Treatment of intermetatarsal Morton's neuroma with alcohol injection under US guide: 10-month follow-up

Mortons neuroma (MN) is a frequent cause of metatarsalgia. The aim of our study was to evaluate the efficacy of neuroma alcohol-sclerosing therapy (NAST) under US guide in MN after a 10-month follow-up. Forty intermetatarsal neuromas underwent alcohol-sclerosing therapy after sonographic evaluation of their dimensions and echotexture. After subcutaneous anesthesia, a sclerosing solution composed of anesthetic (carbocaine-adrenaline 70%) and ethylic alcohol (30%) was injected inside the mass under US guidance. The procedure was repeated at intervals of 15 days until the resolution of the symptoms. A total or partial symptomatic relief was obtained in 36 cases (90%). No procedure-related complications were observed. Transitory plantar pain, due to the flogistic reaction induced by the sclerosing solution, occurred in 6 cases (15%). The 10-month follow-up revealed a 20-30% mass volume reduction and an adiposus-like change in echotexture. In the 4 cases (10%) of therapeutic failure, the preliminary sonography demonstrated a hypoechoic echotexture with a strong US beam attenuation corresponding to a highly fibrous neuroma after surgical resection. The NAST is a feasible and cost-efficient procedure with high rates of therapeutic success

Diffusion-weighted MRI in the evaluation of renal lesions:preliminary results

The purpose of this study was to evaluate the capability and the reliability of diffusion-weighted MRI in the evaluation of normal kidney and different renal lesions. 39 patients (10 normal volunteers and 29 patients with known renal lesions) underwent MRI of the kidneys by using a 1.5 T superconducting magnet. Axial fat suppressed turbo spin echo (TSE) T2 and coronal fast field echo (FFE) T1 or TSE T1 weighted images were acquired for each patient. Diffusion-weighted (DW) images were obtained in the axial plane during breath-hold (17 s) with a spin-echo echo planar imaging (SE EPI) single shot sequence (repetition time (TR)52883 ms, echo time (TE)561 ms, flip angle590°), with b value of 500 s mm22. 16 slices were produced with slice thickness of 7 mm and interslice gap of 1 mm. An apparent diffusion coefficient (ADC) map was obtained at each slice position. The ADC was measured in an approximately 1 cm region of interest (ROI) within the normal renal parenchyma, the detected renal lesions and the collecting system if dilated. ADC values in normal renal parenchyma ranged from 1.7261023 mm2 s21 to 2.6561023 mm2 s21, while ADC values in simple cysts (n513) were higher (2.8761023 mm2 s21 to 4.0061023 mm2 s21). In hydronephrotic kidneys (n56) the ADC values of renal pelvis ranged from 3.3961023 mm2 s21 to 4.0061023 mm2 s21. In cases of pyonephrosis (n53) ADC values of the renal pelvis were found to be lower than those of renal pelvis of hydronephrotic kidneys (0.7761023 mm2 s21 to 1.0761023 mm2 s21). Solid benign and malignant renal tumours (n57) showed ADC values ranging between 1.2861023 mm2 s21 and 1.8361023 mm2 s21. In conclusion diffusion-weighted MR imaging of the kidney seems to be a reliable way to differentiate normal renal parenchyma and different renal diseases. Clinical experience with this method is still preliminary and further studies are required

Diffusion tensor magnetic resonance imaging of prostate cancer

Purpose: To explore the feasibility of 3 T magnetic resonance (MR) diffusion tensor imaging (DTI) and fiber tracking (FT) in patients with prostate cancer. Materials and methods: Thirty consecutive patients (mean age, 62.5 years) with biopsy proven prostate cancer underwent 3 T-MR imaging (MRI) and DTI using a 6-channel external phased-array coil before radical prostatectomy. Regions of interest of 14 pixels were defined in tumors and nonaffected areas in the peripheral zone (PZ) and central gland (CG), according to histopatology after radical prostatectomy. Apparent diffusion coefficient (ADC) and fractional anisotropy (FA) values were determined. Differences in mean ADC and FA values among prostate cancer, normal PZ and CG were compared by 2-sided Student t test. The predominant diffusion direction of the prostate anisotropy was color coded on a directionally encoded color (DEC) map. A 3D reconstruction of fiber tract orientations of the whole prostate was determined using the continuous tracking method. The overall image quality for tumor localization and local staging was assessed in retrospective matching with whole-mount section histopathology images. Nodules detected at MRI were classified as matched lesions if tumor presence and extension were evidenced at histopathology. Results: For all the patients, the DTI sequence images were suitable for the evaluation of the zonal anatomy of the prostate gland and the tumor localization. Quantitative evaluation of the regions of interest (ROIs) showed a mean ADC value significantly lower in the peripheral neoplastic area (1.06 0.37 10 3 mm2/s) than in the normal peripheral portion (1.95 0.38 10 3 mm2/s) (P 0.05). The mean FA values calculated in the normal peripheral (0.47 0.04) and central area (0.41 0.08) were very similar (P 0.05). The mean FA values in the neoplastic lesion (0.27 0.05) were significantly lower (P 0.05) than in the normal peripheral area and in the normal central and adenomyomatous area. DEC showed a top-bottom type preferential direction in the peripheral but not in the central area, with the tumor lesions reducing the diffusion coding direction represented as color zones tending toward gray. Tractographic analysis permitted good delineation of the prostate anatomy (capsule outline, peripheral and central area borders) and neoplastic lesion extension and capsule infiltration compared with histopathology. Conclusions: Three tesla DTI of the prostate gland is feasible and has the potential for providing improved diagnostic information

Errors in neuroradiology

Approximately 4 % of radiologic interpretation in daily practice contains errors and discrepancies that should occur in 2-20 % of reports. Fortunately, most of them are minor degree errors, or if serious, are found and corrected with sufficient promptness; obviously, diagnostic errors become critical when misinterpretation or misidentification should significantly delay medical or surgical treatments. Errors can be summarized into four main categories: observer errors, errors in interpretation, failure to suggest the next appropriate procedure, failure to communicate in a timely and a clinically appropriate manner. Misdiagnosis/misinterpretation percentage should rise up in emergency setting and in the first moments of the learning curve, as in residency. Para-physiological and pathological pitfalls in neuroradiology include calcification and brain stones, pseudofractures, and enlargement of subarachnoid or epidural spaces, ventricular system abnormalities, vascular system abnormalities, intracranial lesions or pseudolesions, and finally neuroradiological emergencies. In order to minimize the possibility of error, it is important to be aware of various presentations of pathology, obtain clinical information, know current practice guidelines, review after interpreting a diagnostic study, suggest follow-up studies when appropriate, communicate significant abnormal findings appropriately and in a timely fashion directly with the treatment team

Role of combined DWIBS/3D-CE-T1w whole-body MRI in tumor staging: Comparison with PET-CT

Objectives: To assess the diagnostic performance of whole-body magnetic resonance imaging (WB-MRI) by diffusion-weighted whole-body imaging with background body signal suppression (DWIBS) in malignant tumor detection and the potential diagnostic advantages in generating fused DWIBS/3D-contrast enhanced T1w (3D-CE-T1w) images. Methods: 45 cancer patients underwent 18F-FDG PET-CT and WB-MRI for staging purpose. Fused DWIBS/3D-CE T1w images were generated off-line. 3D-CE-T1w, DWIBS images alone and fused with 3D-CE T1w were compared by two readers groups for detection of primary diseases and local/distant metastases. Diagnostic performance between the three WB-MRI data sets was assessed using receiver operating characteristic (ROC) curve analysis. Imaging exams and histopathological results were used as standard of references. Results: Areas under the ROC curves of DWIBS vs. 3D-CE-T1w vs. both sequences in fused fashion were 0.97, 0.978, and 1.00, respectively. The diagnostic performance in tumor detection of fused DWIBS/3DCE- T1w images were statistically superior to DWIBS (p < 0.001) and 3D-CE-T1w (p ≤ 0.002); while the difference between DWIBS and 3D-CE-T1w did not show statistical significance difference. Detection rates of malignancy did not differ between WB-MRI with DWIBS and 18F-FDG PET-CT. Conclusion: WB-MRI with DWIBS is to be considered as alternative tool to conventional whole-body methods for tumor staging and during follow-up in cancer patients

Static and dynamic evaluation of pelvic floor disorders with an open low-field tilting magnet.

AIM: To assess the feasibility of magnetic resonance defaecography (MRD) in pelvic floor disorders using an open tilting magnet with a 0.25 T static field and to compare the results obtained from the same patient both in supine and orthostatic positions. MATERIALS AND METHODS: From May 2010 to November 2011, 49 symptomatic female subjects (mean age 43.5 years) were enrolled. All the patients underwent MRD in the supine and orthostatic positions using three-dimensional (3D) hybrid contrast-enhanced (HYCE) sequences and dynamic gradient echo (GE) T1-weighted sequences. All the patients underwent conventional defaecography (CD) to correlate both results. Two radiologists evaluated the examinations; inter and intra-observer concordance was measured. The results obtained in the two positions were compared between them and with CD. RESULTS: The comparison between CD and MRD found statistically significant differences in the evaluation of anterior and posterior rectocoele during defaecation in both positions and of rectal prolapse under the pubo-coccygeal line (PCL) during evacuation, only in the supine position (versus MRD orthostatic: rectal prolapse p < 0.0001; anterior rectocoele p < 0.001; posterior rectocoele p = 0.008; versus CD: rectal prolapse p < 0.0001; anterior rectocoele p < 0.001; posterior rectocoele p = 0.01). The value of intra-observer intra-class correlation coefficient (ICC) ranged from good to excellent; the interobserver ICC from moderate to excellent. CONCLUSION: MRD is feasible with an open low-field tilting magnet, and it is more accurate in the orthostatic position than in the supine position to evaluate pelvic floor disorders

Epithelioid hemangioendothelioma of the femur

A 27-year-old man presented at the orthopedic department with a 3-year history of severe limitation on his locomotor capacity and persistent pain at the anteromedial side of the right thigh. These symptoms had been diagnosed and treated as a psychosomatic disorder because of his known mental illness

Differences between Proximal versus Distal Intraorbital Optic Nerve Diffusion Tensor Magnetic Resonance Imaging Properties in Glaucoma Patients

Purpose. To analyze in vivo the diffusion tensor magnetic resonance imaging (DT-MRI) properties of the intraorbital optic nerve at two different levels: Proximal to the optic nerve head (ONH) and distal to the ONH at the level of the orbital apex in glaucoma patients. Methods. Twenty-four patients with primary open-angle glaucoma were examined. The categorization into early and severe glaucoma was performed by Hodapp's classification. Fifteen healthy individuals served as controls. DT-MRI was performed with a 3T-MR unit. Results. At early stage mean diffusivity (MD) values were higher at the proximal site with respect to the distal site. On the contrary, a decrease in fractional anisotropy (FA) was observed only relative to patient stage, independent of optic nerve site. Moreover, at early disease stage an increase in overall diffusivities, was evident at the proximal site, whereas at the distal site a decrease of the largest diffusivity and an increase in both the intermediate and smallest diffusivities were observed. FA and MD measured at the proximal site, had, respectively, the highest sensitivity and specificity in discriminating between healthy and glaucomatous eyes. Conclusions. Our study represents the first attempt to evaluate in vivo fiber integrity changes along the optic nerve with DT-MRI. Optic nerve degeneration appears to be a process that affects differently the proximal and the distal segments of the optic nerve. The complementary high sensitivity of FA with the high specificity of MD at the proximal site may provide reliable indexes for the identification of glaucomatous patients at early stages

Microwave ablation of renal tumors: state of the art and development trends

In the last decades an increased incidence of new renal tumor cases has been for clinically localized, small tumors <2.0 cm. This trend for small, low-stage tumors is the reflection of earlier diagnosis primarily as a result of the widespread and increasing use of non-invasive abdominal imaging modalities such as ultrasound, computerized tomography, and magnetic resonance imaging. Renal tumors are often diagnosed in elderly patients, with medical comorbidities whom the risk of surgical complications may pose a greater risk of death than that due to the tumor itself. In these patients, unsuitable for surgical approach, thermal ablation represents a valid alternative to traditional surgery. Thermal ablation is a less invasive, less morbid treatment option thanks to reduced blood loss, lower incidence of complications during the procedure and a less long convalescence. At present, the most widely used thermal ablative techniques are cryoablation, radiofrequency ablation and microwave ablation (MWA). MWA offers many benefits of other ablation techniques and offers several other advantages: higher intratumoral temperatures, larger tumor ablation volumes, faster ablation times, the ability to use multiple applicators simultaneously, optimal heating of cystic masses and tumors close to the vessels and less procedural pain. This review aims to provide the reader with an overview about the state of the art of microwave ablation for renal tumors and to cast a glance on the new development trends of this technique