Imaging of mandibular fractures: a pictorial review.

Mandibular fractures are among the most common maxillofacial fractures observed in emergency rooms and are mainly caused by road accidents. The clinical features of mandibular fractures include malocclusion and loss of mandibular function. Panoramic radiography is usually limited to isolated lesions, whereas computed tomography is the tool of choice for all other facial traumatic events. No reference standard classification system for the different types of mandibular fractures is defined. Therapeutic options include a conservative approach or surgical treatment based on the anatomic area and the severity of fracture. The main purpose of this pictorial review is to illustrate a practical description of the pathophysiology of mandibular fractures and describe both the imaging techniques to recognise them and the therapeutic indications.

Artefacts in contrast enhanced digital mammography: how can they affect diagnostic image quality and confuse clinical diagnosis?

Contrast-enhanced digital mammography (CEDM) is a diagnostic tool for breast cancer detection. Artefacts are observed in about 10% of CEDM examinations. Understanding CEDM artefacts is important to prevent diagnostic misinterpretation. In this article, we have described the artefacts that we have commonly encountered in clinical practice; we hope to ease the recognition and help troubleshoot solutions to prevent or minimise them.

Electronic processing of digital panoramic radiography for the detection of apical periodontitis.

INTRODUCTION: This study aimed to evaluate the accuracy of both digital complete and small portion of panoramic radiography (PAN) in the detection of clinically/surgically confirmed asymptomatic apical periodontitis (AP) lesions with and without endodontic treatment. METHODS: A total of 480 patients/teeth including 120 AP with and without endodontic treatment, and 120 healthy periapex with and without endodontic treatment were detected via CBCT using the periapical index system. Each diseased and healthy patient underwent PAN first and a CBCT scan within 40 days. All 480 cases were assessed by four different methods, as follows: complete PAN with clinical examination of each tooth available and not available, respectively, and small portion of PAN in which a root with crown and root without crown were displayed, respectively. Periapical index system was also used to assess AP by PAN. Accuracy for both complete and small portion of PAN with respect to CBCT was analyzed. RESULTS: The overall accuracy of the four methods for teeth with endodontic treatment (73.4) was higher than teeth without endodontic treatment (66.6). Accuracy of complete PAN and portion of PAN was 71.3 and 68.7, respectively. As regards teeth without endodontic treatment, accuracy was higher for complete PAN in the upper/lower incisive area and for small portion of PAN in the upper molar area. No difference was found in teeth with endodontic treatment. CONCLUSION: Complete and small portion of PAN showed greater accuracy in the upper/lower incisive area and upper molar area of untreated teeth, respectively, whereas no difference was found in treated teeth.

Magnetic resonance features of sinonasal melanotic mucosal melanoma.

A 67-year-old man presented to ear, nose and throat department complaining of nasal congestion and recurrent epistaxis for 5 months. Nasal endoscopy revealed a pigmented polyp obstructing the right nasal cavity. MRI with contrast agent showed a right nasal cavity polypoid mass with hyper signal intensity (SI) both in non-enhanced T1-w and diffusion imaging, marked hypo SI in T2-w sequences and avidly contrast enhancement characterised by rapid wash-in without significant wash-out on dynamic perfusion imaging. Histological specimen showed epithelioid and spindle cells with focal intense pigmentations and immunohistochemical features compatible with primary melanotic sinonasal mucosal melanoma (SNM). As melanotic SNM shows MRI pathognomonic high non-enhanced T1-w SI, this case underlines the crucial role of MRI not only in assessing the local tumour extension/recurrence but also in increasing the diagnostic confidence of detecting melanotic SNM. Thus, MRI should be always performed in case of clinical-endoscopic suspicion of SNM.

Axillary pseudoaneurysm post core needle biopsy.

Imaging-guided Core Needle Biopsy (CNB) is a procedure for tissue sampling in case of suspicious findings, such as breast masses and abnormal lymph nodes. It provides definitive diagnosis with a high accuracy rate and generally with no significant complications. To our knowledge, this is the first case report to document a pseudoaneurysm of the axilla after CNB. An illustrative case and a diagnostic and therapeutic literature review are presented.

Assisted coiling of saccular wide-necked unruptured intracranial aneurysms: stent versus balloon.

BACKGROUND AND PURPOSE: Assisted coiling with stents or balloons enables a higher percentage of complete occlusions of saccular unruptured intracranial aneurysms to be achieved with a reasonable complication rate. The aim of this study was to compare stent-assisted coiling and the balloon remodeling technique in terms of efficacy, stability, and safety for the treatment of comparable unruptured saccular intracranial aneurysms. MATERIALS AND METHODS: 268 patients with 286 saccular unruptured wide-necked intracranial aneurysms were treated at our institution with stent- or balloon-assisted coiling and retrospectively reviewed. Statistical analysis was performed to assess significant differences between the two groups. RESULTS: The rate of complete occlusion at the end of the procedure was higher with stent-assisted coiling than with balloon-assisted coiling (86.8% vs 78%) and the same results were also observed after 6 months (92.1% vs 77.6%; p=0.05). About 50% of major recurrences occurred in large to giant aneurysms (p<0.001). The overall complication rate was similar in the stent-assisted and balloon-assisted groups (10.3% vs 9.3%). Independently of the technique, a higher complication rate was observed with bifurcational aneurysms, particularly in the middle cerebral artery (p=0.016). CONCLUSIONS: Stent-assisted coiling achieved better results in terms of complete occlusion and stability than balloon-assisted coiling with a lower rate of recurrence without being associated with a higher risk of intraprocedural complications. Bifurcational and large to giant aneurysms were associated with higher complication rates and higher recurrence rates, respectively, and still represent a challenge for both techniques.

Endovascular treatment of unruptured and ruptured brain arteriovenous malformations with Onyx18: a monocentric series of 84 patients.

BACKGROUND: Brain arteriovenous malformations (AVMs) are a rare pathology, and their treatment is discussed. The development of techniques and materials in endovascular, radiosurgical, and neurosurgical fields led to higher rates of complete occlusions and good clinical outcomes. MATERIALS AND METHODS: 84 patients (52 men, 32 women; mean age 38.2 years; range, 9-70 years) were treated at our institution with Onyx18 from 2001 to 2011. Patients treated with other embolic agents, with micro-AVMs, were not included in the analysis. RESULTS: Complete occlusion was achieved in 27/84 patients (32.2%), in 40/84 (47.6%) brain AVMs occlusion of 80-90% of the nidus was obtained, and in 17/84 (20.3%) cases <80% of the nidus was occluded. Intraprocedural adverse events occurred in 11/84 patients (13.1%), and overall mortality and disabling permanent morbidity were 2.3% (2/84) and 4.7% (4/84), respectively. CONCLUSIONS: Endovascular treatment may be considered a safe and effective approach in superficial small brain AVMs in addition to surgery, mostly in ruptured AVMs. The therapeutic strategy should be to cure small and medium AVMs with endovascular treatment alone or combined treatment. Large unruptured AVMs (Spetzler-Martin grades IV-V) should be treated with target embolization of high flow fistulas or intranidal aneurysms.

Balloon-assisted coiling of the cavernous sinus to treat direct carotid cavernous fistula. A single center experience of 13 consecutive patients.

This study evaluated clinical and neuroradiological results in 13 consecutive patients with spontaneous and traumatic direct carotid cavernous fistulas treated at our center between January 2006 and September 2012. All patients were treated by coiling of the cavernous sinus. Coiling was always performed while a semi-compliant non-detachable balloon was temporarily inflated in the internal carotid artery. This technique (balloon-assisted coiling) permitted a clear visualization of the fistula, facilitated coil positioning and protected the patency of the artery. All patients' clinical data and radiological examinations were reviewed; nine patients underwent radiological and clinical follow-up, with a mean duration of 3.8 years (range: six months-six years). Overall results at discharge showed a complete occlusion of the fistula in seven patients (7/13, 54%) and a resolution of symptoms in eight patients (8/12, 67%). Radiological follow-up showed complete occlusion of the fistula in all patients (9/9, 100%) and clinical follow-up showed a resolution of symptoms in eight patients (8/9, 89%) and persistent symptoms in one (1/9, 11%). No procedure-related complications occurred. Balloon-assisted coiling of the cavernous sinus for the treatment of direct carotid cavernous fistulas proved an effective and safe technique, both in angiographic and clinical terms, and may be considered a technical improvement.

Semi-quantitative and qualitative evaluation of pial leptomeningeal collateral circulation in acute ischemic stroke of the anterior circulation: the Careggi Collateral Score.

INTRODUCTION: The imaging of ischemic penumbra in acute stroke is a debated issue and establishing commonly accepted criteria is difficult. Computerized tomography-perfusion studies conducted in animals have showed that the modifications occurring in the brain parenchima are part of a dynamic and progressive process involving the microcirculation. The purpose of this paper is to propose a new angiographic classification of collateral circulation in patients with acute ischemic stroke, with a possible correlation with the clinical outcome. MATERIALS AND METHODS: The basal angiograms of 57 patients with acute ischemic stroke is the territory of anterior circulation secondary to a major occlusion, who underwent endovascular treatment, were retrospectively reviewed and collaterals were classified according to our novel Careggi Collateral Score in 6 grades (0-6). The clinical outcome after 3 months was evaluated with modified Rankin Scale. A ROC (receiver operating characteristic) curve analysis identified a cut-off value of 1. RESULTS: Patients with favorable collateral circulation (grades 2-5) showed a significant correlation with good clinical outcome (modified Rankin Scale < or = 2). CONCLUSIONS: The Careggi Collateral Score resulted a useful tool to evaluate the chance of obtaining a favorable result with endovascular treatment in patients with acute ischemic stroke in the anterior circulation secondary to the occlusion of a major artery.