Pneumorrhachis as a complication of a severe pressure ulcer: An unique case report.

Pneumorrhachis is a medical condition that refers to the presence of air within the spinal canal. Many circumstances, including trauma, infection, or medical procedures, might lead to this syndrome.In some cases, pneumorrhachis may not cause any symptoms and can resolve on its own. However, it can also be associated with more severe underlying conditions, such as spinal fractures, spinal infections, or underlying lung pathologies that lead to air escaping into the spinal canal. In this case we report an incidental finding of pneumorrhachis in a patient who came to our attention for suspected sepsis.

Incidental finding of Bochdalek hernia in an adult: a case report.

A Bochdalek hernia, also known as a congenital diaphragmatic hernia (CDH), is a type of hernia that occurs in infants. The diaphragm, the muscle that separates the chest cavity from the abdominal cavity, is characterized by a hole or gap during birth. This opening allows the abdominal organs, such as the stomach, intestines, or liver, to pass through the thoracic cavity. Here, we report a 56-year-old male patient who came to our hospital because of rectal bleeding, symptoms unrelated to the hernia. We performed a Computed Tomography (CT) scan with contrast enhancement to find the cause of the bleeding and as an incidental finding we diagnosed the hernia: it is very rare to find a silent Bochdalek hernia for more than 50 years.

Mesentero-axial gastric volvulus in an old woman: a case report of a diagnostic challenge.

Gastric volvulus is a rare conditiom defined as an abnormal rotation of the stomach around itself. Acute gastric volvulus is a surgical emergency because it is a life-threatening condition, but its non-specific symptoms make diagnosis difficult. There are two types of gastric volvulus: organoaxial and mesentero-axial. The treatmet is surgical intervention. Computed tomography allows to identify and classify gastric volvulus and rule out complications so that to guide surgery management. We report a case of a mesentero-axial gastric volvulus in an old woman with abdominal pain, who underwent surgery in laparoscopy.

Imaging of thoracolumbar spine traumas.

Spine trauma is an ominous event with a high morbidity, frequent mortality, and significant psychological, social, and financial consequences for patients, their relatives and society. On average three out of four spinal fractures involve the thoracolumbar spine and up to one-third are complicated by spinal cord injury. Spinal cord injuries (SCI) are a significant cause of disability in US and in all western countries. Knowledge of the main principles of biomechanics is essential in understanding the patho-morphology of spinal injuries, and the evolution of the various classification systems. Classification systems should be able to create a common language between specialists in order to improve patients' prognosis, guide treatment and compare treatment outcomes. Imaging has always been crucial in the evaluation of the injury type and accompanied the development of different classification systems. Thoracolumbar spine (TLS) trauma has a wide spectrum ranging from minor isolated fractures to highly unstable fracture-dislocations. Early classification systems were based on the analysis of the pattern of bony injuries on radiographs and CT. Traditionally, conventional radiographs are performed to confirm the clinical suspicion and to depict the level and type of bone injury. However, because of their inherent limitations, radiographs are often more helpful in proving the existence of a suspected bony spinal injury rather than excluding it. Multidetector computed tomography (MDCT) is superior in evaluating bone anatomy and, especially in polytrauma patients, it is the first line imaging modality. Morphological bone damage may be accurately shown and classified on CT. the most recent classifications also incorporate the integrity of soft tissues structures, which is considered equally relevant to spinal stability. Injuries to ligaments and discs can only be suspected on radiographs and conventional CT, although dual-energy CT is offering new insights on collagen mapping of damaged discs. Magnetic resonance imaging (MRI) may directly assess disc and ligamentous injuries, but also subtle osseous injuries, playing a complementary role in defining the whole spinal damage and an eventual instability. MRI is the only valid modality to assess the spinal cord (SC) and is indicated whenever a neurologic injury is suspected. Advanced MRI techniques, such as diffusion weighted imaging (DWI) and tractography, may provide further information regarding the integrity of the white matter which may improve outcome prognostication. Despite challenges in terms of costs, availability, accessibility and specificity, MRI and advanced MRI techniques are increasingly being used in spinal injuries. We present a review on TLS traumas discussing on the development of different classification system used in their evaluation, the role of imaging for their detection and the correlation to the patients' outcomes and treatment options.

Endovascular repair of isolated post-traumatic subclavian artery false-aneurysm (FA) using gore viabahn vbx-balloon-expandable (BE) stent-graft: case report and literature review.

True and false aneurysms (FA) of the subclavian artery are at high risk of rupture due to their localization and proximity/closeness to the articular bone structures of the upper thoracic outlet and shoulders. Surgical and endovascular treatments are good options to avoid complications such as aneurysms rupture, thrombosis and distal embolism alone or in combination. Self-expandable (SE) covered stents are the most used devices for the treatment of subclavian artery aneurysms. We report on a case of post traumatic left intra-thoracic subclavian artery FA treated using endovascular technique, highlighting the usefulness of the new covered Gore Viabahn VBX-BE stent-graft that combines the advantages of a high radial strength of a BE stent with the deliverability and conformability of a SE stent.

The value of DTI: achieving high diagnostic performance for brain metastasis.

BACKGROUND: The evaluation of brain metastases generally requires post-contrast MRI exam, but some patients have contraindication to contrast medium administration. PURPOSE: To investigate the value of the MRI diffusion tensor imaging (DTI) for detection of metastatic brain tumor. MATERIALS AND METHODS: We retrospectively analyzed the MRI data from 23 patients (13 males and 10 females) with brain metastases. The MRI protocol consisted in T1WI, T2WI, post-contrast 3DT1WI and DTI images (b = 1000) sequences. The brain metastatic lesions were counted in each of these sequences. We compared the advantages and limitations of different sequences in the brain metastases detection. The number of metastatic lesions identified on the contrast-enhanced 3DT1WI image is used as the reference. FA values were measured in the intratumoral, adjacent peritumoral and distant peritumoral edema area (PTEA) of brain metastasis, and the differences were statistically analyzed. RESULTS: DTI can detect more brain metastatic lesions rather than T1WI and T2WI. The number of brain metastases on DTI is similar to post-contrast 3D T1WI. There is no statistical difference in the FA value change between the adjacent and distant PTEA. CONCLUSION: The DTI original image can be used as an alternative examination for patients with contraindications to contrast-enhanced MRI. It has high sensitivity to intratumoral hemorrhage, which has advantage to detect brain metastatic lesions as compared with T1WI or T2WI images.

Imaging of cranio-cervical junction traumas.

The craniocervical junction (CCJ) or upper cervical spine (UCS) has anatomic features and a biomechanics completely different from the other spinal segment of the spine. Several ligaments and muscles control its motion and function and ensure the maximum mobility and the visual and auditory spatial exploration. UCS traumas represent approximately one-third of all cervical spine injuries. Most of UCS traumas results from blows to the head and sudden deceleration of the body. Thanks to the improvement of the Advanced Trauma Life Support protocols dissociative injuries of CCJ have become less lethal onsite. In other less severe but unstable injuries, patients are neurologically intact at presentation, but they may deteriorate during the stay in hospital, with important clinical and medico-legal consequences. Knowing the peculiarities of UCS is fundamental for the early detection of imaging findings that influences the patient management and outcome. The classification of UCS traumas is mechanistic. More than in any other spinal segment, fractures of CCJ bones can occur without generating instability; on the contrary highly unstable injuries may not be associated with bone fractures. An early and correct diagnosis of occipito-cervical instability may prevent secondary neurological injury. The goal of imaging is to identify which patients can benefit of surgical stabilization and prevent secondary neurologic damage. Actual helical multidetector-CT (MDCT) offers high sensitivity and specificity for bone lesions and displacements in cervical spine traumas, but magnetic resonance imaging (MRI) is increasingly being used to evaluate soft tissues and ligaments, and mainly to identify possible spinal cord injury.

Assessment of lumbar disc herniaton using fractional anisotropy in diffusion tensor imaging along with conventional T2-weighted imaging.

OBJECTIVE: To assess the usefulness of diffusion tensor imaging and its fractional anisotropy map along with conventional T2-weighted imaging in evaluating the anisotropic water diffusion variations of annulus fibres involved in herniation disc pathology. MATERIALS AND METHODS: Seventy-five patients with previous medical ethics committee approval and informed consent experiencing low back pain were selected for this prospective randomised blinded trial. Lumbar disc fractional anisotropy maps were obtained acquiring diffusion tensor sequences on a 3T machine. The matrix of nucleus pulposus and structures of annulus fibres were analysed using fractional anisotropy textural features to highlight any presence of lumbar disc herniation. Observer variability and reliability between two neuroradiologists were evaluated. The χ2 test, two-tailed t test and linear regression analysis were used to focus differences in patients' demographic data and magnetic resonance imaging findings. RESULTS: Annular fissures with extrusions were identified using diffusion tensor imaging in 10 out of 17 discs (study group) previously assessed as bulging discs using conventional magnetic resonance imaging. Eighteen extrusions out of 39 (study group) disc levels were identified on diffusion tensor imaging compared to eight extrusions highlighted on T2-weighted imaging (P < 0.01). All eight (study group) disc extrusions evaluated on T2-weighted imaging showed annular fissures on diffusion tensor imaging. Seven out of 14 (study group) protrusions highlighted on T2-weighted imaging had no annular fissures on diffusion tensor imaging; thirty-six disc levels in the control group had no evidence of annular fissures on diffusion tensor imaging (P > 0.01). CONCLUSIONS: The addition of diffusion tensor imaging sequences and fractional anisotropy mapping to a conventional magnetic resonance imaging protocol could be useful in detecting annular fissures and lumbar disc herniation.

Dynamic Weight-bearing Magnetic Resonance in the Clinical Diagnosis of Internal Temporomandibular Joint Disorders.

Temporomandibular joint (TMJ) disorders can be painful and cause functional limitations and bone changes. Deeper clinical knowledge of the pathologies related to the TMJ has always been hindered by the difficult identification of the causes that limit its movement. Weight-bearing magnetic resonance imaging (WBMRI) can reproduce the articular movement in orthostasis and allows the evaluation of joint movement. WBMRI, compared with other procedures such as double-type condylography and real-time dynamic ultrasound, helps to better identify tissue characteristics of the articular glenoid-condylar surfaces, articular space, disk position on both the open and closed mouth, and the locoregional musculotendinous area. WBMRI also identifies the true position of the articular disk in orthostasis, emphasizing the different joint positions compared with the study carried out in a clinostatic (supine) position.

Imaging of cervical spine traumas.

Spinal traumas represent a significant proportion of muscle-skeletal injuries worldwide. Spinal injuries involve a complex structure with components having different traumatic susceptibility and variable healing capabilities. The interaction of numerous variables at time of trauma creates a great variety of lesions which makes challenging the creation and comparison of homogeneous groups, with difficulties in classifying spinal lesions, in assessing their instability, and in defining the indication and outcome of different treatment strategies. The evolution of concepts on instability has accompanied that of traumas classification schemes and treatment strategies. The assessment of instability in a spinal injury is actually crucial in front of newer surgical techniques and hardwares. Despite a long history of attempts to classify spinal traumas, it remains some degree of controversy in describing imaging data and a wide variety of treatment strategies. Acute cervical spine injuries affect from 1.9% to 4.6% of subjects reporting a blunt trauma, and up to 5.9% of multiple-injured patients. Most of spinal cord injuries are a consequence of unstable fractures of the cervical spine. An accurate and early diagnosis is mandatory to prevent neurological damage in unstable fractures. Classic and newer classifications are primarily based on features identifiable by using conventional imaging and CT scan, which are the most available modalities at most trauma centers. Even though multidetector-CT remains superior in assessing with high accuracy bone injuries, MRI is the most sensitive modality for detecting soft tissues injuries and spinal cord damage.

Medical radiological procedures: which information would be chosen for the report?

AIMS AND OBJECTIVES: The aim of this study was to properly define the information regarding patient exposure to Ionizing Radiations in the radiological report, according to the European Directive 2013/59/EURATOM (EU 2013/59 art.58(b)). For this purpose, we evaluated the results from other Member States EU 2013/59 transpositions and from Guidelines recommendation published by International Organizations involved in diagnostic radiology. A practical way for implementing art.58 is also traced. MATERIALS AND METHODS: Dosimetric quantities, such as exposure, absorbed dose and effective dose which may be included in radiological report, were first analyzed; then, in order to define international state of art of Member States EU 2013/59 transposition, a Web research using French, English, Spanish and German key words was performed. RESULTS: EU 2013/59 transposition for 5 Member States was reported. Especially regarding art.58, a European project reports that few European countries (11 of 28) have identified the dose metrics to be used in radiological report. Scientific organizations supporting clinical radiologists and medical physicists have published Guidelines reporting parameters useful to quantify the radiation output and to assess patient dose. CONCLUSIONS: Our research revealed that there is not a shared interpretation of patient exposure information to be included in radiological report. Nevertheless, according to scientific community, authors believe that the exposure is the most appropriate information that could be included in radiological report. Alternatively, but with more expensiveness, a risk index based on effective dose could be used. Moreover, the systematic exposure information recorded could be useful for dose estimates of population from medical exposure.

Isolated fungus ball in sphenoid sinus: tips and pitfalls of T 1 hyperintense lesions.

Isolated sphenoid sinus fungus ball is a very rare condition. CT is the most used imaging investigation for diagnosis. In some cases, MRI may provide further information to evaluate the extracompartmental invasion. We report the case of an elderly female patient who presented with headache and a soft tissue mass filling the right sphenoid sinus on CT, misdiagnosed as simple sinusitis. After 1 year, with recrudescence of symptoms, brain MRI showed a hyperintense soft tissue mass on T 1 weighted images within the right sphenoidal sinus; a new CT examination revealed calcifications within the mass. Surgical histological examination showed fungus ball. Fungal ball should be included in the differential diagnosis of T 1 hyperintense lesions in the sphenoid sinus.

Osteoporosis: what the clinician needs to know?

Osteoporosis is a common condition and an important cause of disability. For this reason, early detection of the disease and patients at higher risk of bone fractures is compulsory. In the recent years, conventional quantitative methods have been spreading for the diagnosis of osteoporosis; moreover, new improvements in computed tomography (CT) and magnetic resonance imaging (MRI) have been made in this field and imaging findings may correlate to the morphological and structural changes within the bone.