Diagnostic quality assessment of compressed SENSE accelerated magnetic resonance images in standard neuroimaging protocol: Choosing the right acceleration.

PURPOSE: To investigate the impact of compressed sensing - sensitivity encoding (CS-SENSE) acceleration factor on the diagnostic quality of magnetic resonance images within standard brain protocol. METHODS: Three routine clinical neuroimaging sequences were chosen for this study due to their long acquisition time: T2-weighted turbo spin echo (TSE), fluid - attenuated inversion recovery (FLAIR), and 3D time of flight (TOF). Fully sampled reference scans and multiple prospectively 2x to 5x undersampled CS scans were acquired. Retrospectively, undersampled scans were compared to fully sampled scans and visually assessed for image quality and diagnostic quality by three independent radiologists. RESULTS: Images obtained with CS-SENSE accelerated acquisition were of diagnostically acceptable quality at up to 3x acceleration for T2 TSE (average qualitative score 3.53 on a 4-point scale, with the acquisition time reduction of 64%), up to 2x for FLAIR (average qualitative score 3.27, with the acquisition time reduction of 43%) and 4x acceleration for 3D TOF sequence (average qualitative score 3.13, with the acquisition time reduction of 73%). There were no substantial differences between the readers' diagnostic quality scores (p > 0.05). CONCLUSIONS: CS-SENSE accelerated T2 TSE, FLAIR, and 3D TOF sequences of the brain show image quality similar to that of conventional acquisitions with reduced acquisition time. CS-SENSE can moderately reduce scan time, providing many benefits without losing the image quality.

Diffusion-weighted imaging in the assessment of renal function in patients with diabetes mellitus type 2.

OBJECTIVE: Investigation of functional magnetic resonance (MR) imaging role in early diagnosis of diabetic nephropathy (DN) in patients with diabetes mellitus (DM) type 2, by quantification of the apparent diffusion coefficient (ADC) and fractional anisotropy (FA) values. MATERIAL AND METHODS: 10 healthy volunteers and 91 DM type 2 patients were scanned using diffusion-weighted imaging (DWI) and diffusion tensor imaging (DTI) sequences. Patients were divided into four groups based on the estimated glomerular filtration value (eGFR). ADC and FA values, calculated in six regions of interest in each kidney (cortex and medulla), were compared to eGFR and laboratory parameters of renal function. RESULTS: ADC values of DM patients were higher in the cortex than in the medulla (p < 0.01), while FA values were higher in the medulla (p = 0.284). Creatinine, cystatin C negatively correlated with ADC (cortex, medulla, parenchyma). Medullary FA were lower in DM patients and positively correlated with the eGFR (p = 0.049). Tractography showed disturbed structure in patients with impaired renal function. DISCUSSION: Medullary FA value is a more sensitive parameter than parenchymal ADC in the early detection of renal damage in DM patients. ADC and FA values are significant in the diagnosis of DN; further research is needed for the update and refinement of the established recommendations.

Dynamic simulation and Doppler Ultrasonography validation of blood flow behavior in Abdominal Aortic Aneurysm.

Criteria for rupture prediction of Abdominal Aortic Aneurysm (AAA) are based only on the diameter of AAA. This method does not consider complex hemodynamic forces exerted on AAA wall. The methodology used in our study combines Computer-Aided Design (CAD) with Computational Fluid Dynamics (CFD). Three-dimensional vascular structures reconstructions were based on Computed Tomography (CT) images and CAD. CFD theory was used for mathematical modeling and simulations. In this way, dynamic behavior of blood flow in bounded three-dimensional space was described. Doppler Ultrasonography (US) was used for model results validation. All simulations were based on medical investigation of 4 patients (male older than 65years) with diagnosed AAA. Good correspondence between computed velocities in AAA and measured values with Doppler US (Patient 1 0.60m·s-1 versus 0.61m·s-1, Patient 2 0.80m·s-1 versus 0.80m·s-1, Patient 3 0.75m·s-1 versus 0.78m·s-1, Patient 4 0.50m·s-1 versus 0.49m·s-1) was noticed. The good agreement between measured and simulated velocities validates our methodology and the other data available from simulations (eg. von Misses stress) could be used to provide useful information about the possibility of AAA rupture.

LOWER BACK PAIN--SILENT SYMPTOM OF CHRONIC INFRARENAL ABDOMINAL ANEURYSM RUPTURE.

INTRODUCTION: The rupture of infrarenal abdominal aortic aneurysm is a surgical emergency condition with a high rate of mortality before the patients arrive at hospital. The signs and symptoms of abdominal aortic aneurysm rupture into the retroperitoneal cavity are pulsatile mass, abdominal pain, hypotension and shock, but sometimes silent symptoms also hide a dangerous and life threatening condition, such as chronic aneurysm rupture of abdominal aorta into the retroperitoneal cavity. CASE REPORT: We present a patient having had the lower back pain for 4 months, which had been recognized and treated as lumbar ischialgia but which was eventually diagnosed to be chronic infrarenal abdominal aortic aneurysm rupture by computed tomography angiography. The surgical intervention was successful and the patient was discharged from hospital after 6 days without any clinical complications. Preoperative imaging by computed tomography angiography of ruptured abdominal aortic aneurysm is highly sensitive for detection of several specific signs for rupture. This condition leads to urgent vascular surgery.

The role of the color Doppler ultrasonography and computed tomography in estimation of portal hypertension.

Introduction: Liver diseases with disturbances of hepatic and splanchnic circulation lead to the portal hypertension, with or without a portal vein thrombosis. Objective: This study was based on the testing of hypothesis that more data and more precise diagnosis in patients with disorders of portal circulation can be obtained by using color Doppler ultrasonography (CDU) and computed tomography (CT) with contrast. Methods: The study was conducted from February 2011 to May 2014 and it comprised 120 patients who were suspected to have portal hypertension or already had clinical confirmation of the portal hypertension, patients with hepatitis, and some patients with hematological diseases. The first group of 40 patients was examined by conventional ultrasonography and CDU, the second group by contrast CT, and the third group of patients was examined by both methods (CDU and contrast CT). After six months of adequate therapy, the patients had control examinations with the same diagnostic technique used during their first examination. Results: Retrospective analysis showed that CDU is more sensitive than CT in the assessment of presence and age of thrombi (CDU 93.9%; CT 86.1%). CT gives precise data in detection of portosystemic collaterals. Sensitivity of CT is 100% and its specificity is 67%. Cumulative sensitivity and specificity for most parameters were increased in patients with portal hypertension when both methods were applied. Conclusion: This study emphasizes the possibility of early and more accurate diagnosis achieved when combining two radiological techniques (CDU and contrast CT scan), which is not the case when these methods are used separately.

The question is whether hemiparesis is more common in unilateral than bilateral chronic subdural hematoma.

INTRODUCTION: Chronic subdural hematoma is an intracranial hemorrhagic lesion that illustrates various expressions in clinical and radiological practice. The aim of this study was to emphasize the correlation between the brain site of chronic subdural hematoma and clinical symptoms/signs of disease. Furthermore, the study denotes the significance of hemiparesis occurrence in the patients with unilateral chronic subdural hematomas more than in those with bilateral ones, associated with time required to diagnose hematoma. MATERIAL AND METHODS: A three-year study included 72 patients with chronic subdural hematoma. According to their clinical and neurological symptoms on hospital admission, all patients underwent non-contrast brain computed tomography scan, which confirmed the diagnosis. The radiological parameters, including the site of chronic subdural hematoma, a hematoma width and midline shift were recorded to give precise data about the correlation with neurological symptoms. A special focus was put on the lag time between the onset of symptoms and signs to diagnosis of chronic subdural hematoma. RESULTS: The study proved that the patients with unilateral chronic subdural hematoma had more frequent occurrence of hemiparesis than the patients with bilateral chronic subdural hematoma. It took the left-sided chronic subdural hematomas less time (about 200 hours earlier) than the right-sided ones to present its symptoms although the average hematoma diameter value was almost the same. CONCLUSION: The site and the form of intracranial lesion-chronic subdural hematoma could have a great influence on neurological and functional condition in a patient. Although the length of time required for making diagnosis as well as clinical symptoms greatly differ and the latter are not always so clear, physicians should maintain a high level of suspicion for this disease and thus contribute to prompt diagnosis and better clinical outcome of patients.

The use of the Karnofsky index in the assessment of clinical state in patients with chronic subdural hematoma: the first observation from Vojvodina.

AIM: To evaluate clinical status of patients with chronic subdural hematoma (CSDH) on hospital admission and to predict their outcome after the neurosurgery treatment using Karnofsky index scale (KI). METHODS: Clinical and surgery data of patients with CSDH were collected prospectively. Fifty 50 adults aged over 41 with CSDH diagnosed and hospitalized between November 2010 and April 2012 were investigated. In the analyzed sample there were more CSDHs in males than in females (1.5:1). The diagnosis of CSDH on hospital admission in patients was confirmed by non-contrast computed tomography (CT). Forty-three patients had undergone surgery with Burr-hole drainage and craniotomy, while seven patients were treated conservatively. The KI was used for evaluation of the patient's clinical state before neurosurgery treatment and the quality of survival in all patients, six months after hospital discharge. RESULTS: A statistically significant difference was found between the KI values in patients with CSDHs on hospital admission and KI after the surgical treatment. Six months after, out of 43 patients who underwent surgery in 24 (55.8%) patients KI was between 80-100%, in nine (20.9%) patients KI was between 50-70% and in 10 (23.2%) patients KI was 0-40%. CONCLUSION: Although the elderly with CSDHs are vulnerable because of their age, associated diseases and risk of recurrence of CSDH, their outcome assessed by KI after surgical treatment was good. The Glasgow Coma Scale (GCS) is used for rapid assessment of the state of consciousness in patients on admission and monitoring of the changes in their condition. KI scale could be used as a complementary assessment tool for the general condition of patients with chronic subdural hematoma. This study highlighted that the KI scale had a predictive value for patient's outcome with chronic subdural hematoma.

[Comparative analysis of the position of the graft in the femur after anterior cruciate ligament reconstruction done through the front inner portal and through the shin bone].

Anterior cruciate ligament (ACL) is the most common surgically treated knee ligament. If we take into account the fact that incidence of ACL injuries is growing, it is clearly that the interest of orthopedic surgeons for this pathology is also growing. Increasing number of this operations leads to increasing of complications, which requires its analysis. One of the most common failure of ACL reconstruction is a bad position of the graft in the femoral condyle. This study aimed to analyze the positioning of the graft in to the femur by two generally accepted techniques--transtibial technique and technique through the antero-medial portal. The analysis included postoperative radiographs in 60 patients, of whom 30 were operated by transtibial technique and 30 by technique through anteromedial portal. Radiographic analysis involved the measurement of the AP digital imaging, the tunnel projection X ray measurements and measurements of the computed tomography (CT), which was here a control method. The accuracy of measurement was set at 0.5 degrees or 1 min. All radiographs were made in the same way according to the literature. The results showed that the neoligaments were placed lower in the femoral condyle by technique through anteromedial portal than by transtibial technique, and the difference was statistically significant (on tunnel X ray by anteromedial portal screws were average placed at 50.0 degrees and 10:20 am, and by transtibial technique at 37.5 degrees or 10:45 am). Based on the results, it was concluded that the neoligaments were positioned closer to its anatomical position by technique through anteromedial portal.

Virtual simulation as a learning method in interventional radiology.

INTRODUCTION: Radiology is the fastest growing discipline of medicine thanks to the implementation of new technologies and very rapid development of imaging diagnostic procedures in the last few decades. On the other hand, the development of imaging diagnostic procedures has put aside the traditional gaining of experience by working on real patients, and the need for other alternatives of learning interventional radiology procedures has emerged. A new method of virtual approach was added as an excellent alternative to the currently known methods of training on physical models and animals. Virtual reality represents a computer-generated reconstruction of anatomical environment with tactile interactions and it enables operators not only to learn on their own mistakes without compromising the patient's safety, but also to enhance their knowledge and experience. DISCUSSION: It is true that studies published so far on the validity of endovascular simulators have shown certain improvement of operator's technical skills and reduction in time needed for the procedure, but on the other hand, it is still a question whether these skills are transferable to the real patients in the angio room. CONCLUSION: With further improvement of technology, shortcomings of virtual approach to interventional procedures learning will be less significant and this procedure is likely to become the only method of learning in the near future.

Stent graft infixation after venous dislodgement in a patient with femoral posttraumatic arteriovenous fistula.

INTRODUCTION: An arteriovenous fistula (AVF) is an abnormal connection between an artery and a vein which may result from traumatic injury or may occur as congenital abnormality. Stent graft repair through arteriovenous fistula could lead to complications. CASE REPORT: Endovascular stent graft repair in a 23-year-old patient with posttraumatic superficial femoral arteriovenous fistula was performed to cover a fistula. During the procedure the device migrated through the fistula into the femoral vein. Due to eventual risk of migration to the heart, a prompt decision was made to fix the stent graft with three puncture needles in the common femoral vein region under fluoroscopy guidance. The vascular surgeon was called to perform open surgery. CONCLUSIONS: The presented way of treating this rare complication in an extreme and uncommon situation is very efficient, safe and inexpensive.

Complete spontaneous resolution of compressive chronic subdural hematoma in a patient with liver failure.

Chronic subdural hematoma is usually caused by minor head trauma and occurs frequently with older people. Predisposing factors include alcohol abuse, epilepsy and coagulopathy. This report presents a 65-year old woman who had a large, mixed density, left sided compressive chronic subdural hematoma diagnosed by computed tomography. She also displayed a moderate neurological deficit on admission, confusion and behavioral disorder with Glasgow Coma Score 10. The computed tomography and neurological parameters indicated the necessity of surgery. A difficult general condition and coagulation factor disorder in this patient were determinative for the decision for non-operative treatment. It is very rare that a large chronic subdural hematoma is resolved completely spontaneously, but in our case conservative treatment gave an excellent result.

An unusual origin of proximal coronary bypass anastomosis in a patient with porcelain aorta: how we solved the problem.

Severe calcification of the ascending aorta (porcelain aorta) is a very difficult condition in cardiac surgery because of a high embolization potential during the process of cannulation, aortic cross-clamping and a particular difficulty to suture the proximal anastomosis. We described a case of a 68-year-old female referred to our Institute due to unstable angina. Further diagnostics revealed a severe high grade, multilevel fibrolipid symptomatic carotid stenosis and ostial left main coronary artery stenosis and a highly calcified ascending aorta and aortic arch. We performed simultaneous carotid segment replacement with the Dacron prosthesis and revascularisation of the left anterior descending coronary artery. Proximal venous anastomosis was created in the Dacron prosthesis of the right carotid artery. Perfusion of the patient was achieved via the graft sutured at the right subclavian artery due to impossibility of direct aortic cannulation.

Multislice computed tomography urography in the diagnosis of urinary tract diseases.

BACKGROUND/AIM: . Multislice computed tomography (MSCT) has triggered considerable changes in uroradiological imaging. The aim of this study was to establish the place of MSCT urography (MSCTU) in comparison with intravenous urography (IVU) and to determine the sensitivity and specificity of MSCT in the evaluation of urothelial abnormalities. METHODS: This prospective study included 120 patients with a high clinical suspicion of urinary tract diseases divided into two groups. The group I consisted of 60 patients with macroscopic hematuria, bladder carcinoma and malignant pelvic tumors after radiotherapy or operation. They underwent both IVU and MSCTU. The group II included 60 patients (> or = 40 years old) with retroperitoneal and malignant pelvic tumors, complicated pyelonephritis, microscopic hematuria, acute urinary tract obstruction (without visible calculi on unenhanced scans), and they were submitted to computed tomography with additional scan phase enabling MSCTU. RESULTS: Compared with IVU, MSCTU is more sensitive for the detection of urinary tract diseases (parenchymal changes, renal tumors, urolithiasis, fibrosis) and extraurinary processes. MSCTU is more specific than IVU for renal parenchymal abnormalities, tumors of the excretory system, urolithiasis, bladder tumors, fibrosis and extraurinary diseases. MSCTU is equally sensitive, but more specific for hydronephrosis compared to MSCT. The diagnosis made by the use of MSCTU in patients with macroscopic and microscopic hematuria and with obstruction not caused by stones, perfectly comply with operative findings and histological diagnosis. CONCLUSION: The obtained results support MSCTU to be the modality of choice in the diagnostic algorithm of patients with macroscopic hematuria and in the evaluation of microscopic hematuria and unexplained obstruction of the urinary tract. The only remaining role for IVU in our institution is imaging of the upper urinary tract in patients with hematuria under the age of 40.

Partial rhombencephalosynapsis: prenatal MR imaging diagnosis and postnatal follow up.

We present a case of partial rhombencephalosynapsis, diagnosed by magnetic resonance imaging (MRI), in fetus aged 27 gestational weeks, in a dizygotic twin pregnancy. The distinctive MRI features of this cerebellar malformation (segmental hypogenesis of the cerebellar vermis, partial fusion of the cerebellar hemispheres and dentate nuclei) without associated cerebral abnormalities were confirmed by 32-weeks prenatal and 3-months postnatal MRI studies. At the age of 12 months the affected twin had a slight delay in psychomotor development, mild hypotonia with normal cognitive development. To the authors' best knowledge, this is the first report of a fetal case with isolated partial rhombencephalosynapsis. Its MRI features enlarges the narrow spectrum of uncommon variants of rhombencephalosynapsis, and allow an accurate differentiation from other vermian and cerebellar anomalies with less favorable postnatal outcome.

[Dynamic magnetic resonance imaging of the cerebrospinal fluid flow within the cerebral aqueduct by different FISP 2D sequences].

BACKGROUND/AIM: A vast majority of current radiogical techniques, such as computerized tomography (CT) and magnetic resonance imaging (MRI) have great potencial of vizualization and delineation of cerebrospinal fuid spaces morphology within cerebral aqueduct. The aim of this study was to determine the possibilities of two differently acquired FISP (Fast Imaging with Steady State Precession) 2D MR sequences in the estimation of the pulsatile cerebrospinal fluid (CSF) flow intensity through the normal cerebral aqueduct. METHODS: Sixty eight volunteers underwent brain MRI on 1.5T MR imager with additionally performed ECG retrospectively gated FISP 2D sequences (first one, as the part of the standard software package, with following technical parameters: TR 40, TE 12, FA 17, Matrix: 192 x 256, Acq 1, and the second one, experimentally developed by our investigation team: TR 30, TE 12, FA 70, Matrix: 192 x 256, Acq 1) respectively at two fixed slice positions--midsagittal and perpendicular to cerebral aqueduct, displayed and evaluated by multiplegated images in a closed-loop cinematographic (CINE) format. RESULTS: Normal brain morphology with preserved patency of the cerebral aqueduct in all of 68 healthy volunteers was demonstrated on MRI examination. Cerebrospinal fluid flow within the cerebral aqueduct was distinguishable on both CINE MRI studies in midsagittal plane, but the estimation of intraaqueductal CSF flow in perpendicular plane was possible on CINE MRI studies acquired with experimentally improved FISP 2D (TR 30, FA 70) sequence only. CONCLUSION: Due to the changes of technical parameters CINE MRI study acquired with FISP 2D (TR 30, FA 70) in perpendicular plane demonstrated significantly higher capability in the estimation of the CSF pulsation intensity within the cerebral aqueduct.

Transient cortical blindness following vertebral angiography in a young adult with cerebellar haemangioblastoma.

Transient cortical blindness is reported to occur in 0.3% to 1% of cerebral angiography procedures. It develops within minutes of contrast medium injection and lasts for up to several days. We report a long episode of transient cortical blindness in a 17-year-old boy with cerebellar haemangioblastoma, which started during the preoperative vertebral angiography and lasted for 5 days. CT performed 2 days after the sudden onset of bilateral visual loss showed multiple asymmetrical lesions within the brain parenchyma in the distribution of the posterior cerebral circulation. Even though the patient's vision was completely restored 5 days after angiography, repeat MRI performed 2 months after angiography showed improvement but with residual lesions in the thalami, cerebellum and occipital lobe.

[Chest computed tomography in the localisation of pathologic processes in lymphomas].

INTRODUCTION: The anatomic localisation of Hodgkin disease and Non-Hodgkin lymphoma is very important in the disease prognosis and therapy treatment. Intrathoracic localisation in Hodgkin disease is very frequent and usually occurs in the form of lymph node enlargement. The most frequent manifestation of the thoracic Non-Hodgkin lymphoma is mediastinal and hilarlympha-denomegalia. The purpose of this research study is to analyse chest computed tomography findings in patients suffering from Hodgkin disease and Non-Hodgkin lymphoma prior to any applied therapy. MATERIAL AND METHODS: This retrospective study encompassed 73 patients diagnosed as having Hodgkin disease or Non-Hodgkin lymphoma. They were subjected to III chest CT examinations. The initial occurrence of the disease was found in 35 patients (24 patients suffering from Hodgkin disease and 11 suffering from Non-Hodgkin lymphoma). Simultaneously, analyses of the pretherapy chest CT findings were made. RESULTS AND DISCUSSION: Positive findings were reported in 66.66% patients suffering from Hodgkin disease and 45.45% patients suffering from Non-Hodgkin lymphoma. Enlarged lymphnodes were found in the region of the upper mediastinum (parathracheal and prevascular group) in more than 55% of the patients suffering from Hodgkin disease and in more than 35% of the patients suffering Non-Hodgkin lymphoma. CONCLUSION: The findings of this study coincide to a great extent with the findings presented in world literature.

[Blunt injuries of the lungs, pleura and chest bone structures: computed tomography contribution].

INTRODUCTION: The most frequent incidences of blunt chest injuries occur due to motorvehicle accidents, falls and work-related traumas. Chest computed tomography is usually associated with examination of the subsequent regions with the aim to enable a more efficient diagnostic procedure. The purpose of this research study is to define the contribution of the chest CT in blunt injury patients. MATERIAL AND METHODS: This retrospective study encompasses the results of CT examination of 36 patients with one or more injuries of the thoracic wall, pleura, lungs and spinal column suspected to suffer chest organs traumas. Chest CT survey was performed in 30 patients, while thoracic spine CT survey was performed in 11 patients. RESULTS AND DISCUSSION: The most frequent incidences of injuries were due to motor vehicle accidents (22 patients--61.11%). Falls were the reason of injuries in 11 patients--17.46%. Chest injuries are usually associated with injuries of the surrounding regions, but occurred in isolated form, too (27.78%). Rib fractures and lungs parenchyma traumas were evidenced by CT examination in more than 60% of the patients. Thoracic spine fractures were most frequently reported at the 10-th, 11-th and 12-th vertebra and made more than 70% of the thoracic spine fractures. CONCLUSION: The findings of this study coincide to a great extent with the findings presented in world literature.

[Stromal tumor of colon--case report].

INTRODUCTION: Gastrointestinal stromal tumor is relatively new term, it can be localized anywhere inside the gastrointestinal system. It has formerly been called leiomyoma, leiomyoblastoma, and/or leiomyosarcoma. CASE REPORT: Case report is about a female patient with indefinite difficulties described as "bother", mild anemia and anamnesis data of her mother who had been operated on for colon tumor. After blood examination, which had shown values within referential limits except for mild anemia, patient underwent radiological examination. Primarily, an abdominal cavity ultrasound had been performed, where a suspicious formation in the right hemiabdomen was found, but without distinctive anatomical localization in the abdominal cavity. Secondly, a checkup by Duplex Doppler ultrasound was made, as well as radiological examination with double contrast of colon and computed tomography, where tumor was visualized on ascendant colon with extraluminal localization. DISCUSSION: Radiological findings were confirmed by surgery. Histopathological findings were positive for gastrointestinal stromal colon tumor. CONCLUSION: Gastrointestinal stromal tumors represent extremely rare tumors of gastrointestinal system, especially when localized at the colon but they should be included in a differential diagnosis for their malignant potential.