Rezonans magnetyczny jako nieinwazyjne narzędzie detekcji endometriozy pozajajnikowej – doświadczenie własne

Introduction: Endometriosis – due to its high incidence, associated pain and infertility – constitutes an important problem in gynecological practice. The Polish Gynecological Society Expert Panel recommends to perform magnetic resonance imaging (MRI) prior to laparoscopy. The purpose of this study is to present the usefulness of MRI in the diagnosis of extraovarian endometriosis on the basis of own experience. Material and methods: The material consisted of 35 patients, aged 15-52 (mean 36.5 years), who were diagnosed with extraovarian endometriosis on MRI. MR examinations were performed with 1.5 T scanners according to a routine protocol, which incorporates the LAVA sequence of dynamic contrast studies protocol because of thin sections. Results: Extraovarian endometriosis was isolated in 24 patients (68.6%), while in 11 (31.4%) it coexisted with ovarian endometriomas. In 23 cases (65.7%) extraovarian endometriosis was found in one place, in 12 (34.3%) – in two or more locations. Endometriosis was found in the following locations: abdominal wall – 11 cases (31.4%), uterine body – 9 (25.7%), posterior vaginal fornix – 7 (20%), wall of the rectum and sigmoid colon - 5 (14.3% ), pararectal space – 5, uterine cervix – 4 (11.4%), Douglas pouch – 3 (8.6%), Fallopian tube – 2 (5.7%), wall of the small intestine - 1 (2.8%), and urinary bladder – 1. Adhesions were observed in 28.6% of the patients. Conclusions: MRI is an important addition to the non-invasive diagnosis of extraovarian endometriosis and should be performed before treatment, especially surgical one. The inclusion of fat saturated T1 sequence from the dynamic contrast examination in the study protocol increases the likelihood of detecting small endometrial implants.Wprowadzenie: Endometrioza – ze względu na częstość występowania oraz ból i niepłodność, które powoduje - jest istotnym problemem w praktyce ginekologicznej. Zespół Ekspertów Polskiego Towarzystwa Ginekologicznego postuluje wykonanie rezonansu magnetycznego (MR) przed laparoskopią. Celem pracy jest wykazanie przydatności metody rezonansu magnetycznego w diagnostyce endometriozy pozajajnikowej z perspektywy własnego doświadczenia. Materiał i metoda: Materiał stanowi 35 pacjentek w wieku 15–52 lata (średnio 36,5), u których w badaniu MR rozpoznano endometriozę pozajajnikową. Badania wykonano aparatami o natężeniu pola magnetycznego 1,5T według rutynowego protokołu, do którego włączono sekwencję LAVA z dynamicznego badania kontrastowego ze względu na cienkie warstwy. Wyniki: U 24 chorych (68,6%) endometrioza pozajajnikowa była chorobą izolowaną, a u 11 (31,4%) współistniała z torbielami endometrialnymi jajników. W 23 przypadkach (65,7%) w badaniu MR znaleziono ogniska endometriozy pozajajnikowej w jednym miejscu, w 12 (34,3%) – w dwóch lub więcej lokalizacjach. Endometriozę w ścianie brzucha stwierdzono w 11 przypadkach (31,4%), w trzonie macicy w 9 (25,7%), w tylnym sklepieniu pochwy w 7 (20%), w ścianie odbytnicy lub esicy w 5 (14,3%), okołoodbytniczo w 5, w szyjce macicy w 4 (11,4%), w zagłębieniu Douglasa w 3 (8,6%), w jajowodzie w 2 (5,7%), w ścianie jelita cienkiego w 1 (2,8%) i w ścianie pęcherza moczowego w 1. Zrosty uwidoczniono u 28,6% chorych. Wnioski: Badanie MR stanowi istotne uzupełnienie nieinwazyjnej diagnostyki endometriozy pozajajnikowej i powinno być wykonane przed włączeniem leczenia, zwłaszcza operacyjnego. Włączenie cienkowarstwowej sekwencji T1+fatsat z dynamicznego badania kontrastowego do protokołu badania zwiększa prawdopodobieństwo wykrycia drobnych wszczepow endometrialnych

Postnatal verification of prenatal diagnoses established on foetal magnetic resonance imaging

Objectives: The role of magnetic resonance imaging, similarly to ultrasound, in the evaluation of foetal anomalies is in­disputable. This gives rise to a question, whether prenatal diagnostics can replace postnatal one. To assess the diagnostic accuracy of foetal MRI in children with congenital anomalies by using postnatal MRI, X-ray/US and surgery (histopathol­ogy/autopsy) results as a reference standard. Material and methods: 110 children were included in the analysis. All of them underwent foetal MRI, and the diagnoses were verified after birth. All the results were analysed both by: 1. evaluation of correctness of the prenatal diagnosis with the reference standard diagnosis of each patient, and 2. statistical evaluation of prenatal diagnosis using standard measures of binary diagnostic tests’ abilities. Results: The accordance of prenatal and final diagnoses was 70%. Only 3.64% of patients were misdiagnosed. Most of the prenatal diagnoses that were incomplete (23.64%), concerned children who underwent surgery, and among them patients with abdominal cystic laesions of undetermined origin on foetal MRI constituted the majority. In 2.73% of cases prenatal diagnoses remained inconclusive. Conclusions: High correlation of prenatal and postnatal tests’ results in the study material confirms the high value of foetal MRI in perinatal diagnostics. Comprehensive assessment of the foetus in prenatal MRI is very effective and facilitates impor­tant therapeutic decisions in the prenatal period (in utero treatment) and in perinatal care (application or withdrawal from the EXIT procedure, surgery or backtracking from neonatal resuscitation if it should bear the hallmarks of persistent therapy)

Zmiany w obrazie ultrasonograficznym i obrazie rezonansu magnetycznego mózgu u noworodków leczonych metodą selektywnej hipotermii

Introduction: Hypoxic ischemic insults during labor remain an important cause of brain injury in term and near-term neonates. Selective cerebral hypothermia is a potentially neuroprotective rescue therapy. Ultrasonography (US) andnmagnetic resonance imaging (MRI) are routinely used to visualize intracranial changes in neonatal hypoxic-ischemic injuries. Aim of the study: We attempted to describe all pathological findings on US and MRI in the brains of our patients following selective cerebral hypothermia. Materials and methods: Twenty-nine neonates with hypoxic-ischemic encephalopathy (HIE) following therapeutic cooling were assessed with cranial ultrasound (US) and magnetic resonance imaging (MRI). The findings were compared with the clinical outcome. Results: Over one-fourth (27.6%) of the examined infants had a normal brain on MRI (with only 17.2% on US). Involvement of the basal ganglia and thalami was one of the most frequent findings in our material (9/29 = 31% on MRI, and 7/29-24.1% on US). Cerebral parenchymal hemorrhage was detected on MRI in as many as 7 (24.1%) and cerebellar parenchymal hemorrhage in 4 (13.8%) infants. The loss in the gray-white matter differentiation (‘fuzzy brain’), usually transient on US, was observed in 79.3% of the neonates. Diffusion restriction in the callosal splenium (13.8%) and hyperechoic thalami and basal ganglia were strictly correlated to a significantly higher incidence of severe developmental delay. Conclusion: Abnormalities on MRI and US were observed in 75% of newborns with hypoxic-ischemic encephalopathy treated with therapeutic hypothermia.Wstęp: Uraz niedotlenieniowo-niedokrwienny jest częstą przyczyną okołoporodowego uszkodzenia mózgu u noworodków, u których potencjalną, neuroprotekcyjną metodą leczenia jest selektywna hipotermia. Ultrasonografia (USG) i rezonans magnetyczny (MRI) są rutynowymi metodami obrazowania mózgu u noworodków ze zmianami niedotlenieniowo-niedokrwiennymi. Cel pracy: Podjęłyśmy próbę opisania wszystkich zmian patologicznych wykrytych w badaniu USG i MRI mózgu u noworodków, które leczone były metodą selektywnej hipotermii. Materiał i metoda: Przezciemiączkowe badanie ultrasonograficzne (USG) oraz badanie metodą rezonansu magnetycznego (MR) wykonano u 29 noworodków z encefalopatią niedotlenienieniowo-niedokrwienną (ENN) po zastosowaniu terapeutycznej hipotermii. Wyniki badań porównano z oceną kliniczną. Wyniki: U ponad jednej czwartej badanych dzieci (27,6%) badanie MR mózgu było prawidłowe (w badaniu USG tylko u 17,2%). Zajęcie jąder podstawy i wzgórz było jednym z najczęstszych znalezisk w naszym materiale (9/29= 31% w MR i 7/29 = 24.1% w USG). Krwawienie śródmózgowe wykryto w MR aż w 7 przypadkach (24,1%), a śródmóżdżkowe w 4 (13,8%). Brak zróżnicowaniu istoty szarej i białej (“fuzzy brain”), zwykle przemijające w obrazie USG, obserwowano u 79,3% noworodków. Restrykcja dyfuzji wody w płacie ciała modzelowatego (13,8%) oraz hiperechogeniczność wzgórz i jąder podstawy mózgu ściśle korelowały z istotnie częstszym występowaniem znacznego opóźnienia rozwoju. Wnioski: Nieprawidłowy obraz MRI i US występuje u 75% noworodków z encefalopatią niedotlenieniowoniedokrwienną leczonych metodą selektywnej hipotermii

Widma spektroskopii wodorowej guzów korowych w przebiegu stwardnienia guzowatego u dzieci

Background: Tuberous sclerosis complex (TSC) is an autosomal dominant multisystem disorder with two gene loci located on chromosomes 9q34 (TSC1) and 16p13 (TSC2). Brain abnormalities in TSC include cortical tubers, subependymal nodules, giant cell astrocytomas, and white matter lesions. Cortical tubers present disordered focal neocortical formation. However, their biology remains to be elucidated. Recently, proton magnetic resonance spectroscopy has been clinically applied to the differential diagnosis of brain changes as a noninvasive neuroimaging tool. The purpose of this study was to investigate cortical tubers by single-voxel proton spectroscopy. Material/Methods: Twenty-four children with TSC were examined using a 1.5T scanner with a standard head coil. The group of patients consisted of 12 girls and 12 boys aged 3 weeks to 28 years (median: 8.66 years). Ten healthy children (examined for other reasons, with normal MR images) were the control group. Integrated MR/MRS examinations were performed. Proton MR spectroscopy images were obtained using single-voxel point resolved spectroscopy, the PRESS technique with TE=35 ms and TR=1500 ms. Results: Proton MR spectroscopy of cortical tubers revealed increased mI/Cr ratio (1.023 versus 0.553 in healthy children) and slightly decreased NAA/Cr (0.952 vs. 1.268) and NAA/Cho ratios (0.948 vs. 1.208) in all the spectra of TSC patients. The Cho/Cr ratio was almost the same as in the control group (1.079 vs. 1.058). Lactate peaks were present in ten cortical tubers. Conclusions: Proton spectroscopy can be useful in the examination of cortical tubers in TSC as a noninvasive method to investigate neurochemistry of the brain

Rezonans magnetyczny w diagnostyce zmian imitujących guzy jajnika

Background: The character of a pelvic mass is not always clear on gynecologic and sonographic examination. Magnetic resonance imaging provides the chance to differentiate adnexal tumors from other masses. Materials/Method: Twenty-six women, aged 20-83 years, with suspicion of ovarian tumor, were examined with a 0.5 T unit in 3 cases and a 1.5 T unit in 23. Results: MRI allowed accurate diagnosis in 23 women (88.5%). Uterine myoma was shown in 8 cases, enlarged uterine cervix with large Nabothian cysts in 5, pyosalpinx in 2, nerve root cysts in 3, perirectal abscess in 1, colorectal tumor in 1, and ectopic pelvic kidney in 3. In 2 women, normal ovaries were not identified with the 0.5 T unit and in 2 with the 1.5 T unit. Conclusions: Magnetic resonance imaging, as a method with the highest resolution and tissue specificity, should be performed in every case of sonografically unclear pelvic mass

Multiple brain abscesses caused by citrobacter koseri in a preterm neonate : case report

Background: Brain abscesses are very rarely diagnosed in neonates, but if present, they are associated with a high risk of severe complications and mortality. In neonates, brain abscesses can be detected on transfontanelle ultrasonography, in which they appear as hyperechogenic lesions surrounded by a hypoechogenic border. Case Report: We present a female neonate, born in the 28th week of gestation, with birth weight of 950 grams, who was born in an ambulance by spontaneous vaginal vertex delivery. No signs of infection were present until the 35th day of hospitalization, when a sudden and serious deterioration in the patient's condition was observed due to late-onset sepsis. Cranial US, performed on the 40th day of life, revealed hyperechogenic lesions with a hypoechogenic halo in the right frontal lobe, which could correspond to brain abscesses. These lesions were caused by Citrobacter koseri septicaemia, identified by transfontanelle ultrasonography, and confirmed on magnetic resonance imaging. The patient recovered and was discharged on the 91th day of life (39 PCA) with a recommendation of permanent neurological surveillance. Conclusions: Ultrasonography of the central nervous system can reveal inflammatory changes and developing brain abscesses. In neonates, magnetic resonance imaging should be performed as the method of choice for confirming brain abscesses

Regresja zmian torbielowatych w obrazie MR mózgu u dziecka z noworodkową encefalopatią niedotlenieniowo-niedokrwienną, poddanego hipotermii leczniczej

The authors present the first case of regression of cystic lesions on brain MRI in a newborn after therapeutic hypothermia in Poland. Multicystic encephalopathy is the most severe form of hypoxic-ischemic encephalopathy and its regression is described very rarely in the literature. Magnetic resonance imaging is an accepted, optimal method of evaluation of the brain and establishing prognosis in children with HIE. After normal pregnancy an emergency cesarean section was performed at 37 weeks gestation due to the markers of intrauterine hypoxia on CTG. The condition of the newborn was serious: 3 ,5, 7, 8 points according to Apgar score in 1st, 3nd, 5th and 10th minute of life, respectively. The infant required resuscitation. The cooling procedure lasted 72 hours. The first MRI study was performed at the age of 3 weeks and revealed cavities in the frontal and parietal lobed. The Evans index was 0.33. The second MRI investigation was carried out at the age of 5 weeks. The cavitary appearance did not change, the Evans index decreased to 0.32. The child underwent third MRI at the age of 2 years 4 months. No cystic lesions were found. There were signs of gliosis in their place and focal corticalsubcortical atrophy. The Evans index was 0.28 (within the normal limits). The neuropsychological status of the child at the age of 2.5 years is normal and brain MRI reveals strikingly mild lesions as compared to cavitary injury reported at the age of 3 and 5 weeks. The presented case shows that severe hypoxic-ischemic lesions such as cavities in an infant after cooling procedure do not necessarily mean poor prognosis, as with time even such lesions may regress. Therefore, even after the MRI diagnosis of multicystic encephalopathy the prognosis should be made with care.Autorki przedstawiają pierwszy w Polsce przypadek regresji zmian torbielowatych w obrazie MR mózgu u noworodka poddanego hipotermii leczniczej. Encefalopatia wielotorbielowata jest najcięższą postacią zmian niedotlenieniowo-niedokrwiennych i ustąpienie zmian jest opisywane niezwykle rzadko. Rezonans magnetyczny jest uznaną, optymalną metodą oceny stanu mózgowia, prognozowania dalszego rozwoju dziecka z ENN i określania rokowania. Noworodek z prawidłowej ciąży I został urodzony cięciem cesarskim w 37 tygodniu ciąży ze wskazań nagłych wobec wykładników kardiotokograficznych niedotlenienia wewnątrzmacicznego. Stan dziecka był ciężki, punktacja wg Apgar 3 ,5, 7, 8 odpowiednio w 1., 3., 5. i 10. minucie życia. Noworodek wymagał resuscytacji. Był poddany procedurze chłodzenia przez 72 godz. Pierwsze badanie MR wykonano w 3. tygodniu życia i uwidoczniono jamy wypełnione płynem w płatach czołowych i ciemieniowych. Wskaźnik Evansa wynosił 0,33. Drugie badanie MR wykonano w wieku 5 tygodni. Obraz jam nie uległ zmianie, wskaźnik Evansa zmniejszył się do 0,32. Trzecie badanie MR wykonano w wieku 2 lat i 4/12 i nie uwidoczniono jam. W ich miejscu widoczna była glioza i odcinkowy zanik korowo-podkorowy. Wskaźnik Evansa wyniósł 0,28 (w granicach normy). Stan neuropsychologiczny dziecka w wieku 2,5 lat nie odbiega od normy, a obraz MR mózgu wykazuje uderzająco niewielkie zmiany w stosunku do stwierdzanych w wieku noworodkowym. Prezentowany przypadek pokazuje, że ciężkie zmiany niedotlenieniowo-niedokrwienne w postaci jam u dziecka po leczeniu hipotermią nie muszą rokować źle, ponieważ z upływem czasu nawet zmiany jamiste mogą ulec regresji. Zatem nawet po stwierdzeniu w obrazie MR cech encefalopatii wielotorbielowatej rokowanie odnośnie przeżycia i dalszego stanu neurorozwojowego dziecka powinno być stawiane ostrożnie

Hypertrophic olivary degeneration in a 16-year-old girl after subtotal surgery of a brainstem pilocytic astrocytoma : a case report

Purpose: Hypertrophic olivary degeneration (HOD) is a unique neurological condition caused by interruption of the dentato-rubro-olivary pathway, also known as the triangle of Guillain and Mollaret. Magnetic resonance (MR) imaging is the best modality to diagnose both the degeneration of the inferior olivary nucleus and the underlying cause. Case report: We describe a case of a unilateral HOD in a 16-year-old girl several months after a subtotal excision of a brainstem pilocytic astrocytoma. Taking into account the patient's history, tumour recurrence must have been considered, but the typical location and MR morphology, as well as the time of occurrence after brainstem surgery, contributed to the diagnosis of HOD. The causative factor was the interruption of the central tegmental tract, which forms one arm of the Guillain and Mollaret triangle. Additionally, this is an interesting case of a child, who stayed in a coma for several months following brainstem surgery, but finally was discharged home with only minor neurological defects and returned to normal life. Conclusions: Hypertrophic olivary degeneration is an infrequent neurological condition, especially in the paediatric population. Nevertheless, it should be considered when interpreting late postoperative scans of children with a history of a brain tumour

The symptomatology of aneurysmal bone cyst : the value of diagnostic imaging

Background: An aneurysmal bone cyst (ABC) is a benign lesion occurring mainly in children. Generally it is found in the metaphyses of long bones and in flat bones. Osteolysis, bone expansion, thinning of the cortex, osseous septa and fluid levels belong to the typical imaging findings in ABC cases. The purpose of the study was to determine the value of imaging methods: plain x-ray films, US, CT and MRI for the diagnosis of aneurysmal bone cyst and to work out the diagnostic algorithm for an ABC suspected on plain radiograms. Material/Methods: The material consists of 72 patients (44 boys, 28 girls) aged 2-23 years (mean age 12 yrs) with bone lesions diagnosed as aneurysmal bone cysts on pathologic examination. In all patients, plain radiographs were performed, in 26 - sonography (US), in 41 - computed tomography (CT), in 8 - magnetic resonance imaging (MRI). All the examinations were analyzed according to own system of evaluation of typical presentation in the particular methods. The histopathological diagnosis was established after biopsy or surgery. Results: The aneurysmal bone cysts were most frequently located in the long bones of the lower limbs (43%), in the long bones of the upper limbs (26.4%) and in flat bones (25%). The localization was mainly in the bone methaphyses (56.6%). On pathological examination, primary ABC was diagnosed in 65.3% of cases, secondary ABC in 23.6%, ABC and concomitant osteitis in 7%, ABC and giant cell tumor in 2.7%, ABC and chondrosarcoma in 1.4%. The application of four methods resulted in 72.2% consistency between diagnostic imaging and pathological examination. In case of only one method used the consistency was 75% for MRI, 63% for CT, 55.4% for plain films and 50% for US. In 100% of misdiagnosed cases there were no septa within osteolytic lesions on plain films, whereas in 43.8% features of malignancy were found. In 53% of misdiagnosed cases no fluid levels were observed on CT and in 69% on US. Conclusions: 1. The diagnosis of aneurismal bone cyst based on plain radiography is possible in cases with typical radiological signs. 2. Application of other methods significantly increases the percentage of correct diagnoses. 3. Lack of fluid levels does not exclude the diagnosis of ABC. 4. Imaging features of malignancy do not exclude the diagnosis of ABC