Special Issue:
Challenges and Opportunities in Radiology
Linda Ding, PhD
Department of Radiation Oncology, UMass Chan Medical School, Worcester, MA 01655, USA; Department of Radiation Oncology, UMass Memorial Health, Worcester, MA 01655 USA
Shirin Sioshansi, MD
Department of Radiation Oncology, UMass Chan Medical School, Worcester, MA 01655, USA; Department of Radiation Oncology, UMass Memorial Health, Worcester, MA 01655 USA
Hesham Malik, MD
Department of Radiology, UMass Chan Medical School, Worcester, MA 01655, USA; Department of Radiology, UMass Memorial Health, Worcester, MA 01655, USA
Elisa Franquet-Elia, MD
Department of Radiology, UMass Chan Medical School, Worcester, MA 01655, USA; Department of Radiology, UMass Memorial Health, Worcester, MA 01655, USA
Lacey McIntosh, DO, MPH
Department of Radiology, UMass Chan Medical School, Worcester, MA 01655, USA; Department of Radiology, UMass Memorial Health, Worcester, MA 01655, USA
Evan Ruppell, DO
Department of Radiology, UMass Chan Medical School, Worcester, MA 01655, USA, Department of Radiology, UMass Memorial Health, Worcester, MA 01655, USA
Robert Licho, MD
Department of Radiology, UMass Chan Medical School, Worcester, MA 01655, USA, Department of Radiology, UMass Memorial Health, Worcester, MA 01655, USA
Young Kim, MD
Department of Radiology, UMass Chan Medical School, Worcester, MA 01655, USA, Department of Radiology, UMass Memorial Health, Worcester, MA 01655, USA
Alan Goldstein, MD
Department of Radiology, UMass Chan Medical School, Worcester, MA 01655, USA, Department of Radiology, UMass Memorial Health, Worcester, MA 01655, USA
Kriti Mittal, MD
Department of Medicine, UMass Chan Medical School, Worcester, MA 01655, USA, Department of Medicine, UMass Memorial Health, Worcester, MA 01655 USA
Ming-Jin Wang, MD
Department of Medicine, UMass Chan Medical School, Worcester, MA 01655, USA, Department of Medicine, UMass Memorial Health, Worcester, MA 01655 USA
Patan Gultawatvichai, MD
Department of Medicine, UMass Chan Medical School, Worcester, MA 01655, USA, Department of Medicine, UMass Memorial Health, Worcester, MA 01655 USA
Savant Mehta, MD
Department of Medicine, UMass Chan Medical School, Worcester, MA 01655, USA, Department of Medicine, UMass Memorial Health, Worcester, MA 01655 USA
Kimberly Foley, NP
Department of Medicine, UMass Memorial Health, Worcester, MA 01655 USA
Sean Wilson, MD
Department of Radiology, UMass Chan Medical School, Worcester, MA 01655, USA, Department of Radiology, UMass Memorial Health, Worcester, MA 01655, USA
Maryann L Bishop-Jodoin, MEd
Department of Radiation Oncology, UMass Chan Medical School, Worcester, MA 01655, USA
Thomas J FitzGerald, MD
Department of Radiation Oncology, UMass Chan Medical School, Worcester, MA 01655, USA Department of Radiation Oncology, UMass Memorial Health, Worcester, MA 01655 USA
Abstract
Yttrium-90 (Y-90) therapy has become an important component to the care of patients with primary hepatic malignancies and lesions that have metastasized to the liver. Therapy is administered through an intra-arterial procedure after an interventional procedure is performed using an albumin labeled product to ensure therapy will be delivered to the target volume of interest with minimal migration from the target of choice. In the past, dose to target has been measured by activity delivered and qualitative deposition of dose on metabolic imaging post application. Imaging tools such as single positron emission computer tomography (SPECT) and digital positron emission tomography have given us insight into quantitative dose to volumetric tumor target and dose to normal tissue. Recent validation of computational software has provided voxel-based dosimetry similar to applied processes established in radiation oncology planning systems. This development presents an opportunity to create dose volume analysis similar to teletherapy and brachytherapy dose delivery for Y-90 therapy. In this case report, we review Y-90 dosimetry on a patient with dual diagnosis of a locally advanced high-risk adenocarcinoma of the prostate which required treatment to the para-aortic lymph nodes located in the same axial plane with renal parenchyma. Although not clinically anticipated, hepatocellular carcinoma was serendipitously discovered at the time of staging for prostate cancer. Treatment dosimetry of the hepatocellular carcinoma is reviewed in retrospect with voxel-based commercial software. Same day SPECT study suggested dose localized to the liver, however voxel planning software confirmed unintentional dose to additional structures including the right kidney and uninvolved liver which influenced radiation therapy treatment planning for prostate carcinoma. With modern available tools, post therapy dosimetry for Y-90 can be performed in a manner similar to volumetric dosimetry used in radiation oncology and provide valuable dose volume analysis of dose delivered to target and additional tissue.
Seong K. Mun, PhD
Arlington Innovation Center: Health Research, Virginia Tech, Washington DC Region
Shih-Chung B. Lo, PhD
Arlington Innovation Center: Health Research, Virginia Tech, Washington DC Region
Kenneth Wong, PhD
Arlington Innovation Center: Health Research, Virginia Tech, Washington DC Region
Dow-Mu Koh, MD
Professor in Functional Cancer Imaging, Consultant Radiologist in Functional Imaging the Royal Marsden NHS Foundation Trust
Fred Prior, PhD
Distinguished Professor and Chair, Department of Biomedical Informatics, Professor of Radiology, University of Arkansas for Medical Sciences
Abstract
Radiology has a long history of adopting state-of-the-art digital technology to provide better diagnostic services and facilitate advances in image-based therapeutics throughout the healthcare system. The radiology community has been developing diagnostic artificial intelligence (AI) tools over the past 20 years, long before AI became fashionable in the public press. Currently, there are approximately four hundred Food and Drug Administration approved imaging AI products. However, the clinical adoption of these products in radiology has been relatively dismal, indicating that the current technology-push model needs to evolve into the demand-pull model. We will review the current state of AI use in radiology from the perspective of clinical adoption and explore the ways in which AI products will become an ensemble of critically important tools to help radiology transition from volume-based service to value-based healthcare. This transition will create new demands for AI technologies. We contrast the current “technology-push” model with a “demand-pull” model that will aligns technology with user priorities.
We summarize the lessons learned from AI experience over the past twenty years, mainly working with computer-aided detection for breast cancers and lung cancers. The radiology community calls for AI tools that can do more than detection with increasing attention toward higher workflow efficiency and higher productivity of radiologists. Major radiological societies of North America and Europe promulgated the emerging concept of value-based radiology service, an integral part of overall value-based healthcare. The transition to value-based radiology will happen and that higher value will come from the effective use of AI throughout the radiology workflow.
The value-based radiology will need to work with a full range of machine learning tools, including supervised, unsupervised, and reinforcement learning, as well as natural language processing and large language models (e.g., chatbots). The engineering community is rapidly developing many concepts and sophisticated software tools for data orchestration, AI orchestration, and automation orchestration. Current radiology operation has been supported by PACS, a monolithic IT infrastructure of past generations. This system will need to migrate to an intelligence management system to support the new workflow needed for high value radiology.
L Ding
Department of Radiation Oncology, UMass Memorial Health Care, Worcester Ma. 01655 USA; Department of Radiation Oncology, UMass Chan Medical School, Worcester Ma. 01655 USA
S Sioshansi
Department of Radiation Oncology, UMass Memorial Health Care, Worcester Ma. 01655 USA; Department of Radiation Oncology, UMass Chan Medical School, Worcester Ma. 01655 USA
Y Geng
Department of Radiation Oncology, UMass Memorial Health Care, Worcester Ma. 01655 USA
L McIntosh
Department of Radiology, UMass Memorial Health Care, Worcester, Ma. 01655 USA; Department of Radiology, UMass Chan Medical School, Worcester, Ma. 01655 USA
E Ruppell
Department of Radiology, UMass Memorial Health Care, Worcester, Ma. 01655 USA; Department of Radiology, UMass Chan Medical School, Worcester, Ma. 01655 USA
R Licho
Department of Radiology, UMass Memorial Health Care, Worcester, Ma. 01655 USA; Department of Radiology, UMass Chan Medical School, Worcester, Ma. 01655 USA
Y Kim
Department of Radiology, UMass Memorial Health Care, Worcester, Ma. 01655 USA; Department of Radiology, UMass Chan Medical School, Worcester, Ma. 01655 USA
A Goldstein
Department of Radiology, UMass Memorial Health Care, Worcester, Ma. 01655 USA; Department of Radiology, UMass Chan Medical School, Worcester, Ma. 01655 USA
K Mittal
Department of Medicine, UMass Memorial Health Care, Worcester, Ma. 01655 USA; Department of Medicine, UMass Chan Medical School, Worcester, Ma. 01655 USA
M Wang
Department of Medicine, UMass Memorial Health Care, Worcester, Ma. 01655 USA; Department of Medicine, UMass Chan Medical School, Worcester, Ma. 01655 USA
S Mehta
Department of Medicine, UMass Memorial Health Care, Worcester, Ma. 01655 USA; Department of Medicine, UMass Chan Medical School, Worcester, Ma. 01655 USA
K Foley
Department of Medicine, UMass Memorial Health Care, Worcester, Ma. 01655 USA; Department of Medicine, UMass Chan Medical School, Worcester, Ma. 01655 USA
K Smith
Department of Radiation Oncology, UMass Chan Medical School, Worcester Ma. 01655 USA
M Bishop-Jodoin
Department of Radiation Oncology, UMDepartment of Radiation Oncology, UMass Chan Medical School, Worcester Ma. 01655 USA
TJ FitzGerald
Department of Radiation Oncology, UMass Memorial Health Care, Worcester Ma. 01655 USA ; Department of Radiation Oncology, UMass Chan Medical School, Worcester Ma. 01655 USA
Abstract
This paper is a follow-up report concerning a patient treated with Yttrium-90 to a hepatocellular carcinoma. The radiation therapy dose distribution was published as a case report in 2022, https://doi.org/10.18103/mra.v10i11.3379. The hepatic target volume for directed therapy abutted the right kidney and this report provides clinical follow up information on the patient relative to renal function on unintentional radiation renal dose. Yttrium-90 therapy has become an important therapy component for patient care directed to multiple malignancies with emphasis on treating lesions in close proximity to the hepatic parenchyma. The targets are treated with an intra-arterial approach with a goal of applying target directed radiation therapy. Historically, prior to the development of voxel-based dose volume computation software, dose to target was prescribed as activity of isotope delivered with a qualitative assessment of isotope delivery based on images obtained from single positron emission computer tomography. As a qualitative image, single positron emission computer tomography served as an image reference and qualitative surrogate for representing radiation dose. Today, commercial software is available to fuse single positron emission computer tomography images into radiation oncology planning images and calculate dose to volume in a manner similar to how radiation oncology physics dosimetry teams calculate radiation dose to target volume for external therapy and brachytherapy with image guidance. In this particular case, we demonstrated that the proximity of the right kidney to the target resulted in unintentional radiation dose to renal parenchyma evaluated using voxel-based dosimetry. In this report, we review progressive decrease in renal function with blood urea nitrogen/creatinine of 45 and 2.75 respectively with continued normal liver function. Although potentially multi-factorial in origin, the decrease in renal function is at a time point consistent with radiation injury. In this paper we review radiation oncology dose volume constraints for renal tolerance and strategies for patient care moving forward. The goal is to provide additional knowledge of this issue and provide an additional knowledge layer for patient safety with emphasis on improving patient outcomes.
A. Ajim
Department of Respiratory Diseases 20 August 1953, University Hospital Center IBN Rochd, Casablanca, Morocco
K. Rebbouh
Department of Radiology 20 August 1953, university hospital IBN ROCHD, Casablanca, Morocco
H. Jabri
Department of Respiratory Diseases 20 August 1953, University Hospital Center IBN Rochd, Casablanca, Morocco
M. Chahbounia
Department of Respiratory Diseases 20 August 1953, University Hospital Center IBN Rochd, Casablanca, Morocco
W. Elkhattabi
Department of Respiratory Diseases 20 August 1953, University Hospital Center IBN Rochd, Casablanca, Morocco
N. Bougteb
Department of Respiratory Diseases 20 August 1953, University Hospital Center IBN Rochd, Casablanca, Morocco
H. Arfaoui
Department of Respiratory Diseases 20 August 1953, University Hospital Center IBN Rochd, Casablanca, Morocco
M. H. Afif
Department of Respiratory Diseases 20 August 1953, University Hospital Center IBN Rochd, Casablanca, Morocco
K. Rebbouh
Department of Radiology 20 August 1953, university hospital IBN ROCHD, Casablanca, Morocco
N. Moussali
Department of Radiology 20 August 1953, university hospital IBN ROCHD, Casablanca, Morocco
A. Merzem
Department of Radiology 20 August 1953, university hospital IBN ROCHD, Casablanca, Morocco
H. Belgadir
Department of Radiology 20 August 1953, university hospital IBN ROCHD, Casablanca, Morocco
O. Amriss
Department of Radiology 20 August 1953, university hospital IBN ROCHD, Casablanca, Morocco
N. El Benna
Department of Radiology 20 August 1953, university hospital IBN ROCHD, Casablanca, Morocco
Abstract
Hypersensitivity pneumonitis (HP) classified as an interstitial lung disease is characterized by a complex immunological reaction of the lung parenchyma in response to repetitive inhalation of a sensitized allergen. The estimated worldwide incidence of hypersensitivity pneumonitis is extremely rare and highly dependent on climatic, geographical, occupational and industrial factors. It might be secondary to a domestic or professional exposure, usually occurs in people who work in places where there are high levels of dust, fungus, or molds. Long-term exposure can lead to lung inflammation and acute lung disease. Over time, the acute condition turns into long-lasting (chronic) lung disease. Thus, we distinguish 2 mains aspects fibrotic HP and Nonfibrotic HP. The diagnosis of HP maybe sophisticated especially in fibrotic form. The prognosis of this disease depends on early diagnosis with complete antigen avoidance and most often corticosteroid therapy.
This work aims to study the epidemiological, clinical, paraclinical aspects of hypersensitivity pneumonitis as well as therapeutic management, through a series of eight cases of HP carried out at the Pulmonology Department 20 August 1953, University Hospital Center IBN ROCHD, between January 2020 and January 2022, analyzed using a pre-established exploitation sheet. The average age of the patients studied was 51 years with a female predominance (sex-ratio M/F= 0.34). Domestic and occupational exposures of our patients were equal. The clinical symptomatology is dominated by almost constant dyspnea in all patients. Physical signs increased by crackles, objectified in 75% of patients. Computed tomography (CT) remains a great diagnostic contribution. Thus, allowing to have two categories of patients, depending on the presence or absence of signs of pulmonary fibrosis.
In our study, five patients had fibrotic HP, and three cases had non- fibrotic HP. Precipitins were positive. Plethysmography objectified a restrictive ventilatory disorder in 62.5%. All patients benefited from antigenic eviction with long-term corticosteroid therapy. The evolution was favorable in 87.5% of cases.
J. Douglas Bremner, MD
Departments of Psychiatry & Behavioral Sciences
Marina Piccinelli, PhD
Departments of Radiology and Imaging Sciences
Ernest V. Garcia, PhD
Departments of Radiology and Imaging Sciences
Valeria M. Moncayo, MD
Departments of Radiology and Imaging Sciences
Lisa Elon, M.S., M.P.H
Department of Epidemiology
Jonathon A. Nye, PhD
Departments of Radiology and Imaging Sciences
C. David Cooke, M.S.E.E
Departments of Radiology and Imaging Sciences
Brianna P. Washington, MD
Departments of Psychiatry & Behavioral Sciences
Rebeca Alvarado Ortega, BS
Departments of Psychiatry & Behavioral Sciences
Shivang R. Desai, MD
Departments of Medicine (Cardiology)
Alexis K. Okoh, MD
Departments of Medicine (Cardiology)
Brian Cheung, MD
Departments of Medicine (Cardiology)
Britt O. Soyebo, BS
Departments of Epidemiology
Lucy H. Shallenberger, MPH
Departments of Epidemiology
Paolo Raggi, MD
Mazankowski Alberta Heart Institute and the Department of Medicine, University of Alberta, Edmonton, Alberta, Canada.
Amit J. Shah, MD
Departments of Medicine (Cardiology); Departments of Epidemiology; Atlanta VA Medical Center, Decatur, GA,
Obada Daaboul, MD
Departments of Epidemiology
Mohamed Nour Jajeh, MD
Department of Epidemiology
Carrie Ziegler, BS
Department of Epidemiology
Emily G. Driggers, BS
Department of Epidemiology
Nancy Murrah, RN
Department of Epidemiology
Carlo N. De Cecco, MD
Departments of Radiology and Imaging Sciences; Biomedical Informatics, Emory University School of Medicine, Atlanta, GA
Marly van Assen, PhD
Departments of Radiology and Imaging Sciences
Robert T. Krafty, PhD
Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, USA
Arshed A. Quyyumi, MD
Departments of Medicine (Cardiology)
Viola Vaccarino, MD, PhD
Department of Medicine (Cardiology); Department of Epidemiology
Abstract
Objective: Coronary heart disease is a leading cause of death and disability. Although psychological stress has been identified as an important potential contributor, mechanisms by which stress increases risk of heart disease and mortality are not fully understood. The purpose of this study was to assess mechanisms by which stress acts through the brain and heart to confer increased CHD risk.
Methods: Coronary Heart Disease patients (N=10) underwent cardiac imaging with [Tc-99m] sestamibi single photon emission tomography at rest and during a public speaking mental stress task. Patients returned for a second day and underwent positron emission tomography imaging of the brain, heart, bone marrow, aorta (indicating inflammation) and subcutaneous adipose tissue, after injection of [18F]2-fluoro-2-deoxyglucose for assessment of glucose uptake followed mental stress. Patients with (N=4) and without (N=6) mental stress-induced myocardial ischemia were compared for glucose uptake in brain, heart, adipose tissue and aorta with mental stress.
Results: Patients with mental stress-induced ischemia showed a pattern of increased uptake in the heart, medial prefrontal cortex, and adipose tissue with stress. In the heart disease group as a whole, activity increase with stress in the medial prefrontal brain and amygdala correlated with stress-induced increases in spleen (r=0.69, p=0.038; and r=0.69, p=0.04 respectfully). Stress-induced frontal lobe increased uptake correlated with stress-induced aorta uptake (r=0.71, p=0.016). Activity in insula and medial prefrontal cortex was correlated with post-stress activity in bone marrow and adipose tissue. Activity in other brain areas not implicated in stress did not show similar correlations. Increases in medial prefrontal activity with stress correlated with increased cardiac glucose uptake with stress, suggestive of myocardial ischemia (r=0.85, p=0.004). Conclusions: These findings suggest a link between brain response to stress in key areas mediating emotion and peripheral organs involved in inflammation and hematopoietic activity, as well as myocardial ischemia, in Coronary Heart Disease patients.
AuthorA Ajim
Department of Pneumology 20 August 1953, University Hospital IBN ROCHD, Casablanca, Morocco
W Elkhattabi
Department of Pneumology 20 August 1953, University Hospital IBN ROCHD, Casablanca, Morocco
H Arfaoui
Department of Pneumology 20 August 1953, University Hospital IBN ROCHD, Casablanca, Morocco
N Bougteb
Department of Pneumology 20 August 1953, University Hospital IBN ROCHD, Casablanca, Morocco
H Jabri
Department of Pneumology 20 August 1953, University Hospital IBN ROCHD, Casablanca, Morocco
M. H. Afif
Department of Pneumology 20 August 1953, University Hospital IBN ROCHD, Casablanca, Morocco
K Rebbouh
Emergency radiology department, university hospital IBN ROCHD, Casablanca, Morocco
H Tabakh
Emergency radiology department, university hospital IBN ROCHD, Casablanca, Morocco
A Siwane
Emergency radiology department, university hospital IBN ROCHD, Casablanca, Morocco
N Touil
Emergency radiology department, university hospital IBN ROCHD, Casablanca, Morocco
O Kacimi
Emergency radiology department, university hospital IBN ROCHD, Casablanca, Morocco
N Chikhaoui
Emergency radiology department, university hospital IBN ROCHD, Casablanca, Morocco
Abstract
Tuberculosis and sarcoidosis are two chronic granulomatous diseases that are similar in many aspects, although different.
We report a case of 38-year-old female patient who presented a progressive shortness of breath and recurrent epistaxis associated to a night sweats and fatigue with a deterioration of general condition, in which a CT-scan showed a multiple voluminous lymphadenopathy involving all the mediastinum territories, without parenchymal abnormalities. During investigations bronchoscopy showed mucosal hypertrophy and granulations located on the nasopharyngeal walls. The biopsy of the lip and nasal’s lesion showed a non-caseating granuloma and ACE (angiotensin converting enzyme) was high, which considered sufficient to retain the diagnosis of sarcoidosis, but the blood Quantiferon-TB Gold in Tube test was positive and the excision biopsy of cervical lymphadenopathy, revealed a necrotizing granulomatous inflammation suggestive of tuberculosis. The association between sarcoidosis and tuberculosis was discussed. the patient was treated with antituberculosis drugs during six months. The evolution was marked by a progressive regression of lymph nodes. There was no significant improvement of rhinological symptoms with local corticoids. Consequently, the corticosertoide treatement in form oral was introduced during 1 month. The prednisolone was gradually tapered off after 1 month due to the complete disappearance of lesions.
The case described is suggestive of a coexistent systemic sarcoid manifestation and tuberculosis, which is an underrecognized entity in the medical literature.
Yahia M Lodi
Neurology, Neurosurgery & Radiology, Upstate Medical University and UHS-Hospitals1, Johnson City, NY
Adam Bowen
Neurology, Neurosurgery & Radiology, Upstate Medical University and UHS-Hospitals1, Johnson City, NY
Aria Soltani
Neurology, Neurosurgery & Radiology, Upstate Medical University and UHS-Hospitals1, Johnson City, NY
Varun Reddy
Neurology, Neurosurgery & Radiology, Upstate Medical University and UHS-Hospitals1, Johnson City, NY
Hanish Polavarapu
Neurology, Neurosurgery & Radiology, Upstate Medical University and UHS-Hospitals1, Johnson City, NY
Adam Cloud
Neurology, Neurosurgery & Radiology, Upstate Medical University and UHS-Hospitals1, Johnson City, NY
Rohan Arora
Department of Neurology, Zucker School of Medicine at Hofstra/Northwell, New York
Abstract
Background: Cerebral Aneurysms (CA) including dissecting pseudoaneurysms are treated endovascularly through a trans-radial or trans-femoral approach. When these options are not available, a trans-carotid approach via Direct Carotid Artery Cutdown (DCAC) may be used as the last option. However, the safety and feasibility of DCAC is not well studied or defined in these contexts. Our objective is to present our four unique patients who were treated by the DCAC approach for their cerebral aneurysm and/or internal carotid artery dissecting pseudoaneurysm using flow diversion.
Method: This is a report of a case series and retrospective review.
Results: Patient 1; A 75-year-old woman with known left internal carotid artery (ICA) petrocavernous aneurysm that enlarged from 6 mm to 10 mm resulting in double vision and headaches. Trans-femoral approach failed due to the tortuosity in the common carotid artery (CCA). A multidisciplinary team was formed; A vascular surgeon began the surgery followed by FD by a neuroendovascular surgeon. A 6 French sheath was placed on the right common carotid artery via DCAC then brought to right ICA by vascular surgeon, and a neuroendovascular surgeon confirmed the placement with digital subtraction angiography (DSA). The DSA confirmed a large 10 x 8 x 5mm broad-based aneurysm. Flow diversion was performed with pipeline flex measuring 5 x 30mm. Patient was discharged home and achieved baseline modified Rankin Scale (mRS )1 which sustained in 5 years with aneurysm obliteration. Patient 2; A 65- year-old woman with multiple symptomatic left ICA-Para-ophthalmic artery aneurysm measuring 9 mm. Both femoral and radial arteries were occluded and underwent DCAC and flow diversion with pipeline flex of 4×30 mm using the similar technique described above. Patient discharged home in 48 hours with National Institute of Health Stroke Scale (NIHSS) of 0 and achieved her baseline mRS. However, this patient refused to have any further follow-up studies done. Patient 3; A 67-year-old man with aortic arch endograph with stent graft after previous aortic dissection and diagnosed with bilateral internal carotid artery dissecting pseudoaneurysm (ICADP) by computed topographic angiography (CTA). The right ICADP measured 19 x 15 x 20 mm, was multilevel, extending from skull base to the internal carotid artery (ICA) origin. The left ICADP was 16 x 9 x 22 mm with inflow-zone stenosis. The DSA was attempted but failed due to the aortic stent. The right ICADPA was repaired first using Surpass streamline (Stryker Neurovascular, Irving, CA) device measuring 4 x 50 mm x2 and 5 x 40 mm covering the entire dissecting artery. Patient was discharged home in 48 hours. Three months after the first procedure, using similar technique the left ICADPA was treated with a 5 x 50 mm Surpass evolve flow diverter. Patient achieved mRS 0. In 24-months follow up CTA demonstrated complete resolution of left ICDAP, but occlusion of the right ICA without impairing his mRS 0. Patient 4; a 76-year-old-woman with tinnitus, headaches and dizziness; DSA demonstrated RICA dissecting large 16 x 8 mm pseudoaneurysm. Trans-femoral approach failed and underwent DCAC, and flow diversion with a single surpass evolve flow diverter 4.5 x3 0 mm. Patient was discharged with NIHSS 0 and achieved her baseline mRs 0.
Ayman Nada, MD, PhD Esmat Mahmoud, MD, PhD
Attending, Diagnostic and Interventional Radiology Department, National Cancer Institute, Cairo University, Egypt
Humera Ahsan, MD
Professor of Clinical Radiology, Department of Radiology, University of School of Medicine, Columbia, Missouri. 65212
Gregory Biedermann, MD
Assistant Professor of Clinical Radiology, Department of Radiology, University of School of Medicine, Columbia, Missouri. 65212
Joseph Cousins
Abstract
Purpose: To evaluate the longitudinal change of intra-tumoral susceptibility signal (ITSS) on high-resolution SWI as an adjunctive imaging tool to evaluate treatment response of brain metastasis following stereotactic radiosurgery. This approach will allow further stratification of the patients and guide clinical decision making.
Methods: An IRB approved retrospective study included 63 brain metastatic lesions within 49 patients (33 females and 16 males) who have undergone stereotactic radiosurgery with at least one follow-up MRI and available clinical data. The average age was 63.17 years (±1.48, ranged from 34-83 years). The longitudinal change in ITSS was categorized into 3 groups; increased, stable and decreased. The treatment response of each lesion was evaluated according to the longitudinal change in size, enhancement and susceptibility at the baseline and follow-up MRIs. Chi-square test was used to compare differences in categorical variables. Receiver operating characteristics (ROC) curve was used to evaluate the accuracy of including longitudinal change in ITSS with size and enhancement pattern in determining the treatment response following SRS.
Results: Our results demonstrated higher sensitivity and specificity when including longitudinal change in ITSS with size and enhancement for the evaluation of the treatment response of brain metastatic lesions treated with SRS. There was statistically significant difference between the different ITSS and enhancement patterns at baseline and follow-up MRIs (Wilcoxon Signed Ranks Test (p = .000, and .003) respectively. The multiparametric analysis of the longitudinal change in size, contrast enhancement, and ITSS in the evaluation of treatment response in the follow-up MRIs, showed that the sensitivity and specificity significantly improved (AUC 0.953).
Conclusion: High resolution SWI can contribute as an imaging biomarker with supplemental information for monitoring treatment and predicting treatment response. High resolution SWI can complement the standard contrast enhanced T1 images to evaluate treatment response with a multiparametric MRI approach.
Pamela Causa Andrieu
Radiology Department. Memorial Sloan Kettering Cancer Center, United States.
Refky Nicola
Roswell Park Comprehensive Cancer Center, United States.
Federico Lipsich
Radiology Service. Hospital Italiano de Buenos Aires, Argentina.
Daniel Adri
Radiology Service. Hospital Italiano de Buenos Aires, Argentina.
Mariaangeles Gomez
Radiology Service. Hospital Italiano de Buenos Aires, Argentina.
Melina Pol
Pathology Service. Hospital Italiano de Buenos Aires, Argentina.
Alejandra Wernicke
Pathology Service. Hospital Italiano de Buenos Aires, Argentina.
Gabriel Saraniti
Gynecology Service. Hospital Zonal de Bariloche, Argentina.
Carolina Chacon
Radiology Service. Hospital Italiano de Buenos Aires, Argentina.
Abstract
Purpose: To identify the MRI features that aid in the characterization of ovarian granulosa cell tumors.
Materials and methods: 11 MR pelvis of an adult woman with pathology-proven ovarian granulosa cell tumors with surgical pathology.
We evaluated the patient’s age, Ca-125, size, laterality, and with MRI features such as indirect signs (i.e., thickened endometrium > 0.9 cm), morphology (cystic, solid-cystic, or solid), subacute hemorrhage, T2 signal (low or intermediate-to-high), restricted diffusion (B values: 0, 50, 1000 sec/mm3/ADC), and dynamic enhancement (intense or similar to myometrium). Also, the presence of ascites, peritoneal implants, or adenopathy.
Results: The final cohort included 11 women with a surgical-pathological diagnosis of granulosa cell tumors. The median age was 52.4 years (range, 17-80). The Ca-125 level was with a median within normal limits. The median size was 9.4 cm. Most cases were unilateral (81.8%) and more frequent on the left (54.5%).
MRI Analysis: 36.4% had endometrial thickening. Ovarian granulosa cell tumors were polymorphous: cystic (54.6%), mixed solid-cystic (9.1%), and solid (36.3%). Most GC had intermediate to high signal on T2 (90.9%), restricted diffusion (81.8%), intense enhancement (81.8%), and 36.4% had intraparenchymal bleeding. 9.1% had associated implants/adenopathy/ ascites at diagnosis.
Conclusion: The MRI features characteristic of ovarian granulosa cell tumors were the polymorphous morphology, an intense enhancement to the myometrium, restricted diffusion, and the presence of intraparenchymal hemorrhage.
Nayla Robledo, MD
Gynecology Department. Hospital Raul Angel Ferreyra, Cordoba, Argentina.
Maria Jose Chico, MD
Radiology Service, Hospital Italiano de Buenos Aires, Argentina.
Maria Paz Swiecicki, MD
Radiology Service, Hospital Italiano de Buenos Aires, Argentina.
Maria Contos, MD
Gynecology Department. Hospital Raul Angel Ferreyra, Cordoba, Argentina.
Karina Alejandra Pesce, MD, PhD
Radiology Service, Hospital Italiano de Buenos Aires, Argentina.
Pamela Causa Andrieu, MD
Radiology Department, Memorial Sloan Kettering Cancer Center, United States.
Abstract
We present and discuss a case report of a 70-year-old patient with a primary carcinoma in accessory breast tissue in the anterior chest wall.
Accessory breast tissue has a reported incidence of 0.3% to 6% in the general population, resulting from an incomplete involution of the mammary milk line. It usually presents as a palpable mass. The most frequent localization of accessory breast tissue and its possible pathologies is the armpit, although it can occur in the inframammary region and rarely on thighs, perineum, groin, or vulva.
The diagnosis is mainly clinical, but imaging findings may be helpful to confirm the suspicion because they are similar to breast cancer within the breast. Ultrasound is the most useful radiological method to evaluate these lesions and guide the suspected diagnosis together with the clinical presentation.
Treatment should be performed under the same principles as breast cancer, both surgical and systemic therapies. The prognosis of accessory breast carcinoma may be poor in cases with delayed diagnosis compared to native breast cancer.
Maria Jose Chico
Radiology Service, Hospital Italiano de Buenos Aires, Argentina
Maria Paz Swiecicki
Radiology Service, Hospital Italiano de Buenos Aires, Argentina
Karina Alejandra Pesce
Radiology Service, Hospital Italiano de Buenos Aires, Argentina
Pamela Causa Andrieu
Radiology Department, Memorial Sloan Kettering Cancer Center, United States
Abstract
Breast ultrasound diagnostic performance depends not only on the operator’s experience but also on the correlation of the results with other modalities. Therefore, a strong understanding of the acquisition technique and imaging optimization and the potential pitfalls in interpreting these studies is essential for achieving an adequate diagnosis. However, the trainees’ exposure to image optimization and ultrasound physics may be limited, impacting the quality of the examinations. Therefore, this review aims to provide an approach to breast US acquisition and interpretation, highlighting and illustrating tips for avoiding misinterpretations, mainly for trainees.
Miguel Angel Bertoni
Consultant, Department of Radiology, East Kent Hospitals University NHS Foundation Trust and Hon Senior Lecturer with the University of Kent
Thomas Webb
Consultant Neurologist and Stroke Physician, East Kent Hospitals University NHS Foundation Trust.
Ibrahim Balogun
Consultant Stroke Physician, East Kent Hospitals University NHS Foundation Trust.
Gordon Ellul
Nuclear Medicine Consultant, Department of Radiology, East Kent Hospitals University NHS Foundation Trust
Amod Dalvi
Consultant Psychiatrist, Kent & Medway Partnership NHS Foundation Trust
Hardeep Baht
Consultant Stroke Physician, East Kent Hospitals University NHS Foundation Trust
George Thomas
Consultant Stroke Physician, East Kent Hospitals University NHS Foundation Trust
Saidu Abubakar
Consultant Stroke Physician, East Kent Hospitals University NHS Foundation Trust
Gunaratanam Gunathilaghan
Consultant Stroke Physician, East Kent Hospitals University NHS Foundation Trust
Rami Abdallah
Consultant Stroke Physician, East Kent Hospitals University NHS Foundation Trust
Olobunmi Omojowolo
Consultant Stroke Physician, East Kent Hospitals University NHS Foundation Trust
David Hargroves
Consultant Stroke Physician, East Kent Hospitals University NHS Foundation Trust
Abstract
To assess the relevance clinicians and radiologists assign to making hypertension (HTN) explicit in acutely symptomatic subjects admitted for either stroke, confusion or cognitive deficit, a revision was carried out of cases discussed in our institution in the last eleven years, at either the Neuroradiology-Stroke or the Neuropsychiatry multidisciplinary meetings (MDTs). Consistency of the provided clinical information and radiological findings concerning HTN were checked in 11810 subjects (Group 1), since both influence neuroimaging interpretation, diagnosis and management.
Similar information was collected in a subgroup of 25 subjects (Group 2), with signs of stroke included in Group 1 in whom there was pre-existent history of severe HTN, who were evaluated with multimodality neuroimaging in 48 hours from admission and who had improved clinically in 72 hours.
The word “hypertension” included in the initial neuroimaging request, blood pressure (BP) levels on admission, radiology reports describing intra axial bleed, mentioning “hypertensive encephalopathy”, “chronic hypertensive encephalopathy”, “hypertensive microbleeds”, “amyloid microbleeds”, features and quantification of cerebral small vessel disease (CSVD), a non-specific pattern of cortical atrophy, dolicoarteriopathy, presence and degree of carotid or vertebrobasilar stenosis were tabled.
Electronic records of blood pressure (BP) were available in 10003/11810 cases and in written notes in 1807/11810; 1582/11810 were not hypertensive and 8421/11810 hypertensive. Imaging requests did explicitly include the word “hypertension” in 1184/11810.
Radiology reported acute intracranial bleed on admission in 1516/11810, hypertensive encephalopathy in 248/11810, chronic hypertensive encephalopathy in 148/11810, hypertensive-type microbleeds in 295/11810, amyloid-type microbleeds in 390/11810, SVD features without quantification in 1554/11810, SVD 1/3 in 577/11810, SVD 2/3 in 1402/11810, SVD 3/3 in 776/11810, non-specific cerebral atrophy in 800/11810, vessel tortuosity in 128/11810 and significant carotid or vertebrobasilar stenosis in 1292/11810 of cases. On neuroimaging revision, one or more HTN features were found in 10311/11810 cases.
In group 2 mean systolic BP on admission was 193mmHg, diastolic 104mmHg, age 55 years, 15/25 had PRES, 7/25 acute on chronic hypertensive encephalopathy, 2/25 CAA and 1/25 normotensive PRES. HTN findings were reported in 22/25 cases.
Results suggest an initial underestimation of HTN by both referrers and radiologists in acutely symptomatic subjects, later identified and characterised when reviewed and discussed at MDTs.
