What every radiologist should know about adnexal torsion.

Adnexal torsion is the fifth most common gynecologic surgical emergency, requiring clinician and radiologist awareness. It involves the rotation of the ovarian tissue on its vascular pedicle leading to stromal edema, hemorrhagic infarction, and necrosis of the adnexal structures with the subsequent sequelae. Expedient diagnosis poses a difficult challenge because the clinical presentation is variable and often misleading. Adnexal torsion can mimic malignancy as it can take a subacute, intermittent, or chronic course, and thereby can be complicated to diagnose. The torsion may occur in the normal ovary but is usually secondary to a preexisting adnexal mass. Early surgery is necessary to avoid irreversible adnexal damage and to preserve ovarian function especially in children and young women. Pelvic ultrasound forms the foundation of diagnostic evaluation due to its ability to directly and rapidly evaluate both ovarian anatomy and perfusion. Moreover, it is a noninvasive and accessible technique. However, the color Doppler appearance of the ovary should not be relied upon to rule out torsion because a torsed ovary or adnexa may still have preserved arterial flow due to the dual blood supply. MR and CT may be used as problem-solving tools needed after the ultrasound examination but should not be the first-line imaging modalities in this setting due to ionizing radiation and potential time delay in diagnosis. The goal of this article is to review the adnexal anatomy, to familiarize radiologists with the main imaging features, and to discuss the main mimickers and the most common pitfalls of adnexal torsion. Main points Adnexal torsion is an uncommon gynecological disorder caused by partial or complete rotation of the ovary and/or the Fallopian tube about the infundibulopelvic ligament. The ovaries receive a dual blood supply from the ovarian artery and uterine artery. The lack of pathognomonic symptoms and specific findings on physical examination makes this entity difficult to diagnose. Since the right adnexa are most commonly involved, symptoms may mimic acute appendicitis. Persistence of adnexal vascularization does not exclude torsion. In the pediatric age group, gray-scale ultrasound is the best modality of choice. Obtaining CT and/or MR images should not delay treatment in order to preserve ovarian viability.

Female perineal diseases: spectrum of imaging findings.

The female perineum, which is divided into the anterior urogenital triangle and the posterior anal triangle, is a surface structure often overlooked. Female perineal diseases may present with nonspecific clinical signs due to its close anatomical relationship between the different compartments. Diagnosis of the origin of a perineal disorder may also be a difficult problem encountered in pelvi-perineal imaging. Therefore, a precise knowledge of the female perineal anatomy and the associated disease processes is essential to radiologists, pathologists, and surgeons alike who are involved in the evaluation of the patient who presents with a perineal mass. Cross-sectional imaging plays a crucial role for proper management. Due to the robust contrast resolution of MR, MR imaging is the modality of choice for evaluation of the extent of a complex perineal lesion, its relationship to the adjacent structures. It has a greater sensitivity and specificity for the diagnosis than the other non-invasive imaging techniques and is helpful in guidance for surgical planning. The purpose of this article is to highlight the spectrum of imaging findings of female perineal diseases.

Efficient liver regeneration following temporary portal vein embolization with absorbable gelatin sponge powder in humans.

PURPOSE: To report initial experience of temporary portal vein embolization (PVE) with a powdered form of absorbable gelatin sponge before major liver resection. MATERIALS AND METHODS: From 2009-2013, 20 patients (6 women and 14 men; median age, 61.5 y ± 2.8; range, 49-80 y) considered for major liver resections for both primary and secondary hepatic malignancies underwent temporary PVE. Data were retrospectively reviewed. Embolization of selected portal vein segments was performed using the powdered form of an absorbable gelatin sponge. All patients underwent volumetric computed tomography (CT) assessment before and at 4-6 weeks after PVE. Liver histology was normal in 13 patients; 1 patient had steatosis, and 6 patients had cirrhosis. RESULTS: Subsegmental, segmental, and sectorial embolization was successfully performed in all patients. None of the patients developed liver insufficiency or fever after embolization. Volumetric CT assessment showed the disappearance of all portal thrombosis in 14 patients. The median hypertrophy ratio of the nonembolized liver was 29.4% ± 6.9 (range, 3.3-127.2%). Of 20 patients, 15 underwent surgery 1-2 months after temporary PVE. One (6.7%) patient presented with liver decompensation in the postoperative period. Five patients were not eligible for surgery because of tumor progression. Histologic examination of the resected liver revealed the presence of absorbable gelatin sponge powder in a few distal portal tracts in four patients. No residual absorbable gelatin sponge powder was observed in portal vessels in the remaining 11 patients. CONCLUSIONS: Temporary PVE resulted in sufficient hypertrophy of the liver that did not receive embolization to enable surgical planning in all patients in our series.

An acute abdominal syndrome reveals a postoperative ilio-iliac arteriovenous fistula: about one case.

INTRODUCTION: Postoperative ilio-iliac arteriovenous fistula is an unusual but known complication after lumbar surgery. CASE REPORT: We report the case of a 74-year-old patient consulted at the emergency department for intense acute abdominal syndrome revealing a post-operative common ilio-iliac arteriovenous fistula 5 years after a lumbosacral arthrodesis L3-S1. The patient was treated with an endovascular arterial stent-graft with immediate vascular and clinical results. CONCLUSION: Arteriovenous fistula is a possible etiology of acute abdominal syndrome in patients with lumbar or abdominopelvic surgery history.

Stomach position versus liver-to-thoracic volume ratio in left-sided congenital diaphragmatic hernia.

OBJECTIVE: To describe a new grading method for stomach position (SP) in fetuses with left-sided congenital diaphragmatic hernia (L-CDH) using ultrasound and to correlate SP to liver position and to liver-to-thoracic cavity volume ratio (LiTR) using magnetic resonance imaging. METHODS: SP were graded at the level of the 4-chamber view as following: grade 1-to-4 for stomach not visualised, visualised anteriorly at the apex of the heart, stomach showing abdominal structures anteriorly and stomach with its larger part posterior to the level of the atrial-ventricular heart valves, respectively. The LiTR was calculated and correlated to SP using the Mann-Whitney U test. RESULTS: Seventy-four fetuses were included. Median LiTR for grade 1 SP was 0% and was not different from median LiTR for grade 2 SP (0%, p=NS). Median LiTR for grade 3 SP was 14.9% and was significantly higher than for grade 2 SP (p<0.001). Similarly, median LiTR for grade 4 SP was 20.7% and was significantly higher than for grade 3 SP (p<0.05). When SP was grade 1 or 2, liver was intra-abdominal in 21 (84%) out of 25 fetuses while it was always intrathoracic for SP 3 or 4. CONCLUSION: In L-CDH, SP as described represents a simple indirect measurement of intrathoracic position and quantification of liver.

Clinical predictors of radiographic abnormalities among infants with bronchiolitis in a paediatric emergency department.

BACKGROUND: Acute viral respiratory exacerbation is one of the most common conditions encountered in a paediatric emergency department (PED) during winter months. We aimed at defining clinical predictors of chest radiography prescription and radiographic abnormalities, among infants with bronchiolitis in a paediatric emergency department. METHODS: We conducted a prospective cohort study of children less than 2 years of age with clinical bronchiolitis, who presented for evaluation at the paediatric emergency department of an urban general hospital in France. Detailed information regarding historical features, examination findings, and management were collected. Clinical predictors of interest were explored in multivariate logistic regression models. RESULTS: Among 410 chest radiographs blindly interpreted by two experts, 40 (9.7%) were considered as abnormal. Clinical predictors of chest radiography achievement were age (under three months), feeding difficulties, fever over 38°C, hypoxia under than 95% of oxygen saturation, respiratory distress, crackles, and bronchitis rales. Clinical predictors of radiographic abnormalities were fever and close to significance hypoxia and conjunctivitis. CONCLUSION: Our study provides arguments for reducing chest radiographs in infants with bronchiolitis. For infants with clinical factors such as age less than three months, feeding difficulties, respiratory distress without hypoxia, isolated crackles or bronchitis rales, careful clinical follow-up should be provided instead of chest radiography.

Impact of chest radiography for children with lower respiratory tract infection: a propensity score approach.

BACKGROUND: Management of acute respiratory tract infection varies substantially despite this being a condition frequently encountered in pediatric emergency departments. Previous studies have suggested that the use of antibiotics was higher when chest radiography was performed. However none of these analyses had considered the inherent indication bias of observational studies. OBJECTIVE: The aim of this work was to assess the relationship between performing chest radiography and prescribing antibiotics using a propensity score analysis to address the indication bias due to non-random radiography assignment. METHODS: We conducted a prospective study of 697 children younger than 2 years of age who presented during the winter months of 2006-2007 for suspicion of respiratory tract infection at the Pediatric Emergency Department of an urban general hospital in France (Paris suburb). We first determined the individual propensity score (probability of having a chest radiography according to baseline characteristics). Then we assessed the relation between radiography and antibiotic prescription using two methods: adjustment and matching on the propensity score. RESULTS: We found that performing a chest radiography lead to more frequent antibiotic prescription that may be expressed as OR = 2.3, CI [1.3-4.1], or as an increased use of antibiotics of 18.6% [0.08-0.29] in the group undergoing chest radiography. CONCLUSION: Chest radiography has a significant impact on the management of infants admitted for suspicion of respiratory tract infection in a pediatric emergency department and may lead to unnecessary administration of antibiotics.

Delivery induced intraperitoneal rupture of a cystic ovarian teratoma and associated chronic chemical peritonitis.

Intraperitoneal rupture of cystic ovarian teratoma is a rare complication. We report a case in a 29-year-old female, with increased abdominal circumference 2 months after vaginal delivery. MRI/CT raised this diagnosis associated to chemical peritonitis. A malignant ovarian mass with peritoneal carcinomatosis was excluded. Laparoscopic oophorectomy was performed and histologic analysis confirmed imaging findings. This case demonstrates the interest of imaging before surgery in pelvic masses to avoid misdiagnosing and to provide adequate treatment.

Accuracy of ultrasonography and magnetic resonance imaging in the diagnosis of placenta accreta.

PURPOSE: To evaluate the accuracy of ultrasonography and magnetic resonance imaging (MRI) in the diagnosis of placenta accreta and to define the most relevant specific ultrasound and MRI features that may predict placental invasion. MATERIAL AND METHODS: This study was approved by the institutional review board of the French College of Obstetricians and Gynecologists. We retrospectively reviewed the medical records of all patients referred for suspected placenta accreta to two university hospitals from 01/2001 to 05/2012. Our study population included 42 pregnant women who had been investigated by both ultrasonography and MRI. Ultrasound images and MRI were blindly reassessed for each case by 2 raters in order to score features that predict abnormal placental invasion. RESULTS: Sensitivity in the diagnosis of placenta accreta was 100% with ultrasound and 76.9% for MRI (P = 0.03). Specificity was 37.5% with ultrasonography and 50% for MRI (P = 0.6). The features of greatest sensitivity on ultrasonography were intraplacental lacunae and loss of the normal retroplacental clear space. Increased vascularization in the uterine serosa-bladder wall interface and vascularization perpendicular to the uterine wall had the best positive predictive value (92%). At MRI, uterine bulging had the best positive predictive value (85%) and its combination with the presence of dark intraplacental bands on T2-weighted images improved the predictive value to 90%. CONCLUSION: Ultrasound imaging is the mainstay of screening for placenta accreta. MRI appears to be complementary to ultrasonography, especially when there are few ultrasound signs.

Liver-to-thoracic volume ratio: use at MR imaging to predict postnatal survival in fetuses with isolated congenital diaphragmatic hernia with or without prenatal tracheal occlusion.

OBJECTIVE: To evaluate the relationship of the liver-to-thoracic volume ratio (LiTR) by MRI with postnatal survival in foetuses with isolated congenital diaphragmatic hernia (CDH). METHODS: In 30 conservatively managed CDH foetuses and in 31 who underwent fetoscopic endoluminal tracheal occlusion (FETO), logistic regression analysis was used to investigate the effect on postnatal survival of the observed-to-expected (O/E) ratio of total foetal lung volume (TFLV), LiTR, gestational age at delivery, CDH side, intrathoracic position of the liver and, for those who underwent FETO, gestational age at FETO and occlusion period. For 19 foetuses undergoing FETO, a post-FETO MRI was available. The proportionate increase in O/E ratio of TFLV at 3-8 weeks after FETO was compared with the pre-FETO value and correlated with pre-FETO LiTR using linear regression analysis. RESULTS: For conservatively managed foetuses, only LiTR provided a significant prediction of postnatal survival. For foetuses undergoing FETO, LiTR and gestational age at delivery provided a significant independent prediction of postnatal survival. There was a significant inverse association between lung response and pre-FETO LiTR. CONCLUSION: In foetuses with CDH with/without FETO treatment, the LiTR is predictive of postnatal survival at discharge. In foetuses treated with FETO, LiTR is predictive of post-FETO lung response. KEY POINTS: • Congenital diaphragmatic hernia is usually managed conservatively before surgery soon after delivery • Fetoscopic endoluminal tracheal occlusion (FETO) has been introduced for severely affected foetuses • In conservatively managed CDH, the liver-to-thoracic volume ratio (LiTR) predicted postnatal survival best. • In severe CDH with prenatal FETO, LiTR also helped predict postnatal survival. • LiTR should be integrated into the prenatal decision-making for foetuses with CDH.

[What is the impact of fetal magnetic resonance imaging (MRI) on prenatal diagnosis of cerebral anomalies].

Fetal magnetic resonance imaging (MRI) is an adjunct to sonography (US), often necessary when cerebral abnormality is suspected. With use of fast sequences, such as T2 HASTE or SSFSE, gradient-echo T1- weighted images and diffusion-weighted imaging, it is possible to obtain images of fetal brain in three planes without mother's sedation. Diagnosing brain anomalies using MRI requires good knowledge of normal anatomy depending on gestational age: phases of neuronal migration, sulcation and gyration, myelination in particular. The main indications to perform MRI are as follows : ventricular dilatation, midline and posterior fossa abnormalities, microcephaly (in search for migrational disorders), cerebral location of tuberous sclerosis which is suspected when cardiac tumours are detected. MRI allows to confirm US diagnosis and to answer the question whether the abnormality is isolated or complex. This enables not only to establish the diagnosis but also the prognosis. This method plays an important role in the work of the interdisciplinary team managing the pregnancies with a suspicion of congenital anomalies. Prenatal MRI is a great progress in diagnosing brain anomalies and has become indispensable in modern perinatology in the last decades. The situation of mother and child after the anomaly had been detected requires discussion and care of the interdisciplinary team consisting of an obstetrician, neonatologist, radiologist, geneticist, pathologist, psychologist and paediatric neurologist.

Leiomyosarcoma of the inferior vena cava involving the renal veins: a simple method of right renal vein reimplantation.

In this report we describe a case of leiomyosarcoma of the inferior vena cava involving the renal veins. The abdominal computed tomography scan showed a tumor in the infrahepatic portion of the inferior vena cava and the confluence of the renal veins. After resection of the tumor, venous reconstruction involved the replacement of the inferior vena cava with a prosthetic graft and the implantation of the right renal vein into the portal vein. The left renal vein was ligated distally, with preservation of collateral pathways. To our knowledge, no other reports of such venous reconstruction have been published. After a follow-up of 30 months, the patient has shown no further symptoms, and the abdominal computed tomography scan demonstrates patency of the renal portal anastomosis. Tests indicated normal renal and hepatic function, suggesting good tolerance of the renal portal anastomosis. We believe that the technique described in this report should be adopted routinely for tumors located in the renal veins, provided complete resection of the tumor with a comfortable resection margin is possible.

Progressive neuronal degeneration of childhood: prenatal diagnosis by MRI.

We report two cases in the same family of progressive neuronal degeneration of childhood--Alpers syndrome--with prenatal MRI findings in one case. The first infant presented at birth with severe microcephaly, then rapidly evolved to progressive encephalopathy with refractory epilepsy, leading to death at 10 months. Biochemical investigations including liver function tests were normal. CT and MRI showed severe diffuse brain atrophy. The diagnosis of progressive neuronal degeneration of childhood was made on the clinical and imaging data. The second pregnancy was marked by gradual decrease of fetal cerebral biometry and a prenatal MRI performed at 32 weeks showed diffuse cortical atrophy, as observed in the sibling. The infant died at 5 months. Neuropathological findings were consistent with Alpers syndrome.

Mesenteric adenitis and portal vein thrombosis due to Fusobacterium nucleatum.

We report the first description of portal and mesenteric vein thrombosis associated with suppurative mesenteric adenitis in a 71-year-old woman. The bacterium detected in mesenteric lymph nodes was Fusobacterium nucleatum, an anaerobic Gram-negative bacillus. Our patient had a clinical syndrome of pharyngitis and fever preceding portal vein thrombosis. Abdominal symptoms improved with antibiotics and anticoagulant therapy. This location of F. nucleatum in mesenteric lymph nodes provides an interesting insight into the occurrence of septic thrombosis in the portal vein following pharyngo-tonsillar infection.