can be preferred for total removal of the benign lesions.

[Evaluation of autologous fat volume with magnetic resonance imaging following vocal cord injection]. / Vokal kord otolog yag enjeksiyonu sonrasi greft hacminin manyetik rezonans görüntüleme ile degerlendirilmesi.

OBJECTIVES: The aim of this study was to measure the change in the volume of the autologous fat used for the treatment of glottic insufficiency caused by recurrent laryngeal nerve palsy. PATIENTS AND METHODS: Six patients who were treated by autologous fat injection for the treatment of glottic closure deficiency were included in the study. MRI was performed one week, and 1, 3, 6, and 12 months after the injection. After MRI, the images were transferred to GE Advantage Windows 2.0 workstation. By three-dimensional multiplanar volume rendering technique (MPVR), a threshold between +1500 and +150 was applied and bone and soft tissue signals except fat tissue were erased from images. The volume of the fat graft was calculated by SAVS/paintbrush common window. RESULTS: The mean volume of the fat graft in vocal cord was estimated to be 0.9 ml (100%) after one week of the injection. Measurements after one month and three months of the injection revealed that fat volume reduced to 66% (0.6 ml) and 44% (0.4 ml), respectively. The volume reduced to 33% (0.3 ml) of the baseline volume after six months. Finally, three patients had 33% (0.3 ml) of fat volume after 12 months. CONCLUSION: Approximately two-thirds of the fat graft injected to the vocal cord is resorbed within the first six months. For this reason, techniques with stable long-term results should be performed in patients who are not expected to recover glottic functions.