Distribution of Femoral Metastases; Potential Role for Extended FDG PET/CT Scanning.

This study investigates the distribution of femoral metastases in cancer patients, specifically addressing the incidence of distal femoral metastases. PET/CT examinations routinely extend only to mid-thigh level, precluding detection of distal metastases. We found a total of 208 femoral metastases in 112 patients. 30% had distal femoral metastases in addition to other areas of involvement. 7% of patients with femoral metastases had only distal femur disease. 6 patients had distal pathologic fractures. Exclusion of the distal femur during PET/CT may result in a missed or delayed diagnosis that could contribute to the development of a pathologic fracture with increased morbidity.

Dual energy CT can aid in the emergent differentiation of acute traumatic and pathologic fractures of the pelvis and long bones.

PURPOSE: To determine whether dual energy CT (DECT) scanning can aid in the differentiation between acute traumatic and pathologic fractures of the pelvis and long bones. METHODS: Retrospective review of 11 patients with 15 pathologic fractures proven by biopsy and/or other advanced imaging modalities. Age- and sex-matched patients with non-pathologic traumatic fractures were used as controls. Studies were reviewed by two readers on syngo.via software before and after the creation of virtual bone marrow color maps. Hounsfield units (HU) of the marrow space at the level of the fracture were recorded on both reviews. Differences between the HU of the bone marrow of traumatic and pathologic fractures were compared using two-tailed unpaired t-test. RESULTS: A statistically significant difference was found in the HU of the affected bone marrow on DECT virtual noncalcium bone marrow color maps between the pathologic group (mean HU:4.89) and the non-pathologic group (mean HU: - 286.2) (p = 0.0177). HU measurements on the mixed kVp images were 150.4 for the pathologic and 94.1 for the non-pathologic fracture groups, respectively, with no statistical significance (p = 0.272). CONCLUSIONS: DECT scanning can aid in the differentiation between hematoma at acute traumatic fracture sites and neoplasm at pathologic fracture sites. HU of the bone marrow is higher for pathologic fractures, and the difference in bone marrow attenuation is more evident on the virtual bone marrow color maps.

A comparison of segmented abdominopelvic fluid volumes with conventional CT signs of abdominal compartment syndrome in a trauma population.

PURPOSE: To compare the utility of abdominopelvic fluid volume measurements with established computed tomography signs for refractory post-traumatic abdominal compartment syndrome. METHODS: This retrospective observational cohort study included 64 consecutive adult trauma patients with preoperative CT and diagnosis of refractory abdominal compartment syndrome requiring decompressive laparotomy at a level I trauma referral center between 2004 and 2014. We hypothesized that abdominal fluid volume measurements would be more predictive of the need for early laparotomy than previously described conventional CT signs of refractory ACS. Abdominopelvic fluid volumes were determined quantitatively using semi-automated segmentation software. The following conventional imaging parameters were recorded: abdominal anteroposterior:transverse ratio (round belly sign); infrahepatic vena cava diameter; distal abdominal aortic diameter; largest single small bowel wall diameter; hydronephrosis, inguinal herniation; and mesenteric and body wall edema. For outcome analysis, patients were stratified into two groups: those who underwent early (< 24 h) and late (≥ 24 h) decompressive laparotomy following CT. Correlation analysis, comparison of means, and multivariate logistic regression were performed. RESULTS: Abdominal fluid volumes (p = 0.001) and anteroposterior:transverse ratio (p = 0.009) were increased and inferior vena cava diameter (p = 0.009) was decreased in the early decompressive laparotomy group. Multivariate analysis including conventional CT variables, fluid volumes, and laboratory values revealed abdominal fluid volumes (p = 0.012; Δ in log odds of 1.002/mL) as the only independent predictor of early decompressive laparotomy. CONCLUSIONS: Segmented abdominopelvic free fluid volumes had greater predictive utility for decision to perform early decompressive laparotomy than previously described ACS-related CT signs in trauma patients who developed refractory abdominal compartment syndrome.

Therapeutic Effects of Nano-HAp in a Rat Model of AlCl3 Induced Neurotoxicity.

With the advance in nanomedicine, the present study was conducted to explore the possible therapeutic role of intravenous nano- hydroxyapatite (nano-HAp) in male rats after chronic exposure to aluminum chloride (AlCl3). This exposure interposed DNA fragmentation, apoptosis, alters oxidant/antioxidant status as well as change in content of neurotransmitters. The rats were injected with 100 mg/kg. body weight (b.w.) of AlCl3 intraperitoneally for 90 days, after then nano-HAp was injected intravenously (i.v.) three times per week at a dose level 100 mg/kg b.w. Based on the results obtained, it can be concluded that the treatment with the prepared nano-HAp restrains the damage inflicted on brain modulation by lipid oxidation products and decreased the susceptibility of apoptotic cells death with subsequent repaired the fragmented DNA as well as improved the synthesis of neurotransmitters. The most salient finding of nano-HAp treatment is the disappearance of most pathological changes due to AlCl3 administration.

CT Prediction Model for Major Arterial Injury after Blunt Pelvic Ring Disruption.

Purpose To develop and test a computed tomography (CT)-based predictive model for major arterial injury after blunt pelvic ring disruptions that incorporates semiautomated pelvic hematoma volume quantification. Materials and Methods A multivariable logistic regression model was developed in patients with blunt pelvic ring disruptions who underwent arterial phase abdominopelvic CT before angiography from 2008 to 2013. Arterial injury at angiography requiring transarterial embolization (TAE) served as the outcome. Areas under the receiver operating characteristic (ROC) curve (AUCs) for the model and for two trauma radiologists were compared in a validation cohort of 36 patients from 2013 to 2015 by using the Hanley-McNeil method. Hematoma volume cutoffs for predicting the need for TAE and probability cutoffs for the secondary outcome of mortality not resulting from closed head injuries were determined by using ROC analysis. Correlation between hematoma volume and transfusion was assessed by using the Pearson coefficient. Results Independent predictor variables included hematoma volume, intravenous contrast material extravasation, atherosclerosis, rotational instability, and obturator ring fracture. In the validation cohort, the model (AUC, 0.78) had similar performance to reviewers (AUC, 0.69-0.72; P = .40-.80). A hematoma volume cutoff of 433 mL had a positive predictive value of 87%-100% for predicting major arterial injury requiring TAE. Hematoma volumes correlated with units of packed red blood cells transfused (r = 0.34-0.57; P = .0002-.0003). Predicted probabilities of 0.64 or less had a negative predictive value of 100% for excluding mortality not resulting from closed head injuries. Conclusion A logistic regression model incorporating semiautomated hematoma volume segmentation produced objective probability estimates of major arterial injury. Hematoma volumes correlated with 48-hour transfusion requirement, and low predicted probabilities excluded mortality from causes other than closed head injury. © RSNA, 2018 Online supplemental material is available for this article.

Quantitative MDCT assessment of binder effects after pelvic ring disruptions using segmented pelvic haematoma volumes and multiplanar caliper measurements.

OBJECTIVE: To assess effects of pelvic binders for different instability grades using quantitative multidetector computed tomography (MDCT) parameters including segmented pelvic haematoma volumes and multiplanar caliper measurements. METHODS: CT examinations of 49 patients with binders and 49 controls performed from January 2008-June 2016, and matched 1:1 for Tile instability grade and Pennal/Young-Burgess force vector, were compared for differences in pubic symphysis and sacroiliac displacement using caliper measurements in three orthogonal planes. Pelvic haematoma volumes (ml) were derived using semi-automated seeded region-growing segmentation. Median caliper measurements and volumes were compared using the Mann-Whitney U test, and correlations assessed with Pearson's correlation coefficient. Relevant caliper measurement cutoffs were established using ROC analysis. RESULTS: Rotationally unstable (Tile B) patients with binders showed significant decreases in sacroiliac diastasis (2.7 mm vs. 4.5 mm; p=0.003) and haematoma volumes (135 ml vs. 295 ml; p=0.008). Globally unstable (Tile C) binder patients showed decreased sacroiliac diastasis (4.7 mm vs. 6.4 mm, p=0.04), without significant difference in haematoma volumes (284 ml vs. 234 ml, p=0.34). Four Tile C patients with binders demonstrated over-reduction resulting in pubic body over-ride. CONCLUSION: Rotationally unstable patients with binders have significantly less sacroiliac diastasis versus controls, corresponding with significantly lower haematoma volumes. KEY POINTS: • Haematoma segmentation and multiplanar caliper measurements provide new insights into binder effects. • Binder reduction corresponds with decreased pelvic haematoma volume in rotationally unstable injuries. • Discrimination between rotational and global instability is important for management. • Several caliper measurement cut-offs discriminate between rotationally and globally unstable injuries. • Pubic symphysis over-ride is suggestive of binder over-reduction in globally unstable injuries.

The Ability of Dual-Energy Computed Tomography to Distinguish Normal Bone Marrow From Metastases Using Bone Marrow Color Maps.

OBJECTIVE: The objective of this study was to determine if dual-energy computed-tomography bone marrow color maps can improve sensitivity, specificity, accuracy, and confidence of detection of bone metastases. METHODS: Institutional review board approved this retrospective review of a consecutive series of cancer patients. Two radiologists first evaluated the fused 120 kV computed tomography images and recorded a number of suspicious lesions, confidence level, and Hounsfield units for each lesion. After a time gap, the studies were randomized for a second review with dual-energy computed-tomography bone marrow color maps. RESULTS: Eighteen patients and 1105 bones were reviewed. A total of 227 true metastatic lesions were present. With bone marrow color map review, sensitivity increased from 76.2% to 86.8%, for reader 1, and from 80.2% to 92.8%, for reader 2. Specificity and accuracy also increased. Confidence level increased for 12 lesions. CONCLUSIONS: Dual-energy computed-tomography bone marrow color map analysis of patients with metastatic cancers can improve the sensitivity, specificity, accuracy, and confidence level for the detection of bone metastases.

Predictors of Malignancy in Hyperechoic Breast Lesions.

OBJECTIVES: Hyperechogenicity has been strongly associated with benign breast lesions. Although it is correct in most cases, hyperechogenicity must not always be considered synonymous with benignancy, as hyperechoic breast cancers do occur. The purpose of this study was to review clinical and imaging characteristics of hyperechoic breast lesions, looking for features associated with malignancy. METHODS: Institutional Review Board approval was granted for this research. A total of 19,417 sonographic examinations were performed between January 2009 and June 2013. Among these, hyperechoic lesions with histologic diagnoses, stability on long-term followup, or characteristic imaging appearances were included in the study. The patients' clinical charts, mammograms, and sonograms were reviewed. The clinical and imaging features were recorded, and the data was analyzed by the χ(2) test, Fisher exact test, and independent-samples t test, looking for statistically significant predictors of malignancy. RESULTS: Among the 19,417 scans, 42 patients (0.2%) with 44 hyperechoic lesions were identified. Twenty-six lesions fulfilling the inclusion criteria were included in the study: 5 malignancies (3 invasive ductal carcinomas, 1 invasive lobular carcinoma, and 1 invasive mucinous cancer) and 21 benign lesions. An irregular shape, a nonparallel orientation, and noncircumscribed margins were significantly associated with the risk of malignancy (P = .002, .02, and .01, respectively). CONCLUSIONS: A hyperechoic breast lesion must not always be assumed to be benign. Instead, a full sonographic assessment according to the American College of Radiology Breast Imaging Reporting and Data System descriptors is needed for correct characterization and avoidance of misdiagnosis.

Diffuse leukoencephalopathy in a 29-year-old male with hypertensive emergency.

Severe hypertension is associated with multiple symptoms that reflect the end-organ damage effect of rapidly increasing blood pressure. Encephalopathy is a manifestation of the clinical spectrum of hypertensive emergencies. Hypertensive encephalopathy was initially described as part of the posterior reversible encephalopathy syndrome, which mostly involved the parieto-occipital white matter of the brain. A more detailed review of this syndrome reveals many cases where the brain abnormalities are distributed in a more random pattern. We describe a case of diffuse leukoencephalopthy in a young male who presented with altered mental status, ataxia, and blurred vision. This is the most diffuse brain involvement ever described in hypertensive statuses.

The discrepancy rate between preliminary and official reports of emergency radiology studies: a performance indicator and quality improvement method.

BACKGROUND: At teaching hospitals, radiology residents give preliminary reports for imaging studies requested from the Emergency Department (ED). Discrepancy rates between preliminary and final reports represent an important performance indicator. PURPOSE: To present a system for feedback and follow-up of discrepancies, identify the variables associated with the rate and severity of such discrepancies, target the weaknesses, and suggest the need of a standard reference value for comparison among institutions. MATERIAL AND METHODS: A monitoring and communication system between the Department of Diagnostic Radiology and Emergency Department was initiated to mark and follow all studies from the ED for which the official reading was different than the preliminary interpretation. Data analysis was performed on all studies from 1 June 2011 to 31 May 2012, based on the severity of the discrepancy, imaging modality, resident training level, and organ system. The distribution of the number of discrepancies among the different resident levels and imaging modalities was determined, as well as the distribution of three severity scores in correlation with other variables. RESULTS: The overall discrepancy rate was 1.62%. The discrepancy rate was higher for first and second year residents (1.62% and 1.96%) than for third and fourth year residents (1.35% and 1.24%). It was higher for computed tomography (2.13%) than for radiographs (1.29%) and ultrasound (0.8%) (P value < 0.01), and higher for musculoskeletal (1.61%) than non-musculoskeletal (0.99%) radiographs (P value = 0.0003). Discrepancies with severity score one constituted 35.5% of the total discrepancies, those with severity scores two and three constituted 22.9% and 41.6%, respectively. CONCLUSION: We have demonstrated a system for follow-up of discrepancy in interpreting emergency radiology studies, and recorded the discrepancy rate, with further analysis based on different variables. In terms of quality assurance, a periodical analysis might help to reduce the number of discrepant reports by targeted intervention.

Left-sided appendicitis in children with congenital gastrointestinal malrotation: a diagnostic pitfall in the emergency department.

Acute appendicitis is one of the most common conditions requiring emergency surgery. However, acute appendicitis presenting with left lower quadrant abdominal pain is extremely rare. Imaging, particularly CT , plays an important role in establishing an accurate and prompt diagnosis, as delay in diagnosis may occur due to lack of uniformity in the clinical signs and symptoms. We report a rare case of a 10-year-old boy who presented with persistent left lower quadrant pain of several days duration, in which the CT scan of the abdomen and pelvis was essential in establishing the correct diagnosis. The malpositioned inflamed appendix was clearly identified in the left side of the abdomen, with the characteristic CT findings of uncomplicated intestinal malrotation. Left-sided acute appendicitis should be considered in the differential diagnosis of young patients presenting with left lower quadrant pain, in order to avoid delay in diagnosis and guide the surgical intervention.

Superior mesenteric arteriovenous fistula embolisation complicated by bowel ischaemia.

Superior mesenteric arteriovenous fistulas are rare, especially when iatrogenic in origin. Management of these fistulas can be surgical or endovascular. Endovascular embolisation is the preferred modality with a low rate of complications. Among the reported complications, bowel ischaemia is considered an unlikely occurrence. We report a case of a complex iatrogenic arterioportal fistula that was managed by endovascular embolisation and controlled through both its inflow and outflow, and was later complicated by bowel ischaemia.

Calcaneal osteosarcoma: a rare cause of heel pain in the paediatric population.

Osteosarcoma is the most common primary non-haemopoietic malignant bone tumour in children and adolescents. However, it rarely occurs in the calcaneus with only a few case reports in the literature. We report a case of a 14-year-old boy with calcaneal osteosarcoma, who presented with heel pain followed by swelling. The pain was initially thought to be related to a benign process and treated with analgesics, delaying the diagnosis. We discuss the clinical presentation, the differential diagnosis, multi-imaging and pathological findings of a calcaneal osteosarcoma, its clinical outcome and the importance of early diagnosis to improve outcome.

Bladder metastasis from primary breast cancer: a case report and literature review.

Breast cancer is the most common malignancy in woman. The urinary bladder is an unusual site for metastasis from primary tumors of the breast, especially when it is the only organ involved. We present the case of a female patient with known breast cancer stage T2N3M0 who developed isolated bladder metastasis five years after the primary diagnosis. We reviewed the literature for similar cases and discussed the clinical presentation, pathophysiology, and prognosis of this entity.