Osteogenesis imperfecta, multiple intra-abdominal arterial dissections and a ruptured dissecting-type intracranial aneurysm.

We describe an adult patient with a ruptured dissecting-type superior cerebellar artery aneurysm and known osteogenesis imperfecta. He was successfully treated with coil embolization and intentional parent vessel sacrifice. During his hospital admission, he also suffered from abdominal distension. An incidental note was made of multiple intra-abdominal arterial dissections. These were managed conservatively. We review the rare association of osteogenesis imperfecta and intracranial aneurysms, as well as discuss management implications.

Imaging of hepatic infections.

Imaging plays a significant role in the detection, characterization and treatment of hepatic infections. Infectious diseases of the liver include pyogenic and amoebic abscesses and parasitic, fungal, viral and granulomatous infections. With increases in worldwide travel, immunosuppression and changing population demographics, identification of cases of hepatic infection is becoming more common in daily practice. Knowledge of the imaging features seen with hepatic infections can assist in early diagnosis and timely initiation of appropriate therapy. This review presents the imaging appearances of hepatic infections, emphasizing specific features that may contribute to the diagnosis. Examples of the imaging findings seen with pyogenic and amoebic abscesses, infection with Echinococcus granulosus (Hydatid), schistosomiasis, candidiasis and tuberculosis (TB) are presented.

Triple-phase MDCT of hepatocellular carcinoma.

OBJECTIVE: The purpose of this study was to describe the appearances of hepatocellular carcinoma including intralesional contrast washout using a triple-phase liver protocol on an MDCT scanner. MATERIALS AND METHODS: Fifty-one patients with newly diagnosed hepatocellular carcinoma underwent standardized triple-phase CT using a multidetector scanner. Pathologic proof was obtained in 35 patients (69%); in 16 patients (31%), hepatocellular carcinoma was diagnosed on clinical and laboratory findings. Two radiologists independently reviewed the CT studies for the appearance and attenuation of the lesions. Intralesional washout of contrast material was evaluated subjectively and objectively. Statistical analysis was performed using Fisher's exact test to analyze the relationships between tumor appearance and alpha-fetoprotein level, tumor grade, and risk factor. Correlation between tumor size and appearance was analyzed using the Student's t test and Wilcoxon's rank sum test. RESULTS: The most common enhancement pattern for hepatocellular carcinoma was hypervascularity on hepatic arterial phase images with a mosaic pattern on both arterial and portal venous images; this finding was seen in 86% and 78% of lesions by the two observers, respectively. A hypervascular component was seen in 96% of lesions by both observers, and the observers recorded 86% and 63% of lesions as showing washout, respectively. Objective washout was present in 76% of lesions. Both subjective and objective washout correlated with an elevated alpha-fetoprotein level (p = 0.01). CONCLUSION: The appearances of hepatocellular carcinoma on images obtained using MDCT scanners are similar to those described for images obtained using single-detector helical scanners. However, the prevalence of hypervascular hepatocellular carcinoma on MDCT images is higher than previously described on single-detector helical images and most lesions showed washout on portal venous MDCT images.

Lymphoproliferative disorders after liver transplantation: imaging features.

BACKGROUND: To define the imaging features of lymphoproliferative disorders that occur after liver transplantation. METHODS: A retrospective review of 605 liver transplantations between 1985 and 1998 showed 20 patients with posttransplantation lymphoproliferative disorders (PTLDs). All relevant clinical, imaging, and pathologic findings were reviewed. RESULTS: PTLDs occurred in 13 men and seven women (mean age = 43.3 years, age range = 18-68 years). The time to diagnosis of disease ranged from 1.5 to 51 months (mean = 14 months) posttransplantation. Cervical, thoracic, or abdominal lymphadenopathy was seen in 11 patients (55%). A complex portal mass in five patients (25%) was the second most common manifestation of PTLD, ranging in size from 5 to 12 cm. Other findings included gastrointestinal tract involvement in three patients (15%) seen as a duodenal mass and diffuse wall thickening in one patient and large bowel thickening in two patients with preexisting inflammatory bowel disease. CONCLUSION: There is a wide spectrum of findings in lymphoproliferative disorder after liver transplantation. The presence of lymphadenopathy, a portal mass, or bowel thickening indicates a need for further investigation to reach a pathologic diagnosis.

Radiology reports: examining radiologist and clinician preferences regarding style and content.

OBJECTIVE: The introduction of picture archiving and communication systems (PACS) frequently includes the option of computer-generated itemized reports. This motivated us to reassess the merits of traditional prose dictated reports. This study examines radiologist and clinician preferences regarding report style and content. MATERIALS AND METHODS: The study was conducted in two parts. The first part was a retrospective audit of existing medical imaging prose reports to determine their content. The second part comprised a questionnaire containing three mock clinical scenarios. Three pairs of reports were provided for each scenario, with only essential information in the first pair, some optional information in the second, and the most complete report in the third. Each pair consisted of a prose and itemized report with identical content. Participants ranked reports by preference and were asked specific questions regarding report content. The questionnaires were mailed to referring clinicians and administered during an interactive forum to staff radiologists, radiology fellows, and radiology residents. RESULTS: The audit of existing reports showed a wide variation in all fields with consistency limited to a given radiologist. Responses to the questionnaire showed that, in general, a majority of radiologists and referring clinicians preferred itemized reports. The itemized report with the most detailed content was ranked highest of all three scenarios. CONCLUSION: Prose reports foster a lack of standardization of content among different radiologists. Itemized reports facilitate complete documentation of information and measurements and are more popular with both radiologists and referring clinicians.

Radiological features of epiploic appendagitis and segmental omental infarction.

Epiploic appendagitis and segmental omental infarction are more frequently encountered with the increased use of abdominal ultrasound and Computed tomography (CT) in the radiological assessment of the patient who presents clinically with acute abdominal pain. Recognition of specific imaging abnormalities enables the radiologist to make the correct diagnosis. This is important, as the appropriate management of both conditions is often conservative. Follow-up imaging features correlate with clinical improvement.

Introduction of an ultrasound picture archiving and communication system: experience in the first year.

OBJECTIVE: To describe the authors' first year's experience with a picture archiving and communication system (PACS) for the management and storage of ultrasound images and to discuss the financial impact of the system in terms of costs of purchase, installation and operation. MATERIALS AND METHODS: The Toronto Hospital, General Division, performs more than 30000 ultrasound studies each year. On June 27, 1994, an Ultra PACS (ALI Technology Incorporated, Richmond, BC) was introduced as the only method of image storage and archiving in the Ultrasound Division. RESULTS: After structural renovations and a detailed work flow analysis, the Ultrasound Division converted from film to the PACS over a single weekend with no back-up. The advantages to date include consistently high-quality images; rapid image retrieval (images from the same day [online], 0 to 45 seconds; archived images [online], 3 to 5 minutes; images in storage [offline], 3 minutes); no loss of images; more efficient patient through-put, which allows the division to handle the same number of patients in 20% less operational time (change from a 10-hour day to an 8-hour day, over a 5-day week); less end-of-day overtime; and an improved work environment. There has been no change in the division's complement of full-time equivalent technologists, the number of film librarians has been reduced by 1, and physician service time has decreased by 20%. There has been no significant impact on overall operational financial status. CONCLUSION: The PACS has proved an efficient method for managing large numbers of ultrasound images in a cost-effective and technically sound manner. Its installation provides the basis for meeting the Ultrasound Division's next objective, to eliminate paper as the primary method of managing patient information and reports.

Case for active physician involvement in US practice.

PURPOSE: To assess the benefit of active physician involvement in ultrasound (US) examinations. MATERIALS AND METHODS: Concordance of findings by technologists and physicians was assessed prospectively for examinations of 1,510 consecutive patients who underwent US during regular working hours. RESULTS: Overall concordance was generally good (74%). However, in cases in which a major or minor new diagnosis was made from the US scan, concordance rates were substantially lower (36% and 32%, respectively). Agreement varied with the type of examination. The discordance rate for obstetric examinations (17%) was only half that for abdominal and pelvic examinations (31%). Concordance improved with increasing years of experience of the technologist. CONCLUSION: An active role of physicians in the overall conduct of US examinations is essential to optimize provision of a complete, accurate report.

Misdiagnosis of renal cell carcinoma by computed tomography with angiography: a potential pitfall.

The introduction of helical computed tomography (CT) has led to an increase in the number and complexity of CT protocols. This situation has resulted in a new source of error in the interpretation of CT scans. The authors report a case in which a hyperattenuating cyst discovered incidentally at the time of CT with angiography could have been misdiagnosed as renal cell carcinoma.

Needle size and sample adequacy in ultrasound-guided biopsy of thyroid nodules.

OBJECTIVES: To determine the optimal needle size (23-gauge or 27-gauge) for ultrasound-guided fine-needle aspiration biopsy of thyroid nodules and to compare the interoperator yield for this procedure. PATIENTS AND METHOD: Over an 11-month period, 123 patients underwent biopsy of a thyroid nodule. Three experienced radiologists were assigned at random to sample the nodules. For each nodule, four passes were performed in random order, two with 23-gauge needles and two with 27-gauge needles. If a specific pass yielded no tissue or blood, as determined by visual inspection (i.e., the sample was dry), the procedure was repeated until a satisfactory sample was obtained. After each patient had left the department, the aspirates were reviewed by a cytopathologist (who was not aware of needle size or operator identity) to determine diagnostic adequacy. RESULTS: Among the 123 nodules, 88 were solid, and 35 were complex cysts. There was no significant difference between the two sizes of needle in the adequacy of the samples obtained (102 nodules were adequately sampled with the 23-gauge needle and 95 with the 27-gauge needle; McNemar chi 2 test, p = 0.1456). However, there were significantly fewer dry passes with the larger needle (2 with the 23-gauge needle and 16 with the 27-gauge needle; chi 2 test, p = 0.0022). Sixteen nodules were inadequately sampled with both needles. Eight of these were less than 1 cm in greatest dimension. Only one solid nodule greater than 1 cm in greatest dimension was inadequately sampled. There was no difference in yield among the three radiologists (chi 2 test, p = 0.5192). No significant complications were encountered. CONCLUSIONS: Needles of both 23 and 27 gauge can be used to obtain fine-needle aspiration biopsy samples from thyroid nodules. Using both sizes is recommended, because the number of dry passes is lower with the larger needle, but the diagnostic quality of the aspirate may be better with the smaller one. Experienced physicians can perform fine-needle aspiration biopsy with equal proficiency.