Optimization of CT protocol in polytrauma patients: an update.

Radiologists play a key role in the management of trauma patients. With the improvement of computed tomography (CT), radiologist makes an important contribution to the timely diagnosis of trauma-related findings and the choice of the most suitable treatment, improving patient outcomes. It is important to select the most appropriate imaging technique, which in the trauma patient is CT, and especially the most appropriate CT protocol, to correctly characterize trauma injuries. Currently, there is no agreement on what the optimal protocol is, acquisition times and number of contrast enhanced phases are not standardized. This is a review of the most recent literature on optimizing the CT protocol in polytrauma, with the intent of giving a useful tool for radiologists in the management of trauma patients.

Pediatric musculoskeletal injuries: role of ultrasound and magnetic resonance imaging.

Pediatric musculoskeletal system is particularly prone to traumatic and sports-related injuries, both acute and chronic, i.e., overuse injuries, because of inherent conditions of weakness, such as the open physis, representing the weakest aspect within the bone, the ligamentous supports and changing biomechanics. Being aware that a quick diagnosis is essential to preserve the good functionality of the limb involved, it is mandatory for the radiologist to recognize the most common patterns of these injuries, identifying those requiring a prompt surgery, as well as be confident with the technique performed, and be supported by an important background experience and knowledge skills.

[Torsion of a wandering spleen: ultrasonography and computer tomography in conservative treatment. A case report]. / Torsione di milza migrante: aspetti ecografici e TC di un caso trattato conservativamente.

Torsion of the vascular pedicle in a wandering spleen is treated conservatively in most of the cases whenever irreversible necrosis of the organ is not occurred. A case, in a 10 years old boy, is reported. The patient was admitted for acute abdominal pain and was investigated by ultrasounds, which showed an ectopic enlarged spleen at the left flank, without any sign of parenchymal necrosis. A spiral contrast enhanced angio-CT scan confirmed the diagnosis and demonstrated multiple ischemic lesions of splenic pulp mainly at the lower pole. The child was treated with splenopexy followed by un uneventful recovery. CT scan study in cases of torsion of a wandering spleen is of great help in confirming clinical and ultrasonographic diagnosis and in demonstrating the amount of ischemic lesion of the organ before surgical exploration.

MRI in the study of distal primary myopathopies and of muscular alterations due to peripheral neuropathies: possible diagnostic capacities of MR equipment with low intensity field (0.2 T) dedicated to peripheral limbs.

The purpose of this work was to investigate whether or not an magnetic resonance imaging (MRI) equipment with a low field intensity (0.2 T) used in the study of muscular alterations can diagnose primary or secondary myopathies, due to peripheral neuropathies. In this study the peripheral areas of all patients were examined. A total of 40 patients (23 males and 17 females) were tested. Their age ranged from 10 to 78 years age (mean age 40.8, SD +/- 19,45 years). The group includes 23 patients: 18 with Stainert Myotonic Distrophy, 5 were myositic, and the remaining 17 had peropheral neuropathies. Every patient received a clinic examination, followed by EMG and MRI. The MRI study was done with a system dedicated to the study of limbs (Artoscan, Esaote Biomedica) that used a 0.2 T permanent magnet. Spin-echo T1, T2-weighted, multiple-echo, and STIR sequences were used. A good correspondence was found between clinical and MRI data. Specifically, in the group of 23 myopathies, Sperman's index was found to be 0.80 in its correlation between the clinical examination and MRI; in the group of 17 myopathies it was found to be 0.63. A discrepancy was found among clinical examination, EMG, and MRI in patients with neuropathies who were showing a lack of myelin and mixed ones. The T2-weighted and STIR sequences had great sensitivity in showing initial changes in the muscles. The SE T1-weighted sequence was especially useful in detecting degeneration in the fibrous adipose tissue. The STIR sequence because of its high sensitivity and greater speed of response could be used instead of the SE T2 weighted particularly in the study of patients, who were noted to tolerate a prolonge period of scanning. However, because these sequences have a low signal noise ratio, they must always be associated with a SE sequence, whenever there would be need of a precise determination of the structures under study. The MRI low field intensity was also found to be a useful technique in screening familial groups having a great number of myotonic distrophies. It can have a great clinical role in revealing muscular alterations, even in asymptomatic patients.

[Diagnostic imaging of the salivary glands in patients undergoing radiotherapy of head and neck neoplasms]. / Diagnostica per immagini delle ghiandole salivari nei pazienti sottoposti a radioterapia per neoplasie del capo e del collo.

INTRODUCTION: Radiotherapy of head and neck cancers changes the shape and function of the salivary glands included in the treated region. We investigated the morphological and functional alterations in the major salivary glands in 15 patients treated with radiotherapy for head and neck cancers (total dose: 55-66 Gy). MATERIAL AND METHODS: All the patients underwent B-mode and power Doppler US, CT and 99mTC salivary scintigraphy, before, at the end, and 60-80 days after radiotherapy. RESULTS: At the end of treatment, US showed irregular margins and inhomogeneous parenchymal echogenicity in 13 parotid and in eight submandibular glands. Doppler US showed of focal hyperemia and focally decreased or no intraparenchymal flow in nine parotid and in two submandibular glands. CT demonstrated parenchymal inhomogeneity with increased and decreased density areas, cancers irregular margins, and gland atrophy in 15 parotid and in eight submandibular glands. Salivary scintigraphy depicted injuries of the major salivary glands detecting their reduced pertechnetate uptake in 12 parotid and in eight submandibular glands, with a decreased drug excretion in 12 parotid and in 12 submandibular glands. DISCUSSION AND CONCLUSION: Our findings confirm that the major salivary glands are affected by radiotherapy, which makes their morphological and structural monitoring of vital importance. US is the technique of choice for its low cost and easy execution, and it is well accepted by the patients because it requires no exposure to ionizing radiations. Power Doppler provided no relevant information, but it confirmed the high resistance of small and middle caliber vessels after radiotherapy. Scintigraphy clearly showed the glands involvement demonstrating decreased uptake technetium secretion and excretion. In conclusion, US and CT are both extremely useful in the study of the morphological changes of the major salivary glands.

Peripheral blood lymphocyte decrease and micronucleus yields during radiotherapy.

PURPOSE: To investigate the relationship between lymphocyte decrease and cytogenetic response in individual patients undergoing radiotherapy. MATERIALS AND METHODS: Peripheral blood lymphocytes obtained from 35 patients with pelvic and from 14 with head and neck tumours before and during radiotherapy were PHA-stimulated in vitro and the cultures prepared for the cytokinesis-block micronucleus test. For some patients only, the micronucleus test was carried out after 2 Gy in vitro X-irradiation, and 3-aminobenzamide (2 mM) was used to calculate the 3AB-index. RESULTS: The initially observed individual variation in the decrease of lymphocytes disappeared with increasing number of radiation exposures, reaching a stable level at about 500/microl lymphocytes in the blood. The slope of the relationship between the reciprocal of the lymphocyte decrease ratio and equivalent dose indicates the radiosensitivity of the lymphocyte pool in individual patients. The micronucleus test performed on lymphocytes obtained from patients during radiotherapy (in vivo) provided a lower cytogenetic response than the in vitro micronucleus yield for the same dose, so it was possible to calculate the cytogenetic recovery factor k. A correlation was found between the 3AB-index calculated before radiotherapy, and the recovery factor k. CONCLUSIONS: The 3AB-index, the micronucleus frequency after 2 Gy in vitro X-irradiation, and the cytogenetic recovery factor are proposed as predictive of individual response to radiotherapy.

A hemodynamic approach to clinical results in the TRAM flap after selective delay.

The delay phenomenon in the transverse rectus abdominis myocutaneous (TRAM) flap was studied by means of a laser-Doppler flowmeter and an echo color-flow Doppler device. Twenty-eight patients who underwent breast reconstruction with a TRAM flap in our hospitals were analyzed. Eighteen of them underwent selective delay 1 month before the major surgical procedure, and of them, 15 completed the reconstructive procedure. Ten patients were used as a control group and underwent TRAM flap breast reconstruction without selective delay. Cutaneous blood flow in the TRAM flaps was measured in 20 patients with a laser-Doppler flowmeter, and measurements were taken before, during, and after the surgical procedure, following a standardized protocol, as in Tuominen's original scheme. Variations in the cutaneous blood flow in the standard TRAM flap (10 patients) confirmed data obtained from the literature, i.e., an increase when elevating the cutaneous and subcutaneous parts of the flap and a decrease when ligating the deep inferior and superficial epigastric vessels. Compared with the standard TRAM flap, blood flow in the delayed flaps (10 patients) seemed to be more stable, without falling under the baseline. When elevating the cutaneous and subcutaneous parts of the flap (phase 3), blood flow values reached 120.2 percent (SEM 46.8 percent) on the random side and 131.6 percent (p < 0.009, SEM 9.58 percent, standard deviation 30.3 percent) on the axial side. During phase 4 (cutting the rectus muscles), blood flow values reached 115.0 percent (SEM 40.5 percent) on the random side and 102.8 percent (SEM 1.2 percent, standard deviation 3.8 percent, p < 0.049) on the axial side. In order to obtain further hemodynamic data, 10 patients who underwent selective vascular delay 1 month prior to breast reconstruction with a delayed TRAM flap in our hospitals were then studied by means of an echo color-flow Doppler device. Two of these patients also had been studied with the laser-Doppler flowmeter. Superior epigastric artery diameter (in millimeters) and resistivity (expressed as Pourcelot's index) were measured before and after selective delay of the deep and superficial inferior epigastric vessels, following a standardized protocol. Measurements were taken with 7.5- and 10-MHz linear probes at a point located after the origin of the costomarginal artery. In every patient an increase in the superior epigastric artery diameter and a decrease in the resistivity index were observed, and this was statistically significant. In the nonirradiated patients, the increase in the average diameter of the superior epigastric artery was 98.1 percent, and the average resistivity index decrease was 14.1 percent. In the irradiated patients, the increase in the average diameter of the superior epigastric artery was 35.5 percent, and the average resistivity index decrease was 29.8 percent. In conclusion, laser-Doppler flowmeter evaluations show that cutaneous blood flow in the delayed flap is more constant and undergoes fewer variations than that in the standard TRAM flap. In addition, echo color-flow Doppler indicates that the basis for the increase in the vascular territory of the superior epigastric artery caused by the delay maneuver is an increase in the superior epigastric artery diameter, always accompanied by a decrease in the resistivity index. Two different mechanisms seem to us to be related to these modifications in the blood circulation. In the nonirradiated patients, superior epigastric artery dilation prevails, whereas in the irradiated patients, a decrease in the resistivity index is the dominant mechanism of compensation. These hemodynamic findings well support the decrease in flap necrosis reported in our series (standard TRAM: 30 percent; delayed TRAM: 7.1 percent).

[Myositis: diagnostic potential of a magnetic resonance unit with low intensity field (0.2 T)]. / Le miositi: possibilità diagnostiche di un'apparecchiatura di Risonanza Magnetica dedicata con bassa intensità del campo (0.2 T).

Magnetic Resonance Imaging (MRI) is a useful tool for demonstrating muscle changes in patients with inflammatory myopathies. We investigated the diagnostic capabilities of low field (0.2 T) MRI with a dedicated coil in a series of patients with an unquestionable clinical diagnosis of inflammatory myopathy. Infiltrating processes or muscle swelling are depicted as low-signal areas on T1-weighted SE images and as high-signal areas on T2-weighted SE and short time inversion recovery (STIR) images. Fatty infiltration appears as a high-signal area within muscles on T1-weighted SE images. T2-weighted SE and STIR sequences are highly sensitive in demonstrating infiltrating processes or muscle swelling. The signal-to-noise ratio was higher on T2-weighted SE than on STIR images; on the other hand, fast STIR sequences can effectively reduce scan times. To conclude, low field MRI is a useful tool in the study of inflammatory myopathies thanks to its noninvasiveness and to the good depiction of muscle inflammation provided by T2-weighted SE and STIR images.

[Evaluation of the treatment with thymopentin associated with radiotherapy in head and neck tumors]. / Valutazione del trattamento con timopentina associato alla radioterapia nei tumori della testa e del collo.

The aims of the study has been the analysis of the optimal conditions for the use of thymopentin in reducing the incidence and severity of early and late complications following radiotherapy of patients with head and neck cancers submitted to radiotherapy by means of cobalt or linear accelerator. 168 patients of 10 Center have been examined. Analysis of the results demonstrated that the tymopentin reduce the incidence and severe reactions (p < 0.05) in statistically significant manner in cases of irradiation of the hypopharynx, oropharynx in oral cavity. The complications were more frequent during cobalt beam therapy (p < 0.01) and the beneficial effect of the immunomodulating treatment were greater for females than the males (p < 0.05).

[Loco-regional intra-arterial chemotherapy combined with radiotherapy in cervical carcinoma]. / La chemioterapia intra-arteriosa loco-regionale associata alla radioterapia nel cervicocarcinoma.

Fifteen patients with squamous cell carcinoma of the uterine cervix--7 in stage II, 6 in stage III and 2 in stage IV--were considered not to respond at the end of radiotherapy. Therefore, the whole patient population underwent bilateral intraarterial chemotherapy with Mitomycin-C (3 cycles, 3-4 weeks' intervals). Patients' responses were evaluated with clinical and CT examinations following irradiation and after completing chemotherapy. Pelvic irradiation was administered by external beams (6 Mv), for a 50-Gy dosage (200 cGy/day for 5 weeks); in 4 cases treatment was completed by means of brachytherapy (192 Ir), with 20-25 Gy dosage. Intraarterial infusion was carried out after positioning the catheters in both uterine arteries; in 5 cases, the internal iliac artery alone was cannulated. At the end of the combined treatment, 2 patients (13%) responded completely, 9 (60%) partially and 4 (27%) not at all. Mean survival was 24 months. No hematologic complication was so severe that treatment had to be discontinued. In 4 patients chemotherapy caused a partially ulcerated skin erythema in the buttocks, which was completely cured in all cases.

[Role of CT in radiotherapy radiation planning for tumors of the rhinopharynx]. / Il ruolo della TC nell'impostazione del piano di trattamento radiante dei tumori della rinofaringe.

The authors compare the results obtained by CT with clinics and conventional radiography in the staging of nasopharyngeal tumors. The accurate evaluation of tumor size, localization, and spread, helps optimize treatment planning and fit radiation boosts on small fields. Twenty-six patients underwent clinical examination, radiography of the skull and neck, lateral stratigraphy of epipharynx, and CT of head and neck. We compared the results obtained in the study of: nasopharyngeal walls, parapharyngeal space, paranasal sinuses, nasal cavity, bone erosion of the base of skull, and continuous invasion without bone erosions. Our results point to conventional radiology as the examination of choice for the study of upper nasopharyngeal wall, while CT allows a better evaluation of the lateral wall, and is clearly superior in demonstrating parapharyngeal space, contiguous intracranial invasion, and neck nodes involvement.

Pretreatment scalene node biopsy in cervical carcinoma.

To evaluate incidence of scalene node metastases from carcinoma of the cervix, 20 patients had scalene fat-pad node biopsy. All cases were staged according to FIGO criteria and abdominal lymph nodes were studied by CT and lymphangiography. Scalene node metastases were found in 2 patients with clinically suspicious node and pelvic and paraaortic nodes involvement. Seven patients had sinus histiocytosis in scalene node biopsy and this seems related to a more favourable prognosis. From this study it appears that scalene node biopsy is not a routine procedure and should be performed in all patients with palpable supraclavicular masses or when paraortic nodes are involved.

[Evaluation of the process of lumbo-aortic metastasis in carcinoma of the cervix uteri]. / Valutazione delle modalità di metastatizzazione lomboaortica nel carcinoma della cervice uterina.

Paraaortic lymph nodes involvement in patients with cervical carcinoma, even in less advanced stages, found in 100 cases examined, besides the data reported in literature, has driven the authors to locate, through the examination of lymphangiograms, the routes by which paraaortic metastases can occur. Authors pointed out different ways of invasion, besides the more common subsequent involvement going from pelvic to paraaortic nodes or from posterior channels that can lead to paraaortic spread without lesions in common iliac nodes. In detail lymphatic pathways have been opacified connecting distant nodal chains and finally external routes from external iliac lymph nodes directly to paraaortic chain.